Wolfe Frederick, Michaud Kaleb, Gefeller Olaf, Choi Hyon K
Arthritis Research Center Foundation and University of Kansas School of Medicine, Wichita, Kansas 67214, USA.
Arthritis Rheum. 2003 Jun;48(6):1530-42. doi: 10.1002/art.11024.
A number of different variables have been proposed as risk factors for mortality in patients with rheumatoid arthritis (RA), but limited prospective information on the magnitude of their effects is available. This study was undertaken to evaluate the relative predictive strength and usefulness of a wide range of variables on the risk of mortality in a large, long-term, prospectively studied cohort of patients with RA.
Over a 20-year period of followup beginning in 1981, 1387 consecutive RA patients were seen in a single clinic. A wide range of clinical and demographic assessments were recorded and entered into a computer database at the time of each clinical assessment. Assessment of predictive strength included determination of standardized and fourth-versus-first-quartile odds ratios (ORs), goodness-of-fit measures, and contributing fraction.
The Health Assessment Questionnaire (HAQ) disability index was the strongest clinical predictor of mortality. A 1-SD change in the HAQ resulted in a much larger increase in the odds ratio for mortality compared with a 1-SD change in global disease severity, the next most powerful predictor of mortality (OR 2.31 versus 1.83). Considering the contributing fraction, mortality would be reduced by 50% for the HAQ and by 33% for global disease severity if patients in the fourth quartile for these variables could be switched to the first quartile. Global disease severity, pain, depression, anxiety, and laboratory and radiographic features were significantly weaker predictors. Disease duration, nodules, and tender joint count were clinical variables that provided very little predictive information. In multivariable analyses, HAQ and other patient self-report measures were significantly better predictors than were radiographic and laboratory variables. A single baseline observation provided the least information, with substantially increasing predictive ability associated with 1-year, 2-year, and all-time point followup observations (time-varying covariates).
In this large 20-year study from routine clinical practice, the HAQ was the most powerful predictor of mortality, followed by other patient self-report variables. Laboratory, radiographic, and physical examination data were substantially weaker in predicting mortality. We recommend that clinicians collect patient self-report data, since they produce more useful clinical outcome information than other available clinical measures.
已有多种不同变量被提出作为类风湿关节炎（RA）患者死亡的危险因素，但关于其影响程度的前瞻性信息有限。本研究旨在评估一系列变量对一个大型、长期、前瞻性研究的RA患者队列死亡风险的相对预测强度和效用。
从1981年开始的20年随访期间，在一家诊所连续观察了1387例RA患者。在每次临床评估时记录了广泛的临床和人口统计学评估数据，并输入计算机数据库。预测强度评估包括确定标准化和四分位数间（第四四分位数与第一四分位数）的比值比（OR）、拟合优度测量以及贡献比例。
健康评估问卷（HAQ）残疾指数是最强的死亡临床预测指标。HAQ每变化1个标准差导致的死亡比值比增加幅度，远大于全球疾病严重程度（第二强的死亡预测指标）变化1个标准差时的情况（OR分别为2.31和1.83）。考虑贡献比例，如果这些变量处于第四四分位数的患者能转变为第一四分位数，HAQ可使死亡率降低50%，全球疾病严重程度可使死亡率降低33%。全球疾病严重程度、疼痛、抑郁、焦虑以及实验室和影像学特征是明显较弱的预测指标。疾病持续时间、结节和压痛关节数是提供极少预测信息的临床变量。在多变量分析中，HAQ和其他患者自我报告指标比影像学和实验室变量是明显更好的预测指标。单次基线观察提供的信息最少，随着1年、2年和所有时间点的随访观察（时变协变量），预测能力大幅增加。
在这项来自常规临床实践的长达20年的大型研究中，HAQ是最强的死亡预测指标，其次是其他患者自我报告变量。实验室、影像学和体格检查数据在预测死亡率方面明显较弱。我们建议临床医生收集患者自我报告数据，因为与其他可用临床指标相比，它们能产生更有用的临床结局信息。
