Assessment of Risk of Rheumatoid Arthritis Among Underground Hard Rock and Other Mining Industry Workers in Colorado, New Mexico, and Utah.

Importance: Respirable silica exposure has been strongly and consistently linked to rheumatoid arthritis (RA) among foundry workers, persons in the construction trades, stone crushers and drillers, and coal miners. However, risk of RA in hard rock mining has not been thoroughly investigated. Objective: To analyze occupational risk of RA in hard rock miners in Colorado, New Mexico, and Utah. Design, Setting, and Participants: This cross-sectional survey study estimated the association between mining industry work and reported RA in a random-digit telephone survey of men 50 years or older living in selected counties with elevated levels of pneumoconiosis mortality (N = 1988). The survey was conducted between January 12 and May 4, 2021. Exposures: Underground hard rock and other mining and related mineral-processing occupations. Main Outcomes and Measures: Report of a clinician diagnosis of RA further defined by treatment with corticosteroids or disease-modifying antirheumatic drugs. Risk was estimated using logistic regression. Results: The analytic sample of 1988 men (survey response rate, 11.1% of all contacts) had a mean (SD) age of 68.6 (10.1) years. Underground hard rock mining was reported by 118 (5.9%); underground mining of other types, predominantly coal mining (no concomitant hard rock), 62 (3.1%); and surface mining or ore processing (no underground), 262 (13.2%). Adjusting for age and smoking and accounting for nonmining silica exposure, mining employment was associated with increased odds of corticosteroid-treated RA (n = 89) (odds ratio, 4.12 [95%, 2.49-6.81]). The odds were similar for RA treated with disease-modifying antirheumatic drugs (n = 80) (odds ratio, 3.30 [95% CI, 1.93-5.66]). Conclusions and Relevance: In this cross-sectional survey study, workers in hard rock and other underground mining and surface mining occupations experienced 3- to 4-fold increased odds of RA. These findings suggest that clinicians should consider patients with relevant work exposures as at higher risk for developing RA.

Socioeconomic Status, Health Care, and Outcomes in Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) disproportionately affects those with low socioeconomic status. Evidence from the past 2 decades has revealed clearer distinctions on the mechanisms of poverty that affect long-term outcomes in SLE. Poverty exacerbates direct, indirect, and humanistic costs and is associated with worse SLE disease damage, greater mortality, and poorer quality of life. Ongoing commitments from medicine and society are required to reduce disparities, improve access to care, and bolster resilience in persons with SLE who live in poverty.

Poverty, Neighborhoods, Persistent Stress, and Systemic Lupus Erythematosus Outcomes: A Qualitative Study of the Patients' Perspective.

OBJECTIVE: To obtain the perspective of individuals with systemic lupus erythematosus (SLE) regarding the role of poverty, neighborhood, and chronic stress in SLE outcomes. METHODS: Through annual structured interviews as part of the Lupus Outcomes Study, 723 persons with SLE were followed from 2003 to 2015 in order to establish the effect of combinations of poverty, persistent poverty, residence in an area of concentrated poverty, access to health care, and chronic stress on accumulated damage. We obtained a sample of 28 of the 723 individuals on the basis of household income, geography, and outcomes in their last interview, and administered qualitative interviews to explore their perspectives on the impact of these factors on SLE outcomes. The interviews were recorded, transcribed, and analyzed using a grounded theory approach. RESULTS: Persons in poverty frequently reported that poverty necessitated a choice to deal with food, medical care, and housing insecurity on a daily basis and to relegate their management of SLE to occurrences of disease flares. They also reported that exposure to crime in their neighborhoods was a stressor that triggered worse disease activity. Affluent participants reported that neighborhood neither helped nor hindered dealing with SLE, because they relied on networks not tied to neighborhoods to deal with SLE. CONCLUSION: Mitigating poverty and reducing exposure to crime through moving to safer neighborhoods are factors identified by individuals with SLE as potentially critical in disease outcomes.

Medical Expenditures and Earnings Losses Among US Adults With Arthritis in 2013.

OBJECTIVE: We estimated the economic impact of arthritis using 2013 US Medical Expenditure Panel Survey (MEPS) data. METHODS: We calculated arthritis-attributable and all-cause medical expenditures for adults age ≥18 years and arthritis-attributable earnings losses among those ages 18-64 years who had ever worked. We calculated arthritis-attributable costs using multistage regression-based methods, and conducted sensitivity analyses to estimate costs for 2 other arthritis definitions in MEPS. RESULTS: In 2013, estimated total national arthritis-attributable medical expenditures were $139.8 billion (range $135.9-$157.5 billion). Across expenditure categories, ambulatory care expenditures accounted for nearly half of arthritis-attributable expenditures. All-cause expenditures among adults with arthritis represented 50% of the $1.2 trillion national medical expenditures among all US adults in MEPS. Estimated total national arthritis-attributable earning losses were $163.7 billion (range $163.7-$170.0 billion). The percentage with arthritis who worked in the past year was 7.2 percentage points lower than those without arthritis (76.8% [95% confidence interval (95% CI)] 75.0-78.6 and 84.0% [95% CI 82.5-85.5], respectively, adjusted for sociodemographics and chronic conditions). Total arthritis-attributable medical expenditures and earnings losses were $303.5 billion (range $303.5-$326.9 billion). CONCLUSION: Total national arthritis-attributable medical care expenditures and earnings losses among adults with arthritis were $303.5 billion in 2013. High arthritis-attributable medical expenditures might be reduced by greater efforts to reduce pain and improve function. The high earnings losses were largely attributable to the substantially lower prevalence of working among those with arthritis compared to those without, signaling the need for interventions that keep people with arthritis in the workforce.

Socioeconomic Predictors of Incident Depression in Systemic Lupus Erythematosus.

OBJECTIVE: To assess different measures of socioeconomic status (SES) as predictors of incident depression among women with systemic lupus erythematosus (SLE). METHODS: Data were derived from the 2010-2015 waves of the Lupus Outcomes Study, where individuals with confirmed SLE were interviewed annually by telephone. Depression was assessed using the Center for Epidemiologic Studies Depression Scale, using a validated lupus-specific cutoff (≥23) for major depressive disorder. Women interviewed in ≥2 consecutive waves, with scores <23 in the first wave (T1), were included. The level of financial strain was classified as high, moderate, or none based on responses to 3 questions. Generalized estimating equations were used to assess the impact of poverty status, income, education, and financial strain at T1 on the risk of incident depression the next year (T2), with adjustment for sociodemographic and disease status measures. Individuals could contribute more than one 2-year dyad to the analysis. RESULTS: In total, 682 women contributed 2,097 observations, with 19% having high financial strain, 47% moderate strain, and 34% no strain. There were 166 women who had 184 episodes of incident depression (rate = 8.8/100 person-years). In bivariate analysis, poverty, lower income and education, disease activity, and high financial strain were associated with depression onset; race/ethnicity was not. Poverty, income, and education were not significant in multivariate analyses, but disease activity and high financial strain were (odds ratio 1.85 [95% confidence interval 1.06-3.23]). CONCLUSION: High financial strain was a significant predictor of new-onset depression in women with SLE, controlling for disease factors and other SES measures. Determining specific, modifiable sources of financial strain may help prevent the development of depression.

Relationship Between Poverty and Mortality in Systemic Lupus Erythematosus.

OBJECTIVE: A prior study established that concurrent poverty, persistent poverty, and exiting poverty were associated with the subsequent extent of damage accumulation in systemic lupus erythematosus (SLE). In this study, we examined whether concurrent poverty affects mortality after taking extent of damage accumulation into account. METHODS: Analyses were conducted on 807 persons with SLE participating in the University of California-San Francisco Lupus Outcomes Study in 2009, stratified by whether they lived in households with incomes ≤125% of the federal poverty level in that year. We used Cox proportional hazards regression to estimate the risk of mortality as a function of poverty status, with and without adjustment for demographics; lupus status, including extent of disease damage; overall health status; health behaviors; and health care characteristics. RESULTS: Among 807 individuals interviewed in 2009, 71 (8.8%) had died by 2015, 57 (8.3%) among the nonpoor and 14 (12.1%) among the poor (P = 0.18). With adjustment only for age, poverty in 2009 was associated with an increased risk of mortality (hazard ratio [HR] 2.14 [95% confidence interval (95% CI) 1.18-3.88]) through 2015. However, after adjustment for extent of damage and age, poverty was no longer associated with an increased risk of mortality (HR 1.68 [95% CI 0.91-3.10]). Among those who died, those who were poor lived 13.9 fewer years (95% CI 6.9-20.8; P < 0.0001). CONCLUSION: The principal way that poverty results in higher mortality in SLE is by increasing the extent of damage accumulation.

Cost-Effectiveness of Tramadol and Oxycodone in the Treatment of Knee Osteoarthritis.

OBJECTIVE: To evaluate the cost-effectiveness of incorporating tramadol or oxycodone into knee osteoarthritis (OA) treatment. METHODS: We used the Osteoarthritis Policy Model to evaluate long-term clinical and economic outcomes of knee OA patients with a mean age of 60 years with persistent pain despite conservative treatment. We evaluated 3 strategies: opioid-sparing (OS), tramadol (T), and tramadol followed by oxycodone (T+O). We obtained estimates of pain reduction and toxicity from published literature and annual costs for tramadol ($600) and oxycodone ($2,300) from Red Book Online. Based on published data, in the base case, we assumed a 10% reduction in total knee arthroplasty (TKA) effectiveness in opioid-based strategies. Outcomes included quality-adjusted life years (QALYs), lifetime cost, and incremental cost-effectiveness ratios (ICERs) and were discounted at 3% per year. RESULTS: In the base case, T and T+O strategies delayed TKA by 7 and 9 years, respectively, and led to reduction in TKA utilization by 4% and 10%, respectively. Both opioid-based strategies increased cost and decreased QALYs compared to the OS strategy. Tramadol's ICER was highly sensitive to its effect on TKA outcomes. Reduction in TKA effectiveness by 5% (compared to base case 10%) resulted in an ICER for the T strategy of $110,600 per QALY; with no reduction in TKA effectiveness, the ICER was $26,900 per QALY. When TKA was not considered a treatment option, the ICER for T was $39,600 per QALY. CONCLUSION: Opioids do not appear to be cost-effective in OA patients without comorbidities, principally because of their negative impact on pain relief after TKA. The influence of opioids on TKA outcomes should be a research priority.

Poverty, Depression, or Lost in Translation? Ethnic and Language Variation in Patient-Reported Outcomes in Rheumatoid Arthritis.

OBJECTIVE: Despite advances in therapies, disparities in outcomes have been documented for rheumatoid arthritis (RA) patients for both ethnicity and English language proficiency. The goals of these analyses were to compare differences in RA patient-reported outcomes, by both self-identification of ethnicity and English language proficiency, and to identify factors that might explain differences among groups. METHODS: Data were collected through structured telephone interviews of a longitudinal cohort with physician-diagnosed RA (n = 438); only women were included (n = 335). Three groups were defined based on self-reported ethnicity and English proficiency: white/English (n = 219), Hispanic/English (n = 39), and Hispanic/Spanish (n = 77). Outcomes examined were patient-reported physical functioning, pain, and presence of moderate or severe fatigue. Multivariate regression analyses compared outcomes among groups, adjusting for sociodemographic characteristics, health and disease factors, and depression. RESULTS: Hispanic/Spanish women had worse function, pain, and fatigue than either English-proficient group. Depression was associated with all outcomes (P < 0.0001), and accounted for greater differentials in scores than ethnicity/language proficiency. In interaction analyses, differences between women who were and were not depressed were greater for Hispanic/English than for Hispanic/Spanish. Nondepressed Hispanic/Spanish scores were significantly worse than nondepressed Hispanic/English, i.e., the impact of depression was less for Hispanic/Spanish women because both depressed and nondepressed women in this group reported worse outcomes. After adjustment for sociodemographic factors and depression, language remained significantly associated with outcomes. CONCLUSION: Disparities in patient-reported outcomes may be driven less by ethnicity than by sociodemographic or psychological factors. Measurement instruments that are not culturally appropriate and equivalent may also hamper meaningful analyses of disparities.

Interactions between patients, providers, and health systems and technical quality of care.

OBJECTIVE: Prior studies have established disparities by race/ethnicity and socioeconomic status (SES) in the kind, quantity, and technical quality of systemic lupus erythematosus (SLE) care and outcomes. In this study we evaluate whether disparities exist in assessments of interactions with health care providers and health plans and whether such interactions affect the technical quality of SLE care. METHODS: Data derive from the Lupus Outcomes Study (LOS). Principal data collection is an annual structured phone interview including items from the Consumer Assessment of Health Plans and Interpersonal Processes of Care Scale measuring dimensions of health care interactions. We use general estimating equations to assess whether disparities exist by race/ethnicity and SES in being in the lowest quartile of ratings of such interactions and whether ratings in the lowest quartile of interactions are associated with technical quality of care after adjustment for sociodemographic and disease characteristics. RESULTS: In the 2012 LOS interview, there were 793 respondents, of whom 640 had ≥1 visit to their principal SLE provider. Nonwhite race/ethnicity and education were not associated with low ratings on any dimension of provider or system interaction; poverty was associated only with low ratings of health plan interactions. After adjustment for demographics, SLE status, and health care variables, ratings in the lowest quartile on all dimensions were associated with significantly lower technical quality of care. CONCLUSION: Ratings in the lowest quartile on all dimensions of interactions with providers and the health care system were associated with lower technical quality of care, potentially resulting in poorer SLE outcomes.

Lifetime medical costs of knee osteoarthritis management in the United States: impact of extending indications for total knee arthroplasty.

OBJECTIVE: The impact of increasing utilization of total knee arthroplasty (TKA) on lifetime costs in persons with knee osteoarthritis (OA) is understudied. METHODS: We used the Osteoarthritis Policy Model to estimate total lifetime costs and TKA utilization under a range of TKA eligibility criteria among US persons with symptomatic knee OA. Current TKA utilization was estimated from the Multicenter Osteoarthritis Study and calibrated to Health Care Cost and Utilization Project data. OA treatment efficacy and toxicity were drawn from published literature. Costs in 2013 dollars were derived from Medicare reimbursement schedules and Red Book Online. Time costs were derived from published literature and the US Bureau of Labor Statistics. RESULTS: Estimated average discounted (3% per year) lifetime costs for persons diagnosed with knee OA were $140,300. Direct medical costs were $129,600, with $12,400 (10%) attributable to knee OA over 28 years. OA patients spent a mean ± SD of 13 ± 10 years waiting for TKA after failing nonsurgical regimens. Under current TKA eligibility criteria, 54% of knee OA patients underwent TKA over their lifetimes. Estimated OA-related discounted lifetime direct medical costs ranged from $12,400 (54% TKA uptake) when TKA eligibility was limited to Kellgren/Lawrence grades 3 or 4 to $16,000 (70% TKA uptake) when eligibility was expanded to include symptomatic OA with a lesser degree of structural damage. CONCLUSION: Because of low efficacy of nonsurgical regimens, knee OA treatment-attributable costs are low, representing a small portion of all costs for OA patients. Expanding TKA eligibility increases OA-related costs substantially for the population, underscoring the need for more effective nonoperative therapies.

Educational and vocational outcomes of adults with childhood- and adult-onset systemic lupus erythematosus: nine years of followup.

OBJECTIVE: To compare educational and vocational outcomes among adults with childhood-onset systemic lupus erythematosus (SLE) and adult-onset SLE. METHODS: We used data derived from the 2002­2010 cycles of the Lupus Outcomes Study, a longitudinal cohort of 1,204 adult subjects with SLE. Subjects ages 18­60 years living in the US (n = 929) were included in the analysis and were classified as childhood-onset SLE if age at diagnosis was <18 years (n = 115). Logistic regression was used to assess the unadjusted and adjusted effect of childhood-onset SLE, sex, race/ethnicity, baseline age, urban or rural location, and US region on the likelihood of completing a bachelor's degree. Generalized estimating equations were used to assess the effect of childhood-onset SLE, demographics, education, and disease-related factors on the odds of employment, accounting for multiple observations over the study period. RESULTS: Subjects with childhood-onset SLE were on average younger (mean ± SD 29 ± 10 years versus 44 ± 9 years), with longer disease duration (mean ± SD 15 ± 10 years versus 11 ± 8 years). Subjects with adult-onset SLE and childhood-onset SLE subjects were equally likely to complete a bachelor's degree. However, subjects with childhood-onset SLE were significantly less likely to be employed, independent of demographic and disease characteristics (odds ratio 0.62, 95% confidence interval 0.42­0.91). CONCLUSION: While subjects with SLE are just as likely as those with adult-onset SLE to complete college education, childhood-onset SLE significantly increases the risk of not working in adulthood, even when controlling for disease and demographic factors. Exploring reasons for low rates of employment and providing vocational support may be important to maximize long-term functional outcomes in patients with childhood-onset SLE.

Relationships between driving distance, rheumatoid arthritis diagnosis, and disease-modifying antirheumatic drug receipt.

OBJECTIVE: Disease-modifying antirheumatic drugs (DMARDs) are recommended for all patients with rheumatoid arthritis (RA). Some estimate that approximately one-half of patients with RA do not receive DMARDs. We hypothesized that patients with RA living farther from rheumatologists would be less likely to receive RA diagnoses and to receive DMARDs. METHODS: US-based Medicare patients ages >65 years were study eligible. We calculated driving distance from patients' homes to the nearest rheumatologist. Using multivariable logistic regression, we assessed relationships between driving distance and RA diagnosis and between driving distance and DMARD receipt. In one set of analyses, distance was divided into quartiles: 0-2, 2.1-5, 5.1-15.9, and ≥16 miles. In a second set of analyses, we used predefined categories: 0-15, 15.1-30, 30.1-60, and >60 miles. RESULTS: Among 59,426 Medicare beneficiaries, 918 had diagnosed RA. Compared to the first quartile, increased distance was associated with decreased odds of RA diagnosis (odds ratio [OR] 0.96 [95% confidence interval (95% CI) 0.80-1.16] in second quartile, OR 0.88 [95% CI 0.72-1.07] in third quartile, and OR 0.72 [95% CI 0.56-0.93] in fourth quartile; P < 0.01 for trend). Similar results were observed using predefined categories. Among those with RA, increased distance was associated with increased odds of DMARD receipt across quartiles (OR 1.15 [95% CI 1.06-1.25] in second quartile, OR 1.41 [95% CI 1.29-1.54] in third quartile, and OR 1.32 [95% CI 1.18-1.46] in fourth quartile; P = 0.001 for trend). There was no relationship between predefined categories and DMARD receipt (P = 0.45 for trend). CONCLUSION: Increased driving distance to rheumatologists was associated with decreased odds of RA diagnosis. Among those with diagnosed RA, the odds of DMARD receipt rose as distance increased from <2 to 16 miles, but not beyond. Urban residents living closer to rheumatologists may have barriers to DMARD use besides geographic access.

Sociodemographic, disease, health system, and contextual factors affecting the initiation of biologic agents in rheumatoid arthritis: a longitudinal study.

OBJECTIVE: To analyze the effect of sociodemographic, disease, and health system characteristics and contextual features about the community of residence on the subsequent initiation of treatment with biologic agents for rheumatoid arthritis (RA). METHODS: We analyzed data from the University of California, San Francisco Rheumatoid Arthritis Panel Study for the years 1999-2011. Principal data collection was by a structured annual phone survey. We estimated Kaplan-Meier curves of the time until initiation of biologic agents, stratified by age and income. We also used Cox regression to estimate the effect of individual-level sociodemographic and medical factors, contextual-level socioeconomic status measures, and density of health providers in the local community on the probability of initiating therapy with biologic agents for RA. RESULTS: In total, 527 persons were included in the panel in 1999, and 229 persons (44%) had initiated therapy with biologic agents by 2011. In multivariable Cox regression models, age <70 years (hazard ratio [HR] for ages 19-54 years 1.89 [95% confidence interval (95% CI) 1.24-2.87] and HR for ages 55-69 years 1.25 [95% CI 0.84-1.87]), Hispanic ethnicity (HR 2.02 [95% CI 1.05-3.86]), household income ≥$30,000/year (HR 1.61 [95% CI 1.12-2.32]), being married or with a partner (HR 1.39 [95% CI 1.00-1.92]), and residence in rural environments (HR 1.96 [95% CI 1.28-2.99]) were associated with a higher probability of initiating biologic agents. Having no (HR 0.18 [95% CI 0.08-0.40]) or only 1-4 rheumatology visits in the year prior to interview (HR 0.60 [95% CI 0.45-0.81]) and living in an area with ≥1 federally qualified health centers (HR 0.63 [95% CI 0.41-0.96]) were associated with a lower probability. CONCLUSION: The probability of initiating therapy with biologic agents is affected by sociodemographic and health system characteristics as well as the nature of the community of residence, resulting in disparities in access to these medications.

Ethnically diverse patients' perceptions of clinician computer use in a safety-net clinic.

Electronic health record (EHR) implementation may affect patient-clinician communication for diverse safety-net populations. We conducted a cross-sectional survey of English-, Spanish-, and Cantonese-speaking patients in a public hospital clinic with a basic EHR. We examined multivariate associations of patient race/ethnicity, language, and education with perceptions of primary-care provider (PCP) computer use. Among 399 respondents, 25% had less than a high school education, 22% preferred Spanish, and 17% Cantonese. Asian (AOR 3.1), non-English-speakers (AOR 3.6) were more likely to report that PCPs used the computer half or more of the visit. Asians were more likely to report that computers helped PCPs remember patient concerns (AOR 5.6). Non-English-speakers had lower odds of reporting that PCPs listened less carefully to them because of computers (AOR 0.3). Patients at risk for communication barriers may perceive advantages of PCP computer use. Safety-net clinics should consider EHR impact on communication disparities.

Risk adjustment for health care financing in chronic disease: what are we missing by failing to account for disease severity?

BACKGROUND: Adjustment for differing risks among patients is usually incorporated into newer payment approaches, and current risk models rely on age, sex, and diagnosis codes. It is unknown the extent to which controlling additionally for disease severity improves cost prediction. Failure to adjust for within-disease variation may create incentives to avoid sicker patients. We address this issue among patients with chronic obstructive pulmonary disease (COPD). METHODS: Cost and clinical data were collected prospectively from 1202 COPD patients at Kaiser Permanente. Baseline analysis included age, sex, and diagnosis codes (using the Diagnostic Cost Group Relative Risk Score) in a general linear model predicting total medical costs in the following year. We determined whether adding COPD severity measures-forced expiratory volume in 1 second, 6-Minute Walk Test, dyspnea score, body mass index, and BODE Index (composite of the other 4 measures)-improved predictions. Separately, we examined household income as a cost predictor. RESULTS: Mean costs were $12,334/y. Controlling for Relative Risk Score, each ½ SD worsening in COPD severity factor was associated with $629 to $1135 in increased annual costs (all P<0.01). The lowest stratum of forced expiratory volume in 1 second (<30% normal) predicted $4098 (95% confidence interval, $576-$8773) additional costs. Household income predicted excess costs when added to the baseline model (P=0.038), but this became nonsignificant when also incorporating the BODE Index. CONCLUSIONS: Disease severity measures explain significant cost variations beyond current risk models, and adding them to such models appears important to fairly compensate organizations that accept responsibility for sicker COPD patients. Appropriately controlling for disease severity also accounts for costs otherwise associated with lower socioeconomic status.

Treatment of rheumatoid arthritis in the Medicare Current Beneficiary Survey.

INTRODUCTION: Numerous studies across different health systems have documented that many patients with rheumatoid arthritis (RA) do not receive disease-modifying anti-rheumatic drugs (DMARDs). Relatively little is known about correlates of DMARD use and whether there are socioeconomic and demographic disparities. We examined DMARD use during 2001 to 2006 in the Medicare Current Beneficiary Survey (MCBS), a longitudinal US survey of randomly selected Medicare beneficiaries. METHODS: Participants in MCBS with RA were included in the analyses, and DMARD use was based on an in-home assessment of all medications. Variables included as potential correlates of DMARD use in weighted regression models included race/ethnicity, insurance, income, education, rheumatology visit, region, age, gender, comorbidity index, and calendar year. RESULTS: The cohort consisted of 509 MCBS participants with a diagnosis code for RA. Their median age was 70 years, 72% were female, and 24% saw a rheumatologist. Rates of DMARD use ranged from 37% among those <75 years of age to 25% of those age 75 to 84 and 4% of those age 85 and older. The multivariable adjusted predictors of DMARD use include: visit with a rheumatologist in the prior year (odds ratio, OR, 7.74, 95% CI, 5.37, 11.1) and older patient age (compared with <75 years, ages 75 to 84, OR 0.58, 95% CI 0.37, 0.92, and 85 and over, OR 0.09, 95% CI 0.02, 0.31). In those without a rheumatology visit, lower income and older age were associated with a significantly reduced probability of DMARD use; no association of DMARD use with income or age was observed for subjects seen by rheumatologists. Race and ethnicity were not significantly associated with receipt of DMARDs. CONCLUSIONS: Among individuals not seeing rheumatologists, lower income and older age were associated with a reduced probability of DMARD use.

Mediators of the socioeconomic gradient in outcomes of adult asthma and rhinitis.

OBJECTIVES: We estimated the extent to which socioeconomic status (SES) gradients in adult asthma and rhinitis outcomes can be explained by home and neighborhood environmental factors. METHODS: Using survey data for 515 adults with either asthma or rhinitis, or both, we examined environmental mediators of SES associations with disease severity, using the Severity of Asthma Scale, and health-related quality of life (HRQL), using the Rhinasthma Scale. We defined SES on the basis of education and household income. Potential environmental mediators included home type and ownership, exposures to allergens and irritants, and a summary measure of perceived neighborhood problems. We modeled each outcome as a function of SES, and controlled for age, gender, and potential mediators. RESULTS: Gradients in SES were apparent in disease severity and HRQL. Living in a rented house partially mediated the SES gradient for both severity and HRQL (P < .01). Higher perceived levels of neighborhood problems were associated with poorer HRQL and partially mediated the income-HRQL relationship (P < .01). CONCLUSIONS: Differences in home and neighborhood environments partially explained associations of SES with adult asthma and rhinitis outcomes.

Sex differences in assessment of obesity in rheumatoid arthritis.

OBJECTIVE: To determine the prevalence of obesity and how accurately standard anthropometric measures identify obesity among men and women with rheumatoid arthritis (RA). METHODS: Dual x-ray absorptiometry (DXA) was performed for 141 persons with RA (56 men and 85 women). Two anthropometric proxies of obesity (body mass index [BMI] and waist circumference [WC]) were compared to a DXA-based obesity criterion. Receiver operating characteristic curves determined optimal cut points for each anthropometric measure, relative to DXA. The association of body fat and anthropometric obesity measures with disease status and cardiovascular risk was assessed in multiple regression analyses, controlling for age and glucocorticoid use. All analyses were performed separately for men and women. RESULTS: A total of 20%, 32%, and 44% of women and 41%, 36%, and 80% of men were classified as obese by BMI, WC, and DXA, respectively. Cut points were identified for anthropometric measures to better approximate DXA estimates of percent body fat (BMI ≥26.1 kg/m(2) for women and ≥24.7 kg/m(2) for men; WC ≥83 cm for women and ≥96 cm for men). For women and men, higher percent fat was associated with poorer RA status. Anthropometric measures were more closely linked to RA status for women, but identified cardiovascular risk for both women and men. CONCLUSION: A large percentage of this RA sample was overfat; DXA-defined obesity was twice as common in men as in women. Utility of revised BMI and WC cut points compared to traditional cut points remains to be examined in prospective studies, but results suggest that lower, sex-specific cut points may be warranted to better identify individuals at risk for poor RA and/or cardiovascular outcomes.

Compromised access to prescriptions and medical care because of cost among US adults with arthritis.

INTRODUCTION: Study objectives were to: 1) determine the magnitude of three outcomes (prescription unaffordable, care delayed and needed care not obtained) related to cost-attributable compromised medical care access among US adults ≥18 years with and without arthritis and 2) identify US adults with arthritis with the highest levels of these outcomes. MATERIALS AND METHODS: We analysed 2009-2011 US National Health Interview Survey data and estimated prevalence of outcomes by arthritis status and, among people with arthritis, by socio-demographic, medical care access and health status characteristics. Unadjusted and multivariable (MV) adjusted (prevalence ratios) PRs quantified associations between each outcome and arthritis status, and, among people with arthritis, selected characteristics. Number and proportion of adults with arthritis without health insurance coverage were estimated. RESULTS: Outcomes were more prevalent (statistically-significant) among those with arthritis than those without: prescription unaffordable = 14% (9%), care delayed = 14% (11%) and needed care not obtained = 11% (8%). Outcomes were marginally more likely (statistically significant) among adults with arthritis than those without (range MV PRs = 1.2-1.3). Among those with arthritis, the uninsured had the highest prevalence of, and were most likely to have, each outcome (MV PRs: prescription unaffordable = 3.6 (95% confidence interval [CI] = 3.6-4.4), delayed care = 4.7 (95% CI = 3.9-5.7) and needed care not obtained = 5.9 (95% CI = 4.7-7.5) (referent: those with both public and private coverage)). An estimated 4.5 million adults with arthritis were uninsured. CONCLUSIONS: Cost-attributable compromised access is common among US adults with arthritis; they are also slightly more likely than those without arthritis to have compromised care. Compromised access is highest among the uninsured. For those with limited access, convenient, inexpensive and proven community-based strategies that improve physical and psychosocial health may be especially practical.