Reumatología Clínica

Reumatología Clínica

Volume 8, Issue 6, November–December 2012, Pages 334-341
Reumatología Clínica

Original article
A meta-analysis of mortality in rheumatic diseasesMortalidad en las enfermedades reumáticas: un metaanálisis

https://doi.org/10.1016/j.reuma.2012.05.006Get rights and content

Abstract

Introduction

Data reporting mortality in rheumatic diseases vary widely. The objective of this systematic review and meta-analysis of published data is to provide an accurate overview of the current risk of mortality in rheumatic diseases.

Methods

Systematic review and meta-analysis of published studies identified by a sensitive search using free text and MeSH synonyms of “mortality” and of “rheumatic diseases”, in general and by specific diagnoses. Eligibility criteria were (1) study population with rheumatoid arthritis, systemic lupus erythemathosus, systemic sclerosis, vasculitis, osteoarthritis, osteoporosis, dermatomyositis, or spondyloarthritis; (2) outcome of interest mortality, reported as an standardized mortality ratio (SMR), or easily calculated from data reported; and (3) cohorts or longitudinal observational studies. Assessment of risk of bias relied on the New Castle-Ottawa scale for cohorts; only moderate to high quality studies were included. Separate meta-SMRs were calculated for specific diagnoses. Heterogeneity was studied with meta-regression.

Results

A total of 32 studies were included, none in spondyloarthritis or osteoarthritis. The overall pooled SMR was 2.03 (95% confidence interval (CI) 1.79–2.29), ranging from 1.36 in psoriatic arthritis to 4.80 in vasculitis. The largest individual overall SMR came from studies on inflammatory diseases, and the specific SMR were very high for infections and pulmonary events. Heterogeneity between studies was large; however, the analysis of such heterogeneity within diseases did not provide any association with the collected variables.

Conclusions

Based on our results and on the good quality of the included studies, we can conclude that rheumatic diseases increase in general the risk of death, and especially inflammatory diseases.

Resumen

Introducción

Losdatos de mortalidad en las enfermedades reumáticas es muy variable. El objetivo de esta revisión sistemática y meta-análisis de datos publicados es proporcionar una visión general más precisa del riesgo actual y mortalidad en las enfermedades reumáticas.

Métodos

Revisión sistemática y meta-análisis de estudios publicados e identificados por una búsqueda utilizando texto libre y sinónimos MeSH de “mortalidad” y “enfermedades reumáticas”, en general, y por diagnósticos específicos. Los criterios de selección fueron: 1) población de estudio con artritis reumatoide, lupus eritematoso sistémico, esclerosis sistémica, vasculitis, osteoartritis, osteoporosis, dermatomiositis, o espondiloartritis, 2) resultados de mortalidad de interés, reportados como SMR, o fácilmente calculados a partir de los datos comunicados, y 3) cohortes longitudinales o estudios observacionales. Evaluación del riesgo de sesgo basado en la escala de cohortes New Castle-Ottawa, sólo estudios de moderada a alta calidad fueron incluidos. Se calculó meta-SMR para diagnósticos específicos. La heterogeneidad se estudió con meta-regresión.

Resultados

Un total de 32 estudios fueron incluidos, ninguno de espondiloartritis o osteoartritis. El SMR general combinada fue 2,03 (IC 95%: 1,79 a 2,29), desde 1,36 en la artritis psoriásica a 4,80 en las vasculitis. El mayor SMR general individual fue a partir de estudios sobre enfermedades inflamatorias, y SMR específicos fueron muy altos para las infecciones y reacciones pulmonares. La heterogeneidad entre los estudios era grande, sin embargo, el análisis de heterogeneidad dentro de las enfermedades no presentó ninguna asociación con las variables recogidas.

Conclusiones

En base a los resultados y la buena calidad de los estudios incluidos, se puede concluir que las enfermedades reumáticas en general aumentan el riesgo de muerte, y especialmente las enfermedades inflamatorias.

Introduction

Mortality is a reliable indicator of illness severity.1 Rheumatic diseases are frequent chronic diseases with a great burden from disability and complications that ultimately lead to large losses of quality of life and cumbersome dependency, with demonstrated worse quality of life than other more serious diseases2; albeit they are considered benign diseases as a whole, because they are perceived to have a low mortality. Nevertheless, some rheumatic diseases may be mortal, especially those under the category of inflammatory diseases,3, 4 and others may seem less deadly than they actually are. The recognition of the gradient of death risk among rheumatic diseases and of a decreased life expectancy in general, may subsequently lead to an acknowledgement of rheumatic diseases as relevant ones, with implications in health policies as well as in research budgets; despite the fact that those who manage rheumatic diseases, and rheumatic patients in general, find some very common health states in these diseases worse than death.5

An adequate risk assessment of patients during follow-up can help rheumatologist to improve the management in this rheumatic diseases, including an assessment of death risk, as well as of predictors of such risk.

SMRs are calculated as the ratio of deaths observed in a cohort to those expected in a group of the same size from the general population in the same area and standardized for age and sex of the individuals in the study cohort. Current literature reporting mortality in rheumatic diseases varies widely, and therefore an accurate and weighted analysis of the SMR is of importance. The objective of this systematic review and meta-analysis of published data is to provide an accurate overview of the current risk of mortality in rheumatic diseases.

Section snippets

Methods

We conducted a systematic review and meta-analysis by adapting the procedures of the Cochrane Collaboration (http://www.cochrane.org/training/cochrane-handbook) to a small local team. The findings are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement9 and MOOSE.10

Results

The electronic searches yielded 3526 articles (2121 from PubMed, 1331 from EMBASE, and 74 from Cochrane Library), in all 2776 after removing duplicates, plus 38 abstracts from congresses. The selection by title and abstract left 132 articles plus 7 abstracts for detailed review. Only 32 studies met the complete set of selection criteria and were finally included in the review. Many studies were excluded for not providing the SMR or because the quality was not high enough. Fig. 1 shows the flow

Discussion

We have performed a systematic review and meta-analysis on the standardized mortality in rheumatic diseases. The major result is that mortality is generally increased, especially in inflammatory conditions, and it is supported by moderate to high quality cohort studies. The causes of death in our review actually match those of the general population, where cardiovascular events and cancer are the most frequent causes, but notably, infections and respiratory complications of the underlying

Conclusions

The major result is that mortality is generally increased, especially in inflammatory conditions, and it is supported by moderate to high quality cohort studies. The causes of death in our review actually match those of the general population, where cardiovascular events and cancer are the most frequent causes, but notably, infections and respiratory complications of the underlying inflammatory diseases are actually the causes related to an excess mortality in the diseases of interest.

Based on

Ethical disclosures

Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this investigation.

Confidentiality of Data. The authors declare that no patient data appears in this article.

Right to privacy and informed consent. The authors declare that no patient data appears in this article.

Funding sources

This work was partially supported by the RETICS Program, RD08/0075 (RIER), from Instituto de Salud Carlos III (ISCIII), within the VI Plan Nacional de I+D+I 2008–2011 (FEDER).

Conflicts of interest

All authors declare no conflicts of interest.

Acknowledgment

We would like to thank Research Unit of Sociedad Española de Reumatología (Madrid, Spain) for the collaboration in this manuscript.

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