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Evaluation of the 1987 revised criteria for rheumatoid arthritis in a cohort of newly diagnosed female patients.

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BRIEF REPORT
EVALUATION OF THE 1987 REVISED CRITERIA FOR
RHEUMATOID ARTHRITIS IN A COHORT OF NEWLY DIAGNOSED
FEMALE PATIENTS
CARIN E. DUGOWSON, J. LEE NELSON, and THOMAS D. KOEPSELL
The revised criteria for the diagnosis of rheumatoid arthritis (RA) were presented in 1987. We tested
these criteria on 135 women from a population-based
study of patients with newly diagnosed RA. None of the
19 women with probable RA and 100 of the 116 women
with definite RA met the 1987 criteria. The 1987 criteria
appear to be less sensitive or more specific than the
criteria formulated in 1956.
In 1956, a committee of the American Rheumatism Association (ARA) proposed criteria for the diagnosis of rheumatoid arthritis (RA) ( I ) . These criteria
were revised in 1958 (2). This classification system has
been used to define RA for the last 30 years. Patients
who met 3 or 4 criteria were diagnosed as having
probable KA, those who met 5 or 6 criteria were
diagnosed as having definite RA, and those who met 7
or more criteria were diagnosed as having classic RA.
A list of multiple exclusions was provided.
Compared with earlier studies, those studies
conducted in the last 30 years using these criteria have
provided useful information on the clinical status of
the study subjects. Nevertheless, as time has passed,
From the University of Washington and the Fred llutchinson Cancer Research Center, Seattle, Washington.
Supported by NICHD contract NOI-HD-62914.
Carin E. Dugowson. MD. MPH: Assistant Professor of
Medicine and Adjunct Assistant Professor of Epidemiology, University of Washington: J. Lee Nelson. MD: Assistant Member,
Associate in Clinical Research, Fred Hutchinson Cancer Research
Center. and Clinical Assistant Professor, University of Washington;
Thomas D. Koepsell, MD. MPH: Professor of Epidemiology, University of Washington.
Address reprint requests to C a m E. Dugowson. MD,
MPH. I124 Columbia Street. MP381, Seattle. WA 98104.
Submitted for publication October 2. 1989; accepted in
revised form January 25. 1990.
Arthritis and Rheumatism, Vol. 33, No. 7 (July 1990)
several shortcomings in these criteria have become
apparent. Despite the absence of a “gold standard,”
the consensus among rheumatologists has been that
patients who met criteria for probable RA often
seemed to have a different disease than those with
classic or definite RA. In addition, the criteria involving synovial tissue or fluid samples were almost never
used and, thus, rarely contributed to the diagnosis.
Several more commonly diagnosed disorders. including seronegative spondylarthropathy and crystal deposition disorders, exclude patients who previously
would have been diagnosed as having RA.
New approaches to therapy and increased interest in the measurement of outcomes and prognosis
in RA have made these shortcomings increasingly
apparent. The ARA therefore mandated a revision of
the 1958 criteria. The ncw 1987 criteria madc several
changes (see Figure 1). The total number of criteria
was decreased to 7; the presence of any 4 criteria now
constitutes a diagnosis of RA. The long list of exclusions was deleted, and the use of levels of certainty
was eliminated. One new item (3 or more swollen
joints) and a revised item (arthritis of specified joints)
complete the new list.
This revision is an important change in our
approach to the classification of RA. Criteria help
define a disease and influence the findings of studies of
etiology, pathogenesis, and therapy. ‘To help evaluate
the likely impact of these new criteria, we applied
them to a cohort of women with RA who had recently
been diagnosed according to the 1958 criteria.
Patients and methods. We are currently conducting a prospective, population-based case-control
study of all women with newly diagnosed RA who live
in King County, Washington (Seattle and surrounding
1043
BRIEF REPORTS
1958 Criteria
1987 Criteria
Morning stiffness‘
Positive RF: Titer:
Date observed:
Figure 1. Comparison of 1958 and 1987 diagnostic criteria for the classification of rheumatoid
arthritis (RA)Stippled areas indicate cnteria with no comparable item i n the other set of critena.
a = specified cnteria present for at least 6 weeks; b = right or left proximal interphalangeal (PIP).
metacarpophalangeal (MCP), wrist, elbow, knee, ankle. and metatarsophalangeal (MTP) joint
RF = rheumatoid factor.
area) or who receive medical care at Group Health
Cooperative of Puget Sound, a large Seattle-based
prepaid health plan organization. Women are referred
to the study by all practicing rheumatologists, internists, and family practitioners in the area. Multiple
methods are used to enhance completeness of ascertainment.
The patients described in this report were the
first 135 qualifying patients referred to this study. All
were women, ages 18 to 64, who were either residing
in King County, Washington or were members of
Group Health Cooperative at the time of diagnosis.
Their diagnosis date was no earlier than November 15.
1986.
All women were examined by a board-certified
rheumatologist (CED or JLN), and the findings of the
joint examination were recorded in a standardized
manner, keyed to the diagnostic criteria. Other information, including duration of morning stiffness, rheumatoid factor positivity and titer, duration of disease,
and demographic information, was obtained directly
from each patient and from her medical record. A
feature was considered present if it was found either
on examination by the study rheumatologist or on
review of the patient’s ,medical record. Radiograph
interpretation was taken from the radiologist’s report.
Rheumatoid factor was assayed at the University of
Washington clinical immunology laboratory using the
Singer-Plotz latex agglutination method.
The data were coded according to which of the
1958 and 1987 criteria for RA were met. We then
compared the performance of the 2 criteria sets in this
cohort.
Results. Characteristics of the study subjects
are summarized below. All patients were women, with
a mean age of 44.6 years. Eighty-five percent of the
patients were white, 6% were black, 4% were Asian,
and 5% were of other races. The median duration of
disease (the time between the onset of symptoms and
the patient’s first physician visit) was 3.5 months.
The number and percentage of women with
each clinical feature of the 1958 criteria and the 1987
BRIEF REPORTS
1044
Table 1. Classification of rheumatoid arthritis (Rh) in 135 women
by the 1958 and 1987 revised diagnostic criteria'
Probable
All patients
RA
(n = 135) (n = 19)
1958 criteria
1. Morning stiffness
2. Pain on motion or
tenderness in at least I
joint
3. Swelling of at least 1
joint
4. Swelling of at least I
other joint
5 . Symmetric arthritis
6. Subcutaneous nodules
7. Radiographic changest
8. Serum rheumatoid
factor
1987 criteria
1. Morning stiffness of 1
hour
2. Arthritis of 3 or more
joint areas
3. Arthritis of the PIP.
MCP. or wrist joints
4. Symmetric arthritis
5. Rheumatoid nodules
6. Serum rheumatoid
factor
7. Radiographic changes
in hand and/or wrist
joint st
Definite/
classic RA
(n = 116)
134 (99)
14 (74)
18 (95)
I14 (98)
116 (100)
135 (100)
19 (100)
I16 (100)
130 (%)
14 (74)
I I6 (100)
128 (95)
108 (80)
16 (12)
19 (29)
63 (47)
106 (91)
16 (14)
19 (29)
62 (53)
1 I5 (85)
I05 (91)
I05 (78)
101 (87)
130 (96)
116 (100)
I08 (80)
16 (12)
63 (47)
106 (91)
16 (14)
62 (53)
19 (29)
19 (29)
Values are the number (%). No patients had information on items
9, 10. or I I of the 1958 criteria (mucin clot. synovial biopsy. or
nodule biopsy, respectively). PIP = proximal interphalangeal; MCP
= metacarpophalangeal.
t Erosions or periarticular osteopenia present. Percentages based
on the 66 patients with documented radiographs.
criteria in relation to their RA classification are shown
in Table 1. Nineteen women met the 1958 criteria for
probable RA. and 116 satisfied the criteria for definite/
classic RA. The 1958 criteria did not stipulate a
minimum duration for morning stiffness. Accordingly.
morning stiffness was coded as present by the 1958
criteria if this symptom was present at all. By this
definition, morning stiffness was present in 98% of
patients classified as having definite/classic RA and in
74% of those classified as having probable RA. Overall, 63 women (47%) had positive results on tests for
rheumatoid factor, defined as a titer of z 1 :40. None of
the women had information on items 9 (mucin clot), 10
(synovial histology). or 1 1 (nodule histology) of the
1958 criteria.
Almost all women in both groups had 1 swollen
joint and 1 tender joint; however, many more women
with definiteklassic RA had symmetric arthritis (91%)
and serum rheumatoid factor (53%) compared with
those with probable R A (1 1% and 5%. respectively).
None of the patients with probable RA had documented radiographic changes or subcutaneous nodules.
Four of the 7 items in the 1987 criteria (symmetric arthritis, subcutaneous nodules, radiographic
changes, and rheumatoid factor positivity) are identical to items in the 1958 criteria (Table I). The 20
women with morning stiffness lasting less than 1 hour
were classified by the 1987 criteria as not having
morning stiffness.
The items retained from the 1958 criteria along
with the 2 new items of the 1987 criteria were positive
more often among patients with definite RA than those
with probable RA. Simultaneous arthritis in at least 3
of the 14 specified joint areas (item 2) was satisfied by
105 (78%) of all patients. However, while 87% of
patients with definite RA met this requirement, only
21% of those with probable RA did. Swelling of at least
1 joint of the hand (excluding the distal interphalangeal
joints; item 31, was present in 100% of the patients
with definite RA and 74% of the patients with probable
RA. This item is very similar to item 3 of the 1958
criteria, but the number of eligible joints is lower.
Overall, 74% (100 of 135) of the women meeting
the 1958 criteria for probable, definite, or classic RA
also met the 1987 criteria for RA. None of the 19
patients with probable RA satisfied the 1987 criteria.
Of those patients who met the 1958 criteria for definite
RA, 86% (I00 of 116) were classified as having RA by
the 1987 criteria.
Characteristics of the women who were classified as having definite R A by the 1958 criteria but were
excluded by the 1987 revision are shown in Table 2.
The features in this group are markedly different from
those in the group of women who met the 1987 criteria.
in terms of morning stiffness (69% versus 95%), arthritis in specifiedjoints (25% versus 97%). and symmetric
arthritis (50% versus 97%). Nodules were not commonly present in patients of either group.
Discussion. One of the main goals of the 1987
revision of the diagnostic criteria for RA was to
improve the specificity of the 1958 criteria by making
several items more restrictive. Thus, a patient with
bilateral swollen, painful knees would meet 4 items in
the 1958 criteria for probable RA, whereas the same
patient would meet only 2 items in the 1987 criteria and
would therefore not qualify as having RA. The criteria
committee found the criteria to be 91.2% sensitive and
89.3% specific for RA when diagnoses of expert rheumatologists were used as a benchmark. This repre-
1045
BRIEF REPORTS
Table 2. Analysis of women with discordant eligibility for the
classification of rheumatoid arthritis (RA) by the 1958 and 1987
criteria*
1. Morning stiffness of I hour
2. Arthritis of 3 or more joint
areas
3. Arthritis of the PIP. MCP.
or wrist joints
4. Symmetric arthritis
5. Rheumatoid nodules
6. Serum rheumatoid factor
7. Radiographic changes in
hand and/or wrist jointst
Eligible by
1987 criteria
(n = 100)
Ineligible by
1987 criteria
(n = 16)
95 (95)
97 (97)
II (69)
4 (25)
100 (100)
16 (100)
97 (97)
16 (16)
54 (54)
31 (47)
8 (50)
0
9 (56)
0
Values are the number (%). All women were classified as having
definite RA by the 1958 criteria. Sixteen of these women did not
meet the 1987 criteria for RA. PIP proximal interphalangeal: MCP
= metacarpophalangeal.
t Erosions or periarticular osteopenia present. Percentages based
on the 66 patients with documented radiographs.
sented an improvement in both characteristics. but
particularly the specificity, over the 1958 criteria (3).
Because the present study did not apply either
the old or the new criteria to persons who were known
not to have RA, numerical estimates of specificity
cannot be directly obtained from our data. However,
useful information can be gained by examining those
study patients for whom the 1958 and 1987 criteria
yielded different classifications. All 19 patients who
had "probable" R A by the 1958 criteria failed to meet
the 1987 criteria for RA.
The label "probable" RA may be a misnomer,
because the followup of such patients suggests that
most of them probably do not have RA (4). If this were
the case for the 19 patients with "probable" RA in the
present study, then at least some of them would be
false-positive by the 1958 criteria but true-negative by
the 1987 criteria, suggesting that the 1987 criteria are
more specific.
Improving specificity can sometimes be
achieved only by sacrificing sensitivity, however. In
this regard, the 16 women in the present study who
had "definite" or "classic" RA by the I958 criteria
but were classified as not having RA by the 1987
criteria are of particular interest (Table 2). Most of
these patients were referred to the study by rheumatologists. Treatment information was available on 1 1
of these 16 women. Seven of them were being treated
with prednisone and/or a remittive agent, suggesting
that the referring physician was sufficiently convinced
of the clinical diagnosis of RA to have initiated therapy. It is possible that at least some of these 16 women
may have had RA and were thus false-negative on the
1987 criteria. This. in turn, would suggest a possible
problem with the sensitivity of the revised criteria.
It is important to note that all women in the
present study had newly diagnosed RA. with a median
disease duration of 3.5 months. In contrast, most
patients studied by the AKA rheumatoid arthritis
subcommittee for the 1987 criteria had established
disease, with a median disease duration of 7.7 years.
The subcommittee conducted a subanalysis on patients with disease of less than l year's duration and
obtained an estimated sensitivity of 81%. which was
lower than the 91% obtained for all their patients.
These findings support the concerns expressed by
Silman ( 5 ) in a recent commentary about possible
shortcomings in the 1987 criteria with regard to identification of patients with early disease.
The rheumatoid factor test can be negative in
the early stages of RA. while the likelihood of a
positive result has been shown to increase during the
years following diagnosis (6). Thus, a patient with
early disease is less likely to meet 1 of the 4 criteria
needed to qualify for a diagnosis of RA. Even among
our patients with "definite" or "classic" RA by the
1958 criteria. only 53% had a positive rheumatoid
factor test result. In addition, RA typically affects an
increasing number of joints over time, making it easier
for a patient with longstanding disease to satisfy item 2
(arthritis in at least 3 qualifying joint areas) and item 4
(symmetry) in the 1987 criteria.
Any comparison of alternative diagnostic criteria for RA is hampered by the lack of a universally
accepted gold standard for diagnosis; without this, it
may be particularly worthwhile to conduct careful
followup studies of those patients whose diagnostic
classification differs between the 1958 and the 1987
criteria. If these patients develop more clinical features of RA and eventually meet both sets of criteria.
then concerns about the possible insensitivity of the
1987 criteria for early disease would be well founded.
If, on the other hand, these patients have an evanescent syndrome and a benign long-term prognosis. such
findings would providc reassurance that the restrictions built into the revised criteria have served chiefly
to improve the specificity for clinically significant RA.
Distinguishing between these 2 possibilities may be
especially important in deciding whether such patients
are to be included in studies of early remittive therapy.
The present study suggests that the 1987 criteria
BRIEF REPORTS
are more restrictive than the 1958 criteria, and this
may soon affect the interpretation of findings from
epidemiologic investigations of RA. In monitoring
future trends in the incidence and prevalence of RA.
we will need to be cautious to distinguish between a
true decline in disease frequency and artifactual
changes due to a revision in the operational definition
of RA. For this reason alone, it may be useful in future
studies to gather sufficient data to allow both the 1958
and the 1987 criteria to be applied.
Acknowledgments. We thank Dr. Mart Mannik and
Dr. Bruce Gilliland for their review of the manuscript and
Diane Rosman for design of the coding form.
3.
4.
5.
REFERENCES
1. Ropes MW. Bennett GA, Cobb S, Jacox R, Jessar RA:
Proposed diagnostic criteria for rheumatoid arthritis. Bull
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2. Ropes MW, Bennett GA, Cobb S, Jacox R, Jessar RA:
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Arnett FC, Edworthy SM, Bloch DA, McShane DJ. Fries
JF. Cooper NS, Healey LA, Kaplan SR, Liang MH,
Luthra HS, Medsger TA Jr, Mitchell DM, Neustadt DH,
Pinals RS, Schaller JG, Sharp JT, Wilder RL, Hunder
GG: The American Rheumatism Association 1987 revised
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O'Sullivan JB, Cathcart ES: The prevalence of rheumatoid arthritis: follow-up evaluation of the effect of criteria
on rates in Sudbury, Massachusetts. Ann Intern Med
76:573-577, 1972
Silman AJ: The 1987 revised American Rheumatism
Association criteria for rheumatoid arthritis. Br J Rheumatol 27:341-343, 1988
Jacoby RK. Jason MIV. Cosh JA: Onset, early stages,
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Erratum
It has recently been brought to our attention that, in an article by Tate et al published in Arthritis and
Rheumatism (Tate GA, Mandell BF, Karmali RA, Laposata M, Baker DG, Schumacher HR Jr,
Zurier RB: Suppression of monosodium urate crystal-induced acute inflammation by diets enriched
with gamma-linolenic acid and eicosapentaenoic acid. Arthritis Rheum 31 :1543-1551, 1988), one
of the sources of grant support was not listed. Dr. Brian Mandell's work was supported by a grant
from the Eastern Pennsylvania Chapter of the Arthritis Foundation.
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patients, diagnosed, evaluation, newly, female, arthritis, cohort, criterias, revised, 1987, rheumatoid
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