Results

Table 1 shows the percentage of patients in each deprivation category compared with the population in the west of Scotland, Scotland as a whole, and in England and Wales. A total of 8.8% of patients in the sulphasalazine and 5.2% in the gold group could not be categorised. The proportion of RA patients in the most and least affluent groups is similar in the cohorts recruited in the 1980s and the 1990s. These RA patients live in more deprived areas and are substantially more deprived than the population in Scotland as a whole and that in England and Wales.

Table 2 shows the demographic and clinical parameters for the two RA cohorts at outset. The 1990s cohort tended to have slightly milder disease. Age, disease duration, and disease activity did not differ significantly across the three Carstairs groupings (that is, 1 and 2, 3, 4, and 5, 6 and 7). However, significantly poorer functional status was seen in patients in more deprived areas (Kruskal-Wallis). In the gold group the median HAQ was 1.75 in the most affluent and 2 in the most deprived; and in the sulphasalazine cohort the values were 1.625 and 2.125 respectively. Initial weights were available in the gold cohort and showed, as might be expected, significantly higher median weight in the more disadvantaged patients.

Five year follow up data in the gold group showed that at five years 35% of the 440 gold patients were still receiving treatment, 40% had discontinued treatment because of side effects, and a further 11% because of lack of efficacy. In addition 6% had stopped treatment because of lack of compliance or intercurrent illness. Fifty six (13%) had died of problems unrelated to treatment (table 3). Figure 1 shows the percentage of patients receiving injectable gold over the five year period in the three deprivation categories. It can be seen that the likelihood of remaining on treatment is similar in all three groups.

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Figure 1

Percentage of patients still receiving gold treatment split for deprivation categories.

Table 4 shows the paired year 0 and year 5 data for those remaining on gold treatment. It can be seen that significant within group improvements occurred for all measurements (Wilcoxon matched pairs signed ranks test). The HAQ score improves in all groups with treatment. However those patients from more deprived areas—that is, Carstairs groups 3, 4, and 5, and 6 and 7 did not achieve at five years the median functional ability that the most affluent had enjoyed at the beginning.

Discussion

Our results show that functional status is significantly worse in RA patients from the most deprived areas at enrolment to the gold and sulphasalazine studies. Pincus and colleagues found HAQ to be the most representative of all variables measured in depicting the clinical status in an RA patient.8 In addition it is predictive of morbidity and death rates over 5–10 years. Thus those patients with poor HAQ at outset can be expected to have a worse prognosis in terms of disease outcome. As the patients with most severe disease and deprivation are more likely to have died over the five years the results obtained are almost certainly a conservative estimate of the extent of the problem.

There were minor although non-significant differences in disease duration between the three groups of patients in both the sulphasalazine and gold cohorts. In the sulpasalazine cohort the patients with longest disease duration (deprivation categories 3, 4, and 5) do not have the poorest function. Thus disease duration does not fully explain the differences in the HAQ scores. Our data and work by Vliet Vieland et al 9 argue against a longer delay in the most deprived to first consultation with a rheumatologist. It is possible however that patients from more deprived areas only consult their general practitioner when they have severe disease whereas those in more affluent neighbourhoods may consult a doctor with milder symptoms. There may also be differences in perception of onset of disease according to educational level. Access to health care is also an important factor, and will vary between social groups. In an American study¹⁰ higher educational groups were more likely to be hospitalised or undergo surgery for RA. This suggests that more educated people are ‘better equipped to negotiate for medical care’ and not that they are necessarily more ‘needy’. Our data suggest a trend towards worse disease activity in patients from more deprived areas (categories 6 and 7). This has been shown in previous studies and may indicate that more deprived patients have worse RA.3 ,8Furthermore, after five years of gold treatment inequalities in HAQ score persisted with the most deprived patients not achieving over five years the initial functional level of those from the most affluent areas. At present provision of funding in rheumatology and allocation of resources is based on the assumption that the risk of disease and responses to treatment are equal in all people at a given age and sex. Our results would suggest that this is not the case. The most deprived patients have the most severe disease, worse functional outcome, and consequently require more resources. Indeed, it has been shown that caring for the poor costs more in the United States.11

The poorer functional outcome that we have observed in RA patients from more deprived locations is almost certainly multifactorial. The relative contributions of comorbidity, in particular other chronic diseases and of smoking might well be relevant. It has been shown that smoking is associated with more severe disease but it is also true that deprived groups are more likely to smoke. In addition, dietary factors, the association of overcrowding with infection, and lack of formal education are likely to be important. While the development of RA may in itself contribute to relegating the person to a less affluent Carstairs category because of loss of employment and earning capacity, a study in the south of England at outset of RA suggests that this effect is apparent at onset of disease.12

The extent of the problem in our population of RA patients is striking for their functional status is considerably worse than that reported elsewhere in Western Europe and in North America.13 It is ironic that the factors that are associated with poor outcome are in themselves likely to perpetuate disadvantage (that is, lack of access to a car, overcrowded accommodation with lack of privacy and inadequate space for modifications of the home environment).

As the HAQ score has been shown to have an effect on outcome, both in terms of morbidity and mortality, the findings from this study are highly relevant.

Patients from deprived areas have poorer function, which is associated with greater need—medical, social, and paramedical. It is therefore essential that this is recognised and strategies for healthcare planned accordingly.