Ann Rheum Dis 2000;59:794–799
794
Socioeconomic deprivation and rheumatoid
disease: What lessons for the health service?
ERAS Study Group*
Correspondence to:
Dr A Young, Department of
Rheumatology, St Albans
City Hospital, Waverley
Road, St Albans, Herts
AL3 5PN, UK
Email:
Erasay@compuserve.com
Accepted for publication
9 March 2000
*Details of members of the
study group are given in the
appendix.
Abstract
Objective—To assess how socioeconomic
deprivation influences the presentation,
treatment, and outcome of patients with
rheumatoid arthritis (RA).
Methods—Three year follow up of 869
consecutive patients with RA from nine
hospital rheumatology clinics, with patients categorised by the Carstairs deprivation score of their enumeration district
of residence. Outcomes included Health
Assessment Questionnaire (HAQ), joint
and pain scores, grip strength, functional
grade, radiological evidence of bony erosions, and medical/surgical interventions.
Results—Patients from more deprived
enumeration districts presented with
more severe disease as judged by the HAQ
score and joint scores. An increase from
the 5th to the 95th centile of the Carstairs
distribution was associated with an odds
ratio of 1.87 (95% confidence interval (95%
CI) 1.31 to 2.66) for an above-median
HAQ score and 1.77 (95% CI 1.23 to 2.54)
for an above-median joint score. Statistically non-significant deprivation trends
were seen with erythrocyte sedimentation
rate, pain score, and grip strength. By
three years, despite no important diVerences in clinical management, socioeconomic diVerentials had worsened or
remained unchanged such that clear deprivation trends were then seen in HAQ
(p=0.002) and joint scores (p=0.001), in
grip strength (p=0.008), and in functional
grade (p=0.003). The association between
deprivation and HAQ at three years was
present after adjustment for age, sex,
treatment centre, and HAQ at presentation (adjusted odds ratio 1.74, 95% CI 1.1
to 2.74).
Conclusions—Socioeconomic deprivation
was associated with a worse clinical
course of rheumatoid disease, and this
eVect was already apparent at presentation, but not with systematic diVerentials
in its treatment. This suggests that individual susceptibility and lifestyle factors
contribute to socioeconomic diVerentials
in outcome, an observation that has
implications for clinical management.
(Ann Rheum Dis 2000;59:794–799)
Reports from the US,1 the Netherlands,2 and
the west of Scotland3 suggest that outcome in
rheumatoid disease is worse in patients of lower
socioeconomic status. Why is unclear, but possible explanations include delays in reaching
clinical attention due to diVerences in thresholds for seeking medical advice or in access
www.annrheumdis.com
to health care; diVerences in clinical
management4; variation in compliance with
treatment; greater vulnerability to disease progression due to comorbidity1 5; and behavioural
and lifestyle factors, such as smoking, diet,
stress, and occupation.
Evidence about the eVect of these factors in
rheumatoid disease on disease development
and its clinical progression is limited.5–8 Most of
the published evidence is based on cross
sectional or retrospective studies of comparatively small, selective patient groups with
variable disease duration. We report here an
analysis of a large prospective cohort of
patients enrolled in the Early Rheumatoid
Arthritis Study (ERAS) that provides evidence
of diVerentials in clinical outcome despite uniform treatment across socioeconomic groups.
Methods
ERAS was formed in 1987 with the primary
aim of investigating the progress, treatment,
and prognosis of patients with rheumatoid disease in routine practice. The group recruited
patients at nine hospitals in England, serving
populations of varied socioeconomic mix.9
Consecutive patients diagnosed as having
RA by the consultant rheumatologist were
recruited to the study as long as symptoms of
RA had lasted for less than two years and disease
modifying
antirheumatic
drugs
(DMARDs) had not been used. Patients were
excluded if the diagnosis changed—for example, apparent early RA evolving to classical
lupus. Patients did not have to meet the 1987
revised American College of Rheumatology
criteria,10 but whether or not they did meet
these criteria was recorded. In the first year,
patients were seen five times at 0, 1, 3, 6, 12
months and at yearly intervals from then on.
CLINICAL AND LABORATORY ASSESSMENTS
Standard clinical assessments were made by
trained metrologists. The features chosen when
the study started in 1987 included those
recommended in 1992 by the British Society of
Rheumatology and Royal College of Physicians
working group for specialist supervision of
rheumatoid arthritis (RA).11 A doctor’s and a
patient’s global assessment were the only two
features of the core dataset recommended by
the OMERACT conference in 199312 which
were not included at the start of the study. The
following were included: features at onset of
RA and coexistent and family medical conditions. Joint activity was scored according to
both Ritchie13 and a simple joint score, the
latter allowing for both swelling without
pain or tenderness, and for the number of
actual joints aVected to include individual
Socioeconomic deprivation and rheumatoid disease
795
metacarpophalangeal, proximal interphalangeal, and metatarsophalangeal joints (0 or 1 for
each joint, with a maximum of 59).14 Functional grade was assessed by the clinician
according to Steinbrocker (I to IV).15 All
patients completed the disability index of the
modified Stanford Health Assessment Questionnaire (HAQ, range 0–3).16 Early morning
stiVness was recorded in hours duration and
grip strength was measured in millimetres in
both hands (from a resting 30 mm Hg in a
standard way). The patient marked a 100 mm
visual analogue scale for pain experienced. Evidence of any systemic features (weight loss,
fever, etc) or extra-articular signs (nodules,
pulmonary fibrosis, etc) were noted. Erosive
disease was assessed from standard radiographs of hands and feet performed yearly.17
Routine haematological and biochemical
screen, Westergren erythrocyte sedimentation
rate (ESR), and serological tests for rheumatoid factor (RF) and antinuclear antibodies
were carried out.
DRUG TREATMENT AND INPATIENT
INTERVENTIONS
All centres followed the framework of the published UK guidelines for management of RA,
with sequential treatment with one drug at a
time the usual practice. The DMARDs used
were chosen according to the doctor’s preference, though dosage schedules using graduated
regimens were previously agreed according to
standard practice for each drug. Protocols for
treatment eVects had also been previously
agreed and were recorded prospectively for
each patient. Treatment outcome was based on
continuation or not of the initial second line
drug. Reasons for withdrawing drugs were
based on clinical judgments and recorded prospectively as loss or lack of eVect, adverse
events, both reasons, remission, or miscellaneous (for example, pregnancy, lack of compliance). Clinical remission or stability while taking a specific DMARD was coded as eVective.
Inpatient interventions by three years were
classified as rheumatological (for example,
medical treatment of complications of RA or
treatment), or, if orthopaedic, as minor (for
example, carpal tunnel release), moderate (for
example, synovectomy), or major (for example,
joint replacement).
Socioeconomic status was categorised in two
ways:
1 By assigning to each patient the Carstairs
deprivation score of his or her enumeration
district of residence (average enumeration
district size approximately 140 households)
identified from the patient’s address postcode. The Carstairs score,18 a composite of
four variables—male unemployment, social
class of head of household, overcrowding,
and access to a car—was computed from
1991 census small-area statistics. This index
of deprivation, which has been widely used
in geographical studies of health in the
United Kingdom,19 is a strong predictor of
health status: all causes of mortality and
many cause-specific death rates, for exam-
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1004
Patients at
presentation
16 without postcode
match or ED
deprivation score
988
Available for
analysis at
baseline
119 not attending at three
years:
869
Figure 1
Followed up at
three years
20 moved house
10 unable for social
reasons
15 in remission
37 died
37 reason unknown
Patient sample. ED = enumeration district.
ple, show a greater than twofold variation
across the range of Carstairs scores.
2 A subset of 685 patients from eight centres
were also categorised by educational attainment (one ERAS centre did not collect this
item): university/national diploma; school
leavers examination at 17/18 years (for
example, “A” level) or vocational training;
school leavers examination at 15/16 (for
example, “O” level or Certificate of Secondary Education); none.
Of 1004 patients due for their three year follow up by end of 1997, 988 could be matched
to their enumeration district of residence and
hence categorised for deprivation. One hundred and nineteen (12.0% of the 988) were not
followed up at three years for reasons shown in
fig 1, so that 869 patients form the basis of this
report.
STATISTICAL METHODS
The association between socioeconomic status
and clinical variables was examined by tabulation and regression methods. Numerical variables are shown as medians and interquartile
ranges and categorical variables as numbers
and percentages.
Most variables had highly asymmetrical distributions and both trend tests and multivariate
analyses were based on ordinal logistic
modelling.20 In each case the dependent
variable was categorised into quartiles. Odds
ratios from ordinal logistic regression can be
interpreted similarly to those of a conventional
logistic model; here they can be thought of as
the odds ratios of having a score above the
median of the dependent variable in question.
All odds ratios are presented as the ratio for an
increase from the 5th to the 95th centile of the
Carstairs distribution. Analyses of drug treatment (classified as low dose steroids or
non-steroidal anti-inflammatory drugs only;
second line treatment; complex treatment) and
of inpatient treatment (classified as outpatient
only; medical inpatient treatment only; and
surgical intervention) were analysed by multinomial logistic modelling.
ERAS Study Group
796
Table 1
Clinical characteristics and their variation by Carstairs score
Percentage above median or positive for characteristic
Characteristic
n
Median (interquartile
range) or count
(percentage)
Age (years)
988
56 (44–65)
Female (%)
988
643 (65.1)
Symptom duration (months)
988
6 (4–11.5)
Clinical markers at presentation visit
RF¶ positive (%)
984
615 (62.5)
x Ray erosions (%)
859
245 (28.5)
HAQ¶
983
1 (0.5–1.625)
ESR¶
852‡
34 (17–58)
Joint score
985
14 (7–25)
Pain score
953
41 (22–61)
Grip strength
983
140 (95–210)
Clinical markers at three years
HAQ
831
0.75 (0.25–1.375)
ESR
703†
20 (10–41)
Joint score
828
7 (2–16.5)
Pain score
822
27 (7–50)
Grip strength
832
170 (115–260)
Function grade II–IV (%)
838
444 (53.0)
Died (%)
37 (3.7)
Change in clinical markers, presentation to three years
HAQ
829
−0.125 (−0.63–0.25)
ESR
702‡
−8 (−26–3)
Joint score
826
−5 (−14–2)
Pain score
795
−10 (−32–8)
Grip strength
820
20 (−20–70)
Q1*
(n=252)
Q2
(n=242)
Q3
(n=247)
Q4
(n=247)
Unadjusted odds ratio
(95% CI)†
p Value for
trend
49.2
62.7
52.0
43.8
65.3
45.5
48.2
66.4
51.0
48.6
67.0
48.2
0.94 (0.66 to 1.33)
0.97 (0.64 to 1.46)
0.68 (0.48 to 0.97)
>0.2
>0.2
0.16
64.5
24.1
40.9
47.0
46.8
45.6
52.0
64.1
23.3
42.7
46.2
44.4
50.8
52.3
59.4
25.7
49.2
49.3
50.0
49.6
46.9
62.0
28.9
52.9
53.4
54.1
52.8
43.3
0.77 (0.52 to 1.15)
1.37 (0.88 to 2.12)
1.87 (1.31 to 2.66)
1.29 (0.84 to 1.98)
1.77 (1.23 to 2.54)
1.08 (0.75 to 1.54)
0.74 (0.52 to 1.05)
0.17
0.15
0.001
>0.2
0.002
>0.2
0.09
41.0
43.2
36.9
45.8
59.4
42.4
2.6
50.5
48.4
49.0
54.2
49.5
53.4
4.9
49.5
51.4
51.2
43.6
42.9
55.1
4.2
50.0
51.1
57.1
52.8
43.4
61.7
4.2
1.82 (1.24 to 2.67)
1.27 (0.80 to 2.02)
1.91 (1.28 to 2.86)
1.12 (0.76 to 1.64)
0.60 (0.41 to 0.88)
1.95 (1.25 to 3.02)
1.4 (0.55 to 3.6)
0.002
>0.2
0.001
>0.2
0.008
0.003
>0.2
43.3
45.2
43.9
50.0
52.3
49.3
51.6
53.2
50.0
43.4
43.4
53.7
48.5
40.2
47.3
45.6
45.8
42.9
50.3
48.5
0.90 (0.62 to 1.32)
0.87 (0.55 to 1.37)
0.87 (0.60 to 1.27)
1.05 (0.71 to 1.56)
1.02 (0.70 to 1.49)
>0.2
>0.2
>0.2
>0.2
>0.2
*Quartile of the Carstairs distribution: Q1 least deprived, Q4 most deprived.
†Odds ratio associated with an increase from the 5th to the 95th centile of the Carstairs score.
‡Viscosity and not ESR was recorded at one centre.
¶RF = rheumatoid factor; HAQ = Health Assessment Questionnaire; ESR = erythrocyte sedimentation rate.
Table 2
1.2
HAQ score
Results
At presentation, there was little variation across
the deprivation groups in age, sex, duration of
symptoms, the proportion of patients positive
for RF, or in the proportion with bony erosions
(table 1). There was, however, strong evidence
of a positive deprivation trend with HAQ score
and joint score, and weaker evidence of a negative trend with grip strength. ESR and pain
scores were fairly constant across deprivation
groups, and the trends were statistically
non-significant at the 5% level. In England and
Wales the proportions of enumeration districts
in these quartiles are 20.4% (least deprived
quartile, Q1), 17.7%, 19.8%, and 42.0%. Thus
the ERAS study group was somewhat less
deprived than the national average.
The mode of treatment was fairly consistent
across the deprivation groups (table 2), including use of low dose steroids alone (8–10%).
The unadjusted analysis provided evidence of a
trend of more complex drug treatment (that is,
second line drug combinations after loss of
eVect of the first or second disease modifying
drug) in patients from more deprived areas, but
the significance was lost (p=0.18) after adjustment for age, sex, and treatment centre. The
trend of more inpatient medical treatment in
1
Q4
Q3
Q2
0.8
Q1
0.6
0
1
3
2
Years from presentation
Figure 2 Change in mean Health Assessment
Questionnaire (HAQ) score (log scale) by quartile (Q1
least deprived, Q4 most deprived) of the Carstairs
deprivation score.
patients from more deprived enumeration districts was also lost after similar adjustment
(p>0.2).
By three years, each of the main clinical
markers (HAQ, ESR, joint score, pain score,
grip strength) had improved (changes in HAQ
shown in fig 2), though the socioeconomic differentials seen at presentation remained or
were accentuated: statistically significant positive trends were seen between deprivation and
functional grade, HAQ, and joint scores, and a
negative association was seen with grip
strength. As before, x ray erosions, ESR, and
Treatment by quartile of Carstairs score. Results are shown as number (%)
Carstairs deprivation quartile
Drug treatment
Steroids or NSAIDs* only
Second line treatment
Complex
Inpatient treatment
None
Medical only
Surgery
1 (least deprived)
2
3
4 (most deprived)
p Value for
trend
51 (23)
136 (62)
34 (15)
34 (16)
144 (68)
33 (16)
43 (20)
120 (57)
48 (23)
39 (18)
119 (56)
54 (25)
>0.2
0.02
173 (77)
37 (17)
14 (6)
152 (72)
48 (23)
12 (6)
146 (68)
47 (22)
21 (10)
140 (65)
61 (28)
16 (7)
0.01
0.28
*NSAIDs = non-steroidal anti-inflammatory drugs.
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Socioeconomic deprivation and rheumatoid disease
797
Table 3 Ordinal logistic model: odds ratio of a Health Assessment Questionnaire score
greater than 0.75 (that is, median) at three years
Carstairs deprivation score*
Age group (years):
−44
45 to 54
55 to 64
65+
Sex:
Male
Female
Centre
HAQ score at presentation:
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Odds ratio (95% CI)
Likelihood ÷2
df
p Value
1.74 (1.10 to 2.74)
5.76
1
0.02
10.1
3
0.02
24.0
1
<0.001
9.51
8
0.30
121.4
3
<0.001
1
1.71 (1.18 to 2.47)
1.41 (0.98 to 2.02)
1.68 (1.15 to 2.45)
1
2.01 (1.52 to 2.66)
–
1
1.61 (1.14 to 2.30)
4.10 (2.83 to 5.95)
7.66 (5.08–11.6)
*Odds ratio corresponding to an increase from the 5th to the 95th centile of the Carstairs score.
pain score showed no statistically significant
association (trends non-significant at the 5%
level). The change between presentation and
three years in HAQ score, ESR, joint and pain
scores, and grip strength did not vary appreciably with deprivation, and in no case was the
pattern or statistical test strongly suggestive of
a trend.
Table 3 shows the results of the multivariable
analyses. The probability of having an HAQ
score above the median at three years was
greater in women than men and greater in
those aged 45 years or more compared with
younger patients. The probability was also
substantially greater in those with high HAQ
scores at presentation. After adjusting for these
factors and for the treating hospital, an increase
from the 5th to the 95th centile of the deprivation distribution was associated with an odds
ratio of 1.74 (95% CI 1.10 to 2.74). Thus
patients from more deprived enumeration districts were at greater risk of a high HAQ score
at three years after allowing for their higher initial scores—that is, they showed less improvement over time.
EDUCATIONAL ATTAINMENT
Table 4 shows the tabulation of markers of disease by educational attainment. Clear age and
sex diVerences were seen, reflecting the strong
cohort eVect in educational attainment; patients who reached university/national diploma
were relatively younger, and relatively fewer
were women.
Table 4
After adjusting for age and sex, there was
evidence that HAQ, pain scores, and grip
strength at presentation were related to educational attainment, but the ESR and joint scores
were not. At three years all these clinical markers, except ESR, showed evidence of trends
with educational attainment, with the more
highly educated patients having more favourable scores.
The above analyses of clinical progress in
relation to enumeration district Carstairs score
and educational attainment were repeated for
the subset of 818 patients meeting the ACR
criteria. Results for this subgroup diVered in
only minor respects and, therefore, are not
separately reported.
PATIENTS LOST TO FOLLOW UP
Figure 1 gives the reasons why patients did not
complete three years’ follow up. Thus, from the
original cohort, only 37/988 (3.7%) were
unaccounted for, 15 (1.5%) opted to discontinue because of clinical remission, and 37
(3.7%) had died. These patients were analysed
separately. Not surprisingly in the patients who
died, the median age was higher (69 years v 55
years, p<0.0001) and the proportion of men to
women was higher (45:55 v 35:65, not significant). Most of the clinical and laboratory
variables at presentation were worse in this
group—for example, median HAQ 1.5 v 1.0
(p=0.0007), and ESR 54 v 33 (p=0.007).
Although there was a trend for a lower
socioeconomic environment in these patients,
this did not reach significance.
Discussion
There is no evidence that the development of
RA is aVected by socioeconomic status,7 but it
is clear from our results that the eVect of deprivation is apparent at first presentation, and
that older women from a lower socioeconomic
environment and with an initially worse HAQ
did not follow the overall trend for improvement in function.
Functional ability is considered an important measure of clinical status of RA and
outcome, and the HAQ a valuable and widely
used tool for this.16 The HAQ has been
reported to be the most representative of all
Patient characteristics and clinical markers by educational attainment
Percentage above median or positive for characteristic
Age (years)
Female (%)
n
“A” level/
Median (interquartile University/
vocational
National
range) or count
diploma (n=74) training (n=210)
(percentage)
“O” level/CSE
(n=127)
None/no CSEs
(n=274)
p Value for trend
(age and sex
adjusted analysis)
685
685
56 (44–65)
442 (64.5)
29.7
47.3
42.4
54.8
33.9
82.7
52.2
68.3
—
—
Clinical markers at presentation visit
HAQ*
685
0.5 (0.125–1.625)
ESR*
572
34 (17–58)
Joint score
684
14 (7–25)
Pain score
660
41 (22–61)
Grip strength
684
140 (95–210)
29.7
45.1
40.5
40.3
64.4
39.1
49.7
47.1
45.4
54.3
44.1
44.7
33.9
50.4
44.9
53.7
47.6
55.3
54.9
43.1
0.002
>0.2
0.13
0.04
0.06
Clinical markers at three years
HAQ
649
0.75 (0.25–1.375)
ESR
535
20 (10–41)
Joint score
646
7 (2–16.5)
Pain score
644
27 (7–50)
Grip strength
648
170 (115–260)
35.2
48.5
26.8
40.9
65.2
40.3
40.4
45.3
46.2
53.2
53.7
56.9
43.0
58.5
39.7
53.5
50.5
51.4
54.7
42.8
0.002
>0.2
0.006
0.006
0.003
*HAQ = Health Assessment Questionnaire; ESR = erythrocyte sedimentation rate.
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ERAS Study Group
798
variables in depicting clinical status in RA,21
and is the health status measure most commonly used by rheumatologists in the UK at
present.22 In a recent review of prognostic factors in RA the HAQ has been shown to have
predictive qualities for morbidity, mortality,
and functional outcome in a number of
reports.23 This makes the findings of this study
relevant to clinicians and patients for management and prognosis. The HAQ is a measure of
patients’ perspective of disease and reflects the
true needs of patient care. It does not have a
psychological component and any possible
eVect of anxiety or depression on function cannot be included in our analysis. None the less,
it is important to detect early loss of function so
that coping measures can be introduced
without delay and support provided by physiotherapy and occupational therapy departments, and disease modifying drugs given early
consideration.24 25 Older women of lower socioeconomic status with worse HAQ at presentation could be identified early on.
Evidence from this study suggests that
socioeconomic diVerentials in disease status at
presentation were apparent in other more
objective markers of joint disease (for example,
swollen joints). Possible explanations are that
patients from more deprived enumeration districts had higher thresholds for consultation or
that they were more prone to the eVects of
rheumatoid disease. There was, however, no
evidence of longer duration of symptoms
before attending hospital in these patients,
though the measure of disease duration depended on patient recall and may be imprecise.
It is not possible from our study to know
whether patients with milder onset RA in
deprived areas are less likely to seek medical
advice, whereas patients from privileged environments more likely to do so, and whether
perceptions of disease onset and severity vary
according to educational background.
Whether measured by income, occupation,
educational level, or social class, poor socioeconomic environments have been shown to
aVect outcome adversely in many chronic disorders and have important implications for
healthcare strategies.26 The conclusion of a
summary of the current position in the UK
was that most inequalities in health are not
inevitable and are remedial.27 Educational status was first described as an important predictor of outcome in RA in cross sectional studies
from the US,1 8 and confirmed in two small
prospective studies in Europe.28 29 The
strength and significance of this association
vary, probably because of diVerences in ascertainment of the diVerent educational systems
in these countries. In view of the eVect of age
on educational attainment in the UK, enumeration district based on postal code may be
a more reliable index of socioeconomic status,
and a study using this method in patients with
RA entered into clinical trials in western Scotland found similar results.3 This group have
also reported a link between premature
mortality and social deprivation.30 We found
little evidence of this, but over the three year
follow up only 37 deaths occurred. Secure
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conclusions about a deprivation link will be
possible from our cohort only after further follow up.
The wide variation in the severity of
functional outcome in studies of RA progression is, at least in part, due to study design
(especially patient selection) and limited
numbers.23 The design of ERAS was intended
to overcome some of these problems, and has
recruited patients from various socioeconomic
and geographical areas. In the first few years of
RA clinical, functional, and laboratory measures improved overall. There are few reliable
and consistent clinical or laboratory features
which predict those who do badly in this time,
but female sex, acute phase (ESR, C reactive
protein) and RF have all been shown to predict
a variety of outcomes. However, these features
do not always hold for function, and there has
been much less consistency in predicting functional outcome than radiological damage.23
The most reliable measure at the early stages of
RA for predicting eventual functional outcome
is functional ability at presentation,23 but the
clinical use of this finding has been little
explored. The evidence from our study suggests that disease progression over the first
three years from presentation was worse in
patients of greater socioeconomic deprivation,
even after allowing for their poorer initial HAQ
scores. Thus not only did they present with
more severe disease as measured by the HAQ
but they also did not improve as much as
patients of equivalent initial HAQ scores from
areas of less socioeconomic deprivation.
Women and older patients also fared badly.
There was some evidence of diVerences in
treatments received (antirheumatic drugs and
inpatient interventions) by socioeconomic status, but this was largely attributable to diVering
practices at the nine contributing centres in this
study; and adjustment for centre removed evidence of an association. Although predictive
factors have a number of uses, the most important one for clinicians is as a guide to treatment
and early management strategies. Socioeconomic factors may have a place in the currently
rather limited number of reliable prognostic
factors in early RA.
Potential sources of bias in this study arise
from selective referral and losses to follow up.
There were neither appreciable diVerences in
clinical or laboratory variables at presentation
between those who attended at three years and
those who were lost to follow up, nor any clear
socioeconomic trends, except in those patients
who died, and in this group, the higher proportion of older and male patients with worse
function was not surprising. The nature of
selection of our patients and the smaller
percentage of patients who were lost to follow
up favour less bias or cohort eVects. The
observed/expected ratio for survival was similar
to a comparable study,31 and exclusion from the
main analysis of the patients who died would, if
anything, underestimate the extent of deprivation on disease severity.
A few studies have reported a link between
socioeconomic status and severity of RA,1–3 and
while the development of RA may itself
Socioeconomic deprivation and rheumatoid disease
799
contribute to worse socioeconomic status, our
study is the first to show that this eVect is
already apparent at presentation (at a median
of six months from onset of symptoms).
Further research is required to establish the
relevance of other factors which contribute to
greater deprivation—for example comorbidity,
diet, smoking, and which of these factors can
be most easily improved. In recent years greater
emphasis has been towards psychosocial explanations of socioeconomic inequalities and the
concept of low perceived control.32 33 The early
HAQ changes found in our study raise the possibility of a positive discrimination programme
for patients disadvantaged in this way. At
present there is no provision for allocating
funding in rheumatology nationally for those
most in need, but at least rheumatologists and
primary care doctors need to be aware of the
factors likely to be associated with poor
functioning at the early stages of RA, when
intervention is most likely to benefit the
patient. This study suggests that age, sex,
HAQ, and the Carstairs deprivation score are
useful for risk stratification, helping to identify
patients with RA who may need more intensive
drug treatment and other interventions at an
early stage.
The ERAS Group is supported by an Arthritis Research Campaign (ARC) Academic Secretary Grant (ASG). This ERAS
project has been supported by project grants from the ARC, the
BUPA Foundation, and Pharmacia-Upjohn. We are grateful to
Ben Armstrong for his advice on statistical analysis and
commenting on drafts of this paper, Cathy Mayes for coordinating this project, and all ERAS centre metrologists.
Appendix: members of the ERAS Study
Group
A Young, consultant rheumatologist, City Hospital, St
Albans AL3 5PN, Herts, UK
P Wilkinson, senior lecturer, London School of Hygiene and Tropical Medicine, London WC1E 7HT,
UK
J Talamo, public health assistant
J Dixey, consultant rheumatologist, Robert Jones and
Agnes Hunt, Orthopaedic Hospital, Oswestry, UK
N Cox, consultant rheumatologist, Royal Hants
County Hospital, Winchester SO22 5DG, UK
P Davies, consultant rheumatologist, Broomfield Hospital, Chelmsford CM1 6ET, UK
J Devlin, consultant rheumatologist, Pinderfield General Hospital, Wakefield WF1 4DG, UK
P Emery, professor of rheumatology, Rheumatology
Research Unit, Leeds LS2 9NZ, UK
A Gough, consultant rheumatologist, Harrogate Hospital, Harrogate HG2 7SX, UK
D James, consultant rheumatologist, Diana Princess of
Wales Hospital, Grimsby DN33 2BA, UK
P Prouse, consultant rheumatologist, North Hampshire Hospital, Basingstoke RG24 9NA, UK
P Williams, consultant rheumatologist, Medway Hospital, Gillingham ME7 5NY, UK
J Winfield, consultant rheumatologist, Royal Hallamshire Hospital, SheYeld S10 6JF, UK
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