Quality of care in systemic lupus erythematosus: application of quality measures to understand gaps in care

BACKGROUND

Systemic lupus erythematosus (SLE) affects 1 in 2500 Americans and is associated with significant morbidity and mortality. The recent development of SLE quality measures provides an opportunity to understand gaps in clinical care and to identify modifiable factors associated with variations in quality.

OBJECTIVE

To evaluate performance on SLE quality measures as well as differences in quality of care by demographic, socioeconomic, disease, and health system characteristics.

DESIGN AND PATIENTS

Cross-sectional analysis of data derived from the Lupus Outcomes Study, a prospective, longitudinal study of 814 individuals. Principal data collection was through annual structured telephone surveys between 2009-2010. Data on 13 SLE quality measures was collected. We used regression models to estimate demographic, socioeconomic, disease, and health system characteristics associated with performance on individual and overall quality measures.

OUTCOME MEASURES

Performance on each quality measure and overall performance on all measures for which participants were eligible (pass rate).

RESULTS

Participants were eligible for a mean of five measures (range 2-12). Performance varied from 29 % (assessment of cardiovascular risk factors) to 90 % (sun avoidance counseling). The overall pass rate was 65 % (95 % CI 64 %, 65 %). In unadjusted analyses, younger age, minority race/ethnicity, poverty, shorter disease duration, fewer physician visits, and lack of health insurance, were associated with lower pass rates. Receiving care in public sector managed care organizations was associated with higher pass rates. After adjustment, younger age, having fewer physician visits and lacking health insurance remained significantly associated with lower performance; receiving care in public sector managed care organizations remained associated with higher performance.

CONCLUSIONS

We identified a number of gaps in clinical care for SLE. Factors associated with the health care system, including presence and type of health insurance, were the primary determinants of performance on quality measures in SLE.

Validity of brief screening tools for cognitive impairment in rheumatoid arthritis and systemic lupus erythematosus

OBJECTIVE

To determine the validity of standardized screening assessments of cognitive functioning to detect neuropsychological impairment evaluated using a comprehensive battery in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).

METHODS

This is a cross-sectional study using a combined cohort of 139 persons with SLE and 82 persons with RA. Screening cut points were empirically derived using receiver operating characteristic curves and threshold selection methods. Screening measures included the Hopkins Verbal Learning Test-Revised (HVLT-R) learning and delayed recall indices and phonemic fluency, a composite measure of the 3 cognitive screening tests, and the Perceived Deficits Questionnaire-Short Form (PDQ-SF), a self-report measure of cognitive symptoms. A comprehensive neuropsychological battery was administered as the "gold standard" index of neuropsychological impairment.

RESULTS

Rates of neuropsychological impairment were 27% and 15% for the SLE and RA cohorts, respectively. Optimal threshold estimations were derived for 5 screening techniques. The HVLT-R learning and phonemic fluency indices yielded the greatest sensitivity at 81%. The PDQ-SF yielded the lowest sensitivity at 52%. All measures were significantly associated with neuropsychological impairment after controlling for relevant sociodemographic covariates and depression.

CONCLUSION

These results suggest that telephone-administered screening techniques may be useful measures to identify persons with neuropsychological impairment. Specifically, measures of phonemic fluency and verbal learning appeared to be most sensitive and least likely to misclassify impaired individuals as cognitively intact. Self-reported questionnaires may have relatively decreased sensitivity compared to standardized interviewer-administered cognitive measures.

Physical activity, obesity, and cognitive impairment among women with systemic lupus erythematosus

OBJECTIVE

To examine relationships of obesity and physical inactivity to cognitive impairment in women with systemic lupus erythematosus (SLE).

METHODS

Body composition was measured with dual x-ray absorptiometry (DXA) for 138 women with SLE. Obesity was defined by total percent body fat. Physical activity was ascertained with the self-reported International Physical Activity Questionnaire; inactivity was defined as expenditure of <600 metabolic equivalent minutes/week. Cognitive function was assessed with a 12-index neuropsychological battery. Impairment was defined as age-adjusted Z scores ≤1.5 SDs below the mean on 1 of 3 of tests completed. Scores were obtained for the total battery and for memory and executive function components. Multivariate analyses examined the relationship of obesity and physical activity, individually and combined, to cognitive impairment, controlling for education, race/ethnicity, disease activity, glucocorticoid use, and depression.

RESULTS

Fifteen percent of subjects were cognitively impaired, 28% were physically inactive, and 50% were obese. Five percent of active women were impaired on the executive function battery compared to 23% of those who were inactive (P = 0.003). Obese women were more likely to be impaired on the total battery (6% versus 23%; P = 0.007) and on the executive function portion (2% versus 19%) than nonobese women. In multivariate analysis, both inactivity and DXA-defined obesity were significantly associated with impairment in executive function (inactivity: odds ratio [OR] 9.4, 95% confidence interval [95% CI] 1.7-52.8; obesity: OR 14.8, 95% CI 1.4-151.0).

CONCLUSION

Both obesity and inactivity were significantly and independently associated with impairment in cognitive function. If longitudinal studies show that physical inactivity and obesity are precursors to cognitive impairment, these may become important targets for intervention.

Systemic lupus erythematosus and the economic perspective: a systematic literature review and points to consider

Systemic lupus erythematosus (SLE) is a chronic, disabling, progressive disease, with many associated comorbidities, affecting patients during prime working years resulting in a high economic burden on society, producing high direct, indirect and intangible costs. In this article, our goals are two-fold. First, we review and discuss studies published in the period 2002-2012 concerning costs of SLE and point out gaps in the published literature. Second, we propose further research studies to advance our understanding of the economic perspective in SLE in the current area of new and emerging therapies. The literature evaluating disease costs in SLE remains limited and to date has only included a small number of countries. Despite these limitations, available studies indicate that SLE has significant socio-economic ramifications. Future studies are needed, especially to assess novel biologic therapies which have been made available or currently under investigation for SLE. An interesting approach in these new economic evaluations in SLE may be represented by the selection of the targets of the treatment to include in the cost-effectiveness and cost-utility analyses. Future treat-to-target strategies will likely include evaluation of their pharmacoeconomic implications.

Longitudinal study of the impact of incident organ manifestations and increased disease activity on work loss among persons with systemic lupus erythematosus

OBJECTIVE

There is increasing evidence of the impact of systemic lupus erythematosus (SLE) on employment, but few studies have had sufficient sample size and longitudinal followup to estimate the impact of specific manifestations or of increasing disease activity on employment.

METHODS

Data were derived from the University of California, San Francisco, Lupus Outcomes Study, a longitudinal cohort of 1,204 persons with SLE sampled between 2002 and 2009. Of the 1,204 persons, 484 were working at baseline and had at least 1 followup interview. We used the Kaplan-Meier method to estimate the time between onset of thrombotic, neuropsychiatric, or musculoskeletal manifestations, or of increased disease activity, and work loss. We used Cox proportional hazards regression to estimate the risk of work loss associated with the onset of specific manifestations, the number of manifestations, and increased activity, with and without adjustment for sociodemographic, employment, and SLE duration characteristics.

RESULTS

By 4 years of followup, 57%, 34%, and 38% of those with thrombotic, musculoskeletal, and neuropsychiatric manifestations, respectively, had stopped working, as had 42% of those with increased disease activity. On a bivariable basis, the risk of work loss was significantly higher among persons ages 55-64 years and those with increased disease activity and each kind of manifestation. In multivariable analysis, older age, shorter job tenure, thrombotic and musculoskeletal manifestations, greater number of manifestations, and high levels of activity increased the risk of work loss.

CONCLUSION

Incident thrombosis and musculoskeletal manifestations, multiple manifestations, and increased disease activity are associated with the risk of work loss in SLE.

Racial and ethnic disparities in disease activity and function among persons with rheumatoid arthritis from university-affiliated clinics

OBJECTIVE

Health outcomes in rheumatoid arthritis (RA) have improved significantly over the past 2 decades. However, research suggests that disparities exist by race/ethnicity and socioeconomic status, with certain vulnerable populations remaining understudied. Our objective was to assess disparities in disease activity and function by race/ethnicity and explore the impact of language and immigrant status at clinics serving diverse populations.

METHODS

We examined a cross-sectional study of 498 adults with confirmed RA at 2 rheumatology clinics: a university hospital clinic and a public county hospital clinic. Outcomes included the Disease Activity Score in 28 joints (DAS28) and its components, and the Health Assessment Questionnaire (HAQ), a measure of function. We estimated multivariable linear regression models including interaction terms for race/ethnicity and clinic site.

RESULTS

After adjusting for age, sex, education, disease duration, rheumatoid factor status, and medication use, clinically meaningful and statistically significant differences in DAS28 and HAQ scores were seen by race/ethnicity, language, and immigrant status. Lower disease activity and better function was observed among whites compared to nonwhites at the university hospital. This same pattern was observed for disease activity by language (English compared to non-English) and immigrant status (US-born compared to immigrant) at the university clinic. No significant differences in outcomes were found at the county clinic.

CONCLUSION

The relationship between social determinants and RA disease activity varied significantly across clinic setting with pronounced variation at the university, but not at the county clinic. These disparities may be a result of events that preceded access to subspecialty care, poor adherence, or health care delivery system differences.

Impact of obesity on functioning among women with systemic lupus erythematosus

OBJECTIVE

Obesity is associated with high rates of disability in the general population. The nature of the relationship between obesity and disability in systemic lupus erythematosus (SLE), a condition with a high background rate of disability, is unknown.

METHODS

Data were from 2 interviews, 4 years apart, of a longitudinal cohort of individuals with SLE (n = 716 women). Body mass index (BMI) was calculated from self-reported height and weight; obesity was classified by usual (BMI ≥30) and revised (BMI ≥26.8) definitions. Three measures of functioning were examined: the Short Form 36 (SF-36) Health Survey physical function (PF) subscale, Valued Life Activities (VLA) Disability Questionnaire, and employment. Multivariate analyses controlled for demographics, SLE duration and disease activity, glucocorticoid use, depression, and comorbidities. Prospective analyses also controlled for baseline function.

RESULTS

At a BMI of ≥30, 27.8% of the subjects were obese; at a BMI of ≥26.8, 40.6% of the subjects were obese. Regardless of obesity definition, obese women exhibited poorer baseline function, with decrements ranging from 20-33% depending on the functional measure and obesity definition. With a BMI of ≥26.8, the adjusted SF-36 PF scores were 4.3 points lower for obese women (P < 0.0001), VLA difficulty was 0.09 higher (P = 0.01), and odds of employment were 80% of nonobese women (odds ratio 0.8, 95% confidence interval 0.5-1.1). At the 4-year followup, women who were obese at baseline had poorer function and experienced greater functional declines.

CONCLUSION

Obesity was associated with clinically significant negative effects on function, both concurrently and prospectively. This negative impact occurred at a lower BMI than is often considered problematic clinically. Because of the high rate of SLE-related disability, addressing preventable risk factors such as obesity may improve long-term SLE outcomes.

Differences in activity limitation, pain intensity, and global health in patients with rheumatoid arthritis in Sweden and the USA: a 5-year follow-up

OBJECTIVE

In this study we compared activity limitations, pain intensity, and global health in patients with rheumatoid arthritis (RA) in Sweden and the USA and aimed to determine whether nationality is associated with these outcomes.

METHODS

We used longitudinal data from the 'Swedish TIRA project' (n = 149) and the University of California, San Francisco (UCSF) RA panel study (n = 85). Data were collected annually concerning use of medications [disease-modifying anti-rheumatic drugs (DMARDs), biologics, and corticosteroids], morning stiffness, number of swollen joints, and number of painful joints. Three self-reported outcome measures were examined: pain intensity measured on a 0-100 visual analogue scale (VAS), activity limitation according to the Health Assessment Questionnaire (HAQ), and global health. To analyse the data, the Student's t-test, the χ(2)-test, and the generalized estimating equation (GEE) method were used.

RESULTS

Nationality was significantly related to HAQ score and pain intensity, even after adjustment for covariates. The patients in the TIRA cohort reported a lower HAQ score and a higher pain intensity than the patients in the UCSF cohort. Nationality was not related to global health.

CONCLUSION

Patients with RA should be assessed with awareness of the psychosocial and cultural context because disability seems to be affected by nationality. Further knowledge to clarify how a multinational setting affects disability could improve the translation of interventions for patients with RA across nationalities.

Depression in patients with rheumatoid arthritis: description, causes and mechanisms

Two sets of contributory factors to depression among patients with rheumatoid arthritis (RA) are generally examined - the social context of the individual and the biologic disease state of that person's RA. This article will review the evidence for both. RA affects patients both physically and psychologically. Comorbid depression is common with RA and leads to worse health outcomes. Low socioeconomic status, gender, age, race/ethnicity, functional limitation, pain and poor clinical status have all been linked to depression among persons with RA. Systemic inflammation may also be associated with, cause, or contribute to depression in RA. Understanding the socioeconomic factors, individual patient characteristics and biologic causes of depression in RA can lead to a more comprehensive paradigm for targeting interventions to eliminate depression in RA.

Socioeconomic determinants of disability and depression in patients with rheumatoid arthritis

OBJECTIVE

To examine the relationship between functional limitation, socioeconomic inequality, and depression in a diverse cohort of patients with rheumatoid arthritis (RA).

METHODS

The study design was cross-sectional and subjects were from the University of California, San Francisco RA Cohort. Patients were enrolled from 2 rheumatology clinics, an urban county public hospital and a university tertiary care medical center. Age, sex, race/ethnicity, disease activity, functional limitation, and medications were variables collected at clinical visits. The patient's clinic site was used as a proxy for his or her socioeconomic status. The outcome variable was depressive symptom severity measured by the Patient Health Questionnaire 9. Differences in characteristics between depressed and nondepressed patients were calculated using 2-sided t-tests or the Pearson's chi-square test. For the multivariate analysis, repeated measures with generalized estimating equations were used.

RESULTS

There were statistically significant differences between depressed and nondepressed patients related to race/ethnicity, public versus tertiary care hospital rheumatology clinic, disability, and medications. In the multivariate analysis, increased functional limitation and public clinic site remained significantly associated with increased depression scores. A significant interaction existed between clinic site and disability. Mean depression scores rose more precipitously as functional limitation increased at the public hospital rheumatology clinic.

CONCLUSION

There are disparities in both physical and mental health among individuals with low socioeconomic status. The psychological effects of disability vary in patients with RA such that a vulnerable population with functional limitations is at higher risk of developing depressive symptoms.

Obesity and its measurement in a community-based sample of women with systemic lupus erythematosus

OBJECTIVE

To determine the prevalence of obesity and evaluate how accurately standard anthropometric measures identify obesity among women with systemic lupus erythematosus (SLE).

METHODS

Dual x-ray absorptiometry (DXA), height, weight, and waist and hip circumference measurements were collected from 145 women with SLE. Three anthropometric proxies of obesity (body mass index [BMI]≥30 kg/m2, waist circumference [WC]≥88 cm, and waist:hip ratio [WHR]≥0.85) were compared with a DXA-based obesity criterion. Correspondence between measures was assessed with Cohen's kappa. Receiver operating characteristic curves determined optimal cut points for each anthropometric measure relative to DXA. Framingham cardiovascular risk scores were compared among women who were classified as not obese by both traditional and revised anthropometric definitions, obese by both definitions, and obese only by the revised definition.

RESULTS

Of the 145 women, 28%, 29%, 41%, and 50% were classified as obese by WC, BMI, WHR, and DXA, respectively. Correspondence between anthropometric and DXA-based measures was moderate. Women misclassified by anthropometric measures had less truncal fat and more appendicular lean and fat mass. Cut points were identified for anthropometric measures to better approximate DXA estimates of percent body fat: BMI≥26.8 kg/m2, WC≥84.75 cm, and WHR≥0.80. Framingham risk scores were significantly higher in women classified as obese by either traditional or revised criteria.

CONCLUSION

A large percentage of this group of women with SLE was obese. Substantial portions of women were misclassified by anthropometric measures. Utility of revised cut points compared with traditional cut points in identifying risk of cardiovascular disease or disability remains to be examined in prospective studies, but results from the Framingham risk score analysis suggest that traditional cut points exclude a significant number of at-risk women with SLE.

Receipt of disease-modifying antirheumatic drugs among patients with rheumatoid arthritis in Medicare managed care plans

CONTEXT

In 2005, the Healthcare Effectiveness Data and Information Set (HEDIS) introduced a quality measure to assess the receipt of disease-modifying antirheumatic drugs (DMARDs) among patients with rheumatoid arthritis (RA).

OBJECTIVE

To identify sociodemographic, community, and health plan factors associated with DMARD receipt among Medicare managed care enrollees.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed individual-level HEDIS data for 93,143 patients who were at least 65 years old with at least 2 diagnoses of RA within a measurement year (during 2005-2008). Logistic regression models with generalized estimating equations were used to determine factors associated with DMARD receipt and logistic regression was used to adjust health plan performance for case mix.

MAIN OUTCOME MEASURES

Receipt or nonreceipt of DMARD.

RESULTS

The mean age of patients was 74 years; 75% were women and 82% were white. Overall performance on the HEDIS measure for RA was 59% in 2005, increasing to 67% in 2008 (P for trend <.001). The largest difference in performance was based on age: patients aged 85 years and older had a 30 percentage point lower rate of DMARD receipt (95% confidence interval [CI], -29 to -32 points; P < .001), compared with patients 65 to 69 years of age, even after adjusting for other factors. Lower percentage point rates were also found for patients who were men (-3 points; 95% CI, -5 to -2 points; P < .001), of black race (-4 points; 95% CI, -6 to -2 points; P < .001), with low personal income (-6 points; 95% CI, -8 to -5 points; P < .001), with the lowest zip code-based socioeconomic status (-4 points; 95% CI, -6 to 2 points; P < .001), or enrolled in for-profit health plans (-4 points; 95% CI, -7 to 0 points; P < .001); and in the Middle Atlantic region (-7 points; 95% CI, -13 to -2 points; P < .001) and South Atlantic regions (-11 points; 95% CI, -20 to -3 points; P < .001) as compared with the Pacific region. Performance varied widely by health plan, ranging from 16% to 87%.

CONCLUSIONS

Among Medicare managed care enrollees carrying a diagnosis of RA between 2005 and 2008, 63% received a DMARD. Receipt of DMARDs varied based on demographic factors, socioeconomic status, geographic location, and health plan.

Osteoporosis screening, prevention, and treatment in systemic lupus erythematosus: application of the systemic lupus erythematosus quality indicators

OBJECTIVE

Osteoporosis and fragility fractures are associated with significant morbidity for patients with systemic lupus erythematosus (SLE). New quality indicators (QIs) for SLE advise bone mineral density testing, calcium and vitamin D use, and antiresorptive or anabolic treatment for specific subgroups of patients receiving high-dose steroids.

METHODS

Subjects were participants in the University of California, San Francisco Lupus Outcomes Study, an ongoing longitudinal study of patients with physician-confirmed SLE, in 2007-2008. Patients responded to an annual telephone survey and were queried regarding demographic, clinical, and other health care-related variables. Multiple logistic regression was used to predict receipt of care per the QIs described above.

RESULTS

One hundred twenty-seven patients met the criteria for the formal definitions of the denominators for QI I (screening) and QI II (calcium and vitamin D); 91 met the formal criteria for QI III (treatment). The proportions of patients receiving care consistent with the QIs were 74%, 58%, and 56% for QIs I, II, and III, respectively. In a sensitivity analysis of all steroid users (n = 427 for QI I and II and n = 224 for QI III), rates were slightly lower. Predictors of receiving care varied by QI and by denominator; however, female sex, older age, white race, and longer disease duration were associated with higher-quality care.

CONCLUSION

Bone health-related care in this community-based cohort of SLE patients is suboptimal. Quality improvement efforts should address osteoporosis prevention and care among all SLE patients, especially those receiving high-dose, prolonged steroids.

Childhood-onset disease as a predictor of mortality in an adult cohort of patients with systemic lupus erythematosus

OBJECTIVE

To examine childhood-onset disease as a predictor of mortality in a cohort of adult patients with systemic lupus erythematosus (SLE).

METHODS

Data were derived from the University of California Lupus Outcomes Study, a longitudinal cohort of 957 adult subjects with SLE that includes 98 subjects with childhood-onset SLE. Baseline and followup data were obtained via telephone interviews conducted in 2002-2007. The number of deaths during 5 years of followup was determined and standardized mortality ratios (SMRs) for the cohort, and across age groups, were calculated. Kaplan-Meier life table analysis was used to compare mortality rates between childhood- (defined as SLE diagnosis at <18 years of age) and adult-onset SLE. Multivariate Cox proportional hazard models were used to determine predictors of mortality.

RESULTS

During the median followup period of 48 months, 72 deaths (7.5% of subjects) occurred, including 9 deaths (12.5%) in subjects with childhood-onset SLE. The overall SMR was 2.5 (95% confidence interval [95% CI] 2.0-3.2). In Kaplan-Meier survival analysis, after adjusting for age, childhood-onset subjects were at increased risk for mortality throughout the followup period (P< 0.0001). In a multivariate model adjusting for age, disease duration, and other covariates, childhood-onset SLE was independently associated with an increased mortality risk (hazard ratio [HR] 3.1, 95% CI 1.3-7.3), as was low socioeconomic status measured by education (HR 1.9, 95% CI 1.1-3.2), and end stage renal disease (HR 2.1, 95% CI 1.1-4.0).

CONCLUSION

Childhood-onset SLE was a strong predictor of mortality in this cohort. Interventions are needed to prevent early mortality in this population.

Health-related quality of life and employment among persons with systemic lupus erythematosus

This article assesses the effect of systemic lupus erythematosus (SLE) on the shealth-related quality of life (HRQOL) and employment of persons with this condition. Far more than impaired health status can affect an individual's quality of life. The term "health-related quality of life" is used to connote the decrement in an individual's quality of life specifically attributable to a decrease in health status. The article presents evidence on employment because this plays a crucial role in determining the quality of life of most Americans of normal working age. However, evidence is also presented with respect to other domains of activity, because most people work to live but not many live to work.

Role of community and individual characteristics in physician visits for persons with systemic lupus erythematosus

OBJECTIVE

To examine the effects of individual and local level socioeconomic status (SES) and health care access characteristics on the number of self-report physician visits for systemic lupus erythematosus (SLE).

METHODS

Data derived from 755 adult participants from the 2004 to 2007 Lupus Outcomes Study (LOS) resulted in a sample of 2,926 repeated-measures observations. The outcome measure was the number of physician visits in the prior 12 months. Information on disease activity and manifestations, demographics, health insurance, and specialty of the participants' main SLE physician was collected through yearly LOS interviews. Local area measures including neighborhood poverty, the number of subspecialists per capita, and hospital market areas were added from secondary data sources. We used a mixed model with repeated measures to estimate the number of physician visits for SLE by SES and health care access characteristics, as well as the extent of concentrated poverty and number of subspecialists per capita in the local community, and whether these relationships varied by specific hospital market area. Multivariate models were adjusted for demographic and health status covariates.

RESULTS

LOS respondents reported a mean +/- SD of 11.8 +/- 10.7 (range 0-52) physician visits for SLE. After adjustment, having less than a high school education, receiving care in a health maintenance organization, being treated by a generalist, and living in a community of concentrated poverty were associated with a significantly lower number of physician visits for SLE. These relationships varied by hospital market areas.

CONCLUSION

Beyond health status, the number of physician visits for SLE varies by SES, neighborhood poverty, and characteristics of the health care system.

Hydroxychloroquine treatment in a community-based cohort of patients with systemic lupus erythematosus

OBJECTIVE

In recent years hydroxychloroquine (HCQ) has emerged as a key therapy in systemic lupus erythematosus (SLE). We determined the rates of HCQ use in a diverse, community-based cohort of patients with SLE and identified predictors of current HCQ use.

METHODS

Patients were participants in the University of California San Francisco Lupus Outcomes Study, an ongoing longitudinal study of patients with confirmed SLE. We examined the prevalence of HCQ use per person-year and compared baseline characteristics of users and nonusers, including demographic, socioeconomic, clinical, and health system use variables. Multiple logistic regression with generalized estimating equations was used to evaluate predictors of HCQ use.

RESULTS

A total of 881 patients contributed 3,095 person-years of data over 4 interview cycles. The prevalence of HCQ use was 55 per 100 person-years and was constant throughout the observation period. In multivariate models, the odds of HCQ use were nearly doubled among patients receiving their SLE care from a rheumatologist compared with those identifying generalists or nephrologists as their primary sources of SLE care. In addition, patients with shorter disease duration were more likely to use HCQ, even after adjusting for age and other covariates.

CONCLUSION

In this community-based cohort of patients, HCQ use was suboptimal. Physician specialty and disease duration were the strongest predictors of HCQ use. Patients who are not using HCQ, those with longer disease duration, and those who see nonrheumatologists for their SLE care should be targeted for quality improvement.

Frequent use of the emergency department among persons with systemic lupus erythematosus

OBJECTIVE

To describe characteristics of systemic lupus erythematosus (SLE) patients who are frequent users of the emergency department and to identify predictors of frequent emergency department use.

METHODS

Data for this study were derived from the University of California, San Francisco Lupus Outcomes Study, a large cohort of persons with SLE who undergo annual structured interviews. Participants were categorized into 1 of 3 levels of emergency department utilization: nonusers (no visits in the preceding year), occasional users, (1-2 visits), and frequent users (> or =3 visits). We compared characteristics of the 3 groups and determined predictors of frequent emergency department use (> or =3 visits) using multivariate logistic regression, adjusting for a variety of potential confounding covariates.

RESULTS

Of 807 study participants, 499 (62%) had no emergency department visits; 230 (28%) had occasional emergency department visits (1-2 visits); and 78 (10%) had frequent (> or =3 visits) emergency department visits. Frequent users were younger, less likely to be employed, and less likely to have completed college. They also had greater disease activity, worse general health status, and more depressive symptoms. Frequent emergency department users were more likely to have Medicaid as their principal insurance. In multivariate logistic regression, older age predicted a lower likelihood of frequent emergency department visits, whereas greater disease activity and having Medicaid insurance predicted a higher likelihood of frequent emergency department visits.

CONCLUSION

In persons with SLE, greater disease activity and Medicaid insurance are associated with more frequent emergency department use.

Depressive symptoms in middle age and the development of later-life functional limitations: the long-term effect of depressive symptoms

OBJECTIVES

To determine whether middle-aged persons with depressive symptoms are at higher risk for developing activity of daily living (ADL) and mobility limitations as they advance into older age than those without.

DESIGN

Prospective cohort study.

SETTING

The Health and Retirement Study (HRS), a nationally representative sample of people aged 50 to 61.

PARTICIPANTS

Seven thousand two hundred seven community living participants in the 1992 wave of the HRS.

MEASUREMENTS

Depressive symptoms were measured using the 11-item Center for Epidemiologic Studies Depression Scale (CES-D 11), with scores of 9 or more (out of 33) classified as significant depressive symptoms. Difficulty with five ADLs and basic mobility tasks (walking several blocks or up one flight of stairs) was measured every 2 years through 2006. The primary outcome was persistent difficulty with ADLs or mobility, defined as difficulty in two consecutive waves.

RESULTS

Eight hundred eighty-seven (12%) subjects scored 9 or higher on the CES-D 11 and were classified as having significant depressive symptoms. Over 12 years of follow-up, subjects with depressive symptoms were more likely to reach the primary outcome measure of persistent difficulty with mobility or difficulty with ADL function (45% vs 23%, Cox hazard ratio (HR)=2.33, 95% confidence interval (CI)=2.06-2.63). After adjusting for age, sex, measures of socioeconomic status, comorbid conditions, high body mass index, smoking, exercise, difficulty jogging 1 mile, and difficulty climbing several flights of stairs, the risk was attenuated but still statistically significant (Cox HR=1.44, 95% CI=1.25-1.66).

CONCLUSION

Depressive symptoms independently predict the development of persistent limitations in ADLs and mobility as middle-aged persons advance into later life. Middle-aged persons with depressive symptoms may be at greater risk for losing their functional independence as they age.

Translating medical effectiveness research into policy: lessons from the California Health Benefits Review Program

CONTEXT

Legislatures and executive branch agencies in the United States and other nations are increasingly using reviews of the medical literature to inform health policy decisions. To clarify these efforts to give policymakers evidence of medical effectiveness, this article discusses the California Health Benefits Review Program (CHBRP). This program, based at the University of California, analyzes the medical effectiveness of health insurance benefit mandate bills for the California legislature, as well as their impact on cost and public health.

METHODS

This article is based on the authors' experience reviewing benefit mandate bills for CHBRP and findings from evaluations of the program. General observations are illustrated with examples from CHBRP's reports. Information about efforts to incorporate evidence into health policymaking in other states and nations was obtained through a review of published literature.

FINDINGS

CHBRP produces reports that California legislators, legislative staff, and other major stakeholders value and use routinely in deliberations about benefit mandate bills. Where available, the program relies on previously published meta-analyses and systematic reviews to streamline the review of the medical literature. Faculty and staff responsible for the medical effectiveness sections of CHBRP's reports have learned four major lessons over the course of the program's six-year history: the need to (1) recognize the limitations of the medical literature, (2) anticipate the need to inform legislators about the complexity of evidence, (3) have realistic expectations regarding the impact of medical effectiveness reviews, and (4) understand the consequences of the reactive nature of mandated benefit reviews.

CONCLUSIONS

CHBRP has demonstrated that it is possible to produce useful reviews of the medical literature within the tight time constraints of the legislative process. The program's reports have provided state legislators with independent analyses that allow them to move beyond sifting through conflicting information from proponents and opponents to consider difficult policy choices and their implications.

Predictors of depression in a multiethnic cohort of patients with rheumatoid arthritis

OBJECTIVE

Patients with rheumatoid arthritis (RA) who experience depression have worse health outcomes. This study identifies predictors of depression in an ethnically and racially diverse population of patients with RA.

METHODS

Patients with RA in a prospective cohort at the San Francisco General Hospital outpatient rheumatology clinic were included if they were age >or=18 years, met the American College of Rheumatology classification criteria for RA, had a Health Assessment Questionnaire (HAQ) score collected, and had the RA-specific Disease Activity Score performed by a rheumatologist. The outcome variable was a depression score measured by the Patient Health Questionnaire 9 (PHQ-9), a self-report questionnaire validated to correlate with a diagnosis of major depression.

RESULTS

Three hundred forty-nine clinical visits for 172 patients were included in the analysis. Forty percent of patients scored >or=10 on the PHQ-9 during at least one clinic visit, which corresponds to a symptom severity of at least moderate depression. The mean PHQ-9 score was 7, corresponding to a symptom severity of mild depression. In the multivariate analysis, higher HAQ scores were associated with depression, and Asians had lower depression scores compared with Hispanic, white, and African American subjects.

CONCLUSION

Identifying associated predictors of depression in a diverse population of patients with RA can help guide treatment, which should include preventing disability and decreased function as well as targeting depressive symptoms more specifically in patients with RA.

Ambulatory visit utilization in a national, population-based sample of adults with osteoarthritis

OBJECTIVE

To estimate the proportion of adults with osteoarthritis (OA) seeing various medical providers and ascertain factors affecting the likelihood of a patient seeing an OA specialist.

METHODS

We used data from the Medical Expenditures Panel Survey, a stratified random sample of the noninstitutionalized civilian population. We classified adults as having symptomatic OA if their medical conditions included at least 1 occurrence of the International Classification of Diseases, Ninth Revision Clinical Modification, codes 715, 716, or 719, and if they reported joint pain, swelling, or stiffness during the previous 12 months. For the purpose of our analysis, we defined rheumatologists, orthopedists, and physical therapists as OA specialists. We first estimated the proportion of OA individuals seen by OA specialists and other health care providers in a 1-year period. We then used logistic regression to estimate the impact of demographic and clinical factors on the likelihood of an individual seeing an OA specialist.

RESULTS

A total of 9,933 persons met the definition of OA, representing 22.5 million adults in the US. Of these persons, 92% see physicians during the year, 34% see at least 1 OA specialist, 25% see an orthopedist, 11% see a physical therapist, and 6% see a rheumatologist. Higher educational attainment, having more comorbidities, and residing in the northeastern US are significant positive predictors for a patient seeing an OA specialist. Significant negative predictors for seeing an OA specialist are being unmarried but previously married and having no health insurance.

CONCLUSION

Most adults with OA do not visit OA specialists. Those without insurance and with lower levels of education are less likely to see these specialists.

Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume

BACKGROUND

Total knee arthroplasty (TKA) relieves pain and improves quality of life for persons with advanced knee osteoarthritis. However, to our knowledge, the cost-effectiveness of TKA and the influences of hospital volume and patient risk on TKA cost-effectiveness have not been investigated in the United States.

METHODS

We developed a Markov, state-transition, computer simulation model and populated it with Medicare claims data and cost and outcomes data from national and multinational sources. We projected lifetime costs and quality-adjusted life expectancy (QALE) for different risk populations and varied TKA intervention and hospital volume. Cost-effectiveness of TKA was estimated across all patient risk and hospital volume permutations. Finally, we conducted sensitivity analyses to determine various parameters' influences on cost-effectiveness.

RESULTS

Overall, TKA increased QALE from 6.822 to 7.957 quality-adjusted life years (QALYs). Lifetime costs rose from $37,100 (no TKA) to $57 900 after TKA, resulting in an incremental cost-effectiveness ratio of $18,300 per QALY. For high-risk patients, TKA increased QALE from 5.713 to 6.594 QALY, yielding a cost-effectiveness ratio of $28,100 per QALY. At all risk levels, TKA was more costly and less effective in low-volume centers than in high-volume centers. Results were insensitive to variations of key input parameters within policy-relevant, clinically plausible ranges. The greatest variations were seen for the quality of life gain after TKA and the cost of TKA.

CONCLUSIONS

Total knee arthroplasty appears to be cost-effective in the US Medicare-aged population, as currently practiced across all risk groups. Policy decisions should be made on the basis of available local options for TKA. However, when a high-volume hospital is available, TKAs performed in a high-volume hospital confer even greater value per dollar spent than TKAs performed in low-volume centers.

Pain, functional limitations, and aging

OBJECTIVES

To examine the relationship between functional limitations and pain across a spectrum of age, ranging from mid life to advanced old age.

DESIGN

Cross-sectional study.

SETTING

The 2004 Health and Retirement Study (HRS), a nationally representative study of community-living persons aged 50 and older.

PARTICIPANTS

Eighteen thousand five hundred thirty-one participants in the 2004 HRS.

MEASUREMENTS

Participants who reported that they were often troubled by pain that was moderate or severe most of the time were defined as having significant pain. For each of four functional domains, subjects were classified according to their degree of functional limitation: mobility (able to jog 1 mile, able to walk several blocks, able to walk one block, unable to walk one block), stair climbing (able to climb several flights, able to climb one flight, not able to climb a flight), upper extremity tasks (able to do 3, 2, 1, or 0), and activity of daily living (ADL) function (able to do without difficulty, had difficulty but able to do without help, need help).

RESULTS

Twenty-four percent of participants had significant pain. Across all four domains, participants with pain had much higher rates of functional limitations than subjects without pain. Participants with pain were similar in terms of their degree of functional limitation to participants 2 to 3 decades older. For example, for mobility, of subjects aged 50 to 59 without pain, 37% were able to jog 1 mile, 91% were able to walk several blocks, and 96% were able to walk one block without difficulty. In contrast, of subjects aged 50 to 59 with pain, 9% were able to jog 1 mile, 50% were able to walk several blocks, and 69% were able to walk one block without difficulty. Subjects aged 50 to 59 with pain were similar in terms of mobility limitations to subjects aged 80 to 89 without pain, of whom 4% were able to jog 1 mile, 55% were able to walk several blocks, and 72% were able to walk one block without difficulty. After adjustment for demographic characteristics, socioeconomic status, comorbid conditions, depression, obesity, and health habits, across all four measures, participants with significant pain were at much higher risk for having functional limitations (adjusted odds ratio (AOR)=2.85, 95% confidence interval (CI)=2.20-3.69, for mobility; AOR=2.84, 95% CI=2.48-3.26, for stair climbing; AOR=3.96, 95% CI=3.43-4.58, for upper extremity tasks; and AOR=4.33; 95% CI=3.71-5.06, for ADL function).

CONCLUSION

Subjects with pain develop the functional limitations classically associated with aging at much earlier ages.

Patient-reported outcomes following biologic therapy in a sample of adults with rheumatoid arthritis recruited from community-based rheumatologists

OBJECTIVE

To examine self-reported symptoms and functioning in a community-based sample of persons with rheumatoid arthritis who did and did not initiate treatment with biologic agents.

METHODS

Data were from annual telephone interviews (1998-2003) with an observational cohort identified through community rheumatologists. Self-reported function and symptoms of subjects who initiated biologic therapy (etanercept or infliximab) and reported consistent use at 2 annual interviews (continuous use; n = 64) were compared at 1 year prior to initiation of therapy (baseline), and years 1 and 2 of therapy to those with no biologic therapy (n = 183) and those who initiated biologic therapy but discontinued use (n = 42).

RESULTS

At baseline, subjects taking biologic agents reported significantly worse function and symptoms on all measures except fatigue and pain severity. After 2 years, significant differences in the Health Assessment Questionnaire scores remained, but there were no other significant differences between the nonuser group and the continuous use group. The discontinued use group exhibited significantly greater pain severity and more painful joints than nonusers. Improvements in the number of painful (33.4% versus 16.2%; P = 0.004), and swollen (38.4% versus 18.7%; P = 0.003) joints, and morning stiffness (27.3% versus 10.4%; P = 0.001) were more frequent in the continuous use group than in the nonuser group.

CONCLUSION

Results suggest that biologic treatment was initiated based on severe disease. Over approximately 17 months of treatment, differences in some but not all symptoms between the continuous use group and the nonuser group narrowed to statistical nonsignificance.

Work loss and work entry among persons with systemic lupus erythematosus: comparisons with a national matched sample

OBJECTIVE

To prospectively track work loss among those employed and work entry among those not employed in a cohort of persons with systemic lupus erythematosus (SLE), assess risk factors for these outcomes, and compare rates of the outcomes with a matched national sample.

METHODS

The present study analyzed 4 years of data from the Lupus Outcomes Study (LOS), augmented by information on the local labor market from the Census Bureau and the Bureau of Labor Statistics. We used the Kaplan-Meier method to assess time from study initiation until work loss or work entry, and Cox proportional hazards regression to estimate factors affecting these outcomes. Finally, we compared rates of work loss and work entry in the LOS with rates in the Survey of Income and Program Participation (SIPP).

RESULTS

At study initiation, 394 LOS participants (51%) were employed, of whom 92 (23.4%) experienced work loss. In multivariate analysis, older age, lower cognitive and physical functioning, and higher reports of depressive symptoms predicted work loss. In comparison with the SIPP sample, rates of work loss did not differ. Of the 376 LOS participants not employed, 76 (20.2%) experienced work entry. In multivariate analysis, less disease activity, fewer lung manifestations, better physical functioning, and shorter time since last employment predicted work entry. In comparison with the SIPP, rates of work entry were only lower between ages 35 and 55 years.

CONCLUSION

Until age 55 years, low rates of employment among persons with SLE may be due to lower rates of work entry rather than higher rates of work loss. Beyond age 55 years, both high rates of work loss and low rates of work entry contribute to low rates of employment.

Depression, medication adherence, and service utilization in systemic lupus erythematosus

OBJECTIVE

Forgetting to take medications is an important cause of nonadherence. This study evaluated factors associated with forgetting to take medications in a large cohort of persons with systemic lupus erythematosus (SLE) participating in the University of California, San Francisco Lupus Outcomes Study (LOS). Relationships among adherence problems and service utilization (outpatient visits, emergency department visits, and hospitalizations) were also evaluated.

METHODS

The cohort consisted of 834 LOS participants who provided self-reported frequency of forgetting to take medications as directed. Predictors of adherence and service utilization patterns included self-reported sociodemographics, disease-related characteristics (e.g., disease activity, recent SLE flare), and mental health characteristics (Center for Epidemiologic Studies Depression Scale and cognitive function screen). Health care utilization patterns included the presence and quantity of visits to rheumatologists, primary care physicians, other care providers, emergency departments, and hospitalizations.

RESULTS

Forty-six percent of the LOS cohort reported forgetting to take medications at least some of the time. Depressive symptom severity was a strong predictor of adherence difficulties (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02-1.05; P < 0.0001) after accounting for all other predictors. Persons reporting adherence difficulties had significantly greater numbers of outpatient rheumatology and primary care visits, and were more likely to visit the emergency department (OR 1.45, 95% CI 1.04-2.04; P = 0.03).

CONCLUSION

Depression may be an important cause of medication adherence problems, and difficulties with adherence are significantly associated with high-cost service utilization, specifically emergency department visits. In an era of rapidly evolving treatments for lupus, identifying patients at risk for adherence problems may decrease medical expenditures and improve patient outcomes in SLE.

A quality indicator set for systemic lupus erythematosus

OBJECTIVE

To systematically develop a quality indicator (QI) set for systemic lupus erythematosus (SLE).

METHODS

We used a validated process that combined available scientific evidence and expert consensus to develop a QI set for SLE. We extracted 20 candidate indicators from a systematic literature review of clinical practice guidelines pertaining to SLE. An advisory panel revised and augmented these candidate indicators and, through 2 rounds of voting, arrived at 25 QIs. These QIs advanced to the next phase of the project, in which we employed a modification of the RAND/UCLA Appropriateness Method. A systematic review of the literature was performed for each QI, linking the proposed process of care to potential improved health outcomes. After reviewing this scientific evidence, a second interdisciplinary expert panel convened to discuss the evidence and provide final ratings on the validity and feasibility of each QI.

RESULTS

The final expert panel rated 20 QIs as both valid and feasible. Areas covered included diagnosis, general preventive strategies (e.g., vaccinations, sun avoidance counseling, and screening for cardiovascular disease), osteoporosis prevention and treatment, drug toxicity monitoring, renal disease, and reproductive health.

CONCLUSION

We employed a rigorous multistep approach with systematic literature reviews and 2 expert panels to develop QIs for SLE. This new set of indicators provides an opportunity to assess health care quality in patients with SLE and represents an initial step toward the important goal of improving care in this patient population.

Differences in long-term disease activity and treatment of adult patients with childhood- and adult-onset systemic lupus erythematosus

OBJECTIVE

To compare differences in long-term outcome between adults with childhood-onset (age at diagnosis <18 years) systemic lupus erythematosus (SLE) and with adult-onset SLE.

METHODS

Data were derived from the University of California Lupus Outcomes Study, a longitudinal cohort of 885 adult subjects with SLE (90 childhood-onset [cSLE], 795 adult-onset [aSLE]). Baseline and 1-year followup data were obtained via structured 1-hour telephone interviews conducted between 2002 and 2006. Using self-report data, differences in organ involvement and disease morbidity, current disease status and activity, past and current medication use, and number of physician visits were compared, based on age at diagnosis of SLE.

RESULTS

Average disease duration for the cSLE and aSLE subgroups was 16.5 and 13.4 years, respectively, and mean age at followup was 30.5 and 49.9 years, respectively. When compared with aSLE subjects, cSLE subjects had a higher frequency of SLE-related renal disease, whereas aSLE subjects were more likely to report a history of pulmonary disease. Rates of clotting disorders, seizures, and myocardial infarction were similar between the 2 groups. At followup, cSLE subjects had lower overall disease activity, but were more likely to be taking steroids and other immunosuppressive therapies. The total number of yearly physician visits was similar between the 2 groups, although cSLE subjects had a higher number of nephrology visits.

CONCLUSION

This study demonstrates important differences in the outcomes of patients with cSLE and aSLE, and provides important prognostic information about long-term SLE disease activity and treatment.

Health care costs and costs associated with changes in work productivity among persons with systemic lupus erythematosus

OBJECTIVE

To estimate health care costs and costs associated with changes in work productivity among persons with systemic lupus erythematosus (SLE) in the US.

METHODS

Data were derived from the University of California, San Francisco Lupus Outcomes Study. Participants provided information on their health care resource use and employment. Cost estimates were derived for both direct health care costs and costs related to changes in work productivity. Direct health care costs included costs for hospitalizations, emergency department services, physician visits, outpatient surgical procedures, dialysis, and medications. Productivity costs were estimated by measuring changes in hours of work productivity since diagnosis of SLE; these estimates were also compared with normal US population data.

RESULTS

For the total population of participants, the mean annual direct cost was $12,643 (2004 US dollars). The mean annual productivity cost for subjects of employment age (>or=18 and <65 years) was $8,659. The mean annual total cost (direct and productivity) for subjects of employment age was $20,924. Regression results showed that greater disease activity, longer disease duration, and worse physical and mental health were significant predictors of higher direct costs; older age predicted lower direct costs. Older age, greater disease activity, and worse physical and mental health status were significant predictors of higher costs due to changes in work productivity.

CONCLUSION

Both direct health care costs and costs associated with changes in work productivity are substantial and both represent important contributors to the total costs associated with SLE.

Subclinical disability in valued life activities among individuals with rheumatoid arthritis

OBJECTIVE

Subclinical disability, the need for modifications in task performance or frequency without reported difficulty with the task, has been identified as a stage along the disability continuum. We estimated the prevalence of subclinical disability in valued life activities (VLAs) among individuals with rheumatoid arthritis (RA), identified characteristics of individuals with VLA subclinical disability, and estimated the ability of VLA subclinical disability to predict later decrements in functioning.

METHODS

Data were from 3 years of a longitudinal panel study of individuals with RA, for which annual structured telephone interviews are conducted (n=508 in year 1, n=442 in year 3). Respondents rated difficulty in VLAs and then reported whether they used any of 4 behavioral modifications (limitations, extra time, help, or equipment) for each. Subclinical disability was defined for each VLA as no reported difficulty with use of any modification. Multiple regression analyses identified predictors of subclinical disability in year 1 and the role of year 1 subclinical disability in development of overt disability between year 1 and year 3.

RESULTS

Almost three-quarters of the subjects exhibited subclinical disability in at least 1 VLA in year 1. Duration of RA was consistently associated with subclinical disability. Individuals with subclinical disability at baseline were significantly more likely to experience increases in functional limitations (odds ratio [OR] 1.09, 95% confidence interval [95% CI] 1.01-1.18) and VLA disability (OR 1.14, 95% CI 1.06-1.23) over a prospective 2-year period.

CONCLUSION

Subclinical disability may be a valuable marker of individuals in a disability transition phase who are particularly susceptible to intervention that would enable them to maintain functioning.

The role of neighborhood and individual socioeconomic status in outcomes of systemic lupus erythematosus

OBJECTIVE

To determine if neighborhood socioeconomic status (SES) is independently related to physical and mental health outcomes in systemic lupus erythematosus (SLE).

METHODS

Data derived from the first 3 waves of the Lupus Outcomes Study, a telephone survey of 957 patients with confirmed SLE diagnoses, recruited from clinical and non-clinical sources. Residential addresses were geocoded to U.S. Census block groups. Outcome measures included the Systemic Lupus Activity Questionnaire (SLAQ) score, a self-reported assessment of SLE symptoms; the Medical Outcomes Study Short Form-36 Health Survey physical functioning score; and Center for Epidemiologic Studies-Depression (CES-D) score of > or = 19 points. Multivariate analyses adjusted for race/ethnicity and other demographic and health-related covariates.

RESULTS

After adjustment, lower individual SES, measured by education, household income, or poverty status, was associated with all outcomes. In models that did not include individual SES, low neighborhood SES (> 30% of residents in poverty) was also associated with poor outcomes. After adjustment for individual SES, demographic, and health-related covariates, only CES-D > or = 19 remained associated with neighborhood SES: 47% [95% confidence interval (CI) 38-56%] versus 35% (95% CI 32-37%).

CONCLUSION

Individual SES is associated with physical and mental health outcomes in persons with SLE. Low neighborhood SES contributes independently to high levels of depressive symptoms. Future research should focus on mechanisms underlying these differences.

Impact of perceived neighborhood problems on change in asthma-related health outcomes between baseline and follow-up

We investigated whether perceived neighborhood problems (NP) predicted changes over a 2-year period in asthma-specific quality of life (QOL), physical functioning (PF), and depressive symptomology (DEP) in a longitudinal cohort of 340 adults with asthma. There is a threshold and plateau effect between NP and PF, such that NP do not affect changes in PF until the problems reach the level of Quartile 3. People who had NP scores in Quartile 3 had lower PF compared to people who reported NP in Quartiles 1 or 2 (mean difference -3.09). High NP also predicted over two-fold odds of high DEP (Center for Epidemiological Studies Depression [CES-D] score > or = 16) at follow-up (odds ratio=2.34; 95% confidence interval: 1.09-5.00). NP did not predict decline in QOL. Analyses adjusted for demographics, asthma severity, and baseline value of the health outcome.

Valued life activity disability played a significant role in self-rated health among adults with chronic health conditions

OBJECTIVE

Because self-rated health (SRH) is strongly associated with health outcomes, it is important to identify factors that individuals take into account when they assess their health. We examined the role of valued life activities (VLAs), the wide range of activities deemed to be important to individuals, in SRH assessments.

STUDY DESIGN AND SETTING

Data were from three cohort studies of individuals with different chronic conditions--rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and chronic obstructive pulmonary disease (COPD). Each cohort's data were collected through structured telephone interviews. Logistic regression analyses identified factors associated with ratings of fair/poor SRH. All analyses included sociodemographic characteristics, general and disease-specific health-related factors, and general measures of physical functioning.

RESULTS

Substantial portions of each group rated their health as fair/poor (RA 37%, SLE 47%, COPD 40%). In each group, VLA disability was strongly associated with fair/poor health (RA: OR=4.44 [1.86,10.62]; SLE: OR=3.60 [2.10,6.16]; COPD: OR=2.76 [1.30,5.85]), even after accounting for covariates.

CONCLUSION

VLA disability appears to play a substantial role in individual perceptions of health, over and above other measures of health status, disease symptoms, and general physical functioning.

Disability in valued life activities among individuals with systemic lupus erythematosus

OBJECTIVE

To identify the prevalence of disability in a wide range of valued life activities (VLAs) among individuals with systemic lupus erythematosus (SLE), 1-year changes in such disability, and predictors of and changes in VLA disability.

METHODS

Data were from 2 waves of a cohort of 829 individuals with SLE interviewed annually by telephone. VLA disability was assessed using a scale rating the difficulty of performing 21 activities. Scores were also calculated for subscales corresponding to obligatory, committed, and discretionary activities. Changes in VLA disability from baseline to 1-year followup were assessed. Sociodemographic and disease status measures were examined as predictors of and changes in VLA disability using multiple regression analyses.

RESULTS

Almost half of the subjects were unable to perform > or =1 VLA at baseline. Almost all (91%) reported > or =1 VLA affected by SLE. One-quarter of the subjects experienced a significant increase in the number of activities they were unable to perform; approximately half experienced significant increases in the number of activities affected and in difficulty scores. Proportions of individuals whose disability increased and whose disability decreased were roughly equivalent. Disease status measures accounted for 62-72% of the variation in VLA difficulty. More severe disease status was predictive of increases in VLA difficulty; few predictors of improvements were identified.

CONCLUSION

VLA disability was common, with more disability noted in committed and discretionary activities than in obligatory activities. Because VLA disability has been linked to psychological well-being in previous studies, identification of factors that may protect against such disability is important.

Impact of memory impairment on employment status in persons with systemic lupus erythematosus

OBJECTIVE

To assess the specific contribution of memory impairment to employment status in persons with systemic lupus erythematosus (SLE).

METHODS

A total of 832 patients with SLE were surveyed and data collected on demographics, SLE symptoms and activity, health status, depression, medications, health resource utilization, and current employment status. Participants underwent screening for memory impairment and based on their scores were categorized to 3 levels of memory function: intact, mild-moderate impairment, and severe impairment. Employment status was compared across impairment levels using multivariate logistic regression, adjusting for sociodemographic characteristics (i.e., age, sex, race, education, and marital status), employment status at year of diagnosis, disease activity, disease duration, and depression.

RESULTS

In the intact memory function group, 54.2% were employed, versus 40.6% in the mild-moderate impairment group and 31.0% in the severe impairment group. In the intact memory function group, 29.2% were unable to work, versus 40.6% in the mild-moderate impairment group and 56.3% in the severe impairment group. After multivariate adjustment, increasing levels of memory impairment predicted a decreased likelihood of being employed: odds ratio (OR) 0.70, 95% confidence interval (95% CI) 0.48-1.02 for the mild-moderate impairment group and OR 0.57, 95% CI 0.32-1.00 for the severe impairment group. Participants with memory impairment were more likely to report being unable to work: OR 1.36, 95% CI 0.90-2.04 for the mild-moderate impairment group, and OR 1.99, 95% CI 1.12-3.55 for the severe impairment group. These findings were statistically significant only in the severe impairment groups.

CONCLUSION

The findings suggest that severe memory impairment is an important factor associated with employment status in persons with SLE.

Effect of arthritis in middle age on older-age functioning

OBJECTIVES

To examine whether symptomatic arthritis in middle age predicts the earlier onset of functional difficulties (difficulty with activities of daily living (ADLs) and walking) that are associated with loss of independence in older persons.

DESIGN

Prospective longitudinal study.

SETTING

The Health and Retirement Study, a nationally representative sample of persons aged 50 to 62 at baseline who were followed for 10 years.

PARTICIPANTS

Seven thousand five hundred forty-three subjects with no difficulty in mobility or ADL function at baseline.

MEASUREMENTS

Arthritis was measured at baseline according to self-report. The primary outcome was time to persistent difficulty in one of five ADLs or mobility (walking several blocks or up a flight of stairs). Difficulty with ADLs or mobility was assessed according to subject interview every 2 years. Analyses were adjusted for other comorbid conditions, body mass index, exercise, and demographic characteristics.

RESULTS

Twenty-nine percent of subjects reported arthritis at baseline. Subjects with arthritis were more likely to develop persistent difficulty in mobility or ADL function over 10 years of follow-up (34% vs 18%, adjusted hazard ratio (HR)=1.63, 95% confidence interval (CI)=1.43-1.86). When each component of the primary outcome was assessed separately, arthritis was also associated with persistent difficulty in mobility (30% vs 16%, adjusted HR=1.55, 95% CI=1.41-1.71) and persistent difficulty in ADL function (13% vs 5%, adjusted HR=1.85, 95% CI=1.58-2.16).

CONCLUSION

Middle-aged persons who report a history of arthritis are more likely to develop mobility and ADL difficulties as they enter old age. This finding highlights the need to develop interventions and treatments that take a life-course approach to preventing the disabling effect of arthritis.

Association of socioeconomic and demographic factors with utilization of rheumatology subspecialty care in systemic lupus erythematosus

OBJECTIVE

To examine the role of sociodemographic factors (age, race/ethnicity, and sex) and socioeconomic factors (income and education) in the utilization of rheumatology subspecialty care in a large cohort of subjects with systemic lupus erythematosus (SLE).

METHODS

Data were derived from a cohort of 982 English-speaking subjects with SLE. Between 2002 and 2004, trained survey workers administered a telephone survey to subjects eliciting information regarding demographics, SLE disease status, medications, health care utilization, health insurance, and socioeconomic status. We identified predictors of utilization of rheumatology subspecialty care, defined as at least 1 visit to a rheumatologist in the previous year. In addition, we examined factors associated with identifying any specialist as primarily responsible for SLE care.

RESULTS

Older age, lower income, Medicare insurance, male sex, and less severe disease were associated with lack of rheumatology care. However, race/ethnicity and educational attainment were not significantly related to seeing a rheumatologist. After multivariate adjustment, only older age, lower income, and male sex remained associated with absence of rheumatology visits. Those least likely to identify a specialist as primarily responsible for their SLE care included older subjects and those reporting lower incomes.

CONCLUSION

Although elderly subjects and those with lower incomes traditionally have access to health care through the Medicare and Medicaid programs, the presence of health insurance alone did not ensure equal utilization of care. This finding suggests that additional barriers to accessing rheumatology subspecialty care may exist in these patient populations.

Medicaid and access to care among persons with systemic lupus erythematosus

OBJECTIVE

To evaluate the associations between Medicaid insurance and distance traveled by patients to treating physicians and health care utilization for patients with systemic lupus erythematosus (SLE).

METHODS

A total of 982 adults with SLE were recruited between 2002 and 2004. We calculated the distance between patient homes and physicians using Mapquest, an Internet mapping program. We then assessed the association between Medicaid status and distance traveled to the primary SLE provider, presence of > or =1 physician visits, and the number of all physician visits, with and without adjustment for demographic and medical covariates.

RESULTS

On an unadjusted basis, Medicaid patients traveled longer distances to see their primary SLE provider. This effect was pronounced for patients under the care of a rheumatologist. Adjustment reduced, but did not eliminate, these differences. With adjustment for covariates, Medicaid patients were equally as likely to see a rheumatologist as non-Medicaid patients. However, Medicaid patients were more likely to be seen by a general practitioner or in the emergency room for their SLE, and reported more visits to general practitioners and the emergency room for SLE.

CONCLUSION

Medicaid patients with SLE traveled longer distances to see an SLE physician, especially rheumatologists. They also reported a different pattern of health care utilization. These results suggest that Medicaid patients may face barriers in obtaining comprehensive medical services in proximity to their residences.