A workplace health education program that reduces outpatient visits.

A workplace health education program aimed at reducing unnecessary outpatient visits was offered through 22 California employers. A total of 5,200 employees attended a presentation, received self-help books, and completed self-administered questionnaires. All visits for their households were monitored for up to 15 months. The study utilized a quasi-experimental staggered intervention design involving eight different cohorts, before/after comparisons, with statistical adjustment for seasonality and other intervening variables. Visit rates for households insured only by Blue Cross of California were reduced by 17% (P = 0.001), or 2.0 visits per household per year. For all participants, the reduction was 7.2% (P = 0.06), or 0.8 visits. Reductions were seen for all age and educational strata. The program was most effective among households with first dollar fee-for-service insurance coverage. Households with insurance requiring co-payments had less reduction. No reduction was seen among health maintenance organization (HMO) members. The study concludes that a minimal cost, self-care workplace intervention can reduce outpatient visits by important magnitudes.

Outcomes of self-help education for patients with arthritis.

Behavioral and health status outcomes of an unreinforced, self-help education program for arthritis patients taught by lay persons were examined in 2 ways: a 4-month randomized experiment and a 20-month longitudinal study. At 4 months, experimental subjects significantly exceeded control subjects in knowledge, recommended behaviors, and in lessened pain. These changes remained significant at 20 months. The course was inexpensive and well-accepted by patients, physicians, and other health professionals.

Converging and diverging beliefs about arthritis: Caucasian patients, Spanish speaking patients, and physicians.

Ninety-eight Caucasian patients, 46 Spanish speaking patients, and 50 physicians (mainly rheumatologists) took part in surveys of salient beliefs about arthritis and its treatment. The beliefs of Caucasian patients and those of physicians were similar. However, beliefs of physicians about patients' beliefs and actual patient beliefs diverged as did the beliefs of Caucasian and Spanish speaking patients. These results suggest that arthritis education and treatment should be based on patients' perceptions rather than on physicians' beliefs about patients' perceptions.

From experiment to experience: side effects of nonsteroidal anti-inflammatory drugs.

As part of the approval process, new drugs are first studied in controlled clinical trials with carefully selected patients. After gaining approval, however, these drugs are often used in the general community under widely different circumstances. This report explores the effects of such differences on the frequency and severity of side effects using the nonsteroidal anti-inflammatory drugs as a prototype. A review of clinical trials is compared with the accumulated experience at the Stanford and Phoenix Arthritis Centers. Statistical analysis of patient records was accomplished using the American Rheumatism Association Medical Information System Computer Data-Base System. To overcome potential biases in different methods of detecting side effects, a questionnaire was mailed directly to 390 patients, including subjects who were and were not participants in formal drug studies. Agreement between experiment and experience was generally quite good. However, a tendency for severe side effects to occur more frequently in community use than would be predicted from clinical trials was noted.

The variability of immunologic laboratory tests.

To determine the clinical reliability of certain immunologic tests, serum complement (C3), DNA binding (DNAB), and fluorescent antinuclear antibody (FANA) were measured blindly at 2 university immunology laboratories on duplicate serum samples from 667 patients with connective tissue diseases. Twenty-seven percent of patients were differently classified as normal or abnormal for C3 by the 2 laboratories. The mean of paired differences was 25 mg% and large variability remained even after adjustment. Repeat assays on a random subset of 91 sera showed persistent variability. Fifteen percent of patients were differently classified by their DNAB results in 11% by FANA tests. Considering this variability, these "objective" laboratory tests alone are not sufficiently reliable for accurately defining diseases or disease activity.

Nonsteroidal anti-inflammatory agents in rheumatoid arthritis and ankylosing spondylitis.

The relative effectiveness of six nonsteroidal anti-inflammatory agents was studied in 33 patients with rheumatoid arthritis and 32 patients with ankylosing spondylitis in a double-blind, randomized, prospective study employing a six-way multiple crossover design with six-week trials of each agent. In ankylosing spondylitis, naproxen, indomethacin, and fenoprofen calcium were the most effective agents. In rheumatoid arthritis, relatively little mean difference between drugs was found. Most of this difference could be attributed to compliance factors, which favored drugs that required only a small number of pills daily. Despite the small differences in effect, patients had strong preferences. More than 85% of patients were still taking their preferred medication after a mean follow-up period of one year.

Measurement of patient outcome in arthritis.

A structure for representation of patient outcome is presented, together with a method for outcome measurement and validation of the technique in rheumatoid arthritis. The paradigm represents outcome by five separate dimensions: death, discomfort, disability, drug (therapeutic) toxicity, and dollar cost. Each dimension represents an outcome directly related to patient welfare. Quantitation of these outcome dimensions may be performed at interview or by patient questionnaire. With standardized, validated questions, similar scores are achieved by both methods. The questionnaire technique is preferred since it is inexpensive and does not require interobserver validation. These techniques appear extremely useful for evaluation of long term outcome of patients with rheumatic diseases.