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-

Behavioral and health status outcomes of an unreinforced, self-help education program for arthritis patients taught by lay persons were examined in 2 ways: a 4-month randomized experiment and a 20-month longitudinal study. At 4 months, experimental subjects significantly exceeded control subjects in knowledge, recommended behaviors, and in lessened pain. These changes remained significant at 20 months. The course was inexpensive and well-accepted by patients, physicians, and other health professionals.As the prevalence of chronic disease increases, so does the potential usefulness of health education. An informed patient can, in theory, play an important role in reducing predisposing factors and in managing established illness.While there is evidence that patient education can change behaviors and health status in some settings (1,2), this is not clear in the case of arthritis education. Arthritis education increases knowledge (3,16) and sometimes influences health behaviors, such as compliance with treatment regimens, the practice of joint protection, or exercise (6,9,12,15,17,18, and Harlowe D, Yu P: unpublished observations). Some investigators have reported improvements in psychosocial factors, such as coping, family communication, or depression (6,7,9,11,15,17). Finally, a few studies

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The relative effectiveness of six nonsteroidal anti-inflammatory agents was studied in 33 patients with rheumatoid arthritis and 32 patients with ankylosing spondylitis in a double-blind, randomized, prospective study employing a six-way multiple crossover design with six-week trials of each agent. In ankylosing spondylitis, naproxen, indomethacin, and fenoprofen calcium were the most effective agents. In rheumatoid arthritis, relatively little mean difference between drugs was found. Most of this difference could be attributed to compliance factors, which favored drugs that required only a small number of pills daily. Despite the small differences in effect, patients had strong preferences. More than 85% of patients were still taking their preferred medication after a mean follow-up period of one year.

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