Increasing condom usage for African-American and hispanic young fathers in a community based intervention

Objectives: This paper investigates a community-based intervention for young fathers, FatherWorks, compared to care-as-usual, 24/7 Dads. We hypothesized that utilizing the FatherWorks intervention (a 15 session parenting intervention, 13 session employment class, paid internship, case management, and access to behavioral health services) will assist in readiness to use condoms and increase condom usage, which may differ by race/ethnicity.Methods: Eligible males (n = 328) were enrolled into a Randomized Control Trial. Participants were 15-24 years old and had fathered one or more children with a female under the age of 21. A survey was taken at baseline and at 15 weeks following the intervention.Results: Analyses of changes indicated that intervention participants improved from the pre-contemplation stage of condom usage towards contemplation, and from preparation to action. The pattern of improvement in the condom use stage of change was different in African-American versus Hispanic participants. Changes in condom use during last intercourse were not significant.Conclusions: Study findings indicate that FatherWorks is successful in increasing the intent to use condoms, with the effect manifesting differently in African-American and Hispanic young fathers. Future work with minority fathers indicates a need for cultural adaptation of the intervention.

African-American, Puerto-Rican, and Other Hispanic Fathers' Differential Responses to a Parenting Intervention

Despite the recognized importance of fathers to children's well-being, there is a lack of research exploring the impact of parenting interventions on young fathers. Further, little work has been done to identify whether fatherhood interventions differentially benefit specific subgroups of fathers, including Hispanic subgroups.This research examines a 15-week fatherhood intervention for African American, Puerto Rican, and non-Puerto Rican Hispanic young fathers. Data were collected from 312 fathers ages 15-24 at baseline, post-intervention (15 weeks), and at 8 months, 12 months, and 16 months post-baseline follow-up. Latent growth models were used to examine differential shapes of change for the three groups. Results suggest different intervention responses across the three groups on risky parenting attitudes, African American fathers in the study indicated more risky parenting attitudes than Hispanic and Puerto Rican fathers. The practice and research implications of disaggregating data for minority fathers, particularly for Latino subgroups, are discussed.

Health insurance literacy: disparities by race, ethnicity, and language preference

OBJECTIVES

To measure Connecticut's Affordable Care Act qualified health plan enrollees' health insurance literacy (HIL) by race, ethnicity, and language preference.

STUDY DESIGN

Statewide landline and cell phone telephonic survey.

METHODS

Geographically balanced cohort that oversampled black and Hispanic enrollees. Questions tested enrollees' knowledge of basic health insurance terminology and their use. Survey data were supplemented by deidentified administrative data from the state's health insurance exchange.

RESULTS

Overall, subjects answered 62% of 13 questions correctly. The percentages of correct answers were 53% for black enrollees, 50% for Hispanic enrollees, 74% for white enrollees, and 45% for Spanish-speaking enrollees. The differences by race, ethnicity, and language preference were statistically significant. Overall, enrollees with a college education scored higher across all demographic groups, but disparities by race and ethnicity persisted.

CONCLUSIONS

Health insurance terminology and use rules confuse consumers, especially racial and ethnic minorities. Differences in HIL may be a previously underrecognized source of healthcare disparities because even minor errors can result in delayed care or unanticipated medical bills. Low HIL can diminish the practical value of health insurance and exacerbate perceptions of health insurance as offering insufficient value for premium price. Additional research on ways to improve HIL and investments in insurance navigation support for black and Hispanic enrollees are needed.

Innovations in Payer-Community Partnerships: The EmblemHealth Neighborhood Care Program

Comprehensive and innovative strategies are needed to address and manage chronic diseases and conditions and to reduce health disparities. EmblemHealth Neighborhood Care (EHNC) sites provide community-based linkages across payers, health providers, and delivery systems and underserved communities using culturally sensitive methods tailored to meet the needs of the community. This article describes this novel initiative and early indicators of its feasibility. Three EHNC sites were established in New York City: Harlem, Cambria Heights, and Chinatown. Each site provides core health and customer services to members and the community. In addition, sites provide tailored services to meet the unique needs of each community. Preliminary data suggest that program and community members are utilizing the sites and returning for follow-up visits. Sites also demonstrate success in cross referral between EHNC teams. The EHNC program is both feasible from the payer's perspective and acceptable to diverse patient populations and settings.

Defining Disability for Women and the Problem of Unpaid Work

National policy and much of scholarly research on disability overlook the importance of unpaid family work and instead focus on disability in paid work, largely in male samples. Because of societal expectations about appropriate social roles for men and women, women tend to assume responsibility for unpaid work in the family and also tend to have paid work that is characterized by low pay and limited autonomy. This article discusses the political, theoretical, and methodological issues relating to defining and measuring paid and unpaid work disability for women and men within the context of these structural factors. The results of a study analyzing disability in both paid work and unpaid family work among a sample of 206 women with rheumatoid arthritis are presented. The study demonstrates the feasibility of measuring disability in family work and shows that women experience significant limitations in homemaker functioning as well as in paid work roles.

U.S. Dental Specialty Residents' Expectations and Anticipated Benefits of Academic Employment

The aims of this study were to assess features of an academic career that dental specialty residents, as a group and by gender, find most attractive and to identify what determines their expectations for responsibilities and professional growth in academic employment. In November 2013, an invitation to participate in the study along with a link to an online survey was sent to the 407 U.S. program directors of six of the dental specialties (endodontics, oral and maxillofacial surgery, pediatric dentistry, periodontics, prosthodontics, and orthodontics), asking them to forward the survey to their residents. A total of 287 residents responded (112 [41.3%] female and 159 [58.7%] male) out of 4,400 enrolled in these specialty training programs (6.5% response rate). The female respondents were significantly more interested in joining academia than were the male respondents (female 48%; male 31.5%; p<0.005). Respondents of both genders were attracted to academic dentistry by opportunities for intellectual and professional stimulation, but the lifestyle of academicians was significantly more important for the female respondents. The most important feature of a successful academic career for the female respondents was the ability to have a good balance between career and personal life. While opportunity to conduct research was a positive feature for all residents interested in academia and both male and female respondents agreed strongly on the need for collaboration between faculty members for productive research, male respondents agreed significantly more than female respondents that faculty members should conduct independent research. Faculty members' feedback about academic employment were a significantly positive influence on those planning an academic career compared to those planning to enter private practice. This study found that the female and male residents differed in their expectations of responsibilities and professional growth in academic employment. These results may be useful for academic dental institutions and organizations when developing faculty recruitment and retention programs.

A Review of Graphical Approaches to Common Statistical Analyses: The Omnipresence of Latent Variables in Statistics

We provide a comprehensive review of simple and advanced statistical analyses using an intuitive visual approach explicitly modeling Latent Variables (LV). This method can better illuminate what is assumed in each analytical method and what is actually estimated, by translating the causal relationships embedded in the graphical models in equation form. We recommend the graphical display rooted in the century old path analysis, that details all parameters of each statistical model, and suggest labeling that clarifies what is given vs. what is estimated. We link in the process classical and modern analyses under the encompassing broader umbrella of Generalized Latent Variable Modeling, and demonstrate that LVs are omnipresent in all statistical approaches, yet until directly 'seeing' them in visual graphical displays, they are unnecessarily overlooked. The advantages of directly modeling LVs are shown with examples of analyses from the ActiveS intervention designed to increase physical activity.

Development and validation of the Medical Home Care Coordination Survey for assessing care coordination in the primary care setting from the patient and provider perspectives

Background

Community health centers are increasingly embracing the Patient Centered Medical Home (PCMH) model to improve quality, access to care, and patient experience while reducing healthcare costs. Care coordination (CC) is an important element of the PCMH model, but implementation and measurability of CC remains a problem within the outpatient setting. Assessing CC is an integral component of quality monitoring in health care systems. This study developed and validated the Medical Home Care Coordination Survey (MHCCS), to fill the gap in assessing CC in primary care from the perspectives of patients and their primary healthcare teams.

Methods

We conducted a review of relevant literature and existing care coordination instruments identified by bibliographic search and contact with experts. After identifying all care coordination domains that could be assessed by primary healthcare team members and patients, we developed a conceptual model. Potentially appropriate items from existing published CC measures, along with newly developed items, were matched to each domain for inclusion. A modified Delphi approach was used to establish content validity. Primary survey data was collected from 232 patients with care transition and/or complex chronic illness needs from the Community Health Center, Inc. and from 164 staff members from 12 community health centers across the country via mail, phone and online survey. The MHCCS was validated for internal consistency, reliability, discriminant and convergent validity. This study was conducted at the Community Health Center, Inc. from January 15, 2012 to July 15, 2014.

Results

The 13-item MHCCS - Patient and the 32-item MHCCS - Healthcare Team were developed and validated. Exploratory Structural Equation Modeling was used to test the hypothesized domain structure. Four CC domains were confirmed from the patient group and eight were confirmed from the primary healthcare team group. All domains had high reliability (Cronbach’s α scores were above 0.8).

Conclusions

Patients experience the ultimate output of care coordination services, but primary healthcare staff members are best primed to perceive many of the structural elements of care coordination. The proactive measurement and monitoring of the core domains from both perspectives provides a richer body of information for the continuous improvement of care coordination services. The MHCCS shows promise as a valid and reliable assessment of these CC efforts.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0893-1) contains supplementary material, which is available to authorized users.

Statistical Power of Alternative Structural Models for Comparative Effectiveness Research: Advantages of Modeling Unreliability

The advantages of modeling the unreliability of outcomes when evaluating the comparative effectiveness of health interventions is illustrated. Adding an action-research intervention component to a regular summer job program for youth was expected to help in preventing risk behaviors. A series of simple two-group alternative structural equation models are compared to test the effect of the intervention on one key attitudinal outcome in terms of model fit and statistical power with Monte Carlo simulations. Some models presuming parameters equal across the intervention and comparison groups were underpowered to detect the intervention effect, yet modeling the unreliability of the outcome measure increased their statistical power and helped in the detection of the hypothesized effect. Comparative Effectiveness Research (CER) could benefit from flexible multi-group alternative structural models organized in decision trees, and modeling unreliability of measures can be of tremendous help for both the fit of statistical models to the data and their statistical power.

Developing culturally congruent weight maintenance programs for African American church members

OBJECTIVES

Developing community-based and culturally congruent weight loss maintenance programs is an important component of weight reduction interventions in high-risk populations. This qualitative investigation was conducted to guide development of faith-based weight maintenance programs for African American church members.

DESIGN

Twenty African American church members who previously participated in a church-based group weight loss program were recruited to participate in focus groups. This qualitative inquiry focused on the role of faith in maintaining healthy lifestyle behaviors, such as healthy eating and regular physical activity. Within these groups, a nominal group process was used to identify activities and language to be included within a faith-based maintenance program.

RESULTS

Content analysis identified seven conceptual domains that participants thought were important aspects of a faith-based weight maintenance program: (1) accountability for change targets, (2) programmatic tools, (3) group benefits and support, (4) keys to successful behavior change, (5) keys to church and programmatic level success, (6) addressing barriers, and (7) faith. The faith sub-domains included faith in the Lord, using the body for God, and a spiritual focus. The nominal group process resulted in 11 recommended components for a faith-based weight maintenance program. The top four included scriptures and prayers are 'walk of faith,' healthy diet, exercise, and focusing on God.

CONCLUSIONS

The results suggest that integrating faith themes into a weight loss maintenance program may increase its long-term impact on participants' health behavior change.

Improving pediatric asthma control among minority children participating in medicaid: providing practice redesign support to deliver a chronic care model

BACKGROUND

Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have over-reliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach.

OBJECTIVE

The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC).

METHODS

In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt.

RESULTS

Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315-4.204). In Phase II (the post-enrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients' asthma control.

CONCLUSIONS

The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.

Employment and health status changes among women with fibromyalgia: a five-year study

OBJECTIVE

To assess changes in health status of women with fibromyalgia (FM) over 5 years and determine whether baseline employment status influences health outcomes adjusting for other baseline factors.

METHODS

Two hundred eighty-seven women with FM were recruited from a national sample of rheumatologists and interviewed by phone at baseline and annually for 4 years. Data were collected on pain, fatigue, Center for Epidemiologic Studies Depression Scale and Modified Health Assessment Questionnaire (M-HAQ) scores, demographic characteristics, and employment status. At the end of the study, 211 participants remained. Data were analyzed using multilevel modeling techniques. Bootstrap methods adjusted for the cluster sampling.

RESULTS

The participants' mean +/- SD age was 47 +/- 11 years, their mean +/- SD education level was 14 +/- 2 years, 90% were white, 50% employed, 64% married, and their median household income was >or=$50,000. Mean +/- SD scores at baseline were 57.2 +/- 24 for pain, 75.4 +/- 22 for fatigue, 22.9 +/- 13 for depression, and 0.73 +/- 0.5 for the M-HAQ. Multilevel modeling indicated that all health status measures declined significantly over time except for pain. Rates of change varied from -1.22 for fatigue to -0.03 for the M-HAQ. Except for pain, patients who were employed at baseline had better health status over time. The employment and time interaction was not significant, indicating that health status changed at the same rate regardless of employment status. Other significant factors were age and income.

CONCLUSION

Employed women with FM have better health status at baseline and maintain that advantage over time. Employment does not seem to provide a protective health benefit.

Centers speak up: the clinical context for health information technology in the ambulatory care setting

BACKGROUND

Clinicians in ambulatory care settings are increasingly called upon to use health information technology (health IT) to improve practice efficiency and performance. Successful adoption of health IT requires an understanding of how clinical tasks and workflows will be affected; yet this has not been well described.

OBJECTIVE

To describe how health IT functions within a clinical context.

DESIGN

Qualitative study, using in-depth, semi-structured interviews.

PARTICIPANTS

Executives and staff at 4 community health centers, 3 health center networks, and 1 large primary care organization.

APPROACH

Transcribed audio-recorded interviews, analyzed using the constant comparative method.

RESULTS

Systematic characterization of clinical context identified 6 primary clinical domains. These included results management, intra-clinic communication, patient education and outreach, inter-clinic coordination, medication management, and provider education and feedback. We generated clinical process diagrams to characterize these domains. Participants suggested that underlying workflows for these domains must be fully operational to ensure successful deployment of health IT.

CONCLUSIONS

Understanding the clinical context is a necessary precursor to successful deployment of health IT. Process diagrams can serve as the basis for EHR certification, to identify challenges, to measure health IT adoption, or to develop curricular content regarding the role of health IT in clinical practice.

Work disability among two cohorts of women with recent-onset rheumatoid arthritis: a survival analysis

OBJECTIVE

To analyze factors associated with leaving employment among women with newly diagnosed rheumatoid arthritis (RA).

METHODS

Women with RA were recruited from a national sample of rheumatologists in 1987 and 1998. Inclusion criteria were RA diagnosis <18 months earlier, age >or=18 years, and no other disabling health condition. The 1987 and 1998 cohorts comprised 48 and 91 women, respectively. Data were collected by telephone for 4 years. Survival analysis was conducted using Kaplan-Meier curves and a proportional hazards generalized linear model to assess whether the time to stopping work differed between the cohorts and to identify baseline predictors and time-varying covariates of leaving work.

RESULTS

Most patients were age <50 years, married, had >12 years of education, and were white. Fifteen patients (31%) in the 1987 cohort and 24 patients (26%) in the 1998 cohort stopped working in the observation periods. Kaplan-Meier survival curves for each cohort were not significantly different. Multivariate analyses demonstrated that married women (P = 0.03) and those with joint deformities (P = 0.00) were more likely to stop working. A significant flares by cohort interaction (P = 0.01) indicated that, in comparison with patients in the 1998 cohort, those in the 1987 cohort with <2 disease flares had the lowest risk of stopping work and those with >or=2 flares had the greatest risk.

CONCLUSION

Unexpectedly, the cumulative rate of stopping work among women in the 1998 study did not differ from that among women diagnosed >16 years earlier. However, disease flares greatly affected employment in the 1987 but not the 1998 cohort, possibly indicating that newer medications were effective in maintaining functional status among those with more severe disease activity, measured by number of flares, in the 1998 group.

Coping with rheumatoid arthritis pain in daily life: within-person analyses reveal hidden vulnerability for the formerly depressed

This study examined the association between history of depression and day-to-day coping with rheumatoid arthritis (RA) pain. The sample was 188 RA-diagnosed participants, 73 of whom were identified by a structured clinical interview as having a history of major depression. None had current major depression. All participated in a 30-day prospective study in which they made end-of-day ratings of their arthritis pain, the strategies for how they coped with their pain, their appraisals of daily pain, and daily mood. Hierarchical linear models evaluated whether individuals with and without depression history differed in their average pain and the other daily measures; and separately, whether they differed in their within-person associations between pain and the daily measures (e.g., the day-to-day contingency between pain and mood). All analyses controlled for current mild depressive symptoms, neuroticism, and age. Previously depressed individuals were indistinguishable from their never depressed peers in their average pain and the other daily measures; however, the previously depressed exhibited significantly stronger associations between pain and several aspects of their daily emotional experience, suggesting more pain-contingent well-being. For individuals with a history of depression, increases in daily pain corresponded with more frequent efforts to cope with their pain by venting their emotions, significantly stronger impairments in mood, and, if they were also presently distressed, reduced perceptions of control over their pain, compared to the never depressed. Patterns suggest that formerly depressed individuals exhibit a hidden vulnerability in how they manage chronic pain. This vulnerability is best revealed by a daily process approach.

Measuring disability: application of the Rasch model to activities of daily living (ADL/IADL)

This paper describes a comparative analysis of (ADL) and (IADL) items administered to two samples, 4,430 persons representative of older Americans, and 605 persons representative of patients with rheumatoid arthrisit (RA). Responses are scored separately using both Likert and Rasch measurement models. While Likert scoring seems to provide information similar to Rasch, the descriptive statistics are often contrary if not contradictory, and estimates of reliability from Likert are inflated. The test characteristic curves derived from Rasch are similar despite differences between the levels of disability with the two samples. Correlations of Rasch item calibrations across three samples were .71, .76, and .80. The fit between the items and the samples, indicating the compatibility between the test and subjects, is seen much more clearly with Rasch with more than half of the general population measuring the extremes. Since research on disability depends on measures with known properties, the superiority of Rasch over Likert is evident.

Treating asthma by the guidelines: developing a medication management information system for use in primary care

The aim of this study was to develop, implement, and assess an automated asthma medication management information system (MMIS) that provides patient-specific evaluative guidance based on 1997 NAEPP clinical consensus guidelines. MMIS was developed and implemented in primary care settings within a pediatric asthma disease management program. MMIS infrastructure featured a centralized database with Internet access. MMIS collects detailed patient asthma medication data, evaluates pharmacotherapy relative to practitioner-reported disease severity, symptom control and model of guideline-recommended severity-appropriate medications and produces a patient-specific "curbside consult" feedback report. A system algorithm translates actual detailed medication data into actual severity-specific medication-class combinations. A table-driven computer program compares actual medication-class combinations to a guideline-based medication-class combinations model. Methodology determines whether the patient was prescribed a "severity-appropriate" amount or an amount "more" or "less" medication than indicated for patient's reported severity. Feedback messages comment on comparison. Missing data, unrecognized amounts of controller medication or unrecognized medication combinations create error cases. Post hoc review analyzed error cases to determine prevalence of non-guideline medicating practices among these practitioners. Proportion of valid and error cases across two clinical visits before and after post hoc clinical review were measured, as well as proportion of severity-appropriate, out-of-severity and non-guideline medications. MMIS produced a valid feedback report for 83% of patient visits. Missing data accounted for 60% of error cases. Practitioners used severity-appropriate medications for 60% of cases. When non-severity-appropriate medications were used they tended to be "too much" rather than "too little" (22%, 5%), suggesting appropriate use of guideline-recommended "step down" therapy by these practitioners.

Employment and Quality of Life Outcomes Among Women with Fibromyalgia Compared to Healthy Controls

The purpose of this study was to assess the effects of paid employment on health related quality of life among women with fibromyalgia compared to a group of women who were otherwise healthy. Participants were recruited from 118 rheumatology practices randomly sampled from the membership of the American College of Rheumatology. Three hundred and sixty-five patients were referred to the study and 287 completed a telephone interview. At the end of each interview, participants were asked to nominate 2 individuals to serve as control subjects. Because of lagging enrollment of control subjects, we initiated an additional method of asking control subjects to nominate controls. Of 381 control subjects nominated for the study, 286 or 75% completed the initial interview. As with patients, controls completed a computer assisted phone interview with a trained interviewer similar to that of the patient. The mean age of women with FMS was 47 years, most were married (59.6%), 87.8% were of white race and non-Hispanic ethnicity, 47.7% were employed, had an average of 14 years of education and household annual incomes generally exceeded $20,000, with 40.4% having incomes in excess of $50,000. There we no significant differences between women with FMS and those without FMS on these characteristics. Women with FMS had significantly worse physical and mental health related quality of life measured by SF-12 Physical (PCS) and Mental (MCS) Component Summary Scores; those who were not employed had significantly worse PCS scores but there were no differences by employment for MCS. Ordinal regression analysis adjusting for demographic characteristics showed that there were significant main effects for condition and employment on PCS in that those with FMS and those who were not employed had worse PCS scores. Initially, we also found an interaction effect between condition and employment in that the beneficial effects of employment was restricted to the FMS cases. However, when adjustments were made for the double nesting design, the interaction effect was no longer significant. For MCS, FMS cases had significantly worse health related quality of life, but there were no main effects for employment and no interactions were significant. Our results concur with findings in community studies that employed women report better quality of life than those not employed, but only for the physical dimension of quality of life. The findings regarding MCS are intriguing in that women with FMS are not very different from controls and that employment has little effect on the mental health component of quality of life.

Rate of change in functional limitations for patients with rheumatoid arthritis: effects of sex, age, and duration of illness

OBJECTIVE

To estimate the rate of change in functional limitations for patients with rheumatoid arthritis (RA) as a function of age, duration of illness, and sex.

METHODS

Patients with RA (n = 700) aged 21-65 years in 1988 were interviewed yearly for 6 years in The National Rheumatoid Arthritis Study. Functional limitations scores based on a Rasch measurement model of 20 Health Assessment Questionnaire items were analyzed in mixed-effects models to estimate the rate of change in functional ability as a function of age, duration of illness, sex, and interactions.

RESULTS

Models for both patient age and duration of illness significantly predicted limitations in functional ability for men and women. The model for age included a significant cubic effect; the model for duration of illness included a significant linear effect only. Sex was significant in both models and no interactions were significant in either model. The AIC index of fit, an indicator of the information value of the model, favored the model for duration of illness over the model for age. While both models showed higher levels of functional limitations in women than men, the rate of change for women was similar to men.

CONCLUSION

Limitation in functional ability in RA progressed in a linear manner with duration of illness and progressed at the same rate for both men and women, but functional limitations were greater for women.

From Research to Daily Clinical Practice: What Are the Challenges in “Translation”?

BACKGROUND

Translating research findings into sustainable improvements in clinical and patient outcomes remains a substantial obstacle to improving the quality and safety of care. The Agency for Healthcare Research and Quality funded two initiatives to assess strategies for improvements--Translating Research into Practice (TRIP). The TRIP II initiative supported 13 quality improvement projects. SURVEYING THE TRIP II STUDIES: The principal investigators (PIs) of the 13 projects were surveyed regarding encountered barriers to implementation at 6 months and 18 months (when they were also asked about solutions).

RESULTS

Seven of the 13 PIs responded to the survey at both times--6 and 18 months. For each project stage--Select a TRIP focus and develop intervention strategies (Stage 1), Conduct the intervention (Stage 2), and Measure the Impact (Stage 3)--barriers were described, and field-tested solutions were provided. For example, for Stage 2, if the target audience lacked buy-in and would not participate, solutions would be to get up-front buy-in from all staff, not just leaders; address root causes of problems; use opinion leaders and incentives; plan interventions ahead and provide make-up videos; and accept that targets vary in their readiness to change.

DISCUSSION

The framework and examples provided should help overcome challenges in any work in which research findings are applied to clinical practice.

History of affective disorder and the experience of fatigue in rheumatoid arthritis

OBJECTIVE

To evaluate how a prior affective disorder (major depression or generalized anxiety disorder) affects current fatigue among individuals with rheumatoid arthritis (RA). To determine whether that relationship is mediated by self-efficacy expectations.

METHODS

Forty-eight RA patients with a prior affective disorder and 74 without a history of affective disorder completed a mailed questionnaire that included the Multidimensional Assessment of Fatigue and indicators of neuroticism and self efficacy.

RESULTS

RA patients with a history of affective disorder reported higher levels of fatigue than those with no previous affective disturbance. Controlling for neuroticism and self efficacy, affective disorder history continued to predict current fatigue. Mediational analyses revealed both direct and indirect effects (via self efficacy) of history of affective disorder on the experience of fatigue in RA.

CONCLUSION

History of affective disorder independently predicts higher levels of fatigue in RA patients, and self efficacy plays a mediating role in this relationship.

Do employment and family work affect the health status of women with fibromyalgia?

OBJECTIVE

To assess health status differences of women with fibromyalgia syndrome (FM) who are employed and not employed, and to evaluate whether employment and family work influence the health status of women with FM as it does for women in community studies.

METHODS

Participants were 287 women recruited from 118 randomly selected rheumatology practices. They completed telephone interviews that collected data on demographic characteristics, health status, symptoms, family work, and social support. One hundred thirty-seven were employed and 150 were not employed. Formal statistical analysis, including estimation and testing, focused on the relationship between employment and 4 health status measures: Modified Health Assessment Questionnaire (MHAQ), visual analog scale (VAS) for pain on the interview day, number of painful areas, and VAS for fatigue on the interview day. The relationship between employment and these measures was evaluated using analysis of variance, chi-square, linear regression, and ordinal logistic regression.

RESULTS

The majority of participants reported high levels of symptoms and poor health status. In the bivariate analyses, employed women reported significantly less pain, less fatigue, and better functional status than those who were not employed. In the multivariate analyses, employment remained a significant factor in explaining number of painful areas, functional status (MHAQ), and fatigue, with employed women reporting better health status than those not employed. Employment was not associated with pain on the day of the interview when other factors were considered in the analysis. The psychological demands of family work were consistently related to all dependent measures of health status, as those with greater psychological demands reported worse health status.

CONCLUSION

As in community studies, employed women with FM report better health status than women who are not employed. The demands of family work exert a serious and significant effect on every dimension of health status and should be the focus of greater clinical attention. Further followup will assess whether employment has a protective effect for women with FM as in community studies or whether women with less severe FM tend to remain in the workforce.

A comparison of self-reports of distress and affective disorder diagnoses in rheumatoid arthritis: a receiver operator characteristic analysis

OBJECTIVE

To compare 3 commonly used psychiatric symptom checklists (the Center for Epidemiological Studies Depression Scale [CES-D], the Positive and Negative Affect Schedule, and the Endler Multidimensional Anxiety Scales [EMAS]) to determine their sensitivity, specificity, and ability to discriminate between a disorder (Major Depression [MD], Generalized Anxiety Disorder [GAD]), and no disorder. To compare the checklists for their ability to discriminate between type of disorder (MD and GAD). To evaluate the discriminant ability of the subscales, particularly positive affect; whether the somatic items in the CES-D artificially inflate affective scores; and the optimal cut off score for the CES-D.

METHODS

We compared the 3 scales to diagnostic criterion of MD, GAD, and comorbid disorder using receiver operator characteristic (ROC) and logistic regression analyses. The sample consisted of a national panel of 415 individuals with rheumatoid arthritis (RA).

RESULTS

Each of the scales had high sensitivity and specificity (areas under the curve: CES-D = 0.92, negative affect = 0.88, positive affect and EMAS = 0.82). The CES-D, however, demonstrated better sensitivity and specificity than the positive affect and the EMAS, but not the negative affect scale.

CONCLUSION

All 3 self-reports have high combined sensitivity and specificity as measures of affective disorders among RA patients.

Stratifying medical and pharmaceutical administrative claims as a method to identify pediatric asthma patients in a Medicaid managed care organization

Claims data are a problematic indicator of underlying clinical diagnosis. They are attractive because of their affordability, a criterion especially salient in resource-shy environments such as the Medicaid Managed Care Organization. This study tested the validity of administrative medical and pharmaceutical claims stratified by treatment modality to identify true pediatric asthma patients. Primary and secondary data were used. Secondary data consisted of 1997 medical and pharmaceutical claims. Primary data consisted of chart data collected through expert chart review. We stratified claims by treatment modality hypothesized to better identify true asthma patients. Claim patterns were analyzed for support of expectations. Expert chart review determined true asthma status on study sample. We found that claims are patterned in accordance with hypotheses about stratification groups. The combined use of both medical and pharmaceutical claims was more effective in identifying asthmatics than the use of either set of claims by itself. The Medicaid Managed Care Organization can begin to identify its asthma population using the stratification meth.

Rehabilitation therapy self-efficacy and functional recovery after hip fracture

Little is known about the role of psychological factors in the functional recovery process of hip fracture patients. This study employed a prospective cohort design to test the hypothesis that hospitalized hip fracture patients with greater reported self-efficacy for conducting rehabilitation therapy would have a greater likelihood of recovering to a pre-fracture level of locomotion function six months after the fracture. This hypothesis was tested controlling for pre-fracture level of function and depressive symptoms reported during hospitalization for surgical repair. An original measure of rehabilitation therapy self-efficacy was evaluated prior to hypothesis testing. Study patients were recruited from two hospitals, interviewed during hospitalization and followed up six months later. Patients included in hypothesis test analyses (n = 24) were mostly women (82%) with a mean age of 79 years. Results showed that patients with higher self-efficacy scores had a greater likelihood of locomotion recovery, controlling for pre-fracture locomotion function level (adjusted odds ratio (AOR) = 1.21; 95% confidence interval (CI) = 1.00-1.45; P= 0.05). This positive association between rehabilitation therapy self-efficacy and likelihood of locomotion recovery persisted after adding depressive symptoms (the Center for Epidemiological Studies-depression (CES-D) score) to this logistic regression model (AOR for self-efficacy = 1.18; 95% CI = 0.99-1.42; P= 0.07). It is concluded that rehabilitation therapy self-efficacy is a potentially important psychological factor in helping hip fracture patients recover locomotion functioning.

Factors associated with continued employment among patients with rheumatoid arthritis: a survival model

OBJECTIVE

To evaluate the association of demographic, disease, workplace, social, and household factors with the ability of patients with rheumatoid arthritis (RA) to remain employed over time.

METHODS

Four hundred seventy-two employed patients with RA recruited from a national sample of rheumatology practices were followed. Patients were interviewed once a year by telephone for 9 years and patients' physicians provided data on clinical aspects such as disease stage, joint deformity, and flares. A proportional hazards survival model based on stepwise variable selection was developed to investigate the association between continuance of work over a 9 year period and demographic, work, attitudinal, disease, and social support variables.

RESULTS

In the univariate analysis, the significant factors associated with longer work survival were being younger, being self-employed, having a higher prestige occupation, working more hours per week, having higher education level, and missing fewer days of work during the baseline year. The final multivariate model included age, type of occupation and number of days missed from work as a time varying co-variate.

CONCLUSION

Ability to remain employed over the 9 year study was more strongly associated with age, work characteristics, and time lost from work than with disease factors. The underlying mechanisms related to occupational prestige as a predictor of work survival should be investigated in order to develop interventions to reduce the risk of work disability.

History of affective disorder and the temporal trajectory of fatigue in rheumatoid arthritis

This study examines whether the general level and rate of change of fatigue over time is different for those rheumatoid arthritis (RA) patients with and those without a history of affective disorder (AD). Four hundred fifteen RA patients from a national panel had yearly telephone interviews to obtain fatigue and distress reports, and a one-time semistructured assessment of the history of depression and generalized anxiety disorder Growth-curve analysis was used to capture variations in initial fatigue levels and changes in fatigue over 7 years for those with and without a history. RA patients with a history of major AD reported levels of fatigue that were 10% higher than those without a history in the 1st year of the study. Their fatigue reports remained elevated over 7 years. Further analysis showed that the effects of a history of AD on fatigue are fully mediated through current distress, although those with a history had a significantly smaller distress-fatigue slope. Thus, a history of AD leaves RA patients at risk for a 7-year trajectory of fatigue that is consistently higher than that of patients without a history. The elevation in fatigue reports is, at least in part, a function of enduring levels of distress.

Measuring disability: application of the Rasch model to activities of daily living (ADL/IADL)

This paper describes a comparative analysis of (ADL) and (IADL) items administered to two samples, 4,430 persons representative of older Americans, and 605 persons representative of patients with rheumatoid arthrisit (RA). Responses are scored separately using both Likert and Rasch measurement models. While Likert scoring seems to provide information similar to Rasch, the descriptive statistics are often contrary if not contradictory, and estimates of reliability from Likert are inflated. The test characteristic curves derived from Rasch are similar despite differences between the levels of disability with the two samples. Correlations of Rasch item calibrations across three samples were .71, .76, and .80. The fit between the items and the samples, indicating the compatibility between the test and subjects, is seen much more clearly with Rasch with more than half of the general population measuring the extremes. Since research on disability depends on measures with known properties, the superiority of Rasch over Likert is evident.

Characteristics of rheumatoid arthritis patients: who participates in long-term research and who drops out?

OBJECTIVE

A 10-year study of rheumatoid arthritis (RA) patients was conducted to identify characteristics associated with continued participation in a long-term research project.

METHODS

Nine hundred eighty-eight RA patients were recruited from 56 private rheumatology practices. Over the course of the study, 45 patients died and were eliminated from the analysis. Patients were interviewed by phone each year for 10 years, and their physicians provided clinical data. Variables measured included demographic characteristics, perceived health status, employment status, family responsibilities, social support, and clinical health status.

RESULTS

Forty-six percent of patients remained in the study after 10 years. Survival analysis using Cox regression techniques assessed baseline factors that significantly predicted characteristics of patients who remained in the study. The multivariate analysis found that more educated patients, female patients, those with moderate to high levels of social support, patients having fewer joint groups with flares, and employed patients were more likely to remain in the study. Disease characteristics of stage of disease, level of pain, self-reported level of physical disability, and duration of RA were not significantly associated with continued study participation.

CONCLUSION

The results suggest that psychosocial and socioeconomic factors are more important determinants of continued participation in long-term research studies than are most clinical disease characteristics. Among clinical variables, only the active disease characteristic of joint flares predicted continued study participation. Overall disease characteristics such as disease stage or duration did not predict subject attrition.

Employment patterns and their effect on health outcomes among women with rheumatoid arthritis followed for 7 years

OBJECTIVE

To evaluate the effect of employment on health outcomes in a sample of women with rheumatoid arthritis (RA) and to test the hypothesis that employment confers a health benefit to women.

METHODS

Seven hundred sixty women with a diagnosis of RA were recruited from a national random sample of private rheumatology practices in 1988, and 416 remained in the study after 7 years of followup in 1994. Women were interviewed each year by telephone to collect data on demographic variables, health status, and employment status. Clinical data were provided by referring physicians.

RESULTS

Most women (175, 42%) were not employed outside the home 1988-94, although 96 of those women (23% of the sample) had been employed previously. Twenty-seven percent (n = 112) were employed all 7 years and 31% (n = 129) had been employed between one and 6 years. Women who were employed had significantly better health outcomes measured by pain, disability, role functioning, and clinical status compared to those who were never employed and those who had been employed before the study. Women who were previously employed, but not employed during the study period experienced the worst health outcomes. This difference in health status, however, appeared before entry into this study.

CONCLUSION

Employed women with RA had better health status than women who were not employed outside the home. Previously employed women had worse health outcomes than both working women and women who were never employed, suggesting that loss of employment is associated with worse health. Further research is needed to investigate underlying factors contributing to worse health status among unemployed women and to better health among employed women.

Depression and the long-term risk of pain, fatigue, and disability in patients with rheumatoid arthritis

OBJECTIVE

To determine whether a previous episode of major depression leaves a "scar" that places previously depressed patients with rheumatoid arthritis (RA) at risk for experiencing high levels of pain, fatigue, and disability.

METHODS

A cohort of 203 patients with RA was randomly selected from a national panel and interviewed by phone about pain, fatigue, depressive symptoms, disability, and history of major depression.

RESULTS

Excluding patients who met the criteria for current major depression, patients with both a history of depression and many depressive symptoms at the time of the interview (dysphoria) reported more pain than those without current dysphoria, irrespective of whether they had a history of depression. Dysphoria alone was not reliably related to pain reports.

CONCLUSION

An episode of major depression, even if it occurs prior to the onset of RA, leaves patients at risk for higher levels of pain when depressive symptoms persist, even years after the depressive episode.

Gender, paid work, and symptoms of emotional distress in rheumatoid arthritis patients

OBJECTIVE

To evaluate the relative contribution of gender-related work conditions, gender-related socialization practices, and disease characteristics to the explanation of emotional distress in men and women with rheumatoid arthritis (RA).

METHODS

Three hundred sixty-nine RA patients who were employed outside the home were recruited from a national randomized sample of rheumatology practices. Data on paid work and disease characteristics were obtained by telephone interview. Emotional distress was measured by the Center for Epidemiological Studies Depression (CES-D) scale. Hierarchical ordinary least-squares regression was used to assess the relationship of sex, class, work characteristics, and disease characteristics to both the CES-D summary scale and the CES-D factor structure.

RESULTS

Differences in emotional distress were explained best by functional ability and pain and secondarily by the characteristics of paid work, with no independent effect for sex. Distress increased with decreasing functional ability, increasing pain, and exposure to such work characteristics as low autonomy, low income, and high demands. No sex differences in any of the CES-D subscales remained after controlling for disease and work variables.

CONCLUSION

Among employed RA patients with high levels of functional disability and exposure to stressful work characteristics, men and women are at equal risk of experiencing emotional distress.

Predictors of work disability in rheumatoid arthritis patients. A five-year followup

OBJECTIVE

To evaluate regression models that include social, attitudinal, work structure, health status, and family characteristics, with regard to their prediction of work disability in a national sample of patients with rheumatoid arthritis (RA).

METHODS

Four hundred ninety-eight employed RA patients were recruited from a national sample of private rheumatology practices. Three hundred ninety-two remained in the study after 5 years. Data were collected from patients by telephone interview, and patients' physicians provided written clinical assessments. Only variables on which information was obtained in year 1 were used to predict work status in year 5, using hierarchical multiple logistic regression analysis.

RESULTS

The significant predictors of work disability were age (odds ratio [OR] 1.04), number of deformed joints (OR 1.26), number of joints with flare (OR 1.23), the complexity of working with things at work (OR 0.88), and the desire to remain employed (OR 2.3). The risk of work disability increased with increasing age, more severe disease, greater complexity of involvement with things at work, reduced work hours, and desire to not be working outside the home.

CONCLUSION

The risk of becoming work disabled in 5 years was predicted more by clinical status at entry into the study than by work structure. These results, which contradict previous research on work disability in arthritis, prompt a rethinking of future studies of work disability in RA.

Health insurance problems among insured rheumatoid arthritis patients

OBJECTIVE

To describe limitations in insurance coverage and their financial impact among a sample of rheumatoid arthritis (RA) patients.

METHODS

A national sample of RA patients followed since 1988, completed a telephone interview about health insurance coverage, experiences with preexisting conditions clauses, and the financial impact of arthritis. Descriptive and multivariate logistic regression techniques were used to analyze the demographics and health status data.

RESULTS

Trends in insurance coverage among people in this sample showed that participants were more likely to be in an HMO or PPO currently than 5 years previously. A majority of participants (67%) experienced financial impact from arthritis; 35% said that arthritis limited their ability to earn a living. Twenty-one percent had some insurance limitation because of arthritis as a preexisting condition. Eleven percent had been denied insurance. Those who had higher scores on the Stanford Health Assessment Questionnaire, were younger, were covered by Blue Cross/Blue Shield, and were more likely to be affected by a preexisting condition limitation.

CONCLUSION

The data clearly indicate that even well-insured RA patients receiving care from rheumatologists experience limitations related to preexisting conditions and considerable financial impact.

The measurement structure of the Center for Epidemiologic Studies Depression Scale

This study examined the temporal stability of the measurement structure of the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) in 813 individuals with rheumatoid arthritis. Participants completed the CES-D (Radloff, 1977) on three occasions 1 year apart. Structural equation models and polyserial correlations were used to address methodological limitations of previous studies. Four competing measurement structures were tested with one factor, three factors, four factors, and a single second-order factor underlying the four-factor model. The four-factor and the second-order-factor models provided the best fit at Time 1. When cross-validated at Times 2 and 3, the four-factor and the second-order-factor models remained invariant. Researchers can now more confidently use the CES-D to examine how distress changes in chronic physical disorders.

Family work demands, employment demands and depressive symptoms in women with rheumatoid arthritis

The effects of psychological demands, work autonomy and social support on psychological well-being are evaluated in a sample of employed women with rheumatoid arthritis (RA). Two hundred sixty-seven employed women with a diagnosis of RA were recruited from a national random sample of private rheumatology practices. Women were interviewed by telephone and data were obtained on demographic variables, health status, demands in paid and family work, autonomy in paid and family work, social support and depressive symptoms. Women reported relatively high levels of psychological demands in both paid and family work, with time constraints being the most frequent problem. Women also had relatively high levels of autonomy in family work. Hierarchical regression analysis showed that family demands appeared to be more important than paid work demands in psychological well-being. High autonomy in family work seemed to mediate the effects of family demands. Having higher social support reduced the effects of work demands on depressive symptoms in employed women with RA.

Characterizing the meaning of psychological distress in rheumatoid arthritis

Symptoms of depression are frequently reported by people with rheumatoid arthritis (RA). To advance our understanding of how best to assess and treat these symptoms, their meaning must be elucidated. This article explores two possible meanings for the emotional distress of RA patients reported on the Center for Epidemiological Studies Depression (CES-D) scale: (1) Certain CES-D scale items may inflate actual depressive symptom scores. (2) Depressive symptoms are experienced and/or expressed in unique ways in an RA population due to the presence of chronic physical symptoms. In this study of 988 people with RA, it was found that there is some modest inflation of the CES-D scale due to the items of "having difficulty getting going" and "everything was an effort." However, irrespective of the modest inflation of the scale, there is evidence that distress in RA is not a static concept. Distress in this RA population was expressed differently from that of a community population, and within the RA population, distress was expressed differently over time.

The impact of Hurricane Hugo and the San Francisco earthquake on a sample of people with rheumatoid arthritis

The health effects of two natural disasters on 32 people with rheumatoid arthritis (RA) were assessed during the second-year wave of interviews in an ongoing 3-year study. Although the severity of Hurricane Hugo exceeded that of the San Francisco earthquake, no significant differences in health impacts were found. Both groups reported significantly increased ratings of RA activity, pain, and depression compared with ratings during the first year. However, comparison with the rest of the sample (n = 767) showed that increases in disease activity and pain were a general phenomenon but that the increase in depression was unique to the disaster subsample. Physician health status assessments also indicated that those who experienced the disaster were more likely to be classified in later stages of the disease subsequent to the disaster and were more likely to experience flares. These results suggest that people with RA may constitute a special high-risk population for adverse health effects after natural disasters.

Pirmenol: an antiarrhythmic drug with unique electrocardiographic features--a double-blind placebo-controlled comparison with quinidine

Previous reports have stated that pirmenol is a Class IA antiarrhythmic drug that prolongs the QT interval, but did not use computerized electrocardiography. We randomized 18 patients with frequent ventricular ectopic depolarizations to pirmenol (8 patients) or quinidine (10 patients). Pirmenol was effective and tolerated for suppression of arrhythmia in all 7 patients treated (1 patient withdrew for personal reasons) but quinidine was effective and tolerated for 4 weeks in only 5 of 10 patients (p less than 0.05). Using computerized 12-lead electrocardiography, the mean change in PR interval from placebo to treatment was 5 +/- 18 ms for quinidine and 5 +/- 11 ms for pirmenol (p = NS). The mean change in QRS interval was 5 +/- 14 ms for quinidine and 10 +/- 5 ms for pirmenol (p = NS). The mean change in QT interval was 46 +/- 30 ms for quinidine and 8 +/- 9 ms for pirmenol (p less than 0.01) and the mean change in JT interval was 41 +/- 36 ms for quinidine and -2 +/- 10 ms for pirmenol (p less than 0.01). After the double-blind phase, 4 quinidine patients had computerized electrocardiographic intervals measured on pirmenol; the above findings were confirmed. These electrocardiographic features of pirmenol clearly distinguish it from quinidine, the prototype Class IA drug. However, pirmenol has minimal effect on the PR and QRS intervals, and thus does not appear to be a Class IC drug either. Although its electrocardiographic features are closest to Class IB, its electrophysiology in isolated cells and its antiarrhythmic and side effect profile are atypical for a IB agent.(ABSTRACT TRUNCATED AT 250 WORDS)

Work disability and the experience of pain and depression in rheumatoid arthritis

People with rheumatoid arthritis (RA) who are work disabled report more pain and depression than do those who are able to continue in paid employment. This paper explores the connections between work ability, clinical disease factors and symptom reports among people with this chronic disease. Using the expanded Biopsychosocial model of disease and illness it is shown that both work ability and clinical factors have independent, additive effects on pain and depression. The paid work effect is found even after controlling for the large and significant effect of pain on depression and depression on pain. This suggests that the pain and depression experience associated with RA is a function of both the underlying disease and the structural barriers that prevent continued participation in the workplace. It also suggests that contrary to popular notions of how disease severity affects symptoms, one does not have to be in the highest categories of disease severity to be in the highest levels of depression and/or pain.

Lack of effect of hypertonic sodium bicarbonate on QRS duration in patients taking therapeutic doses of class IC antiarrhythmic drugs

Hypertonic sodium bicarbonate (HSB) has been reported to reduce the toxicity of Class IC antiarrhythmic agents in rats and, anecdotally, in patients. A pilot study was conducted of the safety and efficacy of HSB for reversing the electrocardiographic effects of therapeutic doses of encainide or flecainide in ten patients taking these drugs for chronic ventricular arrhythmias. Patients had a mean drug-induced QRS prolongation before treatment of 27.6 +/- 8.8%. Each patient received a single dose of HSB 100 mEq or normal saline IV over 5 minutes on two separate occasions. The administration of treatments was blinded and balanced. There were no important side effects of HSB. Venous blood pH, CO2 content and sodium concentration were all significantly increased by HSB in comparison to saline. No differences were found during the 2-hour observation period in the primary endpoint, QRS duration, the PR or QT intervals, or the frequency of premature ventricular beats. It was concluded that HSB 100 mEq does not reduce QRS duration in patients taking therapeutic doses of flecainide or encainide. Because HSB was well tolerated, investigation of its use in higher doses or in patients with overt toxicity due to Class IC drugs is feasible.

Antiarrhythmic drug therapy for suppression of ventricular arrhythmia: experience with 122 patients treated for two years

Although there are many reports of the short-term effectiveness of antiarrhythmic drugs for suppression of ventricular ectopic depolarizations, there are less data available on the long-term use of these drugs. We treated 122 patients for up to 2 years with antiarrhythmic drugs for suppression of frequent ventricular ectopic depolarizations. The percent suppression of ventricular ectopic depolarizations and nonsustained ventricular tachycardia for each drug was determined at 1, 3, 6, 12, 18, and 24 months of therapy. Among 33 patients treated with flecainide, the mean suppression of ventricular ectopic depolarizations (average of all data during 24 months) was 93 +/- 17% and of nonsustained ventricular tachycardia was 97 +/- 7%. In 27 patients treated with encainide, the mean suppression of ventricular ectopic depolarizations was 88 +/- 18% and of ventricular tachycardia was 95 +/- 16%. Among 26 patients treated with propafenone, the mean suppression of ventricular ectopic depolarizations was 77 +/- 32% and of ventricular tachycardia was 93 +/- 15%. For the 20 patients treated with moricizine, the mean suppression of ventricular ectopic depolarizations was 62 +/- 35% and of ventricular tachycardia was 90 +/- 14%. Among 16 patients treated with amiodarone, the mean suppression of ventricular ectopic depolarizations was 92 +/- 14% and of nonsustained ventricular tachycardia was 99 +/- 3%. In 54 of the 122 patients (44%), the study drug was stopped during 2 years of therapy because of death (2 sudden, 2 unwitnessed and 6 noncardiac), side effects (21 patients), lack or of loss of efficacy (13 patients), and noncompliance (10 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Work disability among women with rheumatoid arthritis. The relative importance of disease, social, work, and family factors

Yelin and others have shown social work factors to be more important than disease factors in predicting work disability among arthritis patients; however, the effects of family factors on work role functioning have not been considered in previous explanatory models. In this study, we use Yelin's model to explain work disability among 122 women with rheumatoid arthritis and to incorporate family factors into the model. Using logistic regression, we found, as with previous studies, that work autonomy, social factors, and disease factors are important predictors of work disability. In the logistic regression model, self-assessed health status seemed to be more important than work factors in predicting work status. Further, family factors significantly contributed to the explanatory model, in that having more home responsibilities was associated with lower risk of work disability.