Evidence for decline in disability and improved health among persons aged 55 to 70 years: the Framingham Heart Study.

OBJECTIVES: This study detected secular change in disability and health among persons aged 55 to 70 years, the life period when increases in disability and morbidity begin and retirement occurs. METHODS: Cross-sectional comparisons were completed with data from similarly aged members of the original (n = 1760) and offspring (n = 1688) cohorts of the Framingham Heart Study, which represent 2 generations. Analyses were conducted by gender and on chronic disease subgroups by logistic regression. RESULTS: There was substantially less disability in the offspring cohort than in the original cohort. Thirty-six percent of offspring men were disabled vs 52% of original cohort men (P = .001); among women, these proportions were 54% vs 72% (P = .001). Fewer offspring perceived their health as fair or poor and fewer had chronic diseases. Offspring were more physically active and less likely to smoke or consume high amounts of alcohol, but their average weight was greater. The secular decline in disability was strongly evident among individuals with chronic diseases. CONCLUSIONS: Our findings depict a secular change toward a less disabled and globally healthier population in the period of life when retirement occurs.

Short-form Arthritis Impact Measurement Scales 2: tests of reliability and validity among patients with osteoarthritis.

OBJECTIVE: To validate a short-form Arthritis Impact Measurement Scales 2 (AIMS2-SF) among 147 patients with osteoarthritis (OA). METHODS: We used factor analysis to identify domains of functional health associated with OA. Multitrait scaling analysis was used to evaluate the reliability and validity of the AIMS2-SF. RESULTS: The results suggested that upper body limitations should be distinguished from lower body limitations in the physical function scale. The AIMS2-SF was psychometrically sound, with all 5 scales having high item-discriminant validity and Cronbach's alpha reliability above the 0.70 criterion (except 0.67 for the social function scale). CONCLUSION: The AIMS2-SF is a reliable and valid instrument among patients with OA. Because of its simplicity and ease of application, it may be useful in routine evaluation of health status, in clinical research, and in predicting use of medical services among OA patients.

Resource utilization and cost of care for rheumatoid arthritis and osteoarthritis in a managed care setting: the importance of drug and surgery costs.

OBJECTIVE: To describe the frequency and costs of medical services for patients with osteoarthritis (OA) or rheumatoid arthritis (RA) in a managed care setting. METHODS: Individual utilization records of medical and pharmacy services for OA and RA patients were obtained from a group-model health maintenance organization (HMO). Estimates were made for costs of drugs and medical services for arthritis from July 1, 1993 to June 30, 1994 using Medicare reimbursement schedules and average wholesale drug prices. Calculated rates for each population were expressed as counts of events or as dollars per person-year. RESULTS: The average individual cost rate of arthritis-related care for 365 RA patients was $2,162 per year, and the total cost of RA care to the HMO was $703,053. Prescription medications accounted for 62% ($436,440) of the total cost of RA care, while ambulatory care accounted for 21% ($150,938), and hospital visits accounted for 16% ($115,674). With regard to 10,101 OA patients, the average individual cost rate was $543 per year, and total cost to the HMO was $4,728,425. Hospital care accounted for 46% ($2,170,890) of the total cost of OA care, medications accounted for 32% ($1,509,637), and ambulatory care accounted for 22% ($1,047,898). CONCLUSION: RA care, in the setting of this study, was characterized by intensive treatment, especially frequent use of medications that were delivered to most patients. Although the cost of RA care per patient was high, cost to the managed care provider was relatively low, owing to the rarity of RA. OA care tended to be infrequent, and the largest component of cost was hospital care for a small proportion of patients (5%). Owing to the greater prevalence of OA, care of OA was nearly 7 times more costly to the managed care provider than was care of RA.

Reducing work disability associated with rheumatoid arthritis: identification of additional risk factors and persons likely to benefit from intervention.

OBJECTIVE: To study additional risk factors for rheumatoid arthritis (RA)-related work disability and to identify the groups of individuals at high risk and the potentially modifiable factors which place them at risk. METHODS: A cross-sectional mail survey was conducted among 469 adults with RA. Work disability was defined as unemployment due to RA. A broad range of explanatory factors was examined, including sociodemographic, health, work, support given by others, and commuting difficulty. Employed and work-disabled subjects were compared by t-test and chi-square. Attributable fractions were calculated to assess the predictive value of factors. A recursive partitioning procedure identified individuals at varying risks for work disability, and their characteristics were defined. RESULTS: The risk factors joint pain and functional status, commuting difficulty, physical demands of the job, and disease duration were important predictors of work disability in both the attributable fraction and recursive partitioning analytic models. Having a professional or administrative job was protective, provided the salary earned was not low. Younger individuals with RA of shorter duration were placed at high risk by potentially modifiable factors. While older persons with RA of long duration were at high risk, modifiable factors could not be identified. CONCLUSION: Commuting difficulty, a previously overlooked factor, is an important predictor of RA work disability. Younger individuals with RA of relatively short duration can be placed at high risk by potentially modifiable factors including commuting difficulty, physically demanding jobs, greater joint pain and poor functional status, and nonprofessional/non-administrative jobs.

The correlates of health perceptions in rheumatoid arthritis.

OBJECTIVE: Although measures of health perceptions have been routinely incorporated into assessments of individuals with rheumatoid arthritis (RA), the relationships of other characteristics of these individuals to their health perceptions is not fully understood. We describe the cross sectional associations of sociodemographic, disease, and functional status characteristics with perceived health in individuals with RA. METHODS: This description was generated through a 2-phase secondary data analysis using 2 statistical approaches: recursive partitioning of the sample and standard multivariate logistic regression techniques. RESULTS: Both methodological approaches identified education, race, depression, and physical activity as important correlates of self-assessed health in RA. Each approach, in its own way, also identified an interactive effect between physical activity and education and between depression and race in these models. CONCLUSION: An individual's sociodemographic, disease, and functional status characteristics form a complex model of the correlates of health perceptions of individuals with RA.

The total costs of drug therapy for rheumatoid arthritis. A model based on costs of drug, monitoring, and toxicity.

OBJECTIVE: We created a model to estimate the total medication costs of treating patients with rheumatoid arthritis with 6 second-line agents for the first 6 months of treatment. METHODS: Drug costs were obtained from a survey of pharmacies; monitoring costs were calculated from utilization information obtained in a survey of rheumatologists; toxicity costs were obtained using decision trees to represent the evaluation and treatment of potential toxicities. Monitoring and toxicity costs were estimated using costs from the Boston University Medical Center or, for hospitalizations, using appropriate diagnosis-related group categories. The sum of the 3 components determined the total medication costs. RESULTS: The least expensive medication was penicillamine, at $10.62/week, and the most expensive was injectable gold, at $30.89/week. In terms of monitoring costs, methotrexate had the highest costs associated with necessary laboratory tests and office visits. Hydroxychloroquine had the lowest monitoring costs for office visits, and oral gold had the lowest for laboratory costs. Hematologic toxicities were the largest component of toxicity costs for all 6 medications, and renal toxicities were costly for patients taking oral gold, penicillamine, and injectable gold. Total medication costs revealed oral gold as the least expensive medication and injectable gold as the most expensive. The combination of monitoring and toxicity costs accounted for more than 60% of the total costs for all medications except injectable gold. In all cases, the cost of treating toxicities was the smallest of the 3 components. CONCLUSION: When calculating the costs of drug therapy, it is important to consider not only the price of the drug, but also the costs of monitoring and treating the toxicities that might occur. Failure to do so will result in underestimating the true costs of treatment with these medications.

The costs of rheumatoid arthritis.

The economic costs associated with rheumatoid arthritis (RA), a chronic, systemic, inflammatory disorder that affects many joints, are high, approximating those of coronary heart disease. The estimated prevalence of RA in the US is 0.9%. Incidence increases with age, and is highest among women in the fourth to sixth decades of life. The primary impact of RA is due to the significant morbidity associated with this disease. Mortality is increased among a poorly defined subgroup of RA patients. The average level of disability among RA patients is moderate, but 6.5 to 12% of patients are severely disabled. Between one- and two-thirds of previously employed patients have a reduced work capacity. Treatment primarily involves the use of nonsteroidal anti-inflammatory drugs and disease modifying antirheumatic drugs. Rehabilitation measures and orthopaedic surgery are also used. Total annual direct costs of RA (total charges) have been calculated to be $US5275 and $US6099 (1991 dollars) per patient. Lifetime medical care charges were estimated at $US12,578 per patient (1991 dollars). The direct costs of RA are substantial, but indirect costs have been calculated to be much higher because of extensive morbidity. The difference between the direct and indirect costs of RA is decreasing because salary increases have not kept pace with rising healthcare costs. The latter are increasing rapidly in RA because of the use of new technology, surgical procedures, and the greater use of drugs with frequent monitoring requirements and significant toxicity. Because intangible costs such as pain form a substantial part of the overall costs of RA but are difficult to evaluate, cost estimates inevitably underestimate the impact of the disease on individuals and society.

The efficacy and toxicity of combination therapy in rheumatoid arthritis. A meta-analysis.

OBJECTIVE: To evaluate the efficacy and toxicity of combination therapy, compared with single second-line drug therapy, in rheumatoid arthritis. METHODS: This study was a meta-analysis of published trials that evaluated combinations of full-dose second-line drugs and compared them with single second-line drugs at full dose. Using a random effects model, we summarized the difference between improvement with combination therapy and improvement with single-drug therapy. RESULTS: Five trials that met inclusion criteria, which contained 749 entering patients and 516 completing patients, were identified. The mean +/- SEM difference in improvement in tender joint count between combination and single-drug therapy at end of trial (24-52 weeks) was 2.4 +/- 0.7 joints (out of 60) (P < 0.001). At end of trial the difference between therapies in swollen joint counts was 1.0 +/- 1.2 joints (P = 0.42). The difference in grip strength improvement was 3.7 +/- 4.3 mm Hg (P = 0.40), and for erythrocyte sedimentation rate it was 3.4 +/- 3.1 mm/hour (P = 0.27). In general, the differences in efficacy between combination and single-drug therapy were clinically marginal. Nine percent more combination therapy-treated patients experienced side effect-related discontinuation of therapy than patients receiving single-drug therapy (P = 0.008). CONCLUSION: Combination therapy, as it has been used in recent clinical trials, does not offer a substantial improvement in efficacy, but does have higher toxicity than single drug therapy. These combination therapy regimens are not recommended for widespread use. Other more aggressive regimens with additional drugs or higher drug doses than have been studied might be more efficacious, but with an even higher rate of toxicity.

Use of short-term efficacy/toxicity tradeoffs to select second-line drugs in rheumatoid arthritis. A metaanalysis of published clinical trials.

OBJECTIVE: Preferred drugs for rheumatoid arthritis (RA) should be those that have maximal efficacy with the least toxicity. We evaluated the efficacy and toxicity tradeoffs for drugs frequently used in the treatment of RA. METHODS: We updated 2 metaanalyses of published clinical trials, by adding trials published through 1990 and trials of azathioprine (AZA). We tested 3 different definitions of efficacy, each plotted against 3 different toxicity measures, for antimalarial drugs, methotrexate (MTX), auranofin, injectable gold, D-penicillamine, sulfasalazine (SSZ), AZA, and placebo. Efficacy measures included composite efficacy (a combination of joint count, grip strength, and erythrocyte sedimentation rate), tender joint count alone, and a measure based on how many patients dropped out due to inefficacy. Toxicity measures were the proportion dropping out due to toxicity, the same dropouts with side effects weighted for severity using a modification of a published toxicity index, and the proportion with severe toxicities (defined as a score of at least 7 of 10 on the toxicity index). The latter were usually organ toxicities (e.g., cytopenias and renal involvement). RESULTS: All 9 efficacy/toxicity tradeoff plots suggested that MTX and antimalarial drugs had the highest efficacy relative to toxicity. MTX scored among the most efficacious of the drugs and, of these, had the least toxicity. Antimalarial drugs, though showing only moderate efficacy, had the lowest toxicity rate of all the drugs. SSZ scored close to MTX but was, in general, slightly more toxic. CONCLUSION: In the short-term context of clinical trials, antimalarial drugs and MTX have the best efficacy/toxicity tradeoffs and may, therefore, be the preferred drugs.

Do self-reported arthritis symptom (RADAR) and health status (AIMS2) data provide duplicative or complementary information?

This study assessed whether self-report measures of symptoms and functional health status provide unique outcome information, or whether functional status assessments primarily serve as a proxy for self-reported arthritis symptoms. Symptom scores of 138 individuals with rheumatoid arthritis (RA) collected with the Rapid Assessment of Disease Activity in Rheumatology (RADAR) measure were compared with same-day functional health scores collected with the recently revised Arthritis Impact Measurement Scales (AIMS2). Correlational and factor analyses revealed that self-assessed arthritis symptoms, physical function and work impact, psychological status, and social health each made independent contributions to outcome. Satisfaction with health status was shown not to be independent of symptoms, functional capacity, or psychological status. It is important to document that self-reported symptom and health status information, when collected concurrently, provides complementary rather than duplicative information.

The economic impacts of juvenile rheumatoid arthritis.

Our study documents the direct costs, family costs and community (extra school) costs. One hundred and twenty families with children who had juvenile rheumatoid arthritis (JRA) diagnosed by established criteria and who lived in New England were asked to participate. All data except inpatient charged were collected via questionnaire. The questionnaire return rate was 59% (N = 70). The mean annualized direct cost/child was 7,905 (inpatient, $1,717; outpatient, $5,700; and nonmedical, $488). Family costs averaged $1,524/year (out of pocket medical and nonmedical, $1,196; lost salary, $328), which represented 5% of mean family income. The mean extra school cost was $1,449/9 months. The economic impacts of JRA appear to be substantial.

The rapid assessment of disease activity in rheumatology (radar) questionnaire. Validity and sensitivity to change of a patient self-report measure of joint count and clinical status.

OBJECTIVE: This study documents the measurement properties of a brief, self-administered questionnaire of disease signs and symptoms in patients with rheumatoid arthritis. METHODS: The Rapid Assessment of Disease Activity in Rheumatology (RADAR) questionnaire assesses joint pain/tenderness and clinical status. One hundred ninety-three pairs of RADAR forms were completed by 45 subjects and their assigned clinician evaluators. RESULTS: Subject-clinician agreement (intraclass correlation coefficients [ICC]) for joint pain/tenderness and clinical status ranged from 0.52 to 0.87 (P = 0.0001), with 83% greater than or equal to 0.65. The ICC for change in joint scores over 6 months was 0.83 (P = 0.0001). CONCLUSION: The 2-page RADAR questionnaire produces valid estimates of joint count and clinical status that are sensitive to change.

AIMS2. The content and properties of a revised and expanded Arthritis Impact Measurement Scales Health Status Questionnaire.

OBJECTIVE: The goal of this project was to develop a more comprehensive and sensitive version of the Arthritis Impact Measurement Scales (AIMS). METHODS: AIMS scale items were revised, and 3 new scales were added to evaluate arm function, work, and social support. Sections were also added to assess satisfaction with function, attribution of problems to arthritis, and self-designation of priority areas for improvement. The new instrument was designated the AIMS2. A pilot test of format and content and a performance test of reliability and validity were carried out. RESULTS: Questionnaire completion times in a pilot study of 24 subjects averaged 23 minutes, and evaluations were positive regarding the instrument's length and ease of completion, and the subjects' willingness to complete serial forms and return them by mail. Measurement performance was tested in 408 subjects: 299 with rheumatoid arthritis (RA) and 109 with osteoarthritis (OA); 45 of these subjects completed a second AIMS2 within 3 weeks. Internal consistency coefficients for the 12 scales were 0.72-0.91 in the RA group and 0.74-0.96 in the OA group. Test-retest reliability was 0.78-0.94. All within-scale factor analyses produced single factors, except for mobility level in OA. Validity analyses in both the RA and the OA groups showed that patient designation of an area as a problem or as a priority for improvement was significantly associated with a poorer AIMS2 scale score in that area. Reliability, factor analysis, and validity results were consistent in age, sex, and education subgroups. Satisfaction was moderately correlated with level of function in the same health status area, and the satisfaction items formed a reliable scale. Responses to the arthritis attribution items showed that most dysfunction in this sample was due to arthritis. CONCLUSION: The AIMS2 is a revised and expanded health status questionnaire with excellent measurement properties that should be useful in arthritis clinical trials and in outcomes research.

Subspecialty training: is it financially worthwhile?

OBJECTIVE: To determine the financial return of additional training in a cognitive-oriented medical subspecialty (rheumatology) and in a procedure-oriented medical subspecialty (gastroenterology) relative to general internal medicine. DESIGN: Analysis of existing data to compare lifetime discounted earnings of physicians in different medical specialties. PARTICIPANTS: General internists, gastroenterologists, and rheumatologists were surveyed. MAIN OUTCOME MEASURES: Using data from surveys conducted by Medical Economics and the American College of Rheumatology, we constructed lifetime earnings streams that allowed the calculation of the net present values of discounted lifetime earnings in general internal medicine, gastroenterology, and rheumatology. Net present values of lifetime earnings were calculated for each group at two discount rates. Sensitivity analyses were done to estimate how changes in relative income would affect calculations of the net present values. MAIN RESULTS: The average net incomes before taxes for general internists, gastroenterologists, and rheumatologists in 1988 were $115,825, $201,875, and $118,056, respectively. At 5% and 10% discount rates, the net present values of the estimated career earnings stream for additional training in gastroenterology relative to general internal medicine were + $1,101,863 and + $512,952, respectively; for additional training in rheumatology relative to general internal medicine, the respective values were - $84,748 and - $92,467. If the incomes of general internists were decreased by 3% and the incomes of gastroenterologists were decreased by 25% to reflect the effect of potential changes due to the resource-based relative value scale (RBRVS), or if gastroenterology training were increased to 3 years and rheumatology fellowship stipends were increased by 30%, large differences would still exist between the groups. CONCLUSION: Gastroenterologists have an extremely large return on their additional investment in training, but rheumatologists have a negative return. When considered exclusively as a financial decision, fellowship training in a cognitive-oriented medical subspecialty such as rheumatology is a poor investment. Even major changes in reimbursement policies will not affect the relative pecuniary attractiveness of procedure-oriented medical subspecialties.