Agreement of Physicians and Nurses Performing Tender and Swollen Joint Counts in Rheumatoid Arthritis.

OBJECTIVE: The aims of this study were to assess the agreement of physicians and nurses performing tender and swollen joint counts (TJCs/SJCs) in rheumatoid arthritis (RA) and identify factors that might influence their examinations including patient age, sex, race, RA disease duration, body mass index, RA disease activity level, comorbid fibromyalgia, comorbid osteoarthritis, and levels of acute-phase reactants. METHODS: Seventy-two RA participants underwent TJCs/SJCs of 28 joints using a standardized protocol by 2 nurses and 2 rheumatologists. Demographic, laboratory, radiographic, and clinical data were obtained to assess the influence of these factors on TJCs/SJCs. Intraclass correlations (ICCs) among examiners were determined for TJCs/SJCs. Nurse-physician differences and agreement of individual joints were evaluated using Cohen κ. Analysis of variance was performed to detect differences in means between examiners for TJCs/SJCs. Intraclass correlation and Fisher Z tests were used to identify factors influencing TJCs/SJCs. RESULTS: Agreement was strong among these nurses and physicians for total TJCs/SJCs (ICC = 0.84/ICC = 0.79, respectively). κ was best for hand joint tenderness and poorest for shoulder swelling. Some significant differences in mean TJCs/SJCs were found between examiners. Fibromyalgia significantly reduced agreement of both TJCs and SJCs. Agreement of TJC was significantly reduced when patients had lower disease activity, greater work impairment, lower mental health quality of life, and elevated erythrocyte sedimentation rate, whereas female sex, assessor's perception of but not radiographic hand osteoarthritis, and elevated C-reactive protein significantly reduced agreement for SJC. CONCLUSIONS: Strong agreement was found among nurses and physicians for total 28-joint counts, with agreement at individual joints being stronger for tenderness than swelling. Fibromyalgia significantly reduced ICCs of TJCs/SJCs.

Assessing for risk and progression of osteoarthritis: the nurse's role: understanding pathophysiology, epidemiology, and risk will aid nurses who are seeking to expand their role in management.

OVERVIEW: The authors review the primary and secondary risk factors for osteoarthritis (OA), its pathophysiology and epidemiology, the evidence-based approaches to slowing progression, and the role of nurses encountering OA in primary care and other settings.

Assessing for risk and progression of osteoarthritis: the nurse's role.

The authors review the primary and secondary risk factors for osteoarthritis (OA), its pathophysiology and epidemiology, the evidence-based approaches to slowing progression, and the role of nurses encountering OA in primary care and other settings.

Heterogeneity within the fibromyalgia population: theoretical implications of variable tender point severity ratings.

OBJECTIVE: The American College of Rheumatology (ACR) tender point (TP) criterion is used in diagnosing fibromyalgia syndrome (FM). There has been little research investigating patterns of positive TP. We investigated response patterns of TP in a sample of patients with FM. METHODS: Manual TP survey data were available on 1433 patients with FM. Factor analysis was conducted on ACR TP and control (CON) points. Factor scores were cluster analyzed to identify subgroups based on TP scores. Subgroups were compared on demographic and psychosocial variables. RESULTS: Factor analysis resulted in 4 TP groupings: neck/shoulder girdle, gluteal/trochanteric, and upper extremity regions, and a set of CON TP. Cluster analysis revealed 3 clusters. Group 1 was high on all 3 TP regions and the CON set; Group 2 moderate on the 3 TP regions, low on the CON set; and Group 3 was relatively low on all 3 TP regions and the CON set. The group highest on the CON and TP regions reported the greatest pain (7.58 +/- 1.23; p < 0.001), sleep disturbance (7.05 +/- 1.61; p < 0.001), anxiety (10.14 +/- 4.57; p < 0.001), and depression (8.42 +/- 4.4; p < 0.001). CONCLUSION: TP severity ratings varied among cluster groups, suggesting patients with FM are not homogeneous. Variations in TP severity provide information regarding the degree to which FM affects patients' quality of life. Patients with elevated scores on the CON TP demonstrated a general pattern reflecting lower thresholds for symptom reporting and, perhaps, disease severity. Research is needed to elucidate mechanisms underlying heterogeneity among the FM population.

Couple-Oriented Education and Support Intervention for Osteoarthritis: Effects on Spouses' Support and Responses to Patient Pain.

The purpose of this study was to determine whether a couple-oriented education and support intervention for osteoarthritis was more efficacious than a similar patient-oriented intervention in terms of enhancing spouses' support of patients and their positive and negative responses to patient pain. Repeated-measures analyses of covariance with the completers sample (N = 103 dyads) showed that at the postintervention assessment, patients in the couple-oriented intervention reported a greater decrease in their spouses' punishing responses (e.g., anger, irritation) than did patients in the patient-oriented intervention. In addition, a trend effect was observed in regard to the advantage of couple-oriented intervention for increasing spouses' attempts to distract patients from their pain. At the 6-month follow-up, patients in the couple-oriented intervention reported greater increased spouse support than those in the patient-oriented intervention. Findings illustrate the value of examining change in specific types of marital interactions targeted in a couples intervention, and the need to strengthen the impact of future couple-oriented interventions.

Older spouses' perceptions of partners' chronic arthritis pain: implications for spousal responses, support provision, and caregiving experiences.

This study of older patients with osteoarthritis and their spouses examined concordance between patients' and spouses' reports of patients' pain severity and the association of concordance with support and caregiving outcomes. Patients and spouses independently viewed videotapes of the patient performing simulated household tasks and provided ratings of patients' pain. Spousal overestimation of patients' pain was the most common type of nonconcordance. Spouses who were accurate in their perceptions of their partner's level of pain during a log-carrying task responded less negatively and provided emotional support that was more satisfying to patients. In addition, spouses who were accurate in their perceptions of their partner's pain during the log-carrying task reported less stress from providing support and assistance. Future research that uses such observational methods may be highly useful for understanding the effects of chronic illness on older couples.

Analgesic usage for low back pain: impact on health care costs and service use.

STUDY DESIGN: Cross-sectional analysis of analgesic use by patients with low back pain (LBP). OBJECTIVES: To describe patterns of analgesic use and their cost implications for the use of other care services among individuals with LBP enrolled in a health insurance plan during 2001. It was hypothesized that the use of analgesics would be most frequent among patients with LBP with neurologic findings. SUMMARY OF BACKGROUND DATA: National guidelines have recommended analgesics as the primary pharmacologic treatment of LBP. The choice of specific analgesics has major cost and service use implications. METHODS: The University of Pittsburgh Health System includes 18 affiliated hospitals, more than 5000 physicians, and a commercial health plan with 255,958 members in 2001. This study uses the System Health Plan's insurance claims database to identify members who had services provided for one of 66 International Classification of Diseases, Version 9, Clinical Modification codes that identify mechanical LBP (n = 17,148). RESULTS: In 2001, 7631 (43.5%) members with claims for LBP services had no analgesic pharmacy claims. The other 9517 (55.5%) had analgesics claims costing a total of $1.4 million; 68% of claimants were prescribed an opioid and 58% nonselective nonsteroidal antiinflammatory drugs (NSAID). The costs of opioids, NSAID, and cyclooxygenase-2 selective NSAID for patients with LBP represented 48%, 24%, and 28%, respectively, of total health plan expenditures for all uses of these drugs, including cancer. Opioid use was associated with the high volume usage of LBP care services. Patients with LBP with and without neurologic involvement and those with acquired lumbar spine structural disorders had similar patterns of analgesic use: those with congenital structural disorders were less likely to use analgesics; and those with psychogenic pain and LBP related to orthopedic devices were more likely to use opioids. CONCLUSIONS: With this health plan, a high proportion of patients with LBP had claims for opioids during 2001. The use of opioids by patients with LBP represents a major cost for the health plan, and is associated with specific patient characteristics and their use of other LBP services.

Factors associated with attrition of African Americans during the recruitment phase of a clinical trial examining adherence among individuals with rheumatoid arthritis.

OBJECTIVE: To examine factors contributing to the loss of potential minority participants in a study of medication adherence among rheumatoid arthritis patients. METHODS: Chi-square statistics were used to test for differences in refusal/ineligibility by race and site at 4 screening points (initial eligibility review, initial patient contact, adherence screening, and informed consent). Differences in criteria-specific risks for exclusion at initial eligibility review were examined across 4 sites by race. Odds ratios (95% confidence intervals) were estimated if differences were significant. Multivariate logistic regression was used to examine sociodemographic factors associated with the probability for ineligibility at the initial eligibility review. Stated reasons for refusal were qualitatively quantified. RESULTS: A greater percentage of African Americans were lost at every screening point when compared with whites, but only the difference at the initial eligibility review was statistically significant. CONCLUSION: Factors associated with attrition included selection of area medical sites, research design issues, comorbid conditions, alcohol abuse, and being younger, unmarried, African American, and male.

Quadriceps activation failure as a moderator of the relationship between quadriceps strength and physical function in individuals with knee osteoarthritis.

OBJECTIVE: To determine if quadriceps activation failure (QAF) moderates the relationship between quadriceps strength and physical function in individuals with knee osteoarthritis (OA). METHODS: Quadriceps strength and QAF were measured in 105 subjects (80 females) with radiographically confirmed knee OA using a burst-superimposition maximum voluntary isometric quadriceps torque test procedure. Subjects performed the Get Up and Go test as a physical performance measure of function and completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as a self-report measure of function. A principal component analysis was performed to combine the Get Up and Go score and the WOMAC subscores into a single function score. Hierarchical regression analysis was performed to examine the ability of 3 models to predict physical function (strength = function; strength + QAF = function; strength + QAF + [strength x QAF] = function). Partial F tests were used to compare differences in R(2) values between each model. RESULTS: Each model independently predicted the principal component score for function. Adding the strength x QAF interaction term with strength to the model resulted in the highest prediction of function. The strength x QAF interaction indicated that subjects with lower levels of quadriceps strength and higher levels of QAF had lower levels of function than those with comparable levels of weakness but low levels of QAF. CONCLUSION: The magnitude of QAF serves to moderate the relationship between quadriceps strength and physical function. Physical function may be more severely affected by weakness of the quadriceps muscles in individuals with knee OA who have higher degrees of QAF than those who may have quadriceps weakness, but do not have QAF.

Concordance of four methods of disability assessment using performance in the home as the criterion method.

OBJECTIVE: To determine the concordance of 4 methods of disability assessment with the criterion method. Performance testing in the home was selected as the criterion. METHODS: The task performance of 57 community-dwelling older women (>/=70 years) with knee osteoarthritis was examined through self report, proxy report, clinical judgment based on impairment measures, performance testing in an occupational therapy clinic, and performance testing in participants' homes. The 26 tasks represented 4 domains of daily living activities: 5 functional mobility, 3 personal care, 14 cognitively oriented instrumental activities of daily living (IADL), and 4 physically oriented IADL. RESULTS: In general, self reports and proxy reports had the highest concordance with in-home performance test results. Nonetheless, even for these methods, depending on task domain, the rate of discordance ranged from 31% to 54%, being least in personal care and greatest in the physically oriented IADL. CONCLUSION: Disability estimates based on self reports, proxy reports, clinical judgments, and hospital performance-based assessments are not interchangeable with in-home task performance.