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      Poor physical function, pain and limited exercise: risk factors for premature mortality in the range of smoking or hypertension, identified on a simple patient self-report questionnaire for usual care

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          Abstract

          Objective

          To analyse poor physical function, pain, limited exercise and smoking, assessed in a patient-friendly self-report questionnaire format that has been completed by every patient at every visit over 20–30 years in the authors’ and other usual care settings, to predict 5-year mortality in a general older population.

          Methods

          An extended version of a Multidimensional Health Assessment Questionnaire was mailed to 2000 subjects in Finland, identified as a randomly selected control cohort for a rheumatoid arthritis cohort. The questionnaire included queries concerning baseline physical function, pain, exercise and smoking status, identical to the clinic version, as well as age and 25 medical conditions. Five-year survival was analysed according to descriptive statistics, Kaplan–Meier curves and Cox regressions.

          Results

          The questionnaire was returned by 1523 subjects (76%). Five-year survival was 94% in all subjects, 98% in subjects with no disease or no acutely life-threatening disease, and 17% in subjects with an acutely life-threatening disease. Hazard ratios (HRs) for 5-year mortality were 3.5 for poor physical function, 2.2 for pain, 5.2 for limited exercise and 4.6 for smoking (p<0.01); 5-year survivals were 93%, 97%, 93% and 95%, respectively, compared with 91% for hypertension. Each of the four patient history variables predicted mortality at higher levels in subjects who reported no versus one or more acutely life-threatening conditions.

          Conclusions

          Poor physical function, pain, limited exercise and smoking can be assessed systematically on a simple standard Multidimensional Health Assessment Questionnaire, to identify potentially modifiable risk factors for premature mortality in the infrastructure of usual medical care and health maintenance.

          Article summary

          Article focus
          • A simple, one-page patient self-report questionnaire to assess systematically physical function, pain, limited exercise and smoking has been completed by all patients at all visits in 5–10 min in routine care in several rheumatology clinical settings for 20–30 years, including those of the authors.

          • Responses on this questionnaire indicating poor physical function, pain and limited exercise have been documented as significant prognostic markers for premature mortality in patients with rheumatoid arthritis, with greater significance than radiographs or laboratory tests.

          • Questionnaire responses in an older cohort from the general population, identified from a population register as a control cohort for a rheumatoid arthritis cohort, indicated that poor physical function, pain and limited exercise also predicted 5-year mortality significantly, in the range of smoking and hypertension.

          Key messages
          • Poor physical function, pain and limited exercise are potentially modifiable risk factors for premature mortality in the general population, in a similar range to that of smoking and hypertension.

          • A systematic assessment of these patient history variables is not included at most medical visits, in contrast to blood pressure or serum cholesterol, in part as most available questionnaire formats appear to add to the burden of care for patients and doctors.

          • Scores in a simple format on a questionnaire completed by patient self-report in 5–10 min provide quantitative data concerning physical function, pain, exercise status and smoking as significant risk factors for mortality, with virtually no additional work on the part of a health professional, to ensure that data are available for clinical review.

          • Poor physical function, pain and limited exercise are more significant in prognosis of death over 5 years in individuals who do not versus do report one or more potentially acutely life-threatening diseases.

          Strengths and limitations of this study
          Strengths
          • Population-based subjects? Survey returned by 1523 of 2000 subjects (76%).

          • Questionnaire easily completed by patient self-report in 5–10 min in any clinical or research setting, or even at home.

          Limitations
          • No laboratory tests were available—it would be of interest to compare medical history variables with laboratory tests, such as serum cholesterol, in the prognosis of mortality, and whether a component of the risk according to the laboratory test may be ‘explained’ in part by a patient history measure.

          • All subjects were from Finland, although most data suggest that mortality experience in Finland is similar to that found in most Western countries, and reports from other countries have indicated that poor physical function, pain and limited exercise are prognostic of premature mortality. Furthermore, a response rate of >75% from the general population might be unlikely in most countries, and may be unique to Finland.

          • Diagnoses were available only from self-report, which can be inaccurate for certain diagnoses. However, the excess risk according to poor physical function, pain and limited exercise was greater in subjects who reported no versus any acutely life-threatening diseases.

          • Actual survey includes more queries and is not identical to that used in clinical settings, although actual queries about four risk factors are identical in clinical and study format.

          Related collections

          Most cited references33

          • Record: found
          • Abstract: found
          • Article: not found

          Measurement of patient outcome in arthritis.

          A structure for representation of patient outcome is presented, together with a method for outcome measurement and validation of the technique in rheumatoid arthritis. The paradigm represents outcome by five separate dimensions: death, discomfort, disability, drug (therapeutic) toxicity, and dollar cost. Each dimension represents an outcome directly related to patient welfare. Quantitation of these outcome dimensions may be performed at interview or by patient questionnaire. With standardized, validated questions, similar scores are achieved by both methods. The questionnaire technique is preferred since it is inexpensive and does not require interobserver validation. These techniques appear extremely useful for evaluation of long term outcome of patients with rheumatic diseases.
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            • Article: not found

            Estimates of global mortality attributable to smoking in 2000.

            Smoking is a risk factor for several diseases and has been increasing in many developing countries. Our aim was to estimate global and regional mortality in 2000 caused by smoking, including an analysis of uncertainty. Following the methods of Peto and colleagues, we used lung-cancer mortality as an indirect marker for accumulated smoking risk. Never-smoker lung-cancer mortality was estimated based on the household use of coal with poor ventilation. Relative risks were taken from the American Cancer Society Cancer Prevention Study, phase II, and the retrospective proportional mortality analysis of Liu and colleagues in China. Relative risks were corrected for confounding and extrapolation to other regions. We estimated that in 2000, 4.83 (uncertainty range 3.94-5.93) million premature deaths in the world were attributable to smoking; 2.41 (1.80-3.15) million in developing countries and 2.43 (2.13-2.78) million in industrialised countries. 3.84 million of these deaths were in men. The leading causes of death from smoking were cardiovascular diseases (1.69 million deaths), chronic obstructive pulmonary disease (0.97 million deaths), and lung cancer (0.85 million deaths). Smoking was an important cause of global mortality in 2000. In view of the expected demographic and epidemiological transitions and current smoking patterns in the developing world, the health loss due to smoking will grow even larger unless effective interventions and policies that reduce smoking among men and prevent increases among women in developing countries are implemented.
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              • Article: not found

              Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women.

              To quantify the relation of cardiorespiratory fitness to cardiovascular disease (CVD) mortality and to all-cause mortality within strata of other personal characteristics that predispose to early mortality. DESIGN--Observational cohort study. We calculated CVD and all-cause death rates for low (least fit 20%), moderate (next 40%), and high (most fit 40%) fitness categories by strata of smoking habit, cholesterol level, blood pressure, and health status. Preventive medicine clinic. Participants were 25341 men and 7080 women who completed preventive medical examinations, including a maximal exercise test. Cardiovascular disease and all-cause mortality. There were 601 deaths during 211996 man-years of follow-up, and 89 deaths during 52982 woman-years of follow-up. Independent predictors of mortality among men, with adjusted relative risks (RRs) and 95% confidence intervals (CIs), were low fitness (RR, 1.52;95% CI, 1.28-1.82), smoking (RR, 1.65; 95% CI, 1.39-1.97), abnormal electrocardiogram (RR, 1.64;95% CI, 1.34-2.01), chronic illness (RR, 1.63;95% CI, 1.37-1.95), increased cholesterol level (RR, 1.34; 95% CI, 1.13-1.59), and elevated systolic blood pressure (RR, 1.34; 95% CI, 1.13-1.59). The only statistically significant independent predictors of mortality in women were low fitness (RR, 2.10; 95% Cl, 1.36-3.21) and smoking (RR, 1.99; 95% Cl, 1.25-3.17). Inverse gradients were seen for mortality across fitness categories within strata of other mortality predictors for both sexes. Fit persons with any combination of smoking, elevated blood pressure, or elevated cholesterol level had lower adjusted death rates than low-fit persons with none of these characteristics. Low fitness is an important precursor of mortality. The protective effect of fitness held for smokers and nonsmokers, those with and without elevated cholesterol levels or elevated blood pressure, and unhealthy and healthy persons. Moderate fitness seems to protect against the influence of these other predictors on mortality. Physicians should encourage sedentary patients to become physically active and thereby reduce the risk of premature mortality.
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                Author and article information

                Journal
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2011
                18 June 2011
                18 June 2011
                : 1
                : 1
                : e000070
                Affiliations
                [1 ]Jyväskylä Central Hospital, Jyväskylä, Finland
                [2 ]Medcare Oy, Äänekoski, Finland
                [3 ]New York University School of Medicine and NYU Hospital for Joint Diseases, New York, USA
                Author notes
                Correspondence to Theodore Pincus; tedpincus@ 123456gmail.com
                Article
                bmjopen-2011-000070
                10.1136/bmjopen-2011-000070
                3191419
                22021748
                49ee0b00-ab18-4d8c-9630-d0300da6333d
                © 2011, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                : 25 January 2011
                : 19 April 2011
                Categories
                Health Services Research
                Research
                1506
                1704
                1722
                1734

                Medicine
                Medicine

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