title: Formal education and five-year mortality in rheumatoid arthritis: mediation by helplessness scale score.
abstract: OBJECTIVE
  To analyze scores on a scale designed to measure helplessness, a cognitive variable, as a possible mediator of the association between formal education level and mortality over 5 years in patients with rheumatoid arthritis (RA).
  
  
  METHODS
  A cohort of 1,416 patients with RA from 15 private practices in 6 states and Washington, DC was monitored for over 5 years. Demographic, socioeconomic, therapy, functional status, and psychological variables were analyzed as possible predictors of mortality in invariable and multivariable Cox Proportional Hazards models.
  
  
  RESULTS
  In a 5-year followup, 1,384 patients were accounted for (97.3%), including 174 who died versus 111 expected (standardized mortality ratio = 1.54). Higher mortality was associated significantly with low formal education, high age, poor scores for activities of daily living (ADL) on a modified health assessment questionnaire (MHAQ), and poor scores on a helplessness scale (all P < 0.01) in univariable analyses. High age, few years of formal education, and poor MHAQ ADL scores were all significant independent predictors of mortality when analyzed simultaneously in a Cox Proportional Hazards model. When helplessness scale scores were included in a model, scores greater than 2.4 (on a scale of 1 to 4), higher age, male gender, and increased MHAQ ADL difficulty scores were all independently significantly predictive of 5-year mortality (P < 0.05), while years of education was no longer a significant predictor.
  
  
  CONCLUSIONS
  Scores on a helplessness scale appear to mediate a component of the association between formal education level and 5-year mortality in these patients with RA. Health professionals and policy makers might consider interventions directed at modification of helplessness as adjunctive to standard interventions to improve outcomes in RA.
authors.affiliation: Thurston Arthritis Research Center, University of North Carolina, Chapel Hill 27599, USA.
authors.forename: L F
authors.initials: LF
authors.lastname: Callahan
authors.forename: D S
authors.initials: DS
authors.lastname: Cordray
authors.forename: G
authors.initials: G
authors.lastname: Wells
authors.forename: T
authors.initials: T
authors.lastname: Pincus
mesh_terms: D000328:Adult; D000368:Aged; D001172:Arthritis, Rheumatoid / Q000401:mortality* / Q000523:psychology*; D004522:Educational Status; D005260:Female; D006304:Health Status; D006380:Helplessness, Learned; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D016016:Proportional Hazards Models; D011795:Surveys and Questionnaires