Annals of the Rheumatic Diseases 1992; 51: 186-194 Prevalence of chronic arthritis in four geographical areas of the Scottish Highlands M M Steven Abstract A survey of the prevalence of chronic arthritic conditions was carried out on a population of 35 251 patients registered with 29 general practitioners in the highlands of Scotland. Symptomatic osteoarthritis had an overall prevalence of 65 per 1000 but rose from one in 20 of those aged 40-50 years to one quarter of those over 70 years of age. Rheumatoid arthritis was present in 5.5 per 1000 with a two to threefold female preponderance and there was an unexplained threefold difference between the regions with the highest and lowest prevalence. Seronegative arthritides were found in 2*1 per 1000, polymyalgia rheumatica/temporal arteritis in 1-2 per 1000, and gout in 3-4 per 1000. Juvenile chronic arthritis had a prevalence of 0-39 per 1000 (2.0 per 1000 in those aged 15 years and younger) and connective tissue disease 0-45 per 1000. There was considerable variation in the prevalence of inflammatory arthritis through- out the region. The highest prevalence of rheumatoid arthritis was 14*5 per 1000 women in one east coast area and the lowest 5-2 per 1000 women in the west. The difference did not seem to be due to misclassification. A consultant's review of a questionnaire sent to all except those with osteoarthritis changed the proportions of patients who could be confirmed to have the respective inflammatory arthritides (rheumatoid arthritis between 3*4 and 5-0 per 1000, seronegative arthritides 2-0 per 1000, juvenile chronic arthritis 0-52 per 1000), and a third of those diagnosed as having rheumatoid arthritis failed to meet hospital oriented diagnostic criteria. On the other hand, studies of health care provision may more reasonably consider only cases of symptomatic disease. The Highland Arthritis Prevalence Study (HARPS) was designed to assess the prevalence of chronic rheumatic disease in a large geo- graphical area with a single regional rheumato- logical service which uniquely encompasses east and west coasts of Great Britain. Patients and methods The Highland Health Board provides health care for the Highland region (population 200 800) with additional specialist provision to the Western Isles (population 31 500) and some cross boundary flow from the West Grampian region (population 84 800). The population served is comparable with that of an average United Kingdom health district but is scattered over a vast geographical area (9804 square miles) larger than Wales (fig 1). The Highland Health Board has a single consultant with an interest in rheumatology based in Inverness and inpatient facilities for rheumatology are provided by the 15 bedded Nicolson MacKenzie hospital in the spa village of Strathpeffer. Outpatients are seen in Inverness and at peripheral clinics. The region is therefore well defined geographically and served by a single major hospital providing an ideal environment for epidemiological study. The Highland region is served by 162 general practitioners, including 36 single handed prac- titioners. Thirty general practitioners from nine general practices initially agreed to take part in the study. They were chosen as representatives of urban and rural practices respectively on the east and west coasts of the area (fig 1). Because Raigmore Hospital, Inverness IV2 3UJ, United Kingdom M M Steven Accepted for publication 15 February 1991 Rheumatic diseases impose a considerable burden on the health of the community. Whether measured by temporary or permanent inability to work or by general practitioner or hospital consultation rates, they are among the leading causes of morbidity in the United Kingdom. Epidemiological studies on the prevalence of rheumatic diseases have been complicated by the lack of 'hard' diagnostic criteria which are universally agreed and applicable in the community. These and other reasons probably explain the disparate assess- ments of the prevalence of chronic arthritis.' Useful estimates may depend on the purpose for which a group needs to be identified. Therefore, studies of disease causation or natural history should look at all possible cases of disease, including subclinical or mild forms. Figure I Areas where the prevalence of chronic arthritis was assessed. 186 on May 28, 2021 by guest. Protected by copyright. http://ard.bmj.com/ Ann Rheum Dis: first published as 10.1136/ard.51.2.186 on 1 February 1992. Downloaded from
Transcript
Annals of the Rheumatic Diseases 1992; 51: 186-194
Prevalence of chronic arthritis in four geographicalareas of the Scottish Highlands
M M Steven
AbstractA survey of the prevalence of chronic arthriticconditions was carried out on a population of35 251 patients registered with 29 generalpractitioners in the highlands of Scotland.Symptomatic osteoarthritis had an overallprevalence of 65 per 1000 but rose from one in20 of those aged 40-50 years to one quarter ofthose over 70 years of age. Rheumatoidarthritis was present in 5.5 per 1000 with a twoto threefold female preponderance and therewas an unexplained threefold differencebetween the regions with the highest andlowest prevalence. Seronegative arthritideswere found in 2*1 per 1000, polymyalgiarheumatica/temporal arteritis in 1-2 per 1000,and gout in 3-4 per 1000. Juvenile chronicarthritis had a prevalence of 0-39 per 1000 (2.0per 1000 in those aged 15 years and younger)and connective tissue disease 0-45 per 1000.There was considerable variation in the
prevalence of inflammatory arthritis through-out the region. The highest prevalence ofrheumatoid arthritis was 14*5 per 1000 womenin one east coast area and the lowest 5-2 per1000 women in the west. The difference didnot seem to be due to misclassification.A consultant's review of a questionnaire
sent to all except those with osteoarthritischanged the proportions of patients whocould be confirmed to have the respectiveinflammatory arthritides (rheumatoid arthritisbetween 3*4 and 5-0 per 1000, seronegativearthritides 2-0 per 1000, juvenile chronicarthritis 0-52 per 1000), and a third of thosediagnosed as having rheumatoid arthritisfailed to meet hospital oriented diagnosticcriteria.
On the other hand, studies of health careprovision may more reasonably consider onlycases of symptomatic disease.The Highland Arthritis Prevalence Study
(HARPS) was designed to assess the prevalenceof chronic rheumatic disease in a large geo-graphical area with a single regional rheumato-logical service which uniquely encompasses eastand west coasts of Great Britain.
Patients and methodsThe Highland Health Board provides healthcare for the Highland region (population200 800) with additional specialist provision tothe Western Isles (population 31 500) and somecross boundary flow from the West Grampianregion (population 84 800). The populationserved is comparable with that of an averageUnited Kingdom health district but is scatteredover a vast geographical area (9804 squaremiles) larger than Wales (fig 1).The Highland Health Board has a single
consultant with an interest in rheumatologybased in Inverness and inpatient facilities forrheumatology are provided by the 15 beddedNicolson MacKenzie hospital in the spa villageof Strathpeffer. Outpatients are seen in Invernessand at peripheral clinics. The region is thereforewell defined geographically and served bya single major hospital providing an idealenvironment for epidemiological study.The Highland region is served by 162 general
practitioners, including 36 single handed prac-titioners. Thirty general practitioners from ninegeneral practices initially agreed to take part inthe study. They were chosen as representativesof urban and rural practices respectively on theeast and west coasts of the area (fig 1). Because
Raigmore Hospital,Inverness IV2 3UJ,United KingdomM M StevenAccepted for publication15 February 1991
Rheumatic diseases impose a considerableburden on the health of the community.Whether measured by temporary or permanentinability to work or by general practitioner orhospital consultation rates, they are among theleading causes of morbidity in the UnitedKingdom. Epidemiological studies on theprevalence of rheumatic diseases have beencomplicated by the lack of 'hard' diagnosticcriteria which are universally agreed andapplicable in the community. These and otherreasons probably explain the disparate assess-ments of the prevalence of chronic arthritis.'
Useful estimates may depend on the purposefor which a group needs to be identified.Therefore, studies of disease causation ornatural history should look at all possible casesof disease, including subclinical or mild forms.
Figure I Areas where the prevalence ofchronic arthritiswas assessed.
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of the geographical layout of the area, the date of birth, and specific diagnosis, werepractices each served virtually all the patients in entered on a tailored relational database (Data-those areas with little possibility of selective flex) and stored on a microcomputer (Victor 20cross boundary flow to neighbouring practices. MB personal computer). The specific diagnosisThere is also no significant private medical used was that made by the general practitioner
practice. One part time practitioner (list size from their knowledge of the patient, their own506) in a large group practice later withdrew. records, and hospital letters, where availableBetween December 1986 and December 1987 (table 2). It was emphasised that of the patientsthe 29 practitioners from nine practices in the with osteoarthritis, only those who wereregion (table 1) prospectively collected details of symptomatic were to be included.all patients on their personal NHS list known to Owing to the widely scattered population andhave chronic arthritis. In all, 35 251 patients the large number of patients it was not possiblewere reviewed. Practitioners were asked to to carry out a diagnostic validation including aidentify all patients who had chronic arthritis of specialist consultation. A computer generatedmore than six months' duration in order to questionnaire was therefore sent out to theestimate the point prevalence of these conditions practitioneraccording to the diagnosis requestingin the Highland region. Individual practitioners detailed clinical information. Owing to the largereviewed their diagnostic indices, repeat number of patients with osteoarthritis (about 80prescribing registers, practice records, and an for each practitioner) it was not possible toup to date print outt of the names and addresses collect information on this group. The question-of all patients registered with the practice naire sought details of clinical features, serology,(provided by the primary care division, Highland and radiology (appendix), enabling a consultantHealth Board). In this way all patients with rheumatologist to review the general practitionerchronic arthritis registered with the practice diagnosis. Records of those attending thewere identified, not only those who consulted regional rheumatology outpatient or inpatientduring the study period. The initial details departments during the study period were alsocollected, including the names, addresses, sex, inspected to check the level of ascertainment by
Table 2 The chronic* arthritides
Symptomatic osteoarthritis
Rheumatoid arthritis(seropositive and seronegative rheumatoid factor)
Ankylosing spondylitis 1Psoriatic arthritis | SeronegativeArthritis of inflammatory bowel disease arthritides InflammatoryReiter's disease r arthritidesOther seronegative arthritis J
'OA=symptomatic rheumatica osteoarthritis; RA=rheumatoid arthritis; SN=seronegative arthritis; JCA= juvenile chronic arthritis;PMR/TA=polymyalgia rheumatica temporal arteritis; CTD=connective tissue disease; AR=other arthritis.tHARPS=Highland Arthritis Prevalence Study.tOne hundred and twelve patients had osteoarthritis and another arthritis: RA= 51; SN =3; PMR =20; GT=37; CT= 1.
the general practitioner. Data were analysed tomeasure the overall and regional point pre-valence of chronic arthritis in the Highlandregion.
ResultsDuring the 12 month study period 2770diagnoses of chronic arthritis were made by thegeneral practitioners. These included 112patients with more than one diagnosis (table 3).Fourteen patients died during the study periodand were excluded from further consideration.More than three quarters of the cases identifiedwere patients with symptomatic osteoarthritis,which had an overall prevalence of 65 per 1000population. There was considerable variationwith age, varying from one in 20 of thepopulation aged 40-50 years up to one quarterof those over 70 years (fig 2). There was a slightfemale excess but little regional variation.
Based on the general practitioner's owndiagnosis rheumatoid arthritis was the mostprevalent inflammatory arthritis with an overallprevalence of 5 5 per 1000 (6-9 per 1000 forthose aged more than 15 years). There was a twoto threefold female preponderance (table 4) andthe prevalence rose from under 10 per 1000women at age 40-50 years to a peak of 23 per1000 women aged 60-70 (fig 3). There was a
threefold difference in prevalence between theBlack Isle (9 3 per 1000) and Skye (3 3 per1000).
Seronegative arthritides, including ankylosingspondylitis, psoriatic arthritis, and Reiter'sdisease, had an overall prevalence of 2-1 per1000, less than half that of rheumatoid arthritis.There was a reversal of the female predominanceseen in rheumatoid arthritis, and in some areas
300
250
200
0
0
°- 150-0
cL
50
O-0)-
-- Women| Men
-40 -50 -60 -70 -80 80 +Age
Figure 2 Prevalence ofosteoarthritis by age and sex in apopulation of35 251 general practice patients.
the male prevalence of seronegative arthritisexceeded that of rheumatoid arthritis.
Other inflammatory arthritides were lesscommon. Juvenile chronic arthritis had a pre-valence of 0-39 per 1000 (2-0 per 1000 for thoseaged 15 years and younger) and polymyalgiarheumatica was reported in 1-2 per 1000population. There were more women than menwith both juvenile chronic arthritis (0-6 per1000 women v 0-2 per 1000 men) and poly-myalgia rheumatica/temporal arteritis (table 4).Connective tissue disease was rare (overallprevalence 0 45 per 1000), and the numberswere too small (16) to make any comparisonsbetween areas.
Table 4 Prevalence of arthn'tis per 1000 population by general practitioner diagnosis
Prevalence ofchronic arthritis in the Scottish Highlands
A
JddMen
I~~~~~~~~~~~~~~~~~~~~
t~~~~~~~~~~~~~~~~~~~~~~~~
I
I ro \
other case classed as rheumatoid arthritis by thepractitioner the onset of arthritis had been inchildhood and should be considered as a case ofjuvenile chronic arthritis. Of the remainder, 84had rheumatoid arthritis which was considered'moderate' or 'severe' (appendix). Sixty six ofthose had either erosive hand radiographs orwere seropositive for rheumatoid factor, orboth. Six had had neither test performed andthe remaining 12 had non-diagnostic results. Onthe basis of the clinical features, however, all 18were considered to have confirmed rheumatoidarthritis (figure 4).
< 40 -50 -60 -70 -80 80 + >Age
Figure 3 Prevalence ofrheumatoid arthritis by age and sexin a population of35 251 general practice patients.
Thirty patients were diagnosed as 'otherarthritis', including spondylolisthesis, neuro-pathic joints, haemophilic arthritis, andprimary bone diseases.The diagnostic rate for gout varied widely
throughout the region (table 4) with a regionalprevalence of 3-4 per 1000 and a substantialexcess of men.
In an attempt to validate the general practi-tioner's diagnosis further details were obtainedby a questionnaire sent to all patients other thanthose with osteoarthritis. Twenty six practi-tioners returned all their questionnaires, butthree were unable to complete theirs giving anoverall completion rate of 88%. Not all patientshad undergone full serological and radiologicalassessment. Tables 5 and 6 give details of thereturned questionnaires. Of the 170 patientswith a general practitioner diagnosis of rheuma-toid arthritis, six had a concurrent diagnosis ofpsoriasis. Although four had a symmetrical,radiologically erosive polyarthritis affectingsmall joints and another was seropositive forrheumatoid factor, these six patients were allconsidered to have psoriatic arthritis. In one
Of 38 patients considered to have earlyrheumatoid arthritis, serological tests or radio-logy, or both, led to a diagnosis of confirmedrheumatoid arthritis in 18 patients. One patienthad no objective joint swelling and had normalhand radiographs and was seronegative forrheumatoid factor and was classed as undeter-mined diagnosis. The remaining 19 had non-diagnostic results, but the clinical featuressuggested a diagnosis of possible rheumatoidarthritis.The remainder, comprising 41 patients, were
considered to have atypical rheumatoid arthritis.In 14 the clinical features were consideredundetermined for a diagnosis of rheumatoidarthritis or any other chronic inflammatoryarthritis. Twenty seven had one or more featuresthat were suggestive but not diagnostic, andthey were classed as 'possible' rheumatoidarthritis.
Sixty four patients who returned question-naires had a diagnosis of seronegative arthritis(table 5). These included patients with coexistentpsoriasis or inflammatory bowel disease as wellas those with ankylosing spondylitis andreactive arthritis/Reiter's disease. The patternof joint disease and other features reflects thedifferent clinical subgroups of these diseases.One patient with seronegative arthritis wasfound to have had a childhood onset and wasaccordingly reclassified. Fifty three patientswere considered to have a confirmed diagnosisafter consultant review. There remained agroup of patients with seronegative arthritiswhich did not readily fit any of the otherdiagnostic subgroups. Although not part of anyclassification, they are a well represented groupat most specialist clinics.Two of this group had symmetrical peripheral
joint disease and were seropositive for rheuma-toid factor and were therefore reclassified asconfirmed rheumatoid arthritis. Five others hadsimilar clinical features and were seronegativebut could be considered to have possiblerheumatoid arthritis. The remaining nine hadlargely asymmetrical disease or large joints withor without spinal involvement and could repre-sent formes frustes of ankylosing spondylitis orother seronegative disease.A review of questionnaires from patients
with gout showed the expected male pre-
dominance (table 6). Over 90% of those testedhad hyperuricaemia. Diagnostic crystal analysiswas not used by general practiti6ners fordiagnosis, but the diagnosis could not berebutted in any case.
Patients with polymyalgia rheumatica/temporal arteritis were older (median age 78years) and had a 2-8:1 female predominance.Thirty four had a dramatic or good response tosteroid treatment but only 18 of 32 tested had anerythrocyte sedimentation rate greater than 60mm/h (or equivalent plasma viscosity) atdiagnosis. One patient had had neither a signi-ficantly raised erythrocyte sedimentation rate/viscosity nor a good or dramatic response tosteroid treatment and could not be confirmed asa definite case.
Patients diagnosed as having connective tissuedisease included eight with systemic lupuserythematosus, two with dermatomyositis,and five with unclassified forms. Three hadconcurrent rheumatoid arthritis and wereconsidered to have overlap syndromes. Allpatients with this diagnosis had attendedhospital and the diagnoses were thereforeconsidered valid.
Patients with juvenile chronic arthritis (table6) were supplemented by two classified in adultgroups by their practitioner (both seronegativefor rheumatoid factor). Five had a Still's type ofdisease, four were considered to have oligo-articular arthritis, and four polyarticulardisease. Three others did not fit any of thesediagnostic patterns.
After reclassification (fig 4) there were, there-fore, 62 patients with seronegative arthritis and16 with juvenile chronic arthritis. There were104 confirmed, 51 possible, and 15 undeterminedcases of rheumatoid arthritis. There were 18confirmed cases of polymyalgia rheumatica and19 further possible cases. When these figureswere related to the overall population fromwhom questionnaires were returned (30 899) weobtained a prevalence of seronegative arthritisof 2-0 per 1000 and of rheumatoid arthritisbetween 3-4 (confirmed) and 5-0 (confirmedplus possible) per 1000 depending on thecriteria accepted as diagnostic. The prevalenceof juvenile chronic arthritis increased slightly to0-52 per 1000 total population.A review of patients who had attended a
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specialist rheumatology clinic during the studyperiod was carried out. No cases were identifiedfrom the hospital records of patients who hadbeen missed by the general practitioner study.
DiscussionEpidemiological studies of the arthritides arebeset by many problems. Some are common toall medical epidemiology and some particular torheumatic diseases. Choosing cases identifiedby the patient's own (different) doctor mayresult in variable rates of pickup. The rates ofself presentation to practitioners vary betweenindividual patients as do the diagnostic ratesand disease classification between doctors. Inthe absence of specific diagnostic markers forrheumatic diseases there is considerable scopefor intra- and interobserver variation, evenamong experts. Alternative epidemiologicaltechniques, such as community screeningprogrammes, are not immune from these diffi-culties and additionally encounter the problemof asymptomatic subjects with clinical orlaboratory signs of the disease under study.2This study, therefore, chose the level of generalpractitioner identification as the most practicableand meaningful for assessing the prevalence ofchronic arthritis and the demands on healthresources.
Numerically, osteoarthritis of the elderly isthe major problem, the prevalence of symptom-atic osteoarthritis rising from 10% in those aged50-60 to nearly 25% of those over 80. The studyof the Royal College of General Practitionersfound an episode rate of 29-0 per 1000 forosteoarthritis in a large general practice basedstudy but only included those who attendedtheir doctor complaining of their joint symptomsduring the study.3An American study estimated the prevalence
of clinical osteoarthritis at 12-1% of the adultpopulation.4 Community based screening pro-grammes in several countries have shown radio-logical signs of osteoarthritis to be virtuallyuniversal in the elderly,4 5 but these figures areof little value in assessing the impact ofsymptomatic disease on health resources. Atpresent the management of this conditionincludes drugs, physiotherapy, and orthopaedicsurgery, including joint replacement. Demandfor surgery is growing steadily, partly becauseof its efficacy and partly because ofthe increasingelderly (and hence osteoarthritic) population.Provision of facilities currently follows andhence lags behind demand, which has resultedin long waiting lists for joint replacementsurgery. There are no good estimates of theoptimal provision of this facility to aid healthplanners.Inflammatory arthritis as exemplified by
rheumatoid arthritis and seronegative arthritisis much less common than osteoarthritis.Because these two diseases begin in middlelife and because they are often chronic they alsoplace large demands on health and other socialresources. Our current estimate of the overallprevalence of rheumatoid arthritis in the High-land region lies between 0-34 and 0-55% of thepopulation.
Previous studies in Western societies haveshown variable prevalences dependent on thecriteria for diagnosis and the populationstudied.' Strict diagnostic criteria which identifychronic disease produce lower prevalences thanwidely used criteria which identify many casesof apparently self limiting inflammatoryarthritis. A consensus for the prevalence ofrheumatoid arthritis in the developed worldwould be 1% of the adult population.' 2 4 Ourcurrent figure is lower than this but cannot becompared directly with most studies owing todifferences in the methodology. A morecomparable study, such as the morbidity statisticsfrom general practice, recorded an episode rateof 5 9 per 1000 population for rheumatoidarthritis and allied conditions.3 Althoughcomparable with our own figure, this study didnot distinguish other inflammatory arthritidesand only included patients who attended for aconsultation about their arthritis during thestudy period. The study was carried out involunteer practices in England and Wales,which might not have been representative.Nevertheless, this study supports our ownestimate of rheumatoid arthritis as being con-siderably less than that previously cited, and itmay be that the prevalence of rheumatoidarthritis is actually falling.We also noticed the commonly found two- to
threefold excess of women over men, though itis less apparent in younger and older groups.The fall in prevalence over the age of 70 is wellrecognised6 7 and thought to represent an excessmortality in rheumatoid arthritis.A subregional analysis shows an excess of
rheumatoid arthritis in the Black Isle, especiallyin women. This remains even when all inflam-matory arthritides are considered together orwhen osteoarthritis is added (table 4). Mis-classification would not therefore explain theexcess. Rheumatoid arthritis is considered tohave a significant genetic component and it maybe relevant that Huntington's disease, whichhas a much stronger inherited component, has ahigh prevalence on the Black Isle.
Seronegative disorders were less commonthan rheumatoid arthritis, and there are nocommunity based studies with which to compareour results. The study from the Royal College ofGeneral Practitioners did not distinguish thisgroup from those with rheumatoid arthritis.3 Incontrast with rheumatoid arthritis men are morecommonly affected by seronegative arthritis.The review of general practitioner diagnoses bya consultant rheumatologist suggested somecases of seronegative arthritis had been mis-classified as rheumatoid arthritis. Thesedisorders were relatively more common inLochaber and Skye and again may reflect afamilial predisposition.
Connective tissue diseases are rare in theUnited Kingdom and our low prevalence figurereflects this. Juvenile chronic arthritis is alsouncommon but as it can produce considerablemorbidity at a young age there is considerableimplication for the provision of health care tothis group. Our figures suggest 520 cases permillion of the population and might suggest theadvisability of providing regional or supra-
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regional treatment centres for this difficultclinical problem. A recent review estimated12 000 cases of juvenile chronic arthritis in theUnited Kingdom,8 which gives an approximateprevalence of 214 per million, which is less thanour regional assessment.
Although perhaps 5% of the population mayhave hyperuricaemia, chronic symptomaticgout is less common and affected less than 0 5%of the local population. The prevalence else-where is not well established, though thecondition is common in some populations, suchas the New Zealand Maoris. A questionnairestudy in the United States produced a selfreported prevalence of gout of 0.99%,4 butcommunity studies requiring a medical assess-ment failed to confirm two thirds of selfreported cases.9Many scientific studies of chronic arthritis
have considered only patients attending hospitaland it has been suggested that they form anunrepresentative group. We found that in thisarea nearly three quarters of all patients withinflammatory arthritis had attended hospital(data not shown), but they tended to be thosewith more severe or chronic conditions andpatients with self limiting or early arthritis maynot be represented. It is thus important toacknowledge the unrepresentative nature ofpatients who attend hospital. Community basedstudies remain constrained by the lack of harddiagnostic criteria as this and previous studies2 4have shown. Diagnostic subclassification basedon hospital experience may be unhelpful incommunity studies and there is a case forconsidering inflammatory arthritis as a singlediagnosis in this setting.
Epidemiological studies can provide clueswhich may implicate environmental or geneticfactors in disease and direct studies aimed atidentifying them. There are particular difficultiesin collecting groups of patients with chronicinflammatory arthritis that are representativeyet homogeneous in the absence of suitableobjective diagnostic markers. This study hasdetected a large community based cohort ofpatients with chronic arthritis and has high-lighted subregional differences in their pre-valence. Such a population can be used to auditthe level of health care provided for subjectsand to search for genetic and environmentalfactors which may be relevant to the pathogenesisof arthritis.
I acknowledge the cooperation of my general practitionercolleagues and the assistance of their practice staff. Mr R ABowie of Prosoft Systems Analysis wrote and supported thecomputer software. Professor J H Barber and Dr F Sullivan ofthe department of general practice, University of Glasgow, andDr H I McNamara, regional adviser in general practice,Raigmore Hospital gave valuable advice and encouragement atthe outset of the study. Mrs E Robb coordinated the datacollection and analysis and typed the manuscript.The project was supported by a grant from the health services
research committee ofthe Scottish Home and Health Department.
4 Lawrence R C, HochbergM C, Kelsey J L, et al. Estimates ofthe prevalence of selected arthritic and musculoskeletaldiseases in the United States. J Rheumatol 1989; 16:427-41.
5 Gordon T. Osteoarthrosis in U.S. adults. In: Bennet P H,Wood P H N, eds. Population studies of the rheumaticdiseases. Amsterdam: Excerpta Medica, 1968: 391-7.
6 Vanderbroucke J P, Hazevoet H M, Cats A. Survival andcauses of death in rheumatoid arthritis: a prospectivefollow-up. J Rheumatol 1984; 11: 158-61.
7 Spector T D, Scott D L. What happens to patients withrheumatoid arthritis? The long term outcome of treatment.Clin Rheumatol 1988; 7: 315-30.
8 Benjamin C M. Review of the UK data on the rheumaticdiseases. 1-Juvenile chronic arthritis. BrJ Rheumatol 1990;29: 231-3.
9 O'Sullivan J. Gout in a New England town, prevalence studyin Sudbury Massachusetts. Ann Rheum Dis 1972; 31:166-9.
APPENDIX Questionnaire sent to general practi-tioners
The following questionnaire was sent to general practi-tioners on patients other than those with osteoarthritis.A prototype questionnaire for rheumatoid arthritis isshown and questions 4-7 were modified for otherdiagnoses.
VICTOR GENERATED HARPS QUESTIONNAIRE
Patient's usual doctor to complete and return.
Please use the practice record, including any hospitalletters, and your knowledge of the patient to completethe form.If you don't know the answer to any question, pleasestate so.
Patient's name
Address
Date of birth
Sex
HARPS No
Diagnosis
2
3
Rheumatoid arthritis (RA)
Year of diagnosis
Year of assessment
4 Pattern ofinvolvement
Early classical
Moderate classical
Severe classical
Atypical
(Circle correct response)
Symmetrical inflammationwithout deformity of wristand finger joints +/- one ortwo large joints
Symmetrical inflammationwith early deformities ofwrist and finger joints +/-one or more larger joints
Severe symmetricaldeformity of wrist andfinger joints and largerjoints with or withoutinflammation
Other patterns
I Hochberg M C. Adult and juvenile rheumatoid arthritis:current epidemiological concepts. Epidemiol Rev 1981; 3:27-44.
2 Wood P H N, Badley E M. Epidemiology of individualrheumatic diseases. In: Scott J T, ed. Copeman's textbook ofrheumatic diseases. 6th ed. Edinburgh: Churchill Living-stone, 1986: 59-142.
3 Royal College of General Practitioners. Morbidity statisticsfrom general practice 1981-82. London: HMSO, 1986.
N.B. Large joints include shoulders, elbows, hips,knees, and ankles
5 Are there or have there been objective signs of jointswelling? YES/NO
6 Are there or have there been extra-articular mani-
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festations of RA? (Include nodules, vasculitis,scleritis, pulmonary, and other organ involve-ment.) YES/NO
7 Is or was morning stiffness a prominent symptom?YES/NO
8 Is there a history ofarthritis (other than osteoarthritis)or any other related diseases in a relative? YES/NO
9 What was the highest recorded rheumatoid factor inGP notes, including hospital letters?(Give Rose-Waaler dilution or nephelometry units.If not done, state not done.) ..............................
10 What was the highest recorded ESR/plasma viscosityin GP notes, including hospital letters?(If not done, state not done.) .............................
11 Are there hand/foot x-ray reports? YES/NOIf YES, are they (a) Normal
(a) If psoriatic arthritis, state durationof psoriasis .........................
(b) If inflammatory bowel disease,state duration of disease andwhether ulcerative colitis orCrohn's .................................
2 Does it affect(a) Cervical spine YES/NO(b) Lumbar spine YES/NO(c) Large peripheral joints YES/NO(d) Small peripheral joints (carpus, tarsus,
fingers, toes) YES/NO
3 Has there been conjunctivitis or iritis? YES/NO
4 Is there a family history of seronegative disordersincluding Reiter's disease/reactive arthritis? YES/NOIfYES, please state who and what ......................
5 Have the sacroiliac (SI) joints/pelvisgraphed?If YES, (a) normal SI joints
(b) Possible sacroiliitis(c) Definite sacroiliitis(d) Other
been radio-YES/NO
1 Diagnosis Reiter's disease/reactive arthritis(Please circle appropriate diagnosis)
2 Pattern of disease (a) Single attack(b) Recurrent attacks(c) Chronic arthritis(d) Other (please state)
3 Does it affect (a) Cervical spine YES/NO(b) Lumbar spine YES/NO(c) Large peripheral joints
YES/NO(d) Small peripheral joints
(carpus, tarsus, fingers,toes) YES/NO
If YES for peripheral joints, is there symmetricalinvolvement? YES/NO
4 Has there been, or is there conjunctivitis or iritis?YES/NO
S Has there been, or is there urethritis?
6 Has there been, or is there enteritis?
YES/NO
YES/NO
7 Is there a past history of other seronegativedisorders? YES/NOIfYES, please state which.................................
8 Is there a family history of Reiter's diseaseor any other seronegative disorders? YES/NOIf YES, please state who and what ......................
1 Diagnosis Temporal arteritis/polymyalgiarheumatica/both(Please circle appropriate diagnosis)
2 Clinical features at outsetShoulder and/or pelvic girdle pain YES/NOSevere stiffness shoulder and/or pelvicgirdle YES/NOPain or stiffness other joints YES/NO
If YES, state where ...............................Severe headache YES/NOVisual upset YES/NO
3 What was the ESR at diagnosis? ....../NOT DONE
4 Were oral steroids given? YES/NOIfYES, state drug and initial dose ......................Was the response (a) Dramatic within 48 hours
(b) Good response over 2-14 days(c) Poor response(d) No response
1 Diagnosis Juvenile chronic arthritis
2 Pattern of disease(a) Still's (systemic illness +/- arthritis)(b) Symmetrical (rheumatoid-like) polyarthritis(c) Asymmetrical polyarthritis(d) Other (please state) ................................
3 Has there been oris thereeye involvement? YES/NO
4 What was the highest recorded antinuclear antibody(ANA)/antinuclear factor in GP notes, includinghospital letters?(Give highest dilution e.g. 1/1064 etc.If not done, state not done) ...............................
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is: first published as 10.1136/ard.51.2.186 on 1 February 1992. D
3 What was the highest recorded ANA in the GP notes(including hospital letters)?Give dilution, state IgG or IgM and pattern ofstaining if available .........................................
4 What is the highest recorded DNA binding (units)?............./NOT DONE
