Risk factors for hospitalization and surgery in patients with rheumatoid arthritis: implications for capitated medical payment

Relationship between total arthroplasty case volume and patient outcome in an acute care payment system in Japan

We examined the relationship between hospital case volume and patient outcome (ie, length of hospital stay and hospital charges) for both total hip arthroplasty (THA) and total knee arthroplasty (TKA). The study included 1561 patients who had total joint arthroplasty from April 1, 2001, to March 31, 2003. Using the mean values of THA or TKA surgical case volumes, the participating hospitals were divided into high-volume and low-volume groups. Based on this categorization, the association between hospital surgical case volume and the patient outcome measures was tested. Hospital patient case volume has significant effects on the total length of hospital stay for both THA and TKA and on the total cost for THA. Implications of the findings for practice are considered.

The use of rheumatoid arthritis health-related quality of life patient questionnaires in clinical practice: lessons learned

OBJECTIVE

The utilization of health-related quality of life (HRQOL) patient questionnaires by clinical rheumatologists is limited. Yet, considerable literature exists defining the value of such data. In an effort to understand this apparent paradox, we performed a literature review and conducted a survey to describe what has been learned over the past 2 decades concerning the use of these measures in clinical care and explore the reasons for their underutilization.

METHODS

A panel of rheumatologists with extensive clinical experience was convened to review the relevant literature pertaining to the use of HRQOL patient instruments in clinical practice. Additionally, a survey of all American College of Rheumatology practicing clinicians was conducted to assess the use of and beliefs about these measures.

RESULTS

The literature provided evidence to support the use of HRQOL patient measures in clinical practice. Forty-seven percent of the responding rheumatologists stated that none of their patients complete HRQOL patient questionnaires. The majority of respondents (63%) reported that such information is "somewhat valuable." The most frequently reported reason for the underutilization was that such instruments "require too much staff time."

CONCLUSIONS

The literature supports the potential value of HRQOL patient questionnaires in clinical practice. Few rheumatologists routinely gather such information as part of patient care. Reasons for this discrepancy between utility and use are given along with recommendations intended to help increase their utilization in clinical care.

Patterns of Disease-Modifying Antirheumatic Drug Use, Medical Resource Consumption, and Cost Among Rheumatoid Arthritis Patients

We compared medical resource use and costs among rheumatoid arthritis (RA) patients receiving alternative disease-modifying antirheumatic drugs (DMARDs). The cohort study used data from a managed care organization. Health plan members who were prescribed DMARD therapy for at least 2 consecutive months, were age 18 years or older, had at least 6 months of DMARD-free enrollment prior to the first DMARD, and had a diagnosis of RA before or during the first month of DMARD were eligible. Median duration of initial DMARD therapy was 10 months overall: 11 months for hydroxychloroquine (n = 252), 15 months for methotrexate (n = 185), 5 months for sulfasalazine (n = 49), and 5 months for other mono/combination therapy (n = 85) (p < 0.0001). The average monthly cost of care was $853, of which $294 (34%) was for RA-coded medical services. In multivariate analyses, monthly RA-coded costs varied significantly by initial DMARD. RA costs and duration of initial therapy varied significantly by initial DMARD.

Medical resource use and costs among rheumatoid arthritis patients receiving disease-modifying antirheumatic drug therapy

OBJECTIVE

To identify costs among rheumatoid arthritis (RA) patients receiving alternative disease-modifying antirheumatic drug (DMARD) therapies.

METHODS

Using managed care organization data, we identified members who (a) were prescribed any DMARD therapy for two consecutive months between July 1993 and February 1998, (b) were aged > or = 18 years, (c) had > or = 6 months of DMARD-free enrollment prior to the first DMARD, and (d) had a diagnosis of RA.

RESULTS

The average age of the cohort (n = 571) was 51 years, and 70% were women. Mean duration of enrollment following initiation of DMARD therapy (observation period) was 19.5 months; 28.8% of patients switched DMARD regimens. The average monthly cost of care was $853, of which $294 (34%) was for RA-coded medical services. Monthly RA-coded costs varied by DMARD: hydroxychloroquine $227 (n = 252), methotrexate $340 (n = 185); sulfasalazine $233 (n = 49), and other mono/combination therapy $425 (n = 85) (P = 0.001).

CONCLUSION

Costs of RA-coded care in patients receiving DMARDs are low and vary by DMARD.

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.

Education and self-care activities among persons with rheumatoid arthritis

Associations between low formal education and increased morbidity and mortality have been well established among persons with rheumatoid arthritis (RA) and other conditions. This study attempted to identify a partial explanation for the association between low education and poor outcomes among persons with RA by examining self-care activities performed by persons with different levels of education. Persons with 13+ yr of education were significantly more likely to perform specific self-care activities (e.g., using a heated pool, tub, shower, OR = 2.59; using relaxation methods, OR = 3.00; using stress control methods, OR = 2.41; avoiding certain foods, OR = 1.74). The association between education and performance of self-care activities was not linear. When significant differences were noted, 13 yr of education was usually the point at which performance was significantly different than among lower education groups; individuals with 12 yr of education often exhibited lower frequencies of particular behaviors than did individuals with 9-11 yr of education. The association between higher education and performance of more self-care activities may shed light on previously described associations between education and morbidity. However, low education should not be viewed as the cause of increased morbidity and mortality, but as a proxy for a constellation of factors responsible for poor health outcomes.

Outcomes for persons with rheumatoid arthritis with a rheumatologist versus a non-rheumatologist as the main physician for this condition

OBJECTIVE

The authors compared outcomes among persons with rheumatoid arthritis (RA) with a rheumatologist versus a non-rheumatologist as the main physician for this condition.

METHODS

A cohort of 1,025 persons with rheumatoid arthritis were followed for as long as 11 years. The principal measures were obtained from an annual structured telephone interview conducted by a trained survey worker. All persons with rheumatoid arthritis originally were selected from a random sample of community rheumatologists, but some subsequently had migrated to the practices of non-rheumatologists. The main outcome measures included the number of painful and swollen joints, extent of morning stiffness, a global pain rating, functional status, and a measure of global improvement.

RESULTS

The persons with rheumatoid arthritis treated by rheumatologists reported significantly better functional status, fewer painful joints, and a lower overall pain rating, although the magnitude of these differences was small. A significantly greater proportion of the persons with rheumatoid arthritis treated by rheumatologists also reported improvement in a global measure of rheumatoid arthritis outcome and simultaneous improvement in all outcome measures. On all other outcome measures, the point estimate favored those with a rheumatologist as the main rheumatoid arthritis physician, although the differences did not reach statistical significance.

CONCLUSIONS

The evidence suggests an advantage for persons with a rheumatologist as the main rheumatoid arthritis physician, but on several of the measures of outcome, the magnitude of the advantage was small. Because the present study was an observational design, the possibility that the advantage among persons with a rheumatologist as the main rheumatoid arthritis physician is an artifact of selection bias cannot be ruled out.

Predictors of health care utilization in the chronically ill: a review of the literature

The objective of this paper is to identify predictors of health care utilization in the chronically ill. This paper reviews 53 studies on hospitalizations and physician visits, published between 1966 and 1997 and identified by MEDLINE and ClinPSYCH databases. Studies with both univariate and multivariate analyses were included. On the basis of the Andersen-Newman model of health care utilization, the effects of predisposing, enabling and need variables are examined. Most studies reviewed indicate that predisposing factors such as age, sex, and marital status are not predictors of hospital utilization in the chronically ill. The enabling factors income, insurance and social support have not been shown to affect health care utilization, but characteristics of the hospitals could have an effect. Need factors such as disease severity, symptom severity and complications adversely affected health care utilization in the chronically ill, while disease duration and comorbidity do not have such an effect. Quality of life and perceived health might affect hospital utilization and physician use. Finally, depression and psychological distress proved to be among the strongest predictors of hospitalizations and physician visits. In conclusion, both disease severity and psychological well-being are most important in health care utilization. Intervention programs to support depressed or psychologically distressed patients should be considered. These could both help the patient and reduce health care utilization costs.

Differences in symptom reports between men and women with rheumatoid arthritis

OBJECTIVE

To determine if differences exist between men and women in their reports and evaluations of rheumatoid arthritis (RA) symptoms, and, if so, to identify explanations of those differences.

METHOD

Data from a longitudinal panel study of persons with RA were used. Symptom reports were defined as individuals' evaluation of body states, e.g., evaluations of the severity of pain. Analyses were controlled for sociodemographic, clinical, and psychological characteristics.

RESULTS

In unadjusted analyses, women were more likely to evaluate their symptoms as severe. Adjustment for sociodemographic and clinical characteristics changed these results very little. Controlling for depressive symptoms decreased the magnitude of associations somewhat. Analyses controlling for additional respondent-reported clinical characteristics (Health Assessment Questionnaire score, number of painful joints) yielded dramatically different results; in no case did women evaluate their symptoms significantly more severely than men.

CONCLUSION

Our analyses suggest that women reported more severe symptoms, but that these differences may be due to more severe disease rather than a tendency by women to over-report symptoms or over-rate symptom severity. Future research should examine whether physicians respond to reports or prescribe treatments differently for men and women.

Variation among rheumatologists in the use of prednisone and second-line agents for the treatment of rheumatoid arthritis

OBJECTIVE

To test for and estimate variation among rheumatologists in their prescribing of prednisone and second-line agents for the treatment of rheumatoid arthritis (RA), after taking into account the characteristics of their patients.

METHODS

Multiple logistic regression incorporating random effects for rheumatologists, with adjustment for patient characteristics.

RESULTS

Values for the likelihood-ratio statistic provided strong evidence of such variation. Random-effect variance estimates showed that the variation is of great magnitude.

CONCLUSION

Even after patient characteristics have been taken into account, the data show that the rheumatologist may strongly influence the use of prednisone and second-line agents by a patient.

Identification of work disability in rheumatoid arthritis: physical, radiographic and laboratory variables do not add explanatory power to demographic and functional variables

Work disability, a common problem in rheumatoid arthritis (RA), is known to be associated with demographic variables such as occupation, age, and formal education, as well as with disease duration. However, physical, radiographic and laboratory variables, which are included in the traditional "medical model" of work disability and collected routinely in the application process, have not been studied for their capacity to explain whether patients are working or receiving work disability payments. A cross-sectional database which included an extensively characterized group of patients with RA was examined to determine possible associations of demographic, functional, physical, radiographic and laboratory variables with work disability status. All these variables differed in patients who were receiving work disability payments and those who were working full time, but in multivariate analyses, work or disability status was best identified by demographic and functional variables. Physical, radiographic, and laboratory data did not add significantly to explanation of work disability status beyond the demographic and functional variables and disease duration, despite the fact that receipt of disability payments was used as the criterion for work disability status.

The hierarchy of quality-of-life assessment, the Health Assessment Questionnaire (HAQ), and issues mandating development of a toxicity index

Health, as defined by the World Health Organization, encompasses the more redundant and cumbersome phrase "health-related quality of life." Valuations by patients naturally separate this entity into the primary dimensions of absence of death, disability, discomfort, drug toxicity, and destitution. These dimensions separate naturally into subdimensions, and the subdimensions into components, thus providing a hierarchy under which assessment of particular aspects of health may be placed. In the clinical trial situation, it is essential that all dimensions always be assessed and reported, because otherwise, misleading conclusions may be drawn. On the other hand, it is much less important which assessment instrument is chosen, or how much detail is assessed for each dimension. The Health Assessment Questionnaire (HAQ) has been developed under a hierarchical conceptual model and widely used; its characteristics are described. A new index for measurement of drug toxicity has been developed for the HAQ, and its crucial role in comparing treatments in a clinical trial discussed. Issues in reliably describing comparative drug toxicity are developed, a toxicity index presented, and some preliminary results and conclusions outlined. With the ability to quantitatively describe drug toxicity, health assessment becomes conceptually more complete.

A clue from a self-report questionnaire to distinguish rheumatoid arthritis from noninflammatory diffuse musculoskeletal pain. The P-VAS:D-ADL ratio

A clue to distinguishing rheumatoid arthritis (RA) from noninflammatory diffuse musculoskeletal pain is described on the basis of 2 self-report questionnaire scales, one to assess difficulty in activities of daily living (D-ADL) and a pain visual analog scale (P-VAS). Patients with RA have significantly higher scores on the D-ADL scale compared with the P-VAS scale, while patients with noninflammatory diffuse musculoskeletal pain show the reciprocal pattern. Therefore, the ratio of the P-VAS:D-ADL scores differed significantly in the 2 groups. Ratios of less than 3 were seen in 67% of RA patients versus 28% of patients with noninflammatory diffuse musculoskeletal pain, while ratios greater than 5 were seen in 27% of patients with noninflammatory diffuse musculoskeletal pain, but not in any patients with RA. This simple ratio is clearly not a diagnostic test, but provides an initial approach to diagnosis in rheumatic diseases using a self-report questionnaire.

Self-report questionnaires in five rheumatic diseases: comparisons of health status constructs and associations with formal education level

Self-report questionnaire scales to assess various constructs of health status were compared in 602 patients with five rheumatic diseases, including 134 rheumatoid arthritis (RA), 216 osteoarthritis (OA), 84 fibromyalgia, 124 systemic lupus erythematosus (SLE), and 43 scleroderma patients. RA patients showed significantly higher degrees of difficulty, dissatisfaction, and pain in performing eight activities of daily living (ADL) compared to patients with the other four diseases (P less than 0.01), while SLE patients reported the least difficulty, dissatisfaction and pain. Fibromyalgia patients showed significantly higher scores on a visual analog pain scale than patients with the other four diseases (P less than 0.05), followed by OA patients. Fibromyalgia patients reported significantly higher levels of learned helplessness, assessed according to a rheumatology attitudes index (RAI), than patients with all other diseases, and scleroderma patients showed significantly lower RAI scores (P less than 0.05). Patients with all five diseases who had not completed high school showed poorer clinical status than patients who had completed high school on all six scales. Significant differences in questionnaire scores were seen for 24 of 30 comparisons (five diseases and six scales) according to formal education level, versus only two according to age, and none according to duration of disease.