Impact of health maintenance organizations and fee-for-service on health care utilization among people with systemic lupus erythematosus

OBJECTIVE

To compare health care utilization in people with systemic lupus erythematosus (SLE) in health maintenance organizations (HMOs) and fee-for-service (FFS).

METHODS

A structured survey was administered to a cohort of 982 people with SLE who were assembled between 2002 and early 2005. A total of 2,656 person-years of observation were completed by the end of 2005. In each year, respondents reported their health care utilization and whether they had HMO or FFS coverage. We compared health care utilization of those in HMOs and FFS, with and without adjustment for socioeconomic, demographic, and health characteristics using repeated-measures regression techniques.

RESULTS

Compared with people with SLE who were in FFS, those in HMOs were younger (3.3 years), received a diagnosis at an earlier age (3.6 years), had slightly less disease activity (0.4 on a 10-point scale), were more likely to be nonwhite (8.8%), were less likely to be below the poverty line (7.8%), and were less likely to have public insurance (29.7%). The 2 groups did not differ in other characteristics. On an unadjusted basis, subjects with SLE in HMOs had significantly fewer physician visits (3.1; 95% confidence interval [95% CI] 1.7, 4.5) and were less likely to report one or more outpatient surgical visits (6.3%; 95% CI 2.5, 10.0), and hospital admissions (5.5%; 95% CI 1.7, 9.3) than those in FFS. Adjustment reduced the differences in physician visits (2.3; 95% CI 1.1, 3.5), outpatient surgical rates (4.4%; 95% CI 0.6, 8.1), and hospital admission rates (4.0%, 95% CI 0.4, 7.7).

CONCLUSION

Subjects with SLE in HMOs utilized substantially less ambulatory care and were less likely to have outpatient surgery and hospital admissions than those in FFS; the effects were not completely explained by socioeconomic, demographic, and health characteristics.

Medical care expenditures and earnings losses among persons with arthritis and other rheumatic conditions in 2003, and comparisons with 1997

OBJECTIVE

To obtain estimates of medical care expenditures and earnings losses associated with arthritis and other rheumatic conditions and the increment in such costs attributable to arthritis and other rheumatic conditions in the US in 2003, and to compare these estimates with those from 1997.

METHODS

Estimates for 2003 were derived from the Medical Expenditures Panel Survey (MEPS), a national probability sample of households. We tabulated medical care expenditures of adult MEPS respondents, stratified by arthritis and comorbidity status, and used regression techniques to estimate the increment of medical care expenditures attributable to arthritis and other rheumatic conditions. We also estimated the earnings losses sustained by working-age adults with arthritis and other rheumatic conditions. Estimates for 2003 were compared with those from 1997, inflated to 2003 terms.

RESULTS

In 2003, there were 46.1 million adults with arthritis and other rheumatic conditions (versus 36.8 million in 1997). Adults with arthritis and other rheumatic conditions incurred mean medical care expenditures of $6,978 in 2003 (versus $6,346 in 1997), of which $1,635 was for prescriptions ($899 in 1997). Expenditures for adults with arthritis and other rheumatic conditions totaled $321.8 billion in 2003 ($233.5 billion in 1997). In 2003, the mean increment in medical care expenditures attributable to arthritis and other rheumatic conditions was $1,752 ($1,762 in 1997), for a total of $80.8 billion ($64.8 billion in 1997). Persons with arthritis and other rheumatic conditions ages 18-64 years earned $3,613 less than other persons (versus $4,551 in 1997), for a total of $108.0 billion (versus $99.0 billion). Of this amount, $1,590 was attributable to arthritis and other rheumatic conditions (versus $1,946 in 1997), for a total of $47.0 billion ($43.3 billion in 1997).

CONCLUSION

Our findings indicate that the increase in medical care expenditures and earnings losses between 1997 and 2003 is due more to an increase in the number of persons with arthritis and other rheumatic conditions than to costs per case.

Prevalence and correlates of arthritis-attributable work limitation in the US population among persons ages 18-64: 2002 National Health Interview Survey Data

OBJECTIVE

To estimate the national prevalence of arthritis-attributable work limitation (AAWL) among persons ages 18-64 with doctor-diagnosed arthritis and examine correlates of AAWL.

METHODS

Using the 2002 National Health Interview Survey, we estimated the prevalence of AAWL (limited in whether individuals work, the type of work they do, or the amount of work they do) and correlates of AAWL in univariable and multivariable-adjusted logistic regression analyses. Survey data were analyzed in SAS and SUDAAN to account for the complex sample design.

RESULTS

A total of 5.3% of all US adults ages 18-64 reported AAWL; in this age group, AAWL is reported by approximately 30% of those who report arthritis. The prevalence of AAWL was highest among people ages 45-64 years (10.2%), women (6.3%), non-Hispanic blacks (7.7%), people with less than a high school education (8.6%), and those with an annual household income <$20,000 (12.6%). AAWL was substantially increased among people with arthritis-attributable activity limitations (multivariable-adjusted odds ratio [OR] 9.1, 95% confidence interval [95% CI] 7.1-11.6). The multivariable-adjusted likelihood of AAWL was moderately higher among non-Hispanic blacks (OR 1.6, 95% CI 1.2-2.3), Hispanics (OR 1.8, 95% CI 1.2-2.6), and people with high levels of functional/social/leisure limitations (OR 1.8, 95% CI 1.4-2.3) and was decreased among those with a college education (OR 0.6, 95% CI 0.4-0.8).

CONCLUSION

AAWL is highly prevalent, affecting millions of Americans and one-third of adults with doctor-diagnosed arthritis. Findings suggest the need for more targeted research to better understand the natural history, success of interventions, and effects of policy on AAWL. Public health interventions, including self-management education programs, may be effective in countering AAWL.

Work disability in rheumatic diseases

PURPOSE OF REVIEW

To review developments in the literature concerning work disability in the rheumatic diseases.

RECENT FINDINGS

There have been three sets of studies to emerge in the last year. In the first, several studies analyze alternative research methods to document work disability. The second set uses qualitative methods to identify the specific factors that affect the decision to leave work. The third set analyzes interventions to reduce work disability.

SUMMARY

The quantitative and qualitative studies concur on the importance of flexible working conditions as an important, if not the most important risk factor for work disability in a diverse array of rheumatic diseases.

Work dynamics among persons with systemic lupus erythematosus

OBJECTIVE

To track changes in the proportion of persons ages 18-64 with systemic lupus erythematosus (SLE) who were employed from diagnosis through 2004, to estimate changes in annual work hours during this time, and to describe risk factors for work loss among those employed at diagnosis.

METHODS

A structured telephone survey was administered to a cohort of 982 persons with SLE, which was assembled between 2002 and 2004. Of the 900 enrolled in 2002-2003, 832 (92%) were re-interviewed in 2004. We tabulated the proportion employed at diagnosis, at baseline interview, and at followup in 2004. Among individuals employed at each time frame, we estimated the hours of work per year. We then used the Kaplan-Meier method to estimate time until work loss among individuals employed at diagnosis and Cox proportional hazards regression to describe the risk factors for such work loss.

RESULTS

Between diagnosis and followup interview, the proportion employed declined from 74% to 54%. Over the same period, hours of work per year declined by 32.2% among all individuals with a work history, but by only 1% among those continuously employed. Among individuals working at diagnosis, the proportion employed declined by 15% and 63% after 5 and 20 years, respectively. Demographics (age, sex, and education) and work characteristics (physical and psychological demands of jobs and level of control) were the principal determinants of work loss.

CONCLUSION

Total cessation of employment, rather than reduced hours among employed persons, accounts for most of the decline in annual work hours among persons with SLE.

An analysis of California Assembly Bill 2185: mandating coverage of pediatric asthma self-management training and education

OBJECTIVE

To summarize for the California Legislature the evidence on the medical effectiveness of pediatric asthma self-management training and education (PASMTE), including the use of peak flow meters, spacers, and nebulizers and the impact that mandated coverage of these services and devices under Assembly Bill (AB) 2185 would have on total health care expenditures, monthly premiums, health services utilization, and the public's health.

MEDICAL EFFECTIVENESS FINDINGS

The review of the literature finds that PASMTE is medically effective and has favorable effects on the health of children with symptomatic asthma, as well as reduces asthma-related emergency room visits and hospitalizations. There was inadequate evidence to assess the effectiveness of the three medical devices independently of PASMTE.

COST AND UTILIZATION FINDINGS

One-hundred percent of children in health maintenance organization (HMO) plans in California are already covered for PASMTE, with fewer having coverage for the specific medical devices. However, despite full coverage of PASMTE in HMOs, these services are underutilized. We expect that the enactment of AB 2185 would increase utilization of PASMTE among children who are currently covered by 10 percent as a result of increased awareness of current coverage by all HMOs and increased awareness of the importance of these services. We estimate that this increased utilization by children who are already covered may result in a total statewide premiums increase of $170,000 or 0.006 percent, equal to one to two cents per member per month (PMPM).

PUBLIC HEALTH FINDINGS

It is estimated that the public health impact of the mandate, as a result of new utilization of PASMTE by 10 percent of children who are already covered, would reduce the number of school days missed because of asthma per year by 158,000; the number of children reporting restricted activity days by 6,020; the number of emergency department visits by 350; and the number of hospitalizations by 1,105.

LEGISLATIVE ACTION

AB 2185 passed the legislature after being amended six times. The bill as it was signed into law did not mandate coverage for PASMTE, as all HMOs in California presently reported covering these services. However, the bill retained the mandate for coverage of the three medical devices, as their coverage was not as universal across health plans.

Work life of persons with asthma, rhinitis, and COPD: a study using a national, population-based sample

OBJECTIVE

To estimate the duration of work life among persons reporting a physician's diagnosis of COPD, asthma, or rhinitis compared to those with select non-respiratory conditions or none and to delineate the factors associated with continuance of employment.

METHODS

Persons ages 55 to 75 reporting a physician's diagnosis of COPD, asthma, or rhinitis as well as those without any of these conditions were identified by random-digit dialing (RDD) in the continental U.S and administered a structured survey. We used Kaplan-Meier life table analysis to estimate the duration of work life among persons with and without the three conditions and Cox proportional hazard regression to examine the role of demographic and work characteristics in the proportion leaving employment in each time interval.

RESULTS

Persons with COPD, asthma, and rhinitis were no less likely than the remainder of the population to have ever worked, but those with COPD were less likely to be working when interviewed or as of age 65, whichever came first. As of age 55, only 62 percent of persons with COPD continued to work versus 72 and 78 percent of persons with asthma and rhinitis, respectively. Persons with COPD, asthma, and rhinitis all had an elevated risk of leaving work prior to age 65 relative to those without chronic conditions, with and without adjustment for demographic and work characteristics.

CONCLUSION

COPD and to a lesser extent asthma and rhinitis were associated with a substantially shortened work life, an effect not due to demographic and work characteristics.

Is early intervention worth it?

Historically, the largest components of costs associated with rheumatoid arthritis (RA), the most common inflammatory rheumatic disease, were hospitalizations, principally for joint replacement surgery, and work loss. Thus, for expensive interventions such as biological agents to be "worthwhile," they must reduce the prevalence of joint replacement and assist persons with RA in maintaining employment. However, joint replacement surgery and work losses tend to occur at least several years after onset of disease, even in severe cases. Assessing the cost-effectiveness of expenditures becomes computationally and politically difficult when the expenditure and the outcome are separated in time. The computational issue concerns the translation of future benefits--surgeries avoided and jobs held onto years from now--into present monetary values. The computational issue may be even more complex when the benefits are less tangible than surgery and wages; for example, when measured by quality-adjusted life-years. The political issue concerns the disjuncture between the agents making the expenditures--provincial health insurance in Canada or an employer's health plan in the US--and the agents reaping the benefits, a private disability insurance company or provincial or state workers' compensation fund. In addition, there is an ethical dilemma. In the US, many of the advances in the care for RA such as the biological agents derive, at least in part, from federal research expenditures. Such expenditures are financed by increasingly regressive taxes. Yet the individuals bearing an increasing share of the tax burden find themselves relegated to more restrictive health insurance plans less likely to provide access to those agents. Thus, whether expenditures for early interventions are worthwhile may turn on such issues as how long the expenditure and the benefits are separated in time, how well the interests of the agent making the expenditure and the agent reaping the rewards are aligned, and how equitable the financing of the benefit and the access to it.

Medical care expenditures and earnings losses of persons with arthritis and other rheumatic conditions in the United States in 1997: total and incremental estimates

OBJECTIVE

To provide estimates of the total medical care expenditures and earnings losses associated with arthritis and other rheumatic conditions (AORC), as well as the increment in such costs specifically attributable to these conditions, in the US in 1997.

METHODS

The estimates were derived from the 1997 Medical Expenditures Panel Survey (MEPS), a national probability sample of 14,147 households including 34,551 persons, of whom 4,776 self-reported arthritis. After weighting, those who self-reported AORC represent 38.4 million persons. We tabulated all medical care expenditures of the adult MEPS respondents, stratified by arthritis and comorbidity status, and then used regression techniques to estimate the increment in health care expenditures attributable to AORC, after taking comorbidity, demographic characteristics, and insurance status into account. Using the same methods, we also estimated the magnitude of the earnings losses sustained by persons of working ages (18-64 years) who had AORC.

RESULTS

Persons with AORC incurred mean total medical care expenditures of 4,865 dollars (total 186.9 billion dollars). The largest components of these expenditures were inpatient care (39%), ambulatory care (29%), and prescriptions (14%). The mean increment in medical care expenditures specifically attributable to AORC among those ages 18 years and older was 1,391 dollars(total approximately 51.1 billion dollars). Persons with AORC ages 18-64 years earned 3,812 dollars less on average than did other persons of these ages (total 82.4 billion dollars). Of this average, 1,579 dollars was attributable to the AORC (total 35.1 billion dollars).

CONCLUSION

In 1997, persons with AORC incurred direct and indirect costs of 269.3 billion dollars, of which 86.2 billion dollars was attributable to these conditions.

Functional limitations and well-being in injured municipal workers: a longitudinal study

Two instruments, the Health Assessment Questionnaire (HAQ) and the Short Form-36 (SF-36), were used to document both the immediate and short-term effects of workplace injuries in municipal workers. Telephone interviews were conducted up to 3 months following the injury. One hundred fourteen subjects agreed to participate in the study; 90 workers completed at least one useable interview. The relationship between functional limitation and lost days was evaluated using Cox proportional hazards models. At 3 months following the onset of injury, SF-36 scores for physical function, role-physical, and bodily pain differed significantly from population norms. Using one standard deviation of change, statistically significant hazard ratios were seen in subjects with lower SF-36 physical component summary, physical function, and bodily pain scores, and higher HAQ disability and fatigue scores. Functional limitations persisted in workers after relatively minor workplace injuries despite a 91% return to work rate.

The impact of managed care on health care utilization among adults with asthma

STUDY OBJECTIVES

To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings.

DESIGN

Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population.

MEASUREMENTS

Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status.

RESULTS

Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI -5.4, -0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = -16.5, 95% CI -27.8, -5.3). The two groups did not differ significantly in the proportion with asthma-related or nonasthma hospital admissions.

CONCLUSIONS

Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in nonasthma care.

The occupational burden of chronic obstructive pulmonary disease

Although chronic obstructive pulmonary disease (COPD) is attributed predominantly to tobacco smoke, occupational exposures are also suspected risk factors for COPD. Estimating the proportion of COPD attributable to occupation is thus an important public health need. A randomly selected sample of 2,061 US residents aged 55-75 yrs completed telephone interviews covering respiratory health, general health status and occupational history. Occupational exposure during the longest-held job was determined by self-reported exposure to vapours, gas, dust or fumes and through a job exposure matrix. COPD was defined by self-reported physician's diagnosis. After adjusting for smoking status and demography, the odds ratio for COPD related to self-reported occupational exposure was 2.0 (95% confidence interval (CI) 1.6-2.5), resulting in an adjusted population attributable risk (PAR) of 20% (95% CI 13-27%). The adjusted odds ratio based on the job exposure matrix was 1.6 (95% CI 1.1-2.5) for high and 1.4 (95% CI 1.1-1.9) for intermediate probability of occupational dust exposure; the associated PAR was 9% (95% CI 3-15%). A narrower definition of COPD, excluding chronic bronchitis, was associated with a PAR based on reported occupational exposure of 31% (95% CI 19-41%). Past occupational exposures significantly increased the likelihood of chronic obstructive pulmonary disease, independent of the effects of smoking. Given that one in five cases of chronic obstructive pulmonary disease may be attributable to occupational exposures, clinicians and health policy-makers should address this potential avenue of chronic obstructive pulmonary disease causation and its prevention.

Cost of musculoskeletal diseases: impact of work disability and functional decline

Persons with all forms of musculoskeletal conditions incur total medical care expenditures of about US$240 billion, or about 2.9% of GDP. Of this total, approximately US$77 billion, or about 0.9% of GDP, would not have occurred in the absence of the musculoskeletal conditions. Such persons had lower labor force participation rates, resulting in indirect costs of about US$98 billion; of this amount, almost all (over US$90 billion) remained after taking into account characteristics other than the presence of a musculoskeletal condition that might result in lower earnings. Thus, the majority of direct costs incurred by persons with musculoskeletal conditions would occur in the absence of the conditions, but the wage losses would not occur were the conditions to be eradicated. The importance of indirect costs in the economics of musculoskeletal conditions is underscored by the studies of the costs of specific diseases. In all but OA, indirect costs are at least as large as, if not larger than, direct costs. Reducing the economic impact of RA, SLE, AS, and low back pain requires treatments that reduce work disability associated with each of these conditions. Some promising results from short term studies have been reported, but it would appear to be an appropriate time to inaugurate trials focused on longterm work outcomes.

Association between etanercept use and employment outcomes among patients with rheumatoid arthritis

OBJECTIVE

To assess the association between use of etanercept and employment outcomes among patients with rheumatoid arthritis (RA).

METHODS

In 1999, 497 RA patients of working ages (18-64 years) reported their employment status in the year of diagnosis and as of the study year, in structured telephone interviews. Of these, 238 had been in clinical trials of etanercept and were currently taking that medication, while 259 were members of an observational study and were not taking etanercept. We used regression techniques to estimate whether employment outcomes in 1999 (employed versus not and, among the employed, hours of work per week, weeks of work per year, and hours of work per year) among the 379 of the 497 patients who were employed at the time of diagnosis were associated with etanercept use, with and without adjustment for demographic characteristics, RA status, overall health status, and the nature of the job held at the time of diagnosis.

RESULTS

At the time of diagnosis, 75% of RA patients from the observational study who did not take etanercept and 77% of those who did take the medication were employed. By 1999, among those employed at diagnosis, 55% of the former group and 71% of the latter were employed (difference 16 percentage points). After adjustment for demographics, overall health status, duration of RA, RA status, and occupation and industry, the difference widened to 20 percentage points. Among all who were employed at the time of diagnosis, those from the etanercept clinical trials worked an average of 5.4 more hours per week in 1999; after adjustment, the etanercept group worked 7.4 more hours per week.

CONCLUSION

Among all persons who were employed at the time of RA diagnosis, having been in the etanercept clinical trials was associated with higher employment rates in 1999 and a greater number of hours per week of work in that year, suggesting that a randomized trial to establish the relationship between treatment and employment outcomes is now warranted.

Reading and interpreting economic evaluations in rheumatoid arthritis: an assessment of selected instruments for critical appraisal

OBJECTIVE

To describe and compare the relative attributes (reliability, ease of use, applicability, and relevance) of different assessment tools for economic analyses as they pertain to rheumatoid arthritis (RA) literature.

METHODS

An expert panel, comprising rheumatology researchers and clinicians, operationalized 2 economic appraisal instruments and applied them to 11 articles used for analysis. Each expert reviewed 3 articles, with each article independently reviewed by a pair of experts. A summary score for each article per appraisal instrument was calculated by dividing the number of items that received a "positive" response by the total number of items in the appraisal instrument.

RESULTS

Scores for each article were similar across reviewers and appraisal instruments.

CONCLUSION

There is a need for a more comprehensive approach for evaluating this rapidly growing body of economic literature that is not only valid and reliable, but also easy to apply and understand. Although consistency between reviewers was good on both guidelines, inter-guideline discrepancies were noted and reviewers reported some difficulty in using the operationalized format.

The impact of functional status and change in functional status on mortality over 18 years among persons with rheumatoid arthritis

OBJECTIVE

To calculate mortality rate associated with rheumatoid arthritis (RA), to estimate the effect of initial functional status and of change in functional status on mortality among persons with RA, and to compare the mortality experience of such persons to that of the US population.

METHODS

The study used a prospective panel of 1269 persons followed for a mean of 8.4 years (median 7 yrs, interquartile range 3-12, maximum 18). Mortality status was ascertained from contacts with next of kin, study physicians, and search of the National Death Index. The Kaplan-Meier method was used to calculate the proportion dying in each time interval, with and without stratification for initial functional status [Health Assessment Questionnaire (HAQ) score] or average change in functional status. Cox proportional hazards regression was used to establish the effect of functional status, demographic characteristics, and health status on mortality risk.

RESULTS

There were 270 deaths among the 1269 persons with RA. After 18 years of followup the overall death rate was 39%. The death rates in the best through worst initial quartiles of HAQ score were 29, 33, 44, and 54%. The death rate was 51% among persons with declining HAQ score versus 31 and 32% among those with no change or improvement in this measure, respectively. Demographic and health status did not reduce the effect of HAQ or average change in HAQ on mortality risk. Compared to the US population, the persons with RA had a standardized mortality rate of 1.32.

CONCLUSION

The persons with RA in this study had elevated mortality rates. Poor initial functional status and declining functional status significantly increased mortality risk among these persons with RA.

The prevalence and impact of managed care for persons with rheumatoid arthritis in 1994 and 1999

OBJECTIVES

To estimate the proportion of persons with rheumatoid arthritis (RA) in managed care and fee-for-service settings in 1994 and 1999, to ascertain whether there are differences in utilization between persons in the 2 systems of care in the 2 years, and to determine whether 1994 managed care status or change between 1994 and 1999 in managed care status affects outcomes.

METHODS

The present study uses data from the University of California, San Francisco RA Panel Study, in which 310 patients with RA from a random sample of Northern California rheumatologists were interviewed annually between 1994 and 1999 using a structured survey instrument. We use linear and logistic regression to compare the health care utilization and outcomes of persons in managed care and fee-for-service after adjusting for differences in demographic and health characteristics.

RESULTS

The proportion of respondents in managed care increased from 60% to 79% between 1994 and 1999, including an increase from 37% to 68% among persons eligible for Medicare and an increase from 74% to 92% among persons ineligible for Medicare. With the exception of physical therapy visits in 1999, patients with RA in managed care did not report significantly different utilization of any service for RA than those in fee-for-service in either 1994 and 1999, including hospital admissions and joint replacement surgery. Managed care status in 1994, and change in managed care status between 1994 and 1999, were not associated with significantly different outcomes in 1999.

CONCLUSION

Despite the growth in the proportion of patients with RA in managed care, those in managed care did not differ from those in fee-for-service settings in utilization or outcomes.

A national study of medical care expenditures for respiratory conditions

This study was undertaken to estimate the magnitude of medical care expenditures among persons with respiratory conditions in the USA in 1996, and the increment in expenditures attributable to these conditions. The study data were derived from the 1996 Medical Expenditure Panel Survey, a national sample of 21,571 persons. Of the 21,571, 1,027 reported one or more respiratory condition. After weighting, the individuals may represent about 12.1 million persons in the USA. All medical care expenditures of these individuals were tabulated, stratified by comorbidity status, and then compared to those among persons with nonrespiratory conditions or with no conditions. Regression techniques were then used to estimate the increment of healthcare expenditures attributable to the respiratory conditions. From a national total of $45.3 billion, medical care expenditures averaged $3,753 among persons with respiratory conditions. Hospital stays comprised the largest component (45%). The per capita increment in total expenditures attributable to respiratory conditions ranged from $1,003-2,588, from a national total ranging from $12.1-31.3 billion. The total medical care expenditure of persons with respiratory conditions was estimated to be $45.3 billion, of which $12.1-31.3 billion represents an increment in expenditures associated with the conditions themselves.

A national study of medical care expenditures for musculoskeletal conditions: the impact of health insurance and managed care

OBJECTIVE

To provide estimates of all medical care expenditures on behalf of persons with musculoskeletal conditions in the United States in 1996, to estimate the increment in expenditures attributable to the musculoskeletal conditions among such persons, and to ascertain the impact of the presence or absence of health insurance and/or managed care on such expenditures.

METHODS

The estimates were derived from the Medical Expenditure Panel Survey (MEPS), a national probability sample of 9,488 households, which includes responses from 21,571 persons. In the MEPS, respondents are surveyed every 6 months to report on medical care utilization and health care expenditures. Of the 21,571 persons surveyed, 4,161 reported having 1 or more musculoskeletal conditions. After weighting the data, these 4,161 individuals were inferred to represent 53.935 million persons in the nation as a whole. We tabulated all medical care expenditures of these individuals, stratified by comorbidity status, and then compared their expenditures with those among persons with chronic conditions other than musculoskeletal disease or with no chronic conditions. We then used regression techniques to estimate the increment of health care expenditures attributable to the musculoskeletal conditions. Finally, we used regression to estimate the impact of health insurance status and managed care status on the health care expenditures of the persons with musculoskeletal conditions.

RESULTS

Per capita medical care expenditures in 1996 averaged $3,578 among persons with musculoskeletal conditions, for a national total of $193 billion, the equivalent of 2.5% of the Gross Domestic Product in that year. The largest components were hospital admissions (37%), physician visits (23%), and prescriptions (16%). Estimates of the per capita increment in total medical care expenditures attributable to musculoskeletal conditions ranged from a high of $723 when controlling for the other medical conditions present, to $364 when controlling for these variables and demographics. Persons with musculoskeletal conditions ages 16-64 who lacked health insurance reported total expenditures of $793, versus $3,249 among those with insurance (P < 0.0001). Among such persons with insurance, expenditures did not differ significantly between those in fee-for-service plans and those in managed care health plans.

CONCLUSION

Persons with musculoskeletal conditions and health insurance experienced high total expenditures for medical care and high expenditures attributable to the musculoskeletal conditions. Insurance coverage under a managed care plan had no effect on the magnitude of these total expenditures, but lack of insurance coverage did have a significant effect among persons with musculoskeletal conditions.

The prevalence and impact of accommodations on the employment of persons 51-61 years of age with musculoskeletal conditions

OBJECTIVE

To provide estimates of the frequency with which persons 51 to 61 years of age with musculoskeletal conditions receive workplace accommodations from their employers and to determine if the receipt of such accommodations is associated with higher rates of employment two years later.

METHODS

The estimates derive from the Health and Retirement Survey, a national probability sample of 8,781 respondents who were interviewed both in 1992 and 1994 and who were between the ages of 51 and 61 years, of whom 5,495 reported one or more musculoskeletal conditions. We tabulated the frequency of accommodations provided in 1992 and then estimated the impact of accommodations and demographic and medical characteristics on 1994 employment status, using logistic regression.

RESULTS

In 1992, about 14.40 million persons aged 51-61 years reported a musculoskeletal condition. Of these, 1.32 million (9.2%) reported a disability and were employed, the target population for accommodations. Overall, fewer than 1 in 5 persons with musculoskeletal conditions who had a disability and were employed indicated that they had received any form of accommodation on their current jobs. Although no form of accommodation was reported with great frequency, the most commonly used ones included getting someone to help do one's job (12.1%), scheduling more breaks during the work day (9.5%), changing the time that the work day started and stopped (6.3%), having a shorter work day (5.6%), getting special equipment (5.3%), and changing the work tasks (5.3%). Persons with one or more accommodations in 1992, however, were no more likely to be working in 1994 than those with none. Only one specific accommodation--getting someone to help do one's job--was associated with a higher rate of employment in 1994.

CONCLUSIONS

Receipt of employment accommodations occurred infrequently, and was not generally associated with an improvement in the employment rate of persons with musculoskeletal conditions and disabilities.

An assessment of the annual and long-term direct costs of rheumatoid arthritis: the impact of poor function and functional decline

OBJECTIVE

To describe the distribution of direct medical care costs of rheumatoid arthritis (RA) over 1-year and 11-year periods, and to evaluate the impact of poor function and functional decline on direct costs.

METHODS

The present study uses data from the University of California, San Francisco, RA Panel Study in which 1,156 persons with RA have been followed up for as long as 15 years through annual structured interviews and periodic updates on severity from rheumatologists. We present annual direct medical care cost data for the years 1995 and 1996 and estimates of cumulative costs for the period 1986-1996 for the 272 persons followed up continuously for this period.

RESULTS

Medical care costs for RA averaged $5,919 a year from a societal perspective; persons with RA incur another $2,582 in medical care costs for non-RA reasons. Of the RA total costs, hospital admissions account for more than half. Costs are highly skewed, with the costs in the 90th, 95th, and 100th percentiles totaling $8,209, $31,059, and $85,469 a year, respectively. Cumulative costs for the period 1986-1996 averaged $57,201, with cumulative costs in the 90th, 95th, and 100th percentiles totaling $114,844, $142,563, and $191,540, respectively. Persons with RA in the worst quartile of function experienced total annual direct costs that were 2.55 times as high and total hospital costs that were 6.97 times as high as those in the best (e.g., the first) quartile. Poor baseline functional status and declining functional status had similar, large effects on cumulative medical care costs.

CONCLUSION

Medical care costs for RA over 1 year and 1 decade are highly skewed. Persons with RA with poor and declining function experience much higher costs of care.

Work dynamics of adults with asthma

BACKGROUND

Asthma has been found to be among the most common conditions in the working age population and is among the most common causes of work limitation, but we could find no longitudinal studies of employment among persons with this condition.

METHODS

A panel of 601 persons with a diagnosis of asthma from random samples of northern California pulmonologists and allergy-immunologists were interviewed as many as three times at 18-month intervals by a trained survey worker to report on the severity of disease, demographic characteristics, and the extent of their employment. Their employment was then compared to that of a matched sample from the U.S. Bureau of the Census Current Population Survey.

RESULTS

Ninety-two percent of the persons with asthma had worked at some point prior to study enrollment. Among persons with onset during adulthood, only 29% of those who were not employed at disease onset were working at study enrollment, compared to 68% among those who were employed. Among the 420 persons interviewed three times, 75, 81, and 75%, respectively, were employed as of the three interviews. Among these 420, 66% were continuously employed and 15% were continuously not employed. The principal determinants of continuity of employment were demographic and employment characteristics, not medical ones. The employment rate and hours of work per week and per year of the persons with asthma were similar to the matched sample.

CONCLUSIONS

Asthma has not substantially impeded the employment of the persons with asthma we studied, with the exception that those who were not employed at disease onset continued to have low employment rates.

Predictors of rate of return to work after surgery for carpal tunnel syndrome

OBJECTIVE

To evaluate the impact of patient demographics, clinical features, and job-related factors on the time until return to work after carpal tunnel release surgery.

METHODS

We employed a cross-sectional community-based study of 59 patients who had undergone carpal tunnel release surgery. Sociodemographic, clinical, and job-related characteristics and time to return to work were obtained by interview and from medical records. Exposure to ergonomic risk was derived from an independently validated job matrix. Time to return to work after surgery was analyzed by survival techniques.

RESULTS

Median time to return to work was 5 weeks. After adjustment, the relative rate (RR) of return to work per week after surgery was most strongly decreased by the receipt of workers' compensation, RR 0.2 (95% confidence interval [CI] 0.1-0.5), and by the exposure to bending and twisting of the hand prior to surgery, RR 0.7 (95% CI 0.5-0.9) per hour. Female gender was another predictor of decreased return to work, RR 0.5 (95% CI 0.3-0.8).

CONCLUSIONS

Patients receiving workers' compensation, those exposed to higher levels of bending and twisting of their hands and wrists, and women were slower to return to work after carpal tunnel release surgery.

The earnings, income, and assets of persons aged 51-61 with and without musculoskeletal conditions

OBJECTIVE

To describe the personal and family earnings, income, and assets of persons with musculoskeletal conditions.

METHODS

This study uses the Health and Retirement Survey, a national, community based probability sample of persons 51-61 years of age and their spouses in 1992 to estimate earnings, income, and assets (by kind) in the years immediately prior to the normal age of retirement.

RESULTS

Fifty-nine percent of persons 51-61 years of age (13.76 million) report one or more musculoskeletal condition; of these 38% (8.74 million) also report at least one comorbid condition and 21% (5.02 million) report no such comorbidity. Persons with musculoskeletal conditions and comorbidity report 18% lower family earnings, 15% lower family income, and 35% fewer assets than the average among all persons these ages. Persons with musculoskeletal conditions and no comorbidity have earnings, incomes, and assets closer to the average among their peers.

CONCLUSION

Persons with musculoskeletal conditions and comorbidity have lower earnings and incomes now and fewer assets with which to face the future than the remainder of their peers.

Self-reported carpal tunnel syndrome: predictors of work disability from the National Health Interview Survey Occupational Health Supplement

The objective of this study was to identify risk factors for work disability among persons with carpal tunnel syndrome (CTS). The study was designed to analyze data from the Occupational Health Supplement of the National Health Interview Survey, a nationwide, population-based survey. Subjects included 544 survey respondents with self-report of CTS and 32,688 survey respondents without CTS, all aged 18-64 years, and with a history of labor force participation. Measurements were as follows: Dependent variables were work disability, defined either as cessation of employment without attribution of cause or, alternatively, as cessation of employment or job change specifically attributed to CTS by the survey respondent. Independent variables were ergonomic risk of work disability, defined by minutes of workplace repetitive hand and wrist bending for the most recent job held. This measure was derived from responses categorized by an occupation and industry matrix independent of CTS status. Socio-demographic and health status risk factors for work disability were based on the respondent report. The main results were as follows: Among 544 persons with CTS, 58 (11%, CI 8-13%) reported work disability specifically attributed to CTS, representing an estimated national prevalence of 240,578 persons with this limitation. Workplace ergonomic risk, measured as repetitive hand or wrist bending in the occupation and industry of last employment, was a significant factor predictive of CTS-attributed work disability (per 120 min of daily exposure, OR 1.7, CI 1.1-2.6), even after taking into account socio-demographic factors and health status. The conclusions were that work disability among persons with CTS is common. For those with CTS, working conditions characterized by repetitive bending of the hand or wrist may increase the risk of work disability associated with this condition.

The impact on unemployment of an intervention to increase recognition of previously untreated anxiety among primary care physicians

Anxiety is a common, though often unrecognized, problem in primary care settings. This study examines the effect on employment of an intervention designed to attune primary care physicians to previously unrecognized and untreated anxiety. Primary care physicians in a mixed-model health maintenance organization (HMO) were randomized by practice site to groups with (intervention) and without (usual care) intensive one-on-one education about anxiety and periodic feedback about their patients with anxiety. All persons 21-65 years of age presenting to the offices of these primary care providers were screened for anxiety with the SCL-90-R on two occasions. Those meeting the SCL-90-R cutpoints for anxiety and whose medical records provided no evidence of recognition or treatment for a mental health condition within the last 6 months were eligible for the study (n = 637). Of these, 573 (90%) completed two follow-up assessments. The present study evaluates the impact of the intervention aimed at the primary care physicians on the labor force participation rate of the persons with anxiety after 5 months of follow-up. The study also evaluates the impact of the intervention on hours of work and the presence of days spent in bed among the persons with anxiety working at the baseline interview and after 5 months. At baseline, the patients of intervention and usual care physicians with previously unrecognized and untreated anxiety did not differ in labor force participation rates. At the conclusion of the study, the patients of the intervention group physicians had significantly lower rates of labor force participation than those of the usual care group physicians. Among those working both at the beginning and conclusion of the study, the intervention had no impact on hours of work or the presence of days spent in bed. We conclude that attuning physicians may reduce labor force participation rates.

The costs of rheumatoid arthritis: absolute, incremental, and marginal estimates

We determined the average medical and indirect costs of rheumatoid arthritis (RA) from clinical and community based samples and compared those costs to those experienced by similar persons without RA. We reviewed the literature and analyzed the UCSF RA Panel Study and the National Health Interview Survey for the years 1989-91. The annual medical care costs of RA ranged from $4,300 to $5,700 in 1994 terms in the clinical samples, with hospital admissions accounting for half to two-thirds of the total. Indirect costs in the clinical samples exceeded direct costs and ranged from just under $10,000 to more than $16,000 a year. Medical care costs of RA are highly skewed, with persons in the 90th percentile experiencing costs more than 100 times as large as those in the 10th. In the national community based sample, the costs of RA amounted to $8.74 billion, of which more than half was due to medical care. In this sample, the increment of costs experienced by persons with RA compared to those without was $3.07 billion, with 80% of the excess the result of indirect costs due to wage losses.

The economic cost and social and psychological impact of musculoskeletal conditions. National Arthritis Data Work Groups

OBJECTIVE

To provide an indication of the economic, social, and psychological impact of musculoskeletal conditions in the United States.

METHODS

Review of the literature combined with estimates of data concerning health care utilization and acute and chronic disability due to musculoskeletal conditions, from the 1990-1992 National Health Interview Survey.

RESULTS

The cost of musculoskeletal conditions was $149.4 billion in 1992, of which 48% was due to direct medical care costs and the remainder was due to indirect costs resulting from wage losses. This amount translates to approximately 2.5% of the Gross National Product, a sharp rise since the prior studies, even if part of the increase is an artifact of improved accounting methods. Each year, persons with musculoskeletal conditions make 315 million physician visits, have more than 8 million hospital admissions, and experience approximately 1.5 billion days of restricted activity. Approximately 42% of persons with musculoskeletal conditions--more than 17 million in all--are limited in their activities.

CONCLUSION

The economic and social costs of musculoskeletal conditions are substantial. These conditions are responsible for a sizable amount of health care use and disability, and they significantly affect the psychological status of the individuals with the conditions as well as their families.

Access to medical care among persons with musculoskeletal conditions. A study using a random sample of households in San Mateo County, California

OBJECTIVE

To study access to medical care services, including subspecialty care, among persons with musculoskeletal conditions.

METHODS

In early 1993, a random sample of households in San Mateo County, California, was screened for the presence of household members with musculoskeletal conditions, and a member of each household so identified was administered a structured survey about access to medical care and other related subjects.

RESULTS

Eighty-six percent of all persons with a musculoskeletal condition had ever seen at least one physician for the condition, but only 6.5% had ever seen a rheumatologist. Those without health insurance were only 82% as likely as those with health insurance to have ever seen a physician.

CONCLUSION

Most persons with a musculoskeletal condition have seen a physician for the condition, but lack of health insurance significantly reduces the proportion who have done so.

Work disability in adults with cystic fibrosis

Greater numbers of persons with cystic fibrosis (CF) reach adulthood and, therefore, actively participate in the labor force. In this study, we estimated labor force participation rates and determined risk factors for work disability among persons with CF. We recruited 49 (73%) of 67 adults followed at one of two hospital-based CF centers. We ascertained employment history and CF-attributed work disability by structured questionnaire. Independently, we reviewed medical records for demographics and illness severity indicators. We analyzed potential risk factors for work disability by logistic regression analysis. All of those studied reported past or present labor force participation, consistent with high work motivation. Complete cessation of work attributed to CF was reported by 17 (35%; 95% CI, 21 to 49%). Although 23 (47%; 95% CI, 32 to 60%) of those surveyed stated that CF had affected career choice, only nine respondents had ever received career counselling and 16 had ever discussed job choice with their physicians. After adjusting for standard measures of disease severity by multiple logistic regression, age, adult diagnosis of CF, female gender, and single marital status, analyzed as a group, provided significant additional explanatory power to a predictive model of disability risk (model chi square [4 d.f.] = 11.5, p < 0.05). Health care professionals who design interventions targeted at work disability among persons with CF should address demographic factors as well as illness severity and should assess the vocational needs of persons with CF and the potential benefit of career counselling.

Mortality risk among elderly workers

We analyzed population-based data for respondents aged 70 and older from the Longitudinal Study on Aging. We compared mortality risk among 358 baseline-year working with 4,373 nonworking respondents. Including other demographic and health status predictors in a multiple logistic regression model, employment remained a significant predictor of survival (mortality odds ratio (OR) = 0.4). Diabetes mellitus was the only factor that displayed a mortality risk that was significantly interactive with work (OR = 3.5). These data suggest that a healthy worker effect persists in older age groups, but that within the working stratum, patterns of risk may differ as compared to those among the nonworking.

Impact of the American Health Security Act of 1993

In the months to come, opponents of President Clinton's proposal will focus on issues of choice among physicians and health plans and on estimates of the economic impact of reform. Others will raise the issue of the efficiency of the administrative structures necessary to implement the Act. These important concerns notwithstanding, people with rheumatic diseases stand to gain much from the passage of the American Health Security Act of 1993, principally the knowledge that they always will have insurance, that their out-of-pocket costs will be limited, that they will have access to a standard set of benefits, and that these benefits are more comprehensive than the current Medicare and Medicaid programs and all but a small percentage of private health insurance plans.

Work disability among adults with asthma

OBJECTIVE

To estimate the incidence of work disability among adults with asthma and to evaluate a clinically based illness severity score as a predictor of such disability.

DESIGN

Baseline and follow-up telephone interviews and medical record review.

SETTING

University-based outpatient pulmonary specialty practice.

PATIENTS

Fifty-six patients interviewed at baseline; 42 reinterviewed 2 years later.

MEASUREMENTS

Work disability ascertained by interview report and defined as change in job duties, reduction in pay, or change in job or employment status attributed to asthma. Severity of asthma score derived from medical records and based on respiratory symptom frequency, asthma history, and prescribed medications. Pulmonary function by routine testing. Logistic regression analysis of the 5-year incidence of work disability on severity score and forced expiratory volume in 1 s (FEV1).

RESULTS

The 5-year work disability cumulative incidence was 19 percent for change in duties, 17 percent for reduction in pay, 20 percent for change in job or work status, and 36 percent for any of these measures. The median asthma score was 10 (range, 2 to 26). The mean FEV1 as a percent predicted (FEV1 percent) was 88 +/- 25 percent. Score and FEV1 percent were statistically correlated (r = -0.6, p < 0.0001). Severity of asthma score statistically predicted each measure of work disability (p < 0.01). Addition of FEV1 percent added little additional explanatory power to the logistic regression model (maximum chi 2 = 1.3, p > 0.2).

CONCLUSIONS

Work disability is common among adults with asthma. A severity of asthma score based on clinical variables is statistically correlated with lung function but appears to be a stronger predictor of disability than airflow measured at one point in time.

Arthritis. The cumulative impact of a common chronic condition

OBJECTIVE

To document the extent of disability related to arthritis among working-age (18-64-year-old) and elderly (greater than or equal to 70-year-old) individuals.

METHODS

Data from the 1970-1987 National Health Interview Surveys were used to determine the prevalence of arthritis-related disability among working-age adults. The Longitudinal Study on Aging was used to determine the prevalence of arthritis-related disability among the elderly.

RESULTS

Among working-age persons, 3.734 million men and 5.649 million women reported having arthritis, of whom in excess of 2 million and 3 million, respectively, reported activity limitation (the definition of disability in the National Health Interview Survey). Labor force participation among men with arthritis was approximately 20% lower than among those without arthritis and approximately 25% lower among women with arthritis than among those without. Among elderly individuals, 55% reported having arthritis and, of these, more than three-quarters were limited in a physical activity and more than one-third were limited in an activity of daily living. Moreover, disability rates for persons with arthritis were found to be increasing, even on an age-adjusted basis.

CONCLUSION

The impact of arthritis in terms of disability was shown to be high and was probably underestimated, given the high prevalence of the disease among women and elderly persons, and the limitations in the methods used in contemporary social surveys to establish the extent of disability, in these 2 population groups in particular.

Health policy and musculoskeletal conditions

This paper reviews two strains of research within rheumatology relevant to contemporary health policy debates. The first concerns studies of the effectiveness of medical care on outcomes among persons with musculoskeletal conditions; the second, studies of functional status and disability among such persons. The studies of the effectiveness of medical care, largely funded by the Agency for Health Care Policy and Research, are designed to assist in the development of practice guidelines concerning lower back pain, knee replacement, hip disease, and other conditions for use by physicians and other providers as well as third party payers. The studies of functional status and disability in arthritis, largely funded by the National Institute of Arthritis, Musculoskeletal, and Skin Diseases as part of its Multipurpose Arthritis Center Program, are designed to provide measures of outcome for use in studies of medical effectiveness and to assess the societal impacts of musculoskeletal conditions.

The economic impact of the rheumatic diseases in the United States

We review the literature and analyze data from the National Health Interview Survey to provide estimates of the economic cost and social impacts of the rheumatic diseases in the United States. Rheumatic diseases had an economic impact in 1980 of 21 billion dollars due to expenditures for health care and lost wages, an amount equal to 1% of gross national product. These conditions are responsible for 5% of all hospital discharges, 10% of all hospital procedures, and 9% of all physician visits. They are also responsible for over 2 million persons being unable to do major activities, for 5 million being limited in other ways, and for at least 1 million being severely limited in the ability to perform activities of daily living. As great these impacts would appear to be, they are likely to grow since the aging of the population increases both the prevalence and severity of impact of the rheumatic diseases.

The impact of rheumatoid arthritis and osteoarthritis: the activities of patients with rheumatoid arthritis and osteoarthritis compared to controls

We measured the impact of rheumatoid arthritis (RA) and osteoarthritis (OA) by comparing the activities of patients with these illnesses to controls matched for age, sex, and community of residence. Our results indicate that patients with RA experience more losses than controls in every domain of human activity and that patients with OA experience more losses in the performance of household chores, shopping and errands, and leisure activities. The methods described here provide a simple, reliable way to assess the impacts of illness in the same terms for all dimensions of human activity.

The work dynamics of the person with rheumatoid arthritis

This paper traces the work history of patients with rheumatoid arthritis (RA) from the year of diagnosis to 1985. The paper also describes the risk factors for work loss among patients with RA. It uses data from a panel of 698 RA patients, observed for 4 years, from the practices of a random sample of northern California rheumatologists. Of these 698, 353 had worked for pay at some point in their lives. Three hundred six of the 353 had worked when diagnosed as having RA. Of these 306, 157 (51%) were no longer working in 1985. Forty-seven individuals started working after the onset of illness, but of these, approximately one-third had stopped working by 1985. In all, 50% of RA patients with some work experience stopped working within a decade of diagnosis, 60% within 15 years, and 90% within 30 years. We found that the probability of work loss is lessened among persons in jobs that have few physical requirements, among those with high levels of discretion over the pace and activities of work, and among those who were able to stay on the job held when the diagnosis was made. The probability of work loss is increased among service workers. The findings of this longitudinal study, showing that work characteristics profoundly alter the probability of work loss among persons with RA, are consistent with the findings of our earlier cross-sectional studies of work outcome and RA.

Work disability in rheumatoid arthritis: effects of disease, social, and work factors

We explore here the relative contribution of selected disease, social, and work-related factors to disability status in a population of persons with rheumatoid arthritis. Our study differs from previous studies in that it is limited to one diagnostic entity, yet at the same time evaluates a broad range of social and work-related factors in disability. One hundred-eighty persons with rheumatoid arthritis sampled from 19 socially diverse practice settings were given a structured survey about their medical and work histories and social backgrounds. We found significant effects of stage and duration of illness on continued employment but no positive effect of selected therapies. Social and work factors combined had a far larger effect on work disability than all disease factors. Among work factors, control over the pace and activities of work and self-employment status had the greatest effect on continued employment, suggesting that time control issues are crucial to the maintenance of one's job after onset of this illness.