Developing a health promoting university in Trinity College Dublin-overview and outline process evaluation

Higher Education Institutions (HEIs) have the potential to impact positively on the health and wellbeing of their staff and students. Using and expanding on the 'health promoting university' (HPU) platform within HEIs, this article provides a description of 'Healthy Trinity', which is an initiative underway in Trinity College Dublin, the University of Dublin. First, Healthy Trinity is contextualized in background literature including international and national policy and practice. Second, an overview of Healthy Trinity is provided including its vision and goals. Third, the article describes the steps taken relating to the identification of stakeholders and use of a network and a co-lead model. Within this approach, the article describes a partnership approach whereby responsibilities regarding health and wellbeing are shared by individuals and the institution. Fourth, the design and implementation of Healthy Trinity is discussed by taking a 'settings approach', in which the emphasis for change is placed on individual behaviours, environment, policy and organizational culture. Consideration is given to the interplay between intervention, implementation strategy and context for successful systemic implementation. The fifth element presented is the early-stage challenges encountered during implementation, such as the need to secure recurrent funding and the importance of having a direct input to the governance of the University to enable systemic change. The sixth and final component of the article is an outline of Healthy Trinity's intention to utilize a process evaluation of the early implementation phases of this complex intervention within a settings approach. Potential deliverables and impacts of this HPU initiative are presented and discussed.

Stand up, stand out. Feasibility of an active break targeting prolonged sitting in university students

ObjectiveTo assess the acceptability, appropriateness, and feasibility of an active break designed to disrupt prolonged sitting in university students. Participants: Students attending lectures in Trinity College Dublin, Ireland. Methods: Participants took part in an active break, which consisted of following a short exercise video lasting ∼4 min. They then completed a validated questionnaire consisting of 12 statements with two open-ended questions capturing likes/dislikes. Results: Overall 106 (response rate 96%) predominately female (83%, n = 87), health sciences students (91%, n = 96) participated. Percentage agreement ranged from 93.4% (n = 99) to 96.2% (n = 102) for acceptability, 84.9% (n = 90) to 93.4% (n = 99) for appropriateness, and 80.2% (n = 85) to 96.2% (n = 102) for feasibility. Space constraints and warm temperatures impacted negatively. Conclusion: An active break delivered during lectures is an acceptable and feasible intervention to disrupt sitting in students. Further investigation using a broader representation of the university population is needed prior to implementation.

Did physical activity and associated barriers change during COVID-19 restrictions in Ireland? Repeated cross-sectional study

This repeated cross-sectional study investigated physical activity and associated barriers and facilitators during the first two waves of COVID-19 restrictions in Ireland. An online, anonymous questionnaire collated data from adults during May (n = 1274) and November (n = 810) 2020. Statistical analysis used a combination of traditional significance testing and Bayesian lasso logistic regression. The pattern of physical activity changed significantly between waves (χ² 86.8 on 3df; p < 0.001). During wave 1 restrictions, the majority [46.1% (n = 587)] of participants reported being more active than usual, decreasing to 26.3% (n = 213) during wave 2. More participants reported that their activity levels were less than usual [W1 29% (n = 369); W2 35% (n = 283)] during wave 2. Adherence to physical activity guidelines decreased from 56.5% (n = 705) to 43.7% (n = 35). Being unable to access their usual means of exercise [OR, 95% OR intervals; W1 1.611 (1.370–1.904), W2 1.638 (1.3731.968)] and advice not to leave home [OR, 95% OR intervals; W1 1.401 (1.164–1.697), W2 1.367 (1.106–1.696)] predicted less activity than usual during both waves. Increased time [OR, 95% OR intervals; W1 2.326 (1.948–2.794), W2 1.809 (1.478–2.233)], and valuing physical activity as important [OR, 95% OR intervals; W1 1.192 (1.001–1.444), W2 1.253 (1.003–1.637)] predicted increased activity during both waves, whilst finding new ways to be active [OR, 95% OR intervals; 2.515 (1.641–3.887)] predicted more activity in wave 2 only. Increases in physical activity of Irish adults during the first phase of COVID-19 restrictions were not maintained during the second wave and barriers to physical activity persisted.

Performance-based assessment during clinical placement: Cross-sectional investigation of a training workshop for practice educators

Performance-based assessment evaluates a health professional student's performance as they integrate their knowledge and skills into clinical practice. Performance-based assessment grades, however, are reported to be highly variable due to the complexity of decision-making in the clinical environment. The aim of this study was to evaluate the impact of a training workshop based on frame-of-reference principles on grading of student performance by physiotherapy practice educators. This was a prospective cross-sectional study which used a single group pre-test, post-test design. Fifty-three practice educators rated two video vignettes depicting a poor and very good student performance, using a subsection of a physiotherapy performance-based assessment tool before and after training. Overall, results showed that participants amended their scores on approximately half of all scoring occasions following training, with the majority decreasing the scores awarded. This impacted positively on scoring for the poor performance video, bringing scores more in line with the true score. This study provides evidence of the benefit of a training workshop to influence decision-making in performance-based assessment as part of a wider education program for practice educators.

Supervision models in physiotherapy practice education: student and practice educator evaluations

Objectives: To establish the supervision models used during physiotherapy practice placements and to determine student and practice educators' evaluations of the quality of these placements.Design: Cross-sectional study set in clinical sites providing placements for physiotherapy students in Ireland.Participants: Practice educators and students completing placements in 2015/16.Outcome Measure: Questionnaire which measured 18 indicators linked to quality assured placements. Eight additional indicators in the practice educator questionnaire addressed the overall feasibility of the supervision model. Two open-ended questions captured comments on the benefits and challenges of each model.Results: The overall response rate was 72% (112/155). The majority (75%, n = 84) of participants reported a 1:1 (one student: one educator) model of supervision. Fourteen percent (n = 16) reported a 1.2 (one student: two educators) model and 9% (n = 10) a 2.1 (two students: one educator) model. There was generally positive agreement with the questionnaire indicating that all placements, irrespective of supervision model were positively evaluated by participants. Students, however, indicated a more negative evaluation of the placement than practice educators in indictors related to communication, the provision of feedback, establishing an effective relationship with their educator and diversity of available learning opportunities. Indicators relating to productivity and the placement representing an efficient use of resources and personnel received more negative or equivocal ratings by educators.Conclusions: While the 1.1 model remains the most widely used supervision model in physiotherapy practice education, other models also score positively, offering choice to placement providers when determining the model that best suits their service.

The sedentary profile of primary care patients

Background

Primary care is one of the key environments in which to target public health and sedentary behaviours are increasing being linked to several adverse health outcomes. The aim of this study was to determine the prevalence and correlates of sedentary behaviour in an adult primary care population.

Methods

The International Physical Activity Questionnaire was used to collect data on the weekday sitting of participants. Stratified random sampling based on urban/rural location and deprivation was used to identify three primary care centres from which the sample was drawn.

Results

Data were collected from 885 participants (96.7% response rate) of whom 64% (n = 565) were female and 36% (n = 320) were male. The mean age was 42 (SD 14.2). Overall 48% (n = 418) of participants sat for >4 h daily with a median sitting time of 240 min (IQR 150-480). Attendance at the urban non-deprived primary care centre (B = 0.237, P < 0.001), male gender (B = 0.284, P < 0.001), overweight/obesity (B = 0.081, P = 0.048) and having a disability or injury limiting physical activity (B = 0.093, P = 0.028) were associated with higher sitting times.

Conclusion

This study established the factors that influence sedentary behaviours in the primary care population which can help inform the development and targeting of promotional strategies.

Location and deprivation are important influencers of physical activity in primary care populations

OBJECTIVES

To investigate the physical activity of adults attending primary care services in the Republic of Ireland and to determine whether the location (urban/rural) and deprivation of the primary care centre influenced physical activity.

STUDY DESIGN

Cross sectional study.

METHODS

Stratified random sampling based on urban/rural location and deprivation was used to identify three primary care centres from a list of established primary care teams in the Leinster region. The International Physical Activity Questionnaire (IPAQ) was used to collate data on physical activity category (low/moderate/high), total weekly activity (MET-minutes/week) and weekly walking (MET-minutes/week) of participants.

RESULTS

Data from 885 participants with a median age of 39 years (IQR 31-53) were analysed. There were significant differences in physical activity between the primary care areas (P < 0.001). Rural mixed deprivation participants were the least active with almost 60% of this group (59.4%, n = 177) classified as inactive (535 median MET-minutes/week, IQR 132-1197). Urban deprived participants were the most active (low active 37.6%, n = 111, 975 median MET-minutes/week, IQR 445-1933). Upon adjustment for multiple factors, rural participants (OR = 2.81, 95% CI 1.97-4.01), urban non-deprived participants (OR = 1.61, 95% CI 1.08-2.39), females (OR = 1.66, 95% CI 1.23-2.23) and older adults (OR = 1.01, 95% CI 1.00-1.02) were more likely to be categorised as low active. Overall 47.2% (n = 418) of all participants were classified within the low physical activity category.

CONCLUSIONS

Significant disparities exist in the physical activity levels of primary care populations. This has important implications for the funding and planning of physical activity interventions.

Feasibility of a physical activity pathway for Irish primary care physiotherapy services

OBJECTIVES

To establish consensus on a physical activity pathway suitable for use by physiotherapists in Irish primary care. The physical activity pathway "Let's Get Moving" was examined to agree recruitment criteria and seek consensus on component parts.

DESIGN

Modified Delphi approach which attempts to achieve a convergence of opinion, over a series of iterations. Three rounds of questionnaires were used.

SETTING

Primary care.

PARTICIPANTS

41 senior physiotherapists working in primary care for a median of 6 years (IQR 3.7 to 8.5).

MAIN OUTCOME MEASURES

Statements achieving consensus; defined as at least 70% of participants scoring a 6 or a 7, indicating high agreement, on a 7 point Likert scale.

RESULTS

The response rate was 98%. There was a high degree of consensus for many components of the pathway. Participants agreed that all patients attending physiotherapy should be eligible for recruitment onto the pathway as well as accepting referrals from other health professionals and direct access from the public. Private physiotherapists highlighted concerns about recruiting fee paying patients onto the pathway. The pathway should be integrated into other preventative and chronic disease programmes in primary care. Modifications to the original pathway included the use of a pedometer in addition to the General Practice Physical Activity Questionnaire. Training needs in physical activity screening and motivational interviewing, as well as additional staffing were identified to support implementation.

CONCLUSIONS

The Physical Activity Pathway "Let's Get Moving" was accepted as a clinically feasible resource to primary care physiotherapists with some modifications and with the support of additional resources.

Coping and psychological adjustment in recent-onset inflammatory polyarthritis: the role of gender and age

OBJECTIVES

To examine the role of gender, age and coping in psychological adjustment of patients with early inflammatory polyarthritis (IP).

METHODS

One hundred and twelve patients with IP of up to 18 months' duration from the Norfolk Arthritis Register completed questionnaires measuring coping, anxiety, disability and pain.

RESULTS

Thirty-six per cent of the patients were at risk of depressive symptoms. Women had significantly higher levels of depression and anxiety than men. Regression analyses showed that pain and (low) illness acceptance predicted levels of depression. Younger age, wishful thinking and covering up predicted anxiety levels.

CONCLUSIONS

The study found higher levels of depression and anxiety for women than men with early IP. Psychological distress was predicted by younger age, specific coping strategies and high levels of pain.

Total costs and predictors of costs in individuals with early inflammatory polyarthritis: a community-based prospective study

OBJECTIVE

To estimate the health service, non-health service and total costs and predictors of costs in individuals with early inflammatory polyarthritis (IP).

METHODS

We conducted a prospective longitudinal study over a 6-month period. The participants were a random sample of 133 individuals who had enrolled with the community-based Norfolk Arthritis Register (NOAR) database between 1994 and 1999. The main outcome measures were the mean (per person) 6-month health service cost, non-health-service cost and total cost associated with IP.

RESULTS

One hundred and fifteen of the 133 individuals who were recruited into the study completed 6 months of follow-up. The mean 6-month total cost was estimated to be 2800 pounds sterling per person, of which 14% was health service costs and the remainder non-health-service costs. Higher total costs were associated with lower health status and rheumatoid factor positivity.

CONCLUSIONS

Early IP has a considerable impact on both the health-care system and, more importantly, society. Non-health-service costs (i.e. costs incurred by the individual with the disease, their family and friends) account for a substantial proportion (86%) of the total costs associated with early IP.

Benchmarking: the five year outcome of rheumatoid arthritis assessed using a pain score, the Health Assessment Questionnaire, and the Short Form-36 (SF-36) in a community and a clinic based sample

BACKGROUND

Treatment, and therefore outcome, of rheumatoid arthritis (RA) will improve in the next few years. However, improvement in outcome can only be judged against the probability of certain outcomes with current conventional treatment.

AIM

To document the five year outcome of RA in the late 1990s.

SETTING

Norfolk Arthritis Register (NOAR).

DESIGN

Longitudinal observational cohort study.

METHODS

318 patients with recent onset inflammatory polyarthritis recruited by NOAR in 1990-91 completed five years of follow up. Four groups were assessed: the whole cohort, all those referred to hospital, those who satisfied criteria for RA at baseline, and those referred to hospital who satisfied criteria for RA at baseline. Outcome was assessed with a visual analogue scale for pain, the Health Assessment Questionnaire (HAQ), and the Short Form-36 (SF-36).

RESULTS

Of the RA hospital attenders, 50% had a visual analogue scale pain score of 5 cm or less and an HAQ score of 1.125 or less. SF-36 scores were reduced in all domains. Results are presented as cumulative percentages.

CONCLUSIONS

These results can be used for comparison and to set targets for improvement.

Reduced disability at five years with early treatment of inflammatory polyarthritis: results from a large observational cohort, using propensity models to adjust for disease severity

OBJECTIVE

To determine the effect of treatment with disease-modifying antirheumatic drugs (DMARDs) and/or steroids on 5-year disability outcome in patients with inflammatory polyarthritis.

METHODS

Three hundred eighty-four patients registered by the Norfolk Arthritis Register (a primary care-based observational cohort) were followed up for 5 years. Treatment details and Health Assessment Questionnaire (HAQ) scores were recorded annually. Logistic regression was used to model differences in baseline factors associated with the start of DMARDs and/or steroids within 12 months of baseline. Based on this model, each subject was given a probability of starting treatment ("propensity score"). A second model compared the odds of disability (HAQ score > or =1.00) in treated and untreated patients, adjusting for differences in disease severity using the propensity score.

RESULTS

Unadjusted analysis suggested that patients who received treatment had an increased odds of a worse outcome compared with those who did not receive treatment. When adjusted for differences in disease severity, using the propensity score, early treatment (within 6 months of symptom onset) was associated with a similar odds of disability at 5 years compared with those not treated (odds ratio 0.71; 95% confidence interval 0.34, 1.44). In contrast, starting treatment later (> or =6 months) was associated with a 2-fold increased odds of having a HAQ score > or =1.00 at 5 years.

CONCLUSION

The propensity score was a useful method of adjusting for "confounding by indication" in observational studies. Furthermore, this study showed that early treatment with DMARDs/steroids (within 6 months of symptom onset) reduced the odds of disability 5 years later to a level comparable with that of patients judged clinically as not requiring treatment.

The impact of rheumatoid arthritis on employment status in the early years of disease: a UK community-based study

OBJECTIVE

To establish the prevalence of work disability and predictors of change in employment status in patients with early rheumatoid arthritis (RA).

SETTING

The Norfolk Arthritis Register (NOAR), a primary-care based inception cohort of patients with recent-onset inflammatory arthritis.

METHODS

Two cohorts of patients notified to NOAR, who satisfied the 1987 ACR criteria for RA at the time of notification (baseline) and who were economically active at the time of RA symptom onset, were identified. Cohort 1 consisted of 160 patients with an onset of RA between 1989 and 1992, and was followed for a mean of 8.6 yr from symptom onset. For 110 of these cases, a control group, matched for age, gender and employment status at baseline, was identified from the local population. Their employment histories were compared in 1995. Cohort 2 consisted of 134 patients with an onset of RA between 1994 and 1997, and was followed for a mean of 4.1 yr from symptom onset.

RESULTS

One-third of RA cohort 1 had stopped working on the grounds of ill health by 1995. The baseline health assessment questionnaire (HAQ) score was the most important predictor of work disability. These patients were 32 times more likely to stop work on health grounds than the matched controls. The rates for work disability for the RA cases 1, 2, 5 and 10 yr after symptom onset were 14, 26, 33 and 39% respectively. For cohort 2, the rates for work disability 1 and 2 yr from onset were 23 and 33% respectively.

CONCLUSION

Work disability is an important outcome in RA patients of working age. Many people stop working very early in the disease process, often before they are referred to hospital or started on disease-modifying anti-rheumatic drugs. Although the peak rates for work disability are in the early years, people with RA continue to leave the work force several years after onset. Thus, the recent move to earlier, more aggressive treatment has had no effect on the rates of work disability.

One year followup variables predict disability 5 years after presentation with inflammatory polyarthritis with greater accuracy than at baseline

OBJECTIVE

To compare the accuracy of simple demographic and clinical variables recorded at baseline with those recorded after one year followup, in predicting self-reported functional disability recorded 5 years after initial assessment in patients with early inflammatory polyarthritis (IP).

METHODS

We followed annually for 5 years 528 patients registered by the Norfolk Arthritis Register (a primary care based cohort of patients with early IP) using the Health Assessment Questionnaire (HAQ). Backward stepwise logistic regression was used to determine the clinical and demographic variables, collected at either baseline or first followup, that were associated with disability (HAQ > or = 1.00/> or =1.50) at 5 years.

RESULTS

At the 5th anniversary assessment, the prevalence of moderate disability (HAQ > or = 1.00) was 47%. Twenty-nine percent reported more severe disability (HAQ > or = 1.50). Variables recorded at first anniversary assessment were better able to predict patients at risk of developing a poor outcome than baseline variables. Multivariate methods identified age at symptom onset, HAQ score, presence of nodules, and a statistically derived factor describing joint tenderness recorded at first year as important predictors of both moderate disability (HAQ > or =1.00) and a higher level of disability (HAQ > or = 1.50). When tested in an independent validation sample, the accuracy of the models generated from data recorded at the first year was 76% (HAQ > or = 1.00) and 83% (HAQ > or = 1.50).

CONCLUSION

It was possible to predict disability at 5 years with high accuracy using simple clinical variables and demographic data collected 4 or 5 years previously. First year HAQ score was the strongest predictor of future disability. HAQ score at 5 years could be predicted more accurately using data collected at first anniversary visit than using data recorded at baseline.

Secondary health service care and second line drug costs of early inflammatory polyarthritis in Norfolk, UK

OBJECTIVE

To estimate the secondary health service care and second line drug costs (including drug monitoring costs) for a cohort of people with early inflammatory polyarthritis (IP) and the subgroup classified as having rheumatoid arthritis (RA) recruited to a population based register.

METHODS

The study population consisted of 344 people with IP who had enrolled on the Norfolk Arthritis Register (NOAR) in 1990-91, an average of 24 weeks after onset of their symptoms. Utilizing resource use data from NOAR, augmented by unit cost data from other sources, the average (per person) and cumulative secondary care and second line drug costs were estimated for Years 1, 2, 3, 4, and 5 following registration with NOAR.

RESULTS

The total secondary health service care and second line drug costs were 472,125 (338,704 for RA subgroup) (1990-91 prices) over the 5 year study period, with inpatient stays, outpatient visits, and second line drugs accounting for 58, 9, and 33%, respectively. Nineteen percent of the study population neither visited hospital nor were prescribed second line drugs.

CONCLUSION

Overall, inpatient stay costs represented the largest proportion of secondary health service care and second line drug costs, making 21% of the total study cohort responsible for 80% of the total 5 year costs incurred.

The performance of the 1987 ARA classification criteria for rheumatoid arthritis in a population based cohort of patients with early inflammatory polyarthritis. American Rheumatism Association

OBJECTIVE

The 1987 American Rheumatism Association (ARA) criteria for rheumatoid arthritis (RA) were developed to discriminate between patients with established RA and those with another rheumatological disorder. Their ability to determine which patients presenting with early synovitis have "true" RA is not known. We evaluated whether the 1987 ARA classification criteria for RA in patients newly presenting with inflammatory polyarthritis (IP) predict persistent, disabling, or erosive arthritis.

METHODS

We studied 486 patients with early IP referred to the Norfolk Arthritis Register. The 1987 ARA criteria were applied at baseline, and assessed for their ability to identify (1) patients referred to hospital for whom the diagnosis of RA was recorded by the hospital physician; (2) patients at 3 years with (a) persistent synovitis; (b) moderate or greater disability; and (c) erosions.

RESULTS

At baseline, 323 (67%) patients satisfied the ARA criteria in the classification tree format. Exactly 50% of those referred to hospital were given a diagnosis of RA. By 3 years, 76% of the 486 patients had persistent disease, 36% had a Health Assessment Questionnaire score > or = 1, and 40% had erosions. The sensitivity of the criteria was good, ranging from 77 to 87% depending on the outcome. The specificities were poor, and thus the overall discriminatory ability showed little improvement over random probability.

CONCLUSION

. Among patients newly presenting with IP, the 1987 ARA criteria for RA had a low ability to discriminate between patients who developed persistent, disabling, or erosive disease and those who did not. Alternative criteria are required for studies investigating early RA.

Blood transfusion, smoking, and obesity as risk factors for the development of rheumatoid arthritis: results from a primary care-based incident case-control study in Norfolk, England

OBJECTIVE

To examine a range of demographic, social, and clinical risk factors for the development of rheumatoid arthritis (RA).

METHODS

Population-based case-control study in Norfolk, England, involving adult patients, ages 18-70, with an inflammatory polyarthritis of <12 months' duration who were recruited from the Norfolk Arthritis Register. Controls, matched for sex and date of birth, were selected from the primary care register of the Norwich Health Authority. Both cases and controls completed identical self-administered questionnaires. Matched analysis of the 165 case-control sets was conducted for the whole group and for the subset in which the cases satisfied the 1987 American College of Rheumatology criteria for RA.

RESULTS

The controls were of higher socioeconomic status than the cases. This was probably due to response bias. Having a body mass index > or =30 was associated with an adjusted odds ratio (OR) of 3.74 for developing RA (95% confidence interval [95% CI] 1.14-12.27). RA was also associated with a history of blood transfusion (OR 4.83, 95% CI 1.29-18.07). Even after correcting for social class, a history of having ever smoked was associated with a higher risk of developing RA (OR 1.66, 95% CI 0.95-3.06). There was no difference between cases and controls in previous exposure to childhood infections, certain surgical procedures, or reproductive history variables.

CONCLUSION

RA has a number of potential environmental triggers, including smoking, obesity, and blood transfusion.

Presence of psoriasis does not influence the presentation or short-term outcome of patients with early inflammatory polyarthritis

OBJECTIVE

To determine whether the presence of psoriasis influences the presentation and early outcome of disease in a primary case based inception cohort of patients with early inflammatory polyarthritis.

METHODS

In total, 966 patients with early inflammatory polyarthritis referred to the Norfolk Arthritis Register were studied. The clinical and demographic variables of patients with and without psoriasis were compared.

RESULTS

Fifty-one patients (5.3%) had psoriasis on examination. Compared to other patients with inflammatory polyarthritis, those with psoriasis were significantly more likely to be male (49 vs 34%) and less likely to be seropositive for rheumatoid factor (RF) (13 vs 31%). The pattern of joint involvement was similar, as was the outcome at one year. Fewer patients with psoriasis developed radiological erosions (22 vs 39%). Multivariate analysis suggested that this was due to RF acting as a confounder.

CONCLUSION

Among patients with early inflammatory polyarthritis there are few strong differences between patients with and without psoriasis, some of which may be accounted for by the absence of RF.

Patients who develop inflammatory polyarthritis (IP) after immunization are clinically indistinguishable from other patients with IP

Musculoskeletal symptoms may occur following various types of immunization, and it has also been suggested that, like infection, immunization may act as a trigger for rheumatoid arthritis (RA). A total of 48 of 898 (5.3%) patients with early inflammatory polyarthritis (IP) referred to the Norfolk Arthritis Register reported an immunization in the 6 weeks prior to symptom onset. There were no important clinical or demographic differences between the 48 immunized patients and 185 consecutive patients who did not report prior immunization. In addition, the frequencies of HLA-DRB1*01. *04 and the shared epitope in 33 of the immunized patients were similar to those in the 185 non-immunized patients and to those in 136 healthy controls. Further results from a case-control study suggest that the rate of immunization is higher amongst cases (5.5%) than age- and sex-matched controls (2.8%). In a small number of susceptible individuals, immunization may thus act as a trigger for RA.

Natural remission in inflammatory polyarthritis: issues of definition and prediction

This paper reports the frequency and predictors of remission (no arthritis on examination and no treatment with second-line drugs or steroids within the previous 3 months) in 358 patients with early inflammatory polyarthritis (IP) referred to the Norfolk Arthritis Register. Two years after referral, 91 patients (25%) were in remission, 32 of whom had also been in remission at 1 yr. Remission rates were twice as high in patients with undifferentiated inflammatory polyarthritis at baseline as in those who satisfied criteria for rheumatoid arthritis. To identify predictors of remission, a logistic regression model was developed on a random two-thirds of the patients and validated on the remaining one-third. Remission at 2 yr was associated with male gender and fewer than six tender joints at baseline. However, even the best-fitting model was not sensitive enough to be useful clinically. Thus, amongst patients with early IP in the community, remission rates at 2 yr are low. Further, it was impossible, using simple clinical measures, to predict those patients whose arthritis would resolve.

Inflammatory polyarthritis in the community is not a benign disease: predicting functional disability one year after presentation

OBJECTIVE

To predict which patients with early inflammatory polyarthritis presenting to primary care will be functionally disabled one year after presentation, in order to inform treatment and referral decisions.

METHODS

The study population consisted of 381 patients notified to the Norfolk Arthritis Register, a primary care based inception cohort of patients with inflammatory polyarthritis. Patients were regarded as functionally disabled if they had a Health Assessment Questionnaire (HAQ) score of one or more. Clinical, laboratory, and demographic variables easily measured at baseline were analyzed for their ability to predict future disability. Recursive partitioning was used to create a simple decision tree to predict those patients who would be disabled at one year. A logistic regression model was generated on a sample of 277 patients and tested on an independent sample of 104 patients. This was compared with other models, one of which consisted of the 1987 ARA criteria.

RESULTS

112 (29%) patients had a HAQ score of at least 1 at one year. The strongest predictors of future disability were a high baseline HAQ, large joint involvement, female sex, and longer disease duration. The decision tree predicted disability accurately in 67% of patients.

CONCLUSION

It is possible to predict functional outcome at one year among patients with early inflammatory polyarthritis presenting to primary care using simple clinical variables measured at baseline. Satisfying the 1987 ARA criteria could not be used to predict future disability.

Occurrence of rheumatoid arthritis is not increased in the first degree relatives of a population based inception cohort of inflammatory polyarthritis

OBJECTIVE

To determine the risk of rheumatoid arthritis (RA) in first degree relatives of a true population based sample of probands with inflammatory polyarthritis.

METHODS

In a case-control study, a two stage screening procedure was used to ascertain the prevalence of RA in 518 first degree relatives of 207 Norfolk Arthritis Register cases registered in 1990 and 414 first degree relatives of 180 local controls. An initial joint symptom and medical history questionnaire was followed by a physical examination, and serological and radiological evaluation of those with symptoms.

RESULTS

The prevalence of RA in the first degree relatives of all the Norfolk Arthritis Register cases was 7.7/1000, compared with 4.8/1000 in the first degree relatives of the controls, with a risk ratio of 1.6 (95% confidence interval 0.3 to 8.7). This very modest increase was also seen when the analysis was restricted to the first degree relatives of Norfolk Arthritis Register cases who satisfied the American Rheumatism Association criteria for RA: prevalence rate 7.2/1000.

CONCLUSION

There was no evidence of an important increased familial risk of RA in this community based sample. These data are compatible with others from immunogenetic studies showing only weak HLA associations with community ascertained RA.

The incidence of rheumatoid arthritis in the United Kingdom: results from the Norfolk Arthritis Register

This paper provides the first data on the incidence of RA based on a prospective population-based register. All new cases of inflammatory polyarthritis in the Norwich Health Authority are notified by general practitioners to the Norfolk Arthritis Register. The patients are then clinically evaluated by metrologists and blood taken for RF estimation. Cases of RA were defined as all those notified with an onset of symptoms in 1990; who presented by 31 December 1991; and who satisfied the 1987 ARA criteria for RA at the time of presentation. Two hundred and ten patients were notified in the defined time-frame, of whom 104 were classified as having RA. The annual incidence rate was 36/100,000 for women and 14/100,000 for men. RA was rare in men aged under 45 yr. The incidence in men rose steeply with age. The incidence in women rose up to age 45 yr, plateaued to age 75 yr, and fell in the very elderly.