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FibromyalgiaScourge of humankind or bane of a rheumatologist's existence.

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Vol. 40, No. 9, September 1997, pp 1553-1555
0 1997, American College of Rheumatology
Arthritis & Rheumatism
Official Journal of the American College of Rheumatology
On the surface, the 2 articles by Wolfe et a1 in this
issue of Arthritis & Rheumatism (1,2) give chilling messages: first, fibromyalgia costs as much or more than
other rheumatic conditions, and, second, patients with
fibromyalgia, managed by the experts, do not get better,
in general, over an average 7-year followup. These
findings are significant contributions from distinguished
physicians who have done much to increase our understanding of fibromyalgia.
The authors followed up, over a period of 7 years,
538 patients whose median duration of disease at enrollment was 7.8 years. Patients from Wichita were enrolled
consecutively, and the subjects form the other 5 centers
were a quota of patients selected “on a most recently
seen basis.” Overall, the mean pain, physical disability,
fatigue, and depression scores were constant over the
followup period; mean yearly medical costs based on the
patients’ reports were calculated to be $2,274, similar to
self-reported costs for osteoarthritis.
The authors discuss the limitations of the studies,
and we would emphasize several methodologic points.
First, the method of subject ascertainment limits the
internal validity and generalizability of the findings. The
subjects are really 2 different cohorts assembled 14 years
apart; the number of dropouts and the amount of
Supported by NIH grant AR-36308. Dr. Solomon is the
recipient of an Arthritis Foundation Physician Scientist Development
Daniel H. Solomon, MD, Matthew H. Liang, MD, MPH:
Harvard Medical School, Robert B. Brigham Multipurpose Arthritis
and Musculoskeletal Diseases Center, Brigham and Women’s Hospital, Boston, Massachusetts.
Address reprint requests to Matthew H. Liang, MD, MPH,
Division of Rheumatology, Immunology and Allergy, PBB-B2.
Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115.
Submitted for publication April 29, 1997; accepted in revised
form May 13, 1997.
missing data from each center are considerable. In 14
years a sea change has occurred in health care, including
cost-containment strategies that have profoundly reduced inpatient care of rheumatic disease, the largest
component of medical costs. The amount of hospital
resources consumed by the group studied by Wolfe and
colleagues is unlikely to occur again since most hospitalizations, undoubtedly, are physician initiated. Second,
self-reported resource utilization by this population
manifesting depressive symptoms should be validated
against some more objective basis, such as hospital bills
or medical records. This is of special concern with regard
to the attribution to fibromyalgia for hospitalizations
due to symptoms of the nervous, gastrointestinal, genitourinary, and cardiovascular systems. The authors
conclude that almost 50% of hospitalizations in fibromyalgia patients appear to be related to fibromyalgiaassociated symptoms, and we find this difficult to
Most importantly, the authors acknowledge that
they have studied a select group, and we believe this
limits generalizability to the average rheumatology practice or to the typical person with fibromyalgia. It is
axiomatic that subjects already receiving health care are
systematically different than those in the community
with diseases, syndromes, or symptoms who have not yet
sought attention or who have not been referred to
specialists. Of the four Horseman of the Apocalypse that
plague analytic epidemiologic studies-chance, confounding, bias, and generalizability-bias is the bane
and the raison d’etre of epidemiologists. Bias is to be
guarded against, or evaluated and/or controlled in analyses. In the articles by Wolfe et al, all of the likely biases
are toward sicker patients with more complicated and
more costly cases. The patients have chronic problems
and have remained in the specialty practices of physicians known for their work and interest in fibromyalgia,
they have cooperated with the data collection, and for
the most part they have been sampled on a “most
recently seen” basis, and are thus likely to be high
resource users with more complicated cases.
Fibromyalgia has a wide clinical spectrum, almost
certainly much wider than cases defined solely by American College of Rheumatology (ACR) criteria (3). Studies from Denmark (4), Finland ( 5 ) , Norway (6), Germany (7),South Africa (8), the US (9), and the UK (lo),
using similar case criteria but different methods of
sampling and ascertainment, show unadjusted rates of
prevalence of fibromyalgia in the general population
ranging from 0.66% to lo%, with considerable variation
in specific age and sex groups. In rheumatology practice,
fibromyalgia seems to be common, accounting for 1016% of all patient visits (11J2). These numbers must be
taken with a grain of salt, however, since, other than the
initial visit, followup visits are probably driven by the
physician rather than the patient.
Three important studies shed light on the difference between patients with fibromyalgia seen in the
physician’s office and subjects with fibromyalgia in the
community. A stratified sample of individuals from the
registered patient population of 2 general practitioners
in the UK underwent a detailed evaluation and examination (13). Thirty-four of 141 met ACR criteria for
fibromyalgia at the initial evaluation. Approximately 2
years later, only 35% of these patients were symptomatic, which is in stark contrast to the findings of Wolfe et
al. Multivariate analyses showed that being female,
older, less educated, having higher tender point counts,
having worse fatigue, or having additional physical or
psychological symptoms were associated with persistent
symptoms (13).
Researchers at The University of Alabama at
Birmingham compared patients with fibromyalgia seen
in their practice with community volunteers meeting
ACR criteria for fibromyalgia who had not sought care,
and with healthy controls (14). They showed that psychiatric symptoms and lifetime psychiatric diagnoses
were associated with being followed up in the rheumatology clinic for fibromyalgia.
A third study, from Canada, revealed that the
percentage of fibromyalgia patients whose symptoms
had resolved at 2 years was greater in those sampled
from family practices (36%) than those attending a
specialty pain clinic (13%) (15). In aggregate, these
studies indicate that fibromyalgia in the general population has a good prognosis and is less likely to be
accompanied by psychiatric symptoms and past psychiatric diagnoses than that seen in primary care or referral
The reports by Wolfe and colleagues have some
surprises, as well. Despite the fact that the patients had
seemingly refractory symptoms, 41% rated their health
as good or excellent at the start and the end of the study
period (1). This apparent paradox requires explanation.
There was also significant and constant variation in
self-reported outcomes of care, and this begs for additional study (16). For instance, patients from San Antonio were consistently more symptomatic. Since the majority of this population consists of Hispanics with lower
educational attainment, one wonders whether the group
is fundamentally different or whether their responses
were systematically biased due to the use of culturally
inappropriate instruments (17). The clinicians in Boston
must know something we don’t; their patients reported
significant improvement in depressive symptoms, and we
need to understand how these results were achieved.
Patients in Peoria had the lowest resource utilization.
The management strategy of these providers would be of
great interest to all who must practice under risk-sharing
In summary, these studies document gloomy
prognosis and significant resource consumption in patients with established and chronic fibromyalgia cared
for by the best our profession has to offer. One might ask
what is the marginal cost-effectiveness of rheumatology
specialty care (Boston and Peoria excepted!) for fibromyalgia. The published ACR manpower projections
based on needs assumed that 60% of fibromyalgia
patients should be seen by rheumatologists 6 times per
year (18). To these assumptions, the reports by Wolfe et
a1 ask, “why?” For the kind of patient described in these
reports, after confirming the diagnosis, explaining the
condition, and attempting trials of the known effective
therapy and possibly referring for mental health management, should we not admit our ignorance and that we
have done what we can? A patient should feel supported, but until an understanding of the pathophysiology of fibromyalgia yields more effective therapy, continued medical followup may be futile and costly. Next
patient, please!
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rheumatologist, humankind, fibromyalgiascourge, baner, existencia
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