The objectives of this study are: (a) to determine the occurrence of permanent work disability (PWD) in early rheumatoid arthritis (RA); (b) to identify prognostic groups of patients; (c) to assess the employment rates for these groups over time. Seventy-three gainfully employed consecutive out-patients with early RA (> or = 5 ARA 1958 criteria, disease duration < or = 12 months) at time one (T1) were re-examined at time two (T2) after a mean follow-up of 6 yr (S.D. +/- 2 yr). Potential risk factors, identified at T1, for PWD at T2 were entered in a tree structured survival analysis using RECPAM (RECursive Partition and AMalgamation). Cumulative 3 yr employment rates (3-yrER +/- S.E.M.) were computed from the resulting Kaplan-Meier curves. At T2, PWD occurred in 27 of the 73 patients (37%). The fastest decline in the employment rate was found within the first 3 yr of the disease onset, with a 3-yrER reduced to 73 +/- 5%. The group with the poorest prognosis (n = 14; 3-yrER 14 +/- 9%) was defined by age > or = 50 yr with either ESR > or = 60 mm/h or the combination of modified functional class (1-7) > or = 4 with a disease duration > or = 7 months. An intermediate group (n = 38; 3-yrER 79 +/- 6%) was defined by (a) age > or = 50 yr and low or moderate disease activity, (b) age < 50 yr and more strenuous job-related physical requirements, (c) age < 50 yr and less strenuous work, but joint count > or = 15. No case of PWD occurred in 21 individuals aged < 50 yr with a joint count < 15 and less physically demanding jobs. PWD occurs early in a substantial number of patients with RA. RECPAM defines risk profiles that can readily be applied in actual clinical situations and allow an estimation of the risk of PWD at different time points using the resulting Kaplan-Meier curves.

The German version of the HAQ presented here and the two versions of the HFAQ are reliable and valid instruments for measuring functional disability in a German-speaking population with RA. The construct measured by the HAQ and both versions of the HFAQ showed a high degree of correspondence.

No abstract

Of 88 selected patients with possible ankylosing spondylitis (AS) 54 (61%) participated in two phases of a 10 years' follow-up study. Thirty-two (59%) developed definite AS according to the New York criteria, 10 (19%) had possible/undifferentiated seronegative spondylarthropathy (SSA) and 12 patients had other diagnoses. Only 3 (9%) of 35 patients with sacroiliitis did not fulfill the New York criteria for definite AS until the last examination. Sacroiliitis and radiological spinal signs of AS appeared rather late above a mean age of 40 years and after a mean disease duration of more than 10 years. After 18 years mean disease duration 25 (78%) of 32 AS patients had good or sufficient functional capacity indicating an overall good functional prognosis. HLA B27 typing proved to be useful in patients with possible early AS: 29 (71%) of 41 B27 positive and 3 (23%) of 13 B27 negative patients developed definite AS (p less than 0.005). A combination of the B27 test with data of the history, clinical, laboratory, and radiological examination proposed as early diagnostic criteria detected patients with the outcome diagnosis of definite AS with even higher significance (p less than 0.001). These criteria were also useful in the identification of patients with possible or undifferentiated SSA. The recently recognized entity of undifferentiated SSA should only be diagnosed after long term follow-up.

Costs of illness are of major economic relevance in rheumatoid arthritis (RA) as in other chronic diseases. Overall costs of 15,000 Euro/year: 10,000 Euro indirect costs, and 5000 Euro direct costs are estimated, respectively. A further detailed analysis of direct costs underlines that inpatient care (50%) is the most prominent cost driver. Medication costs are also evaluated in detail since they are expected to gain importance with the introduction of the more expensive biologicals. While annual costs for regular disease modifying drugs (DMARDs) vary from 160 to 5000 Euro per patient, costs for the new biologicals amount up to 20,000 Euro (100-125% of the current estimated overall costs). For a comparison of different therapeutic strategies, costs are related to effectiveness in cost-effectiveness analyses. Based on present clinical trials, the ratios of medication costs and response according to the ACR 20-criteria of various DMARDs and biologicals are compared. The most cost-effective medication is sulfasalzine, followed by methotrexate, and leflunomide. Combining etanercept and methotrexate is preferable to methotrexate monotherapy and the combination of infliximab and methotrexate. This review shows that important economic issues in RA have already been addressed by applying cost-of-illness analyses and cost-effectiveness analyses. However, the knowledge about cost-effective therapeutic options is still scarce. Thus, primary data will have to be obtained using standardized approaches. These economic findings can be taken into account in the development of disease-management recommendations for RA-therapy.

Positive therapeutic effects on the work force participation derived from international clinical trials may not be directly transferable to the community based care in Germany. Therefore recent changes of data regarding sick leave (SL), work disability pension (WDP) and employment from the social insurance and from the national database of the German collaborative arthritis centers were analyzed covering a time period of at least 10 years. Health insurance data showed a steeper decline in the average duration of SL caused by rheumatoid arthritis (RA), ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE) compared with all other diseases. In RA patients from the collaborative arthritis centers the mean duration of SL was much more reduced than the average duration of SL for members of the compulsory health insurance. The proportion of gainfully employed RA patients in collaborative arthritis centers has particularly increased in women. According to data from the pension insurance fund less incident cases of WDP due to RA, AS, and SLE have been observed than WDP caused by all other diseases. Thus different nationwide data show positive changes of the work force participation of individuals suffering from inflammatory rheumatic diseases in Germany.

During the three examinations, major differences concerning the implementation of Q-12 were found between the faculties. Therefore, it is recommended that all faculties verify whether they adequately cover the joint educational objectives recommended for Q-12 by two German scientific societies. Furthermore, the more frequent application of up-to-date practice-oriented teaching and examination methods, an intensified implementation of Q-12-related issues in teaching specific indications, the completion of curricula, enhanced offer of compulsory election subjects related to Q-12 issues, continued scientific investigations and symposia/workshops concerning the promotion of Q-12-related teaching as well as the generation and exchange of teaching and examination materials are recommended.

Anmerkung Unter Mitarbeit der Projektgruppe Rehabilitation des Regionalen Kooperativen Rheumazentrums Hannover e. V. mit Förderung der LVA Hannover Institutsangaben 1 Martin-Luther-Universität Halle-Wittenberg, Institut für Rehabilitationsmedizin, Halle (Saale) 2 Regionales Kooperatives Rheumazentrum Hannover e. V., Hannover 3 Medizinische Hochschule Hannover, Abteilung Rheumatologie, Hannover 4 Medizinische Hochschule Hannover, Institut für Balneologie und Medizinische Klimatologie, Hannover Danksagung Die Autoren danken der Deutschen Gesellschaft für Rheumatologie für die Unterstützung bei der Befragung der Rheumatologen. Besonderer Dank gilt Frau Roth, die sich als ¾rztin der Rheumatologischen Ambulanz der Medizinischen Hochschule Hannover besonders bei der Durchführung der Patientenbefragung engagiert hat sowie Frau und Herrn Völker für die Unterstützung bei der Dateneingabe und -auswertung der ¾rztebefragung. ZusammenfassungFür den Zugang zu Rehabilitationsmaßnahmen ist die Einschät-zung der Patienten und ihrer ¾rzte von erheblicher Bedeutung. Deshalb wurden zwei Fragebogenerhebungen bei 172 vertragsärztlich tätigen internistischen Rheumatologen und bei Patienten mit einer chronischen Polyarthritis (cP; n = 88) oder einer Spondylitis ankylosans (Spa; n = 42) aus einer rheumatologischen Ambulanz durchgeführt. Erhoben wurden verschiedene Aspekte der Medizinischen Rehabilitation bei diesen Erkrankungen einschließlich möglicher Hinderungsgründe. Während von allen Patienten lediglich 16 % keinen Reha-Antrag stellen wollen, sieht nur ein kleiner Teil der Rheumatologen bei der Mehrheit der eigenen Patienten einen Reha-Bedarf. Dagegen werden von den Rheumatologen verschiedene Rehabilitationsziele und -elemente hoch bewertet, vor allem Funktionsverbesserung (entsprechend Krankengymnastik, Ergotherapie), Schmerzreduktion und Verbesserung der Eigenkompetenz/Krankheitsverarbeitung (entsprechend physikalische Therapie und Patientenschulung) sowie berufliche Wiedereingliederung. Als Gründe gegen Reha- AbstractThe judgment of patients and rheumatologists regarding in-and outpatient rehabilitation is one of the most relevant factors for referral. Therefore, two separate questionnaires were sent to 172 rheumatologists in private practice and to outpatients with rheumatoid arthritis (RA; n = 88) or ankylosing spondylitis (AS; n = 42). The questionnaires covered different aspects of medical rehabilitation of patients suffering from these diseases including reasons against rehabilitation. Whereas only 16 % of the patients did not intend to request rehabilitation, only a minority of the rheumatologists confirmed the need for in-or outpatient rehabilitation in more than 50 % of their patients with RA or AS. By contrast, the rheumatologists gave high ratings of different rehabilitation objectives and measures, in particular for functional improvement with physiotherapy and occupational therapy, for pain reduction and improvement through self management and coping with the disease by means of physical therapy and patient education,...