4
participation restrictions as a valued outcome domain therefore also reflects a gen-
eral shift from a purely pathophysiological model of health toward a biopsychoso-
cial model where health is seen as an interaction of individual, social, and
environmental factors [ 12 ].
Health-Related Quality of Life
The foregoing intends to make clear that rheumatic disease may affect the quality of
life of patients either through direct suffering caused by impairments or indirectly
through activity limitations imposed by impairments and participation restrictions
resulting from impairments and/or disability and that PROs may focus on any of
these consequences. Collectively, all the ways in which rheumatic disease may
affect subjective experience of health and well-being is referred to as health-related
quality of life (HRQOL). While no comprehensive definition of HRQOL presently
exists, a consensus among health researchers is that it is a multidimensional con-
struct composed of at least the dimensions of physical and psychologic function
(i.e., disability), social role function (i.e., handicaps), and disease or treatment
symptoms (i.e., impairments). Fig. 1.1 presents the HRQOL profile of patients with
early rheumatoid arthritis enrolled in a tight control study, compared with the health
profile of similar age in the Dutch general population [ 13 , 14 ]. It can be seen that the
Fig. 1.1 Health profile of patients with active early rheumatoid arthritis compared with the gen-
eral population of similar age. Bars represent Short Form-36 Health Survey subscale scores, range
0–100 with higher values indicating better health. Dutch general population data were adapted
from Aaronson et al. [ 13 ]. Data for Early RA patients are unpublished observations from data col-
lected as part of the DREAM remission induction study by Vermeer et al. [ 14 ]
M.A.H.O. Voshaar and M.A.F.J. van de Laar