Managed care and arthritis care: patients and providers under the new medical care organizations

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.

Impact of managed care on the use of biologic agents for rheumatoid arthritis

OBJECTIVE

To compare the use of biologic agents among persons with rheumatoid arthritis (RA) in managed care and fee-for-service settings.

METHODS

The present study uses data from the University of California, San Francisco RA Panel Study in which 529 patients with RA from a random sample of northern California rheumatologists were interviewed annually between 1999 and 2002 using a structured survey instrument. Linear and logistic regression were used to compare current utilization, initiation, and cessation of biologic agents and other treatments among patients with RA in managed care and fee-for-service settings, with and without adjustment for differences in demographic and health characteristics.

RESULTS

After adjustment, patients with RA in health maintenance organizations (HMOs) were significantly less likely to use biologic agents than those in other managed care settings (difference of -6.6%; 95% confidence interval [95% CI] -11.4%, -1.7%) or than those in fee-for-service settings (difference of -12.5%; 95% CI -19.0%, -5.9%); patients in other managed care settings and fee-for-service did not differ significantly in their use of biologic agents. Patients with RA in HMOs were significantly less likely than those in other managed care settings to initiate the use of biologic agents (difference of -7.3%; 95% CI -11.5%, -3.1%); there were no other differences between patients in HMOs and those in other managed care and fee-for-service settings in rates of initiation or cessation of these agents. Patients with RA in HMOs were less likely to use methotrexate, cyclooxygenase 2 (COX-2) inhibitors, and corticosteroids than those in other managed care settings; they were also less likely to use COX-2 inhibitors than those in fee-for-service settings.

CONCLUSION

Patients with RA in HMOs were significantly less likely to use biologic agents than those in other managed care and fee-for-service settings, primarily due to lower rates of initiation.

Incidence of functional limitation in older adults: the impact of gender, race, and chronic conditions

OBJECTIVES

To evaluate the relation of chronic conditions, gender, and race to the incidence of activities of daily living (ADLs) limitation in older adults.

DESIGN

The 2-year cumulative incidence of functional limitation was estimated from survival analysis methods by using elders without baseline functional limitations.

SETTING

Longitudinal Study of Aging (LSOA). Initial interviews: 1984; reinterviews: 1986, 1988, and 1990.

PARTICIPANTS

A total of 4205 elderly subjects from the LSOA.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

DEPENDENT VARIABLES

self-reported moderate (1-2 ADLs) and severe (> or =3 ADLs) functional limitation.

INDEPENDENT VARIABLES

sociodemographics, self-reported chronic conditions, and prior levels of functional limitation.

RESULTS

Gender and race predicted moderate functional limitation onset, after controlling for age and education. Arthritis, diabetes, prior cerebrovascular disease (CVD), incontinence, and impaired vision were significant predictors of moderate functional limitation onset after controlling for demographics. Differences in the prevalence of chronic conditions appear to explain why moderate functional limitation incidence rates are higher in older women and blacks. Gender, but not race, predicted onset of severe functional limitation, after controlling for age and education. Prior moderate functional limitation, CVD, and vision impairment predicted onset of severe functional limitation after controlling for demographics.

CONCLUSION

Prevention of functional decline should target chronic conditions and moderate functional limitation in older adults.

Arthritis prevalence and activity limitations in older adults

OBJECTIVE

To evaluate the prevalence of arthritis and activity limitations among older Americans by assessing their demographic, ethnic, and economic characteristics.

METHODS

Data from the Asset and Health Dynamic Survey Among the Oldest Old (AHEAD), a national probability sample of community-dwelling adults born before 1924, were analyzed cross-sectionally. Arthritis that resulted in a physician's visit or a joint replacement not associated with a hip fracture was ascertained by self-report.

RESULTS

The prevalence of arthritis in older adults ranged from 25% in non-Hispanic whites to 40% in non-Hispanic blacks to 44% in Hispanics. A higher prevalence of arthritis was associated with less education as well as lower income and less wealth. The prevalence of limitations in activities of daily living (ADL) among non-Hispanic white, non-Hispanic black, and Hispanic adults who reported arthritis only was 29%, 30%, and 37%, respectively, and increased to 48%, 57%, and 56%, respectively, among those reporting arthritis plus other chronic conditions, after adjustment for age and sex.

CONCLUSION

Non-Hispanic black and Hispanic older adults reported having arthritis at a substantially higher frequency than did non-Hispanic whites. In addition, Hispanics reported higher rates of ADL limitations than did non-Hispanic whites with comparable disease burden. Further study is needed to confirm and elucidate the reasons for these racial and economic disparities in older populations.

The disease process and utilization of health services in rheumatoid arthritis: The relative contributions of various markers of disease severity in explaining consumption patterns

OBJECTIVE

To examine the predictive ability of a wide array of measures of disease severity in explaining Dutch and German patterns of health services utilization during a 2-year period.

METHODS

Slightly over 200 rheumatoid arthritis (RA) patients, 136 from a Dutch and 98 from a German outpatient clinic, supplied information on symptom and functional status, global health, and emotional and social functioning at baseline. The patients' rheumatologists provided clinical assessments of functional grade and disease activity. A questionnaire mailed twice at 12-month intervals was the source of retrospective information on physician consultations, hospitalization, and referrals for surgery and physical therapy during the previous period. Major determinants of use were studied with multivariate analyses.

RESULTS

German patients reported more frequent physician contacts than Dutch patients, but the volume of surgery, hospital admissions, and referrals for physical therapy did not differ between the two countries. In a hierarchical regression, the consultation rate was directly associated with pain quality and global health. Markers of RA progression were related to surgery, and the latter to volume of in-hospital care. Fatigue severity and physical disability predicted referrals for physical therapy. Patient self-management activities were only weakly associated with disease severity variables.

CONCLUSION

The activity and damage components of RA were related to the separate components of total health service utilization. Disease activity was the prime determinant of physician services used, and RA progression the determinant of surgical interventions and hospitalization.