Osteoarthritis: new insights. Part 1: the disease and its risk factors.

Osteoarthritis is the most common form of arthritis, affecting millions of people in the United States. It is a complex disease whose etiology bridges biomechanics and biochemistry. Evidence is growing for the role of systemic factors (such as genetics, dietary intake, estrogen use, and bone density) and of local biomechanical factors (such as muscle weakness, obesity, and joint laxity). These risk factors are particularly important in weight-bearing joints, and modifying them may present opportunities for prevention of osteoarthritis-related pain and disability. Major advances in management to reduce pain and disability are yielding a panoply of available treatments ranging from nutriceuticals to chondrocyte transplantation, new oral anti-inflammatory medications, and health education. This article is part 1 of a two-part summary of a National Institutes of Health conference. The conference brought together experts on osteoarthritis from diverse backgrounds and provided a multidisciplinary and comprehensive summary of recent advances in the prevention of osteoarthritis onset, progression, and disability. Part 1 focuses on a new understanding of what osteoarthritis is and on risk factors that predispose to disease occurrence. It concludes with a discussion of the impact of osteoarthritis on disability.

Health outcomes among Hispanic subgroups: data from the National Health Interview Survey, 1992-95.

BACKGROUND: Within the next 50 years, Hispanics will become the largest minority group in the United States. The largest Hispanic subgroups are those of Mexican, Cuban, and Puerto Rican descent. The Hispanic population is heterogeneous in terms of culture, history, socioeconomic status (SES) and health status. In this report, various health status measures are compared across Hispanic subgroups in the United States. METHODS: National Health Interview Survey (NHIS) data aggregated from 1992 through 1995 were analyzed. NHIS is one of the few national surveys that has a sufficiently large sample size to adequately compare the different subgroups. Data are presented for four Hispanic origin subgroups--Mexican, Cuban, Puerto Rican, and "other Hispanic" persons--for the Hispanic population as a whole and for the non-Hispanic white and non-Hispanic black populations. These groups are compared with respect to several health status outcomes, providing both age-adjusted and unadjusted estimates. RESULTS: The health indicators for Puerto Rican persons are significantly worse than for the other Hispanic origin subgroups. For example, about 21% of Puerto Rican persons reported having an activity limitation, compared with about 15% of Cuban and Mexican persons and 14% of "other Hispanic" persons. In contrast, the health indicators of Cuban persons are often better than those of the other subgroups. For example, Cuban persons reported an average of 3 days per year lost from school or work, compared with about 6 days for Mexican and Puerto Rican persons and 7 days for "other Hispanic" persons. Mexican persons fare better than Puerto Rican persons on measures such as restricted activity days, bed disability days and hospitalizations. CONCLUSION: These data demonstrate clear differences in health status as well as indicators of socioeconomic status across Hispanic subgroups in the United States. Data on Hispanic subgroups facilitate the planning of public health services for various underserved populations.

The prevalence of functional limitations and disability in older persons in the US: data from the National Health and Nutrition Examination Survey III.

OBJECTIVE: To provide estimates by sex and age and by sex and race/ethnicity of the proportion of older Americans who have difficulty with functional limitations and daily activities. SETTING: The Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994. DESIGN: A cross-sectional nationally representative survey. PARTICIPANTS: All persons aged 60 and older who completed a household interview (N = 6,866) during NHANES III (conducted 1988-1994). MEASUREMENTS: The self-reported physical and functional disability questions from NHANES III included: lower-extremity function, instrumental activities of daily living, basic activities of daily living, needing help with personal and routine daily activities, and use of assistive devices for walking. RESULTS: Non-Hispanic black and Mexican-American men and women generally reported significantly (P < .01) more disability than did non-Hispanic white men and women. Disability was greater for minority women than for men. For both men and women, the prevalence in disability increased significantly (P < .01) with age for each measure. CONCLUSIONS: These sex-age and sex-race/ethnicity national estimates of disability indicate that minority women may represent a vulnerable subpopulation.

Reliability and prevalence of physical performance examination assessing mobility and balance in older persons in the US: data from the Third National Health and Nutrition Examination Survey.

OBJECTIVE: This report provides reliability and prevalence estimates by sex, age, and race/ethnicity of an observed physical performance examination (PPE) assessing mobility and balance. SETTING: The Third National Health and Nutrition Examination Survey (NHANES III) 1988-1994. DESIGN: A cross-sectional nationally representative survey. PARTICIPANTS: All persons aged 60 and older (n = 5,403) who performed the PPE either in the mobile examination center (MEC) or in the home during NHANES III (conducted 1988-1994). MEASUREMENTS: The PPE included timed chair stand, full tandem stand, and timed 8-foot walk. RESULTS: Timed chair stand and 8-foot timed walk were reliable measurements (Intraclass Correlations > 0.5). Women were significantly slower (P < .001) than men for both timed chair stands and timed walk. Non-Hispanic white men and women did the maneuvers in significantly less time than non-Hispanic black men and women and Mexican Americans women (P < .001). CONCLUSIONS: Lower extremity functions measured by timed chair stand and walk are reliable. Women at every age group were more physically limited than men.

Dealing with diversity: recruiting churches and women for a randomized trial of mammography promotion.

There is little documentation about the recruitment process for church-based health education programs. In this study, the authors recruit African American, Latino, and white churches and women members (age 50 to 80) for a randomized church-based trial of mammography promotion in Los Angeles County. Efforts to enhance recruitment began 10 months before churches were invited to participate and included a variety of community-based strategies. Subsequently, 45 churches were recruited over a 5-month period through group pastor breakfast meetings and church-specific follow-up. In close collaboration with the 45 churches, the authors administered church-based surveys over 6 months and identified 1,967 age-eligible women who agreed to be contacted by the program team. It was found that an extended resource intensive period of relationship-building and community-based activities were necessary to conduct church-based programs effectively, particularly among older and ethnically diverse urban populations.

Health status measurement performance and health status differences by age, ethnicity, and gender: assessment in the medical outcomes study.

The comparative measurement performance of self-reported health status instruments for African American and Hispanic elderly has rarely been studied, despite evidence of their poor health status. This study examined psychometric performance and health status differences by age, ethnicity, and gender among 10,569 ethnically diverse patients who completed the Short-Form General Health Survey in the Medical Outcomes Study (MOS). Hispanics and African Americans tended to have slightly lower measurement performance than other ethnic groups. Compared with whites, health status scores for African American and Hispanic women were slightly but significantly lower. The small differences in health status by ethnicity may be due to the MOS sampling strategy, which excluded low-socioeconomic status minorities with poor education and no regular medical care. The psychometric performance of MOS health status measures should be examined in studies of ethnically diverse, community-dwelling, elderly populations who have poor access to care, poor education, and/or low socioeconomic status.

Frailty, family, and church support among urban African American elderly.

A community-based survey of 507 African Americans aged 60 and older from South Central Los Angeles was conducted to estimate the prevalence of frailty and describe the correlation between frailty, social support from family and church, and use of community services. Persons were considered frail if they met criteria for any of four conditions: functional impairment, depression, urinary incontinence, falls. Sixty-seven percent met criteria for frailty. Analyses revealed that frail elderly were significantly less likely to report feeling very close to family. Family contact, feeling that church was important, and receiving church support were similar for the frail and nonfrail. Frail elderly were more likely to use community services. These findings suggest that frail elderly in this population may not receive more support from family and church than nonfrail elderly. There is a need for caution when assuming families and churches in urban African American communities are able to support the most vulnerable elderly.

Appropriateness of the decision to transfer nursing facility residents to the hospital.

OBJECTIVES: To develop and test a standardized instrument, the purpose of which is to assess (1) whether skilled nursing facilities (SNFs) transfer residents to emergency departments (ED) inappropriately, (2) whether residents are admitted to hospitals inappropriately, (3) and factors associated with inappropriate transfers. DESIGN: A structured implicit review (SIR) of medical records. SETTING AND PARTICIPANTS: Using nested random sampling in eight community SNFs, we identified SNF and hospital records of 100 unscheduled transfers to one of 10 hospitals. MEASUREMENTS: Seven trained physician reviewers assessed appropriateness using a SIR form designed for this study (2 independent reviews per record, 200 total reviews). We measured interrater reliability with kappa statistics and used bivariate analysis to identify factors associated with assessment that transfer was inappropriate. RESULTS: In 36% of ED transfers and 40% of hospital admissions, both reviewers agreed that transfer/admit was inappropriate, meaning the resident could have been cared for safely at a lower level of care. Agreement was high for both ED (percent agreement 84%, kappa .678) and hospital (percent agreement 89%, kappa .779). When advance directives were considered, both reviewers rated 44% of ED transfers and 45% of admissions inappropriate. Factors associated with inappropriateness included the perceptions that: (1) poor quality of care contributed to transfer need, (2) needed services would typically be available in outpatient settings, and (3) the chief complaint did not warrant hospitalization. CONCLUSIONS: Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals.

Insurance coverage for prescription drugs: effects on use and expenditures in the Medicare population.

BACKGROUND: Although most of the elderly are covered by Medicare, they potentially face large out-of-pocket costs for their health care because of excluded services. Aside from nursing home care, the exclusion of prescription drugs is one of the most significant. Several earlier policy initiatives have proposed adding prescription drug coverage to the Medicare program. To determine the effects of such an expansion, one must account for the potential increase in the demand for prescription drugs from providing insurance coverage. METHODS: The study uses a new data source, the RAND Elderly Health Supplement to the 1990 Panel Study of Income Dynamics (PSID). The endogenity of insurance coverage is tested using instruments that exploit the longitudinal nature of the data. Equations are estimated on 910 persons (> or = 66 years) using a two-part model. RESULTS: Insurance coverage for prescription drugs significantly increases the probability of use, but not of total expenditures, among those who use prescription drugs. However, insurance coverage significantly lowers out-of-pocket expenditures, thereby decreasing the financial burden on elderly households associated with prescription drug use. Medicaid coverage has effects that are smaller than those for private insurance, but the magnitude is less precisely estimated. These findings imply that if prescription drug coverage were added to Medicare, expected expenditures on drugs would rise by on average $83 for each elderly Medicare beneficiary (in 1990 dollars), although this increase is significant only at the 90% level. If the benefit had been included under Medicare, expected spending on prescription drugs by the elderly would have risen by approximately 20%, or $2.6 billion in 1990.

The relationship of self-rated vision and hearing to functional status and well-being among seniors 70 years and older.

PURPOSE: To describe the relationship between self-reported visual and hearing impairment and an index of global functional status among seniors age 70 years or older. METHODS: A total of 7,320 United States community-dwelling persons aged 70 years or older participating in the 1993 Assets and Health Dynamics of the Oldest Old Survey (AHEAD) completed detailed questionnaires about their demographic, socioeconomic, and health status. Multivariate analyses of functional status (using a global index of functional status based on self-reported limitations in 11 activities) were conducted, controlling for demographic and socioeconomic status and common medical conditions, as well as independently for hearing and vision. RESULTS: Of the respondents, 27% rated their vision as fair or poor, whereas 25% rated their hearing as fair or poor. Controlling for demographic factors, socioeconomic status, medical conditions, and general health status, limitations in both vision and hearing correlated independently with worsened functional status. Controlling for income, wealth, and education did not greatly reduce the strength of the association between visual and hearing impairment and function. CONCLUSIONS: Visual and hearing impairment appear to have a significant relationship to overall functioning in the oldest old, regardless of income or wealth. By confirming these findings across income and household wealth groups, adjusted for medical conditions and general health status, in a nationally representative population of Americans age 70 years or older, this study provides a powerful added impetus to efforts for improving vision and hearing for all other Americans, including the oldest old.

The associations between self-rated vision and hearing and functional status in middle age.

OBJECTIVES: To describe the associations between self-reported visual and hearing impairment and an index of global functional status among community-dwelling, middle-aged Americans. DESIGN: Cross-sectional. PARTICIPANTS: A total of 9744 U.S. community-dwelling persons 51 to 61 years of age participated. METHODS: Multivariate analyses of functional status based on cross-sectional data from Wave I (1992) of the Health and Retirement Study (HRS), controlling for demographic and socioeconomic status, common chronic medical conditions, and general health status, were performed. MAIN OUTCOME MEASURE: A global index of functional status based on self-reported limitations in 17 activities was measured. RESULTS: Approximately 3% of respondents in the HRS rated their vision or hearing as poor. Even after controlling for demographic factors, socioeconomic status, medical conditions, and general health status, limitations in both vision and hearing were independently correlated with worse functional status. In addition, controlling for income, wealth, and education reduced the strength of the associations between vision and hearing impairment and function, but did not eliminate them. The magnitude of effect of poor vision exceeded all medical conditions except stroke. CONCLUSIONS: Visual and hearing impairment appear to have a significant relationship with overall functional status, among even community-dwelling, middle-aged Americans and even after controlling for general health status, medical comorbidities, and socioeconomic status.

Primary care of long-stay nursing home residents: approaches of three health maintenance organizations.

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.

Two-year follow-up of AIDS education programs for impoverished women.

The long-term effects of two culturally competent AIDS education programs with different content on the risk behavior and AIDS-related knowledge of 410 homeless African American women 2 years after program completion were examined. Participants were members of a larger cohort of impoverished African American and Latina women recruited in Los Angeles from 1989 to 1991. Of a subsample of 527 African American women selected randomly for a 2-year follow-up interview, 410 (78%) were located and agreed to participate. Women participating in both AIDS education programs reported reduced HIV risk behaviors and demonstrated greatly improved AIDS knowledge at 2-year follow-up (p < .001). Women in a specialized program were less likely than those in a traditional program to report noninjection drug use at 2 years. Women in the traditional program had significantly better AIDS knowledge at follow-up (p < .001). These findings suggest that educational programs can produce sustained benefits among impoverished women.

Use of relevancy ratings by target respondents to develop health-related quality of life measures: an example with African-American elderly.

BACKGROUND: Health-related quality of life (HRQOL) instruments assess functioning and well-being. Generic HRQOL measures are intended to be relevant to everyone whereas population-targeted measures are designed to be relevant to a particular population. METHODS: We asked 99 African-American elderly (mean age 72, 33% female, 47% less than high school education) to rate the relevancy of 33 HRQOL items drawn largely from existing instruments. We assessed the reliability of the relevancy ratings across respondents, rank-ordered the items by relevancy, and tested the significance of difference in relevancy ratings for each item compared to the average of all other items. We also examined the associations of the relevancy ratings with sociodemographic and clinical characteristics. RESULTS: The relevancy ratings were reliable (intraclass correlation = 0.71) and relevancy was generally distinct from HRQOL and demographic characteristics. Items assessing spirituality and weight-related health status were rated as significantly more relevant than other types of items. Generic HRQOL items were not rated as highly relevant. CONCLUSIONS: HRQOL measures assessing spirituality and weight-related concepts are important for future studies of HRQOL in African-American elderly. The method of identifying these concepts used in this study should be valuable in developing new measures targeted to other sociodemographically or clinically defined subgroups.

Racial differences in functional status among elderly U.S. migrants from the South.

This study describes patterns of functional status among older blacks and whites by their history of birth in and migration out of the South. We used multivariate regression to analyze data on functional status of US-born non-Hispanic blacks (N = 1868) and whites (N = 13469) age 60 years or above. In general, the functional status of blacks who were born in the South and migrated was similar to that of blacks born outside the South and better than those born in the South who did not migrate. Whites who migrated from the South had functional status similar to those who did not migrate and worse than those born outside of the South. Socioeconomic status did not explain differences by race and migration history. These results differ sharply from mortality studies, which have found a consistent pattern of high mortality among black migrants from the South. Differences among race groups by migration history vary across health measures. Selective migration and selective survival may account for the complex patterns of racial differences in geographic distributions of function and health.

The persistence of race and ethnicity in the use of long-term care.

We examine the use of nursing homes, formal personal care, informal Activities of Daily Living (ADL) assistance, and no care to identify racial differences in their use. Using the 1987 National Medical Expenditure Survey of both nursing homes and the community, multinominal logistic regressions controlled for predisposing, enabling, and need variables as well as other types of service use. Additional state-level variables make few changes in race/ethnicity parameters, indicating that race/ethnicity are not simply proxies for state-level variables. Older African Americans are less likely to use nursing homes than similar whites, with the lower institutionalization replaced by a higher use of paid home care, informal-only care, and no care. This suggests that formal in-home community care is not fully compensating for the racial differences in nursing home use. Persistent effects of race/ethnicity could be the result of culture, class, and/or discrimination that may impair equitable access to services.

The financial burden of prescription drug use among elderly persons.

Expenditures for prescription drugs are not covered by Medicare and are thus a potential source of large out-of-pocket expenditures for elderly persons. This study, using a new data source, the 1990 Elderly Health Supplement to the Panel Study of Income Dynamics (PSID), demonstrates that, among elderly persons, insurance coverage for drugs reduces the fraction of household income spent on prescription drugs by 50 percent. Groups most likely to benefit from insurance coverage are elderly women and those with common chronic conditions, low incomes, and rural residences.

Long-term determinants of patterns of health insurance coverage in the Medicare population.

Using data from the 1990 Health Supplement to the Panel Study of Income Dynamics, we examine the determinants of patterns of insurance coverage among the elderly. Among those with supplemental insurance through an employment-based source, the primary determinant of having insurance is work history, specifically job tenure and occupation of household heads and their spouses. Among those who do not have employer-provided insurance, wealth is the most important economic factor in the purchase of private insurance. Blacks, persons with less education and women household heads are less likely to purchase supplemental insurance. We find little evidence that persons in prior poor health are more likely to purchase supplemental insurance, and the most important determinant of dental or drug coverage is having employer-based insurance. The current trend toward decreased generosity of post-retirement benefits implies that fewer older Americans will have insurance for these services.

Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases.

OBJECTIVES: This study examined the relationships between wealth and income and selected racial and ethnic differences in health. METHODS: Cross-sectional data on a national sample of 9744 men and women aged 51 through 61 from the 1992 Health and Retirement Survey were analyzed to examine the association between socioeconomic status and racial and ethnic differences in functional status among those with hypertension, diabetes, a heart condition, and arthritis. RESULTS: Compared with Whites, African Americans report higher rates of hypertension, diabetes, and arthritis, while Hispanics report higher rates of hypertension and diabetes and a lower rate of heart conditions. Accounting for differences in education, income, and wealth had little effect on these prevalence differences. In general, among those with chronic diseases, African Americans and Hispanics reported worse function than Whites. This disadvantage was eliminated in every case by controlling for socioeconomic status. CONCLUSIONS: While socioeconomic status, including wealth, accounts for much of the difference in functional status associated with these chronic diseases. It plays a relatively small role in explaining differences in the prevalence of chronic disease, possibly reflecting different causal pathways.

Demographic and economic correlates of health in old age.

In this paper we examine disparities in the ability to function among older Americans. We place special emphasis on two goals: (1) understanding the quantitatively large socioeconomic status-health gradient, and (2) the persistence in health outcomes over long periods. We find that there exist strong contemporaneous and long-run feedbacks from health to economic status. In light of these feedbacks, it is important to distinguish among alternative sources of income and the recipient of income in the household. This research also demonstrates that health outcomes at old age are influenced by health attributes of past, concurrent, and future generations of relatives. Finally, we find that the demographic and economic differences that exist among them explain functional health disparities by race and ethnicity, but not by gender.