Rheumatoid arthritis is a significant of morbidity and contributing cause of mortality in the United States. Although the annual incidence of RA is only 34.8/100,000, the prevalence is 1% of the adult US population/1. Because RA strikes during patients' potentially most productive years its has added social and economic costs. The lifetime costs of RA including medical expenses and illness related to work loss has been estimated at >$29,000 per case in 1990 dollars/2. This is similar to the therapy and work loss related costs of stroke and coronary artery disease. The progression of disease and eventual outcome in RA are both influenced by numerous mutually inclusive factors as depicted in figure 1. The disease process in RA can be conceptualized as a series of crucial points along a time line which result in various interventions. Progression between the various points is influenced by numerous factors which ultimately affect disease outcome. In addition to the inherent biological activity of the disease, the process of care afforded likely affects outcome as postulated below. This process of care has both diagnostic and therapeutic components3/. In order to optimize outcomes in rheumatoid arthritis, we believe a comprehensive disease management strategy will be needed. This scheme would provide a framework to establish early diagnosis and appropriate early treatment. Essential to any such strategy would be a comprehensive mechanism to assess outcomes and quality at both patient and population levels. Quality measures should be based to the greatest extent possible on established process and outcome associations. These outcomes should be patient centered and should include mortality, disability, pain and economic costs/4 as well as physical and emotional functioning.
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