A structure for representation of patient outcome is presented, together with a method for outcome measurement and validation of the technique in rheumatoid arthritis. The paradigm represents outcome by five separate dimensions: death, discomfort, disability, drug (therapeutic) toxicity, and dollar cost. Each dimension represents an outcome directly related to patient welfare. Quantitation of these outcome dimensions may be performed at interview or by patient questionnaire. With standardized, validated questions, similar scores are achieved by both methods. The questionnaire technique is preferred since it is inexpensive and does not require interobserver validation. These techniques appear extremely useful for evaluation of long term outcome of patients with rheumatic diseases.The goal of the medical care system should be to improve or maintain health outcomes. Donabedian (1) and Williamson (2) have emphasized the need to distinguish between "process" and "outcome" measures in the evaluation of health care. The use of "process" indicators to assess outcome assumes that they relate directly to outcome; this is frequently not the case.Outcome measures, however, must be appropri-

Objective. To determine the risk and causes of death and to quantify mortality predictors in patients with rheumatoid arthritis (RA).Methods. RA patients (n = 3,501) from 4 centers (Saskatoon n = 905, Wichita n = 1,405, Stanford n = 886, and Santa Clara n = 305) were followed for up to 35 years; 922 patients died.Results. The overall standardized mortality ratio (SMR) was 2.26 (Saskatoon 2.24, Wichita 1.98, Stanford 3.08, Santa Clara 2.18) and increased with time. Mortality was strikingly increased for specific causes: infection, lymphoproliferative malignancy, gastroenterologic, and RA. In addition, as an effect of the SMR of 2.26, the expected number of deaths was increased nonspecifically across all causes (except cancer), with a large excess of deaths attributable to cardiovascular and cerebrovascular diseases. Independent predictors of mortality included age, education, male sex, function, rheumatoid factor, nodules, erythrocyte sedimentation rate, joint count, and prednisone use.

The factors associated with mortality were examined in a prospective longitudinal study, over an average of 12 years, with 94% followup of patients diagnosed as having rheumatoid arthritis. Of 805 patients, 233 died during the period of the study. Survivorship of rheumatoid arthritis patients was approximately 50% less than that of population controls. Survivorship was decreased by the traditional demographic variables of greater age and male sex; however, a significant independent effect of variables reflecting disease severity (American Rheumatism Association functional class, rheumatoid factor titer, number of involved joints) was identified by multivariate analysis. Seventy-nine excess deaths (i.e., those that would not have been expected in a control population) were due in part to disease-related causes, to infections, and to gastrointestinal complications of therapy. Treatment with gold or prednisone did not seem to affect survivorship or cause of death, except for the clustering of deaths of patients with vasculitis within the prednisone group. Our findings indicate that rheumatoid arthritis, a chronic disabling disease, is also associated with a major decrease in survivorship.

We evaluated methods of grading radiologic progression of osteoarthritis (OA). Sets of radiographs were assessed separately by 8 readers who were blinded to the time sequence. Included were radiographs of patients with OA of the hands (24 pairs), hips (40 pairs), and knees (32 pairs). Most films were taken 1240 months apart. The relative contribution of individual joints (such as particular interphalangeal joints), of observations (such as narrowing or spurs), and of a single joint compartment (such as the medial or lateral compartment of the knee) toward evidence of OA progression Submitted for publication September 30, 1986; accepted in revised form April 9, 1987. was evaluated, as well as the reliability and concordance of scoring, and the sensitivity in detecting change. In assessing OA of the hand, the greatest sensitivity was achieved by reading a single posteroanterior bilateral hand radiograph for narrowing, spurs, and erosions, and scoring 10 joints (second and third distal interphalangeal, second and third proximal interphalangeal, and trapeziometacarpal joints, bilaterally), using a scale of 0-3. In OA of the hip, a single anteroposterior radiograph assessed for joint space narrowing and cyst formation yielded the greatest sensitivity. In OA of the knee, an anteroposterior radiograph, with weight-bearing, assessed for narrowing, spurs, and sclerosis in both the medial and lateral compartments yielded the greatest sensitivity. These techniques will be useful to the investigator in designing experimental studies and to the clinician in determining the rate of disease progression in an individual patient.Standards for the radiographic identification of osteoarthritis (OA) were established by Kellgren and Lawrence in 1957 (1) and were accepted by the World Health Organization in 1961 (2). In several recent descriptions of the radiographic appearance of OA, clinical and pathologic correlations have been used to help differentiate OA from normal states and from other disease entities (3-6). However, there are no methods presently available to assess radiographic progression of OA by use of serial radiographs.Radiographs are frequently used in clinical trials of OA to establish inclusion criteria. However, such trials have not used radiographs to assess disease progression. The consistency of OA progression is not known. The reasons for not utilizing radiographs to evaluate progression in long-term trials are, perhaps,