Two cohorts of 125 patients each, with different onset of disease (group A = before the age of 55, group B = after the age of 54) were selected from a total of 1000 patients with definite rheumatoid arthritis (RA). Both groups were identical with regard to gender (women = 71%) and duration of disease (mean = 7 years). Mean age was in group A = 47, in group B = 68 years, respectively. When compared, in both samples no significant differences were found with regard to acuity of onset, to occurrence and duration of a period with nonspecific complaints prior to synovitis and to incidence of remissions and fever. However, in the elderly onset group progression of disease was significantly higher, the functional status poorer, dynamometer values lower, and the frequency of systemic signs higher. Furthermore, in the late onset group were more rarely reported regular exercise programs, other rehabilitative measures, treatment with gold preparations, and joint surgery. These features seem to indicate that age at onset has a modifying effect on disease expression in RA. One factor of influence, among others, is likely to be the generally decreased functional level in higher age. Late onset RA is not thought to be a separate entity of the disease.

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[Quality assurance in rheumatology].

Measurement of quality in health systems was made possible after the introduction of a scientific instrumentarium for assessment of quality. Effectiveness in medical care must be improved in order to stem the rising costs of health care and to prevent rationing measures in medicine. In Germany, quality assurance in medicine is fixed in a legal framework by several laws and statutes. Practice guidelines are one of the means to identify data necessary for decision making. They should be based on a broad consensus among professional, scientific societies, but must also take into consideration possible cost factors and their acceptance by primary care physicians and patients. They should be regularly revised according to the progress in medicine and should leave freedom of decision in individual cases. The Deutsche Gesellschaft für Rheumatologie is editing a comprehensive manual regarding more than 100 individual topics in diagnosis, therapy and complementary care (orthopedic surgery, physical and occupational therapy, rehabilitation). The first part has already been published; it will be completed in 1997 and updated periodically. In the future it is planned to study the quality of care in rheumatic diseases delivered by nonspecialists and specialists and in clinical settings. Furthermore, quality assessment of different treatment regimes is to be continued and expanded. This needs the construction of effective data base for long-term follow-up studies. In the first place however, it is necessary to gain acceptance of our guidelines among general practitioners by participation of rheumatologists in peer reviews and medical audits at community levels.

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