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Cost versus benefit: a treatment audit

  • Chapter
Rheumatoid Arthritis: The Treatment Controversy

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Abstract

Despite a slightly increased mortality at all ages, the average lifespan of patients with rheumatoid disease is little reduced and the majority will suffer from their arthritis for at least twenty-five years.

The prevalence of this condition has been estimated to be about 2-3 per cent. This high figure conceals different patterns of disease. There are some patients who experience a brief illness with early remission and apparent recovery; in others, gradual functional deterioration over the years is punctuated by a series of remissions and relapses. The pattern of illness may, on the other hand, be progressive with a course that does not seem to be appreciably altered by drug therapy. There is also a minority of, mainly, elderly patients who develop a malignant form of disease with a particularly aggressive and disabling arthritis, leading rapidly to severe handicap.

Treatment should ideally take account of the likely outcome of the illness. For those with the most aggressive disease, powerful and potentially toxic drugs may be appropriate and even radiotherapy may be justified as a part of controlled studies. To give such treatments to a patient who may have been destined to recover however, would be unfortunate, especially as there may be a long-term risk of adverse effects.

Recent studies have shown that only a small proportion of patients prescribed second-line drugs remain on treatment with any one agent for more than four years; the figure may be as low as 15 per cent. A second disease-modifying drug, given following failure of the first, may fare even less well. For patients who show sustained improvement on such drugs, the benefits are unequivocal. This minority, however, must be weighed against the majority whose treatment has to be discontinued. Of the latter, approximately half will have stopped their drugs because of side-effects, which range from the unpleasant to the life-threatening. The remainder will have had to contend with repeated clinic visits and blood tests in order to receive treatment that is at best inefficacious and at worst, dangerous.

As Duthie has shown, functional capacity can be maintained in a majority of patients using a conservation rehabilitation regime without recourse to second line drugs. If we are to continue to use these agents it is imperative that we learn how to use them more efficiently. We must know what constitutes a good or a poor prognosis, who is likely to respond to what treatment and who is most likely to suffer side-effects from the drugs. At present we may be over-treating those with a good prognosis, whilst those with a poor outlook may still be receiving inadequate or inappropriate therapy.

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References

  1. Ropes, M. W., Bennett, G. A., Cobb, S. et al. ‘1958 revision of diagnostic criteria for rheumatoid arthritis’, Bull. Rheum. Dis. 9 (1958) 175–6.

    Google Scholar 

  2. Proposed criteria for use in population studies’, in Kellgren, J. H., Jeffrey, M. R. and Ball, J. (eds) The Epidemiology of Chronic Rheumatism, vol. I ( Philadelphia: Davis, 1963 ) 324–6.

    Google Scholar 

  3. Cathcart, E. S. and O’Sullivan, J. B. ‘Rheumatoid arthritis in a New England town: a prevalence study in Sudbury, Massachusetts’, New Engl. J. Med. 282 (1970) 421–4.

    Article  Google Scholar 

  4. National Centre for Health Statistics, Rheumatoid Arthritis in Adults, United States 1960–62 (Rockville Maryland: National Centre for Health Statistics, 1966) (Vital and health statistics, series II: data from the national health survey No. 17; DHEW Publication No. (HRA) 75–1297).

    Google Scholar 

  5. Lawrence, J. S. Rheumatism in Populations ( London: Heinemann, 1977 ).

    Google Scholar 

  6. Behrend, T., Lawrence, J. S., Behrend, H. et al. ‘Prevalence of rheumatoid arthritis in rural Germany’, Int. J. Epidemiol. 1 (1972) 153–6.

    Google Scholar 

  7. Kellgren, L. ‘Prevalence of rheumatoid arthritis in different geographical areas of Sweden’, Acta Rheum. Scand. 16 (1970) 293–303.

    Article  Google Scholar 

  8. Report from the subcommittee on diagnostic criteria for rheumatoid arthritis’, in Bennett, P. H. and Wood, P. H. N. (eds) Population Studies of the Rheumatic Diseases ( Amsterdam: Excerpta Medica, 1968 ) 454–5.

    Google Scholar 

  9. Ibid.

    Google Scholar 

  10. See note 3.

    Google Scholar 

  11. O’Sullivan, J. B., Cathcart, E. S. ‘Prevalence of rheumatoid arthritis: follow-up evaluation of the effect of criteria on rates in Sudbury, Massachusetts’, Ann. Intern. Med. 76 (1972) 573–7.

    Article  Google Scholar 

  12. Beall, G. and Cobb, S. ‘The frequency distribution of episodes of rheumatoid arthritis as shown by periodic examination’, J. Chron. Dis. 14 (1961) 291–310.

    Article  Google Scholar 

  13. Short, C. L., Bauer, W., Reynolds, W. E. Course of disease before hospital admission in rheumatoid arthritis. A definition of the disease and a clinical description based on the numerical study of 293 patients and controls ( Cambridge: Harvard University Press, 1957 ) 222–39.

    Book  Google Scholar 

  14. Duthie, J. J. R., Thompson, M., Weir, M. M. et al. ‘Medical and social aspects of the treatment of rheumatoid arthritis, with special reference to factors affecting prognosis’, Ann. Rheum. Dis. 14 (1955) 133–48.

    Article  Google Scholar 

  15. Duthie, J. J. R., Brown, P. E., Knox, J. D. E. et al. ‘Course and prognosis in rheumatoid arthritis’, Ann. Rheum. Dis. 16 (1957) 411–24.

    Article  Google Scholar 

  16. Duthie, J. J. R., Brown, P. E., Truelove, L. H. et al. ‘Course and prognosis in rheumatoid arthritis. A further report’, Ann. Rheum. Dis. 23 (1964) 193–203.

    Article  Google Scholar 

  17. Jacoby, R. K., Jayson, M. I. V., Cosh, J. A. ‘Onset, early stages and prognosis of rheumatoid arthritis; a clinical study of 100 patients with eleven year follow-up’, Br. Med. J. ii (1973) 96–100.

    Google Scholar 

  18. See notes 13 and 16.

    Google Scholar 

  19. Sharp, J. T., Calkins, E., Cohen, A. S. et al. ‘Observations of rheumatoid arthritis, based on the course of 154 cases’, Medicine (Baltimore) 43 (1964) 41–58.

    Article  Google Scholar 

  20. Otten, H. A. and Boerma, F. W. ‘Significance of Waaler-Rose test, streptococcal agglutination and anti-streptolysin titre in the prognosis of rheumatoid arthritis’, Ann. Rheum. Dis. 18 (1959) 24–8.

    Article  Google Scholar 

  21. See note 17.

    Google Scholar 

  22. Fleming, A., Crown, J. M. and Corbett, M. ‘Prognostic value of early features in rheumatoid disease’, Br. Med. J. (1976) 1243–5.

    Google Scholar 

  23. Masi, A. T., Maldonaldo-Cocco, J. A., Kaplan, S. B. et al. ‘Prospective study of the early course of rheumatoid arthritis in young adults: comparison of patients with and without rheumatoid factor positivity at entry and identification of variables correlating with outcome’, Sem. Arthritis Rheum. 5 (1976) 299–326.

    Article  Google Scholar 

  24. Feigenbaum, S. L., Masi, A. T. and Kaplan, S. B. ‘Prognosis in rheumatoid arthritis. A longitudinal study of newly diagnosed younger adults’, Am. J. Med. 66 (1979) 377–84.

    Article  Google Scholar 

  25. See note 17.

    Google Scholar 

  26. Rasker, J. J. and Cosh, J. A. ‘Cause and age at death in a prospective study of 100 patients with rheumatoid arthritis’, Ann. Rheum. Dis. 40 (1981) 115–20.

    Article  Google Scholar 

  27. Cosh, J. A. and Rasker, J. J. ‘A 20-year follow-up of 100 patients with rheumatoid arthritis (RA)’, Ann. Rheum. Dis. 41 (1982) 317.

    Google Scholar 

  28. See note 13.

    Google Scholar 

  29. Bywaters, E. G. L., Curwen, M., Dresner, E. et al. ‘Ten-year follow-up of rheumatoid arthritis’, Lancet, 2 (1960) 1381.

    Google Scholar 

  30. See note 22.

    Google Scholar 

  31. Bums, T. M., Cahn, A. ‘The hand radiograph as a diagnostic discriminant between seropositive and seronegative “rheumatoid arthritis”: a controlled study’, Ann. Rheum. Dis. 42 (1983) 605–12.

    Article  Google Scholar 

  32. See notes 16, 17 and 20.

    Google Scholar 

  33. Cats, A. and Hazevoet, H. M. ‘Significance of positive tests for rheumatoid factor in the prognosis of rheumatoid arthritis. A follow-up study’, Ann. Rheum. Dis. 29 (1970) 254–9.

    Article  Google Scholar 

  34. See notes 16, 19 and 22.

    Google Scholar 

  35. Ragan, C. and Farrington, E. ‘The clinical features of rheumatoid arthritis’, J. Am. Med. Assoc. 181 (1962) 663–7.

    Article  Google Scholar 

  36. See note 26.

    Google Scholar 

  37. See note 22.

    Google Scholar 

  38. See note 22.

    Google Scholar 

  39. See notes 16, 17, 20 and 33.

    Google Scholar 

  40. See note 23.

    Google Scholar 

  41. See notes 22 and 35.

    Google Scholar 

  42. Bywaters, E. G. L. and Dresner, E. ‘The prognosis in rheumatoid arthritis’, Quart. J. Med. 21 (1952) 463.

    Google Scholar 

  43. Buckland-Wright, J. C. ‘X-ray assessment of activity in rheumatoid disease’, Br. J. Rheumatol. 22 (1983) 3–10.

    Article  Google Scholar 

  44. Stastny, P. ‘HLA-D typing in rheumatoid arthritis’, Arthritis Rheum. 20 (1977) 845–59.

    Google Scholar 

  45. Stastny, P. ‘Association of the B cell allo-antigen DRW-4 with rheumatoid arthritis’, New Engl. J. Med. 298 (1978) 869–71.

    Article  Google Scholar 

  46. Panayi, G. S., Wooley, P. and Batchelor, J. R. ‘Genetic basis of rheumatoid disease: HLA antigens, disease manifestations and toxic reactions to drugs’, Br. Med. J. ii (1978).

    Google Scholar 

  47. Young, A., Jaraquemada, D., Awad, J. et al. ‘Association of HLA-DR4/ DW-4 and DR2/DW-2 with radiologic changes in a prospective study of patients with rheumatoid arthritis: preferential relationship with HLA-DW rather than HLA-DR specificities’, Arthritis Rheum. 27 (1984) 20–25.

    Article  Google Scholar 

  48. Sjoblom, K. G., Saxne, T., Pettersson, H. et al. ‘Factors related the progression of joint destruction in rheumatoid arthritis’, Scand. J. Rheumatol. (Suppl. 45 ) (1982) 22.

    Google Scholar 

  49. Scott, D. L., Coulton, B. L., Chapman, J. H. et al. ‘The long-term effects of treating rheumatoid arthritis’, J. Roy. Coll. Phys. Lond. 17 (1983) 79–85.

    Google Scholar 

  50. Research Subcommittee of the Empire Rheumatism Council, ‘Gold therapy in rheumatoid arthritis: final report of a multicentre controlled trial’, Ann. Rheum. Dis. 20 (1961) 315–34.

    Article  Google Scholar 

  51. Multicentre Trial Group, ‘Controlled trial of D-penicillamine in severe rheumatoid arthritis’, Lancet i (1973) 275–80.

    Google Scholar 

  52. Urowitz, M. B., Gordon, D. A., Smythe, H. A. et al. ‘Azathioprine in rheumatoid arthritis. A double-blind, cross-over study’, Arthritis Rheum. 16 (1973) 411–18.

    Article  Google Scholar 

  53. Freedman, A. and Steinberg, V. L. ‘Chloroquine in rheumatoid arthritis. A double-blind trial of treatment for one year’, Ann. Rheum. Dis. 19 (1960) 243–50.

    Article  Google Scholar 

  54. Cooperating Clinics Committee of the American Rheumatism Association, ‘A controlled trial of cyclophosphamide in rheumatoid arthritis’, New Engl. J. Med. 283 (1970) 883–9.

    Article  Google Scholar 

  55. Iannuzzi, L., Dawson, N., Zein, N. et al. ‘Does drug therapy slow radiograph deterioration in rheumatoid arthritis?’, New Engl. J. Med. 309 (1983) 1023–8.

    Article  Google Scholar 

  56. Sigler, J. W., Blum, G. B., Duncan, H. et al. ‘Gold salts in the treatment of rheumatoid arthritis’, Ann. Intern. Med. 80 (1974) 21–6.

    Article  Google Scholar 

  57. Cooperating Clinics Committee of the American Rheumatism Association, ‘A controlled trial of gold salt therapy in rheumatoid arthritis’, Arthritis Rheum. 16 (1973) 353–8.

    Article  Google Scholar 

  58. Luukainen, R. ‘Chrysotherapy in rheumatoid arthritis, with particular emphasis on the effect of chrysotherapy on radiographical changes and on the optimal time of initiation of therapy’, Scand. J. Rheumatol. 34 (Suppl.) (1980) 1–56.

    Google Scholar 

  59. See note 54.

    Google Scholar 

  60. Scott, D. L., Grindulis, K. A., Struthers, G. R. et al. ‘Progression of radiological changes in rheumatoid arthritis’, Ann. Rheum. Dis. 43 (1984) 8–17.

    Article  Google Scholar 

  61. Pullar, T., Hunter, J. A. and Capell, H. A. ‘Does second-line therapy affect the radiological progression in rheumatoid arthritis?’, Ann. Rheum. Dis. 43 (1984) 18–23.

    Article  Google Scholar 

  62. Ibid.

    Google Scholar 

  63. Joint Committee of the Medical Research Council and Nuffield Foundation, ‘A comparison of prednisolone with aspirin or other analgesics in the treatment of rheumatoid arthritis’, Ann. Rheum. Dis. 18 (1959) 173–88

    Google Scholar 

  64. Heroic treatment for non-malignant disease’, J. Am. Med. Assoc. 248 (1982) 1743–4.

    Article  Google Scholar 

  65. Williams, I. A., Baylis, E. M. and Shipley, M. E. ‘A double-blind placebo-controlled trial of methylprednisolone pulse therapy in active rheumatoid disease’, Lancet, 31 July 1982, 237–40.

    Article  Google Scholar 

  66. Liebling, M. R., Leib, E., McLaughlin, K. et al. ‘Pulse methylprednisolone in rheumatoid arthritis: a double-blind cross-over trial’, Ann. Intern. Med. 94 (1981) 21–6.

    Article  Google Scholar 

  67. Ibid.

    Google Scholar 

  68. Pullar, T., Hunter, J. A. and Capell, H. A. ‘Sulphasalazine in rheumatoid arthritis: a double-blind comparison of sulphasalazine with placebo and sodium autothiomalate’, Br. Med. J. 287 (1983) 1102–4.

    Article  Google Scholar 

  69. Neumann, V. C., Grindulis, K. A., Hubball, S. et al. ‘Comparison between penicillamine and sulphasalazine in rheumatoid: Leeds-Birmingham trial’, Br. Med. J. 287 (1983) 1099–02.

    Article  Google Scholar 

  70. Kotzin, B. L., Strober, S., Engleman, E. G. et al. ‘Treatment of intractable rheumatoid arthritis with total lymphoid irradiation’, New Engl. J. Med. 305 (1981) 969–76.

    Article  Google Scholar 

  71. Trentham, D. E., Belli, J. A., Anderson, R. J. et al. ‘Clinical and immunologic effects of fractionated total lymphoid irradiation in refractory rheumatoid arthritis’, New Engl. J. Med. 305 (1981) 976–82.

    Article  Google Scholar 

  72. Field, E. H., Strober, S., Hoppe, R. T. et al. ‘Sustained improvement of intractable rheumatoid arthritis after total lymphoid irradiation’, Arthritis Rheum. 26 (1983) 937.

    Article  Google Scholar 

  73. McCarty, D. J. and Carrera, G. F. ‘Intractable rheumatoid arthritis. Treatment with combined cyclophosphamide, azathioprine and hydroxychloropine’, J. Am. Med. Assoc. 248 (1982) 1718–23.

    Article  Google Scholar 

  74. Srinivasan, R., Miller, B. L. and Paulus, H. E. ‘Long-term chrysotherapy in rheumatoid arthritis’, Arthritis Rheum. 22 (1979) 105–10.

    Article  Google Scholar 

  75. Rosenthal, M. ‘Loss of efficacy of antirheumatic drugs in rheumatoid arthritis’, J. Rheumatol. 7 (1980) 586–7.

    Google Scholar 

  76. Rothermich, N. O., Philips, V. K., Bergen, W. et al. ‘Chrysotherapy: A prospective study’, Arthritis Rheum. 19 (1976) 1321–7.

    Article  Google Scholar 

  77. Rothermich, N. O., Philips, V. K., Bergen, W. et al. ‘Follow-up study of chrysotherapy’, Arthritis Rheum. 22 (1979) 423.

    Article  Google Scholar 

  78. Sambrook, P. N., Brown, C. D., Champion, G. D. et al. ‘Terminations of treatment with gold sodium thiomalate in rheumatoid arthritis’, J. Rheumatol. 9 (1982) 932–4.

    Google Scholar 

  79. Evers, A. E. and Sundstrom, W. R. ‘Second course gold therapy in the treatment of rheumatoid arthritis’, Arthritis Rheum. 26 (1983) 1071–5.

    Article  Google Scholar 

  80. Webley, M. and Coomes, E. N. ‘An assessment of penicillamine therapy in rheumatoid arthritis and the influence of previous gold therapy’, J. Rheumatol. 6 (1979) 20–4.

    Google Scholar 

  81. Rothermich, N. O., Thomas, M. H., Phillips, V. K. et al. ‘Clinical trial of penicillamine in rheumatoid arthritis’, Arthritis Rheum. 24 (1981) 1473–8.

    Article  Google Scholar 

  82. Kean, M. F., Dwosh, I. L., Anastassiades, T. P. et al. ‘The toxicity pattern of D-penicillamine therapy’, Arthritis Rheum. 23 (1980) 158–64.

    Article  Google Scholar 

  83. Richter, J. A., Runge, L. A., Pinals, R. S. et al. ‘Analysis of treatment terminations with gold and anti-malarial compounds in rheumatoid arthritis’, J. Rheumatol. 7 (1980) 153–9.

    Google Scholar 

  84. Husain, Z. and Runge, L. A. ‘Treatment complications of rheumatoid arthritis with gold, hydroxychloroquine, D-penicillamine and levamisole’, J. Rheumatol. 7 (1980) 825–30.

    Google Scholar 

  85. Currey, H. L. F., Harris, J., Mason, R. M. et al. ‘Comparison of azathioprime, cyclophosphamide and gold in treatment of rheumatoid arthritis’, Br. Med. J. iii (1974) 763–6.

    Article  Google Scholar 

  86. Dwosh, I. L., Stein, H. B., Hunter, T. et al. ‘Azathioprine in early rheumatoid arthritis: a comparison study with gold and chloroquine’, Arthritis Rheum. 20 (1977) 685–92.

    Article  Google Scholar 

  87. Girdwood, R. H. ‘Death after taking medications’, Br. Med. J. i (1974) 501–4.

    Google Scholar 

  88. Davis, P. ‘Undesirable effects of gold salts’, J. Rheumatol. 5 (Suppl.) (1979) 18–24.

    Google Scholar 

  89. Phenylbutazone and oxyphenbutazone: time to call a halt’, Drug Therap. Bull. 22 (1984) 5–6.

    Google Scholar 

  90. Kay, A. G. L. ‘Myelotoxicity of D-penicillamine’, Ann. Rheum. Dis. 38 (1979) 232–6.

    Article  Google Scholar 

  91. Whisnant, J. K., Pelkey, J. ‘Rheumatoid arthritis: treatment with azathioprime (IMURAN (R)) Clinical side-effects and laboratory abnormalities’, Ann. Rheum. Dis. 41 (Suppl.) (1982) 44–7.

    Article  Google Scholar 

  92. Kinlen, L. J., Sheil, A. G. R., Peto, J. et al. ‘Collaborative United Kingdom-Australasian study of cancer in patients treated with immunosuppressive drugs’, Br. Med. J. ii (1979) 1461–6.

    Article  Google Scholar 

  93. Kahn, M. F., Arlet, J., Bloch-Michel, H. et al. ‘Leucémies aiguës traitement par agents cytotoxiques en rhumatologies: 19 observations chez 2006 patients’, Nouv. Presse Med. 8 /17 (1979) 1393–7.

    Google Scholar 

  94. Allebeck, P., Ahlbohm, A. and Allander, E. ‘Increased morality among persons with rheumatoid arthritis, but where RA does not appear on the death certificate. Eleven years’ follow-up of an epidemiological study’, Scand. J. Rheumatol. 10 (1981) 301–6.

    Article  Google Scholar 

  95. Allebeck, P. ‘Increased mortality in rheumatoid arthritis. The use of a medical information system for assessment of death risks’, Scand. J. Rheumatol. 11 (1982) 8–86.

    Article  Google Scholar 

  96. Koota, K., Isomaki, H. and Mutou, O. ‘Death rate and causes of death in RA patients during a period of five years’, Scand. J. Rheumatol. 6 (1977) 241–4.

    Article  Google Scholar 

  97. Isomaki, H. A., Hakulinen, T. and Joutsenlahti, V. ‘Excess risk of lymphomas, leukaemia and myeloma in patients with rheumatoid arthritis’, J. Chron. Dis. 31 (1978) 691–6.

    Article  Google Scholar 

  98. Hazleman, B. L. and Da Silva, M. ‘The comparative incidence of malignant disease in rheumatoid arthritis exposed to different regimens’, Ann. Rheum. Dis. 41 (Suppl.) (1982) 12–17.

    Article  Google Scholar 

  99. Urowitz, M. B., Smythe, H. A., Able, T. et al. ‘Long-term effects of azathioprine in rheumatoid arthritis’, Ann. Rheum. Dis. 41 (Suppl.) (1982) 18–22.

    Article  Google Scholar 

  100. Kay, A. ‘EULAR register of patients on immunosuppressive drugs’, Ann. Rheum. Dis. 41 (Suppl.) (1982) 30–1.

    Article  Google Scholar 

  101. Court-Brown, W. M. and Doll, R. Leukaemia and Aplastic Anaemia in Patients Irradiated for Ankylosing Spondylitis’, MRC Special Report Series No. 295 ( London: HMSO, 1957 ).

    Google Scholar 

  102. See note 70.

    Google Scholar 

  103. See note 26.

    Google Scholar 

  104. See note 94.

    Google Scholar 

  105. Abruzzo, J. L. ‘Rheumatoid arthritis and mortality’, Arthritis Rheum. 25 (1982) 1020–2.

    Article  Google Scholar 

  106. Huskisson, E. C. ‘The side-effects of penicillamine therapy in rheumatoid arthritis’, J. Rheumatol. (Suppl. 7 ) (1981) 146–8.

    Google Scholar 

  107. Wooley, P. H., Griffin, J., Panayi, G. S. et al. ‘HLA-DR antigens and toxic reactions to sodium aurothiomalate and D-penicillamine in patients with rheumatoid arthritis’, New Engl. J. Med. 303 (1980) 30D - 2.

    Article  Google Scholar 

  108. Bardin, T., Dryll, A., Debeyre, N. et al. ‘HLA system and side-effects of gold salts and D-penicillamine in the treatment of rheumatoid arthritis’, Ann. Rheum. Dis. 41 (1982) 599–601.

    Article  Google Scholar 

  109. Meenan, R. F., Yelin, E. H., Nevitt, M. et al. ‘The impact of chronic disease. A socio-medical profile of rheumatoid arthritis’, Arthritis Rheum. 24 (1981) 544–9.

    Article  Google Scholar 

  110. See note 3.

    Google Scholar 

  111. See note 73.

    Google Scholar 

  112. Sharp, J. T., Lidsky, M. D., Duffy, J. ‘Clinical responses during gold therapy for rheumatoid arthritis. Changes in synovitis, radiologically detectable erosive lesions, serum proteins and serologic abnormalities’, Arthritis Rheum. 25 (1982) 540–9.

    Article  Google Scholar 

  113. Pinals, R. S., Massie, A. T. and Larsen, R. A. ‘Preliminary criteria for clinical remission in rheumatoid arthritis’, Arthritis Rheum. 24 (1981) 130815.

    Google Scholar 

  114. Fries, J. J. ‘Toward an understanding of patient outcome measurement’, Arthritis Rheum. 26 (1983) 697–704.

    Article  Google Scholar 

  115. Fries, J. F. ‘The assessment of disability: from first to future principles’, Br. J. Rheumatol. 22 (Suppl.) (1983) 48–58.

    Article  Google Scholar 

  116. Hurst, J. W. ‘Measuring the benefits and costs of medical care: the contribution of health status measurement’, Health Trends, 16 (1984) 16–19.

    Google Scholar 

  117. See note 14.

    Google Scholar 

  118. See notes 15 and 16.

    Google Scholar 

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Authors
  1. T. Price
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Editors and Affiliations

  1. Department of Rheumatology, Westminster Hospital, London, UK

    David H. Goddard MD, MRCP

  2. Department of Rheumatology, Charing Cross Hospital, London, UK

    Robin C. Butler MB, MRCP

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© 1984 D. H. Goddard and R. C. Butler

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Price, T. (1984). Cost versus benefit: a treatment audit. In: Goddard, D.H., Butler, R.C. (eds) Rheumatoid Arthritis: The Treatment Controversy. Palgrave, London. https://doi.org/10.1007/978-1-349-08808-9_6

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