1
|
|
2
|
Yelin EH, Such CL, Criswell LA, Epstein WV. Outcomes for persons with rheumatoid arthritis with a rheumatologist versus a non-rheumatologist as the main physician for this condition. Med Care 1998; 36:513-22. [PMID: 9544591 DOI: 10.1097/00005650-199804000-00007] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- E H Yelin
- Rosalind Russell Medical Research Center for Arthritis and the Institute for Health Policy Studies, University of California, San Francisco, USA
| | | | | | | |
Collapse
|
3
|
|
4
|
Affiliation(s)
- W V Epstein
- Rosalind Russell Medical Research Center for Arthritis, University of California, San Francisco, USA
| |
Collapse
|
5
|
Epstein WV. Efficacy of standard slow-acting antirheumatic drugs. Semin Arthritis Rheum 1994; 23:32-8. [PMID: 7939729 DOI: 10.1016/0049-0172(94)90082-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
There are few published reports of the efficacy of slow-acting antirheumatic drugs (SAARDs) specific to the treatment of persons with early rheumatoid arthritis. Two published meta-analyses of the literature on SAARD therapy are reviewed, together with some empirical data on patients with less than 2 years' disease duration treated over an 8-year period. Although the literature suggests short-term benefit of SAARDs compared with placebo therapy, there is little to warrant considering presently available drugs to be disease-remittive agents. Based on known toxicities and purported benefits of available SAARDs, a treatment schema is proposed that responds incrementally to the course of the illness when treatment is started before irreversible joint injury occurs. The advent of new classes of therapeutic agents (eg, biologicals) for the treatment of rheumatoid arthritis warrants examination of present methods for the evaluation of antirheumatic drugs.
Collapse
Affiliation(s)
- W V Epstein
- Rosalind Russell Arthritis Center, Department of Medicine, University of California, San Francisco 94143-0920
| |
Collapse
|
6
|
Belza BL, Henke CJ, Yelin EH, Epstein WV, Gilliss CL. Correlates of fatigue in older adults with rheumatoid arthritis. Nurs Res 1993; 42:93-9. [PMID: 8455994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The purposes of this study were to describe the prevalence of fatigue, examine the association between fatigue and doctor visits, and identify correlates of fatigue in rheumatoid arthritis (RA). On average, a high degree of fatigue was reported to occur every day, to remain constant during the course of a week, and to most often affect walking and household chores. When controlling for disease severity and insurance coverage, respondents who reported more fatigue made more visits to the rheumatologist than those reporting less fatigue. A regression model with fatigue as the dependent variable revealed that the following variables explained a significant amount of variance: pain rating, functional status, sleep quality, female gender, comorbid conditions, and duration of disease.
Collapse
Affiliation(s)
- B L Belza
- School of Nursing, University of Washington, Seattle
| | | | | | | | | |
Collapse
|
7
|
|
8
|
Epstein WV, Criswell LA, Henke CJ. Methotrexate for juvenile rheumatoid arthritis. N Engl J Med 1992; 327:893. [PMID: 1508256 DOI: 10.1056/nejm199209173271216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
9
|
Abstract
This article examines practice variation among rheumatologists in their use of time and procedures in follow-up outpatient encounters with rheumatoid arthritis patients. It focuses on differences across individual physicians rather than differences in populations of patients. In addition, the total variance is divided into parts due to patient characteristics, the providers' economic and other incentives to do procedures or reduce contact time, individual practice styles, and the random sampling of encounters. Data are taken from a stratified random sampling of U.S. rheumatologists. Analyses are based on 1,154 outpatient follow-up encounters with rheumatoid arthritis patients provided by 66 physicians, each of whom reported at least ten such encounters. There are large differences among the physicians in visit length, number of monitoring procedures used per encounter, and whether the encounter included measurements of complete blood count/urinalysis or erythrocyte sedimentation rate. Individual practice style differences are far more important causes of the variation that was observed among providers than are patient differences or practice incentive differences. It was determined that 5-40% of the cost of specific management activities could be saved by reducing the highest use.
Collapse
Affiliation(s)
- C J Henke
- Department of Medicine, University of California, San Francisco 94143-0920
| | | |
Collapse
|
10
|
Epstein WV, Henke CJ. On blaming the placebo. Arthritis Rheum 1991; 34:501. [PMID: 2012632 DOI: 10.1002/art.1780340421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
11
|
Abstract
OBJECTIVE To describe the course of rheumatoid arthritis over 5 years in adults and to evaluate the effect of parenterally administered gold salts on that course. DESIGN A prospective observational study of adults with rheumatoid arthritis. Data derived from annual interviews with patients from 1983 to 1988 and from physician surveys in 1983 and 1987. SETTING Rheumatology practices in the community. PATIENTS The study began in 1982 with 822 adults who had rheumatoid arthritis and were under the care of rheumatologists. INTERVENTIONS Those selected by rheumatologists in the management of their patients. MEASUREMENTS Information describing sociodemographic and clinical characteristics, course, and therapy was collected from patients and verified by physician reports. Functional status, measured by the Health Assessment Questionnaire, and the number of painful joints were used as outcome variables. Outcome variables were adjusted for age, sex, disease duration, baseline values of the outcome variable, and the use of four disease-remittive agents other than gold. MAIN RESULTS Multivariate repeated-measures analysis of variance showed no change in the course of rheumatoid arthritis over 5 years. The use of parenteral gold for at least 2 consecutive years at the start of the observation period produced, on average, no change in the course over 5 years in the two outcome variables. CONCLUSION In our study of a community-based population of adults with rheumatoid arthritis who were under the care of community rheumatologists, we found that there was, on average, no statistically significant change in function or number of painful joints between 1983 and 1988. Patients receiving parenteral gold therapy for at least 2 consecutive years did not show a statistically significant difference in outcome when compared with those not receiving such therapy.
Collapse
Affiliation(s)
- W V Epstein
- Rosalind Russell Arthritis Center, University of California, San Francisco
| | | | | | | |
Collapse
|
12
|
Affiliation(s)
- W V Epstein
- Rosalind Russell Multipurpose Arthritis Center, Department of Medicine, University of California, San Francisco 94143-0920
| |
Collapse
|
13
|
Epstein WV. Parenteral gold therapy for rheumatoid arthritis: a treatment whose time has gone. J Rheumatol 1989; 16:1291-4. [PMID: 2681757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- W V Epstein
- Community/Health Services Research Component, Rosalind Russell Arthritis Center, University of California, San Francisco 94143-092
| |
Collapse
|
14
|
Abstract
We examined the question of what distinguishes persons with musculoskeletal disease who continue working after onset of illness from those who do not. We also investigated why persons with musculoskeletal disease have high rates of work disability relative to those with other chronic conditions of comparable activity limitation. Data regarding 3,100 persons with limitations in activities and chronic disease who were respondents to the 1978 Social Security Administration Survey of Disabled and Non-Disabled Adults were used. Persons with musculoskeletal disease who stopped working had poorer overall health status and physical function, and different work attitudes and working conditions than did those who continued to work. Symptoms of the musculoskeletal condition were poor predictors of whether work disability would result. Persons with musculoskeletal conditions had high rates of work disability, relative to those with other chronic conditions, primarily because of their age, level of comorbidity, and the interaction of the physical limitations imposed by their illness and the requirements of their jobs. They had similar levels of commitment to work and a similar proclivity to seek alternative sources of income as did those with other chronic diseases.
Collapse
|
15
|
Nevitt MC, Yelin EH, Henke CJ, Epstein WV. Risk factors for hospitalization and surgery in patients with rheumatoid arthritis: implications for capitated medical payment. Ann Intern Med 1986; 105:421-8. [PMID: 3740682 DOI: 10.7326/0003-4819-105-3-421] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Risk factors for hospitalization in patients with rheumatoid arthritis were analyzed to determine if factors proposed for use in adjusting Medicare capitation payments to prepaid health plans are, in fact, associated with use of costly medical care for this illness. Participating physicians from a random sample of half the rheumatologists in northern California provided us with the names of all patients with rheumatoid arthritis presenting during a 1-month period. We surveyed 754 (89%) of these patients in both 1982-83 and 1984 to obtain information about health care use in the previous 12 months. We found that baseline functional status and prior-year admissions (proposed Medicare adjustment factors), as well as disease-specific severity measures, predicted subsequent admissions. The association of prior with subsequent admissions was independent of disease severity and physician characteristics. Adjusting capitation payments for both health status and prior use will increase incentives for prepaid health plans to enroll patients with rheumatoid arthritis who have high expected medical costs.
Collapse
|
16
|
Yelin EH, Shearn MA, Epstein WV. Health outcomes for a chronic disease in prepaid group practice and fee for service settings. The case of rheumatoid arthritis. Med Care 1986; 24:236-47. [PMID: 3951265 DOI: 10.1097/00005650-198603000-00006] [Citation(s) in RCA: 28] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The authors compare health care use and outcomes of a panel of persons with rheumatoid arthritis receiving health care in prepaid group practice and fee-for-service settings. In 1982, they randomly sampled one half of all 114 board-certified or eligible rheumatologists in Northern California. Those who participated provided the names of all patients with rheumatoid arthritis presenting during a 1-month period; 812 of these patients (97% of those listed) were interviewed. In 1984, 745 of them (92% of the baseline cohort) were interviewed; 569 receive care in fee-for-service settings and 176 in prepaid group practice. As in the baseline survey year, the prepaid patients received similar amounts and kinds of health care as their fee-for-service counterparts. The prepaid and fee-for-service patients achieved similar outcomes, as measured by symptoms of illness, functional status, and work disability. The fee-for-service patients reported poorer overall health status. The authors conclude, after 2 years of follow-up study, that patients in prepaid group practice receive similar medical care inputs and achieve outcomes at least as good as those in fee-for-service.
Collapse
|
17
|
Perkins HS, Jonsen AR, Epstein WV. Providers as predictors: using outcome predictions in intensive care. Crit Care Med 1986; 14:105-10. [PMID: 3943314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Physicians' outcome predictions probably influence their treatment decisions in the ICU. The importance and accuracy of these predictions, however, are poorly defined. We asked 20 ICU physicians to rate the importance of 14 factors used for treatment decisions. Expected functional outcome rated highest. However, physicians' predictions of patient outcome, specifically survival and need for professional nursing care 45 days after ICU admission, had variable accuracy. For example, physicians predicted death for only 41% of adults who died, but survival for 87% of adult survivors. Predictions of survivors' need for professional nursing care proved 100% correct for children after heart surgery, but only 58% to 73% correct for other patient groups. These inaccuracies pose an important ethical question: what is the proper role of outcome predictions in ICU decision-making? We believe outcome predictions have an important role when they are proven accurate and used within the bounds of loyalty to the patients and respect for his wishes.
Collapse
|
18
|
Whiting-O'Keefe QE, Simborg DW, Epstein WV, Warger A. A computerized summary medical record system can provide more information than the standard medical record. JAMA 1985; 254:1185-92. [PMID: 3874972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We assessed the ability of a computerized outpatient medical record (MR) system, the Summary Time-Oriented Record (STOR), to communicate information to clinicians in two randomized single-blind studies. In the first study, physicians were better able to predict their patients' future symptom changes and laboratory test results from outpatient visits to an arthritis clinic when STOR was added to the standard MR than when the standard MR was used alone. In a separate study, the removal of the standard MR did not result in important decrease in the physicians' ability to predict their patients' symptoms and laboratory test results if they had the option of using the full paper record when they thought they needed it. In 134 (26%) of 514 visits, the physicians exercised this option. We conclude that for outpatient visits, the computerized record system STOR operationally added information to that supplied by the full paper MR. This improved flow of information could improve the clinical decision process.
Collapse
|
19
|
Yelin EH, Henke CJ, Kramer JS, Nevitt MC, Shearn M, Epstein WV. A comparison of the treatment of rheumatoid arthritis in health maintenance organizations and fee-for-service practices. N Engl J Med 1985; 312:962-7. [PMID: 3974686 DOI: 10.1056/nejm198504113121506] [Citation(s) in RCA: 72] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This study compares the use of health care services (hospital and ambulatory) by patients with rheumatoid arthritis who were under the care of rheumatologists in prepaid and fee-for-service arrangements. Participating physicians from a random sample of half the rheumatologists in northern California maintained a log of all their patients with well-established diagnoses of rheumatoid arthritis. We interviewed 822 of their patients, using a structured, validated phone survey to obtain information about health care use. Patients in prepaid plans had about the same number and type of hospitalizations and the same rate of surgery as those receiving fee-for-service care. However, fee-for-service patients made more ambulatory visits. We conclude that the use of expensive services (hospital admissions and surgery) for the care of patients with rheumatoid arthritis is not different in fee-for-service and prepaid settings.
Collapse
|
20
|
Nevitt MC, Epstein WV, Masem M, Murray WR. Work disability before and after total hip arthroplasty. Assessment of effectiveness in reducing disability. Arthritis Rheum 1984; 27:410-21. [PMID: 6424686 DOI: 10.1002/art.1780270408] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We evaluated the impact of total hip arthroplasty (THA) on work disability among working age persons. Just over one-third of those totally work disabled prior to THA were working at 1 or at 4 years after surgery. A significant long-term decrease in work disability after surgery was demonstrated by estimating disability prevented by THA, but the decrease was less than suggested by the literature. Preoperative work status and the number of painful joints were significant predictors of return to work.
Collapse
|
21
|
Kramer JS, Yelin EH, Epstein WV. Social and economic impacts of four musculoskeletal conditions. A study using national community-based data. Arthritis Rheum 1983; 26:901-7. [PMID: 6223644 DOI: 10.1002/art.1780260712] [Citation(s) in RCA: 102] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The present study uses data from a national, community-based survey to compare the social impact of and medical care use due to 4 musculoskeletal conditions: rheumatoid arthritis, osteoarthritis, lower back pain, and tendinitis. The study also compares the impacts experienced by persons with these conditions with those experienced by a sample of persons having a broader range of musculoskeletal conditions, and by an age-adjusted sample representing the entire U.S. population. Rheumatoid arthritis leads to the most frequent use of physician services; lower back pain results in the most hospitalizations and surgery. Rheumatoid arthritis also causes the most restriction in activity. We found that as a broad group, persons with musculoskeletal disease experience about the same amount of restriction in activity and use about the same amount of medical care as U.S. citizens as a whole. This study demonstrates that health planning on the basis of specific musculoskeletal conditions is necessary to serve the disparate needs of persons with particular, discrete conditions.
Collapse
|
22
|
Abstract
Previous studies of medical care utilization have controlled for medical need by signs or symptoms or broad disease classifications. The present study uses both symptoms and discrete diagnoses to control for medical need in order to determine if the use of ambulatory and hospital care differs by race, income, education, insurance coverage, or region. Using data from the 1976 National Health Interview Survey, we found that there were no consistent differences in the number of physician visits made in a year by these characteristics, medical need held constant. Lack of insurance coverage was associated with fewer hospitalizations in a year for five of nine chronic diseases under review. Race was associated with fewer hospitalizations for two conditions prevalent among minorities. These effects were not evident when medical need was controlled solely by signs or symptoms.
Collapse
|
23
|
Whiting-O'Keefe Q, Riccardi PJ, Henke JE, Shearn MA, Hopper J, Epstein WV. Recognition of information in renal biopsies of patients with lupus nephritis. Ann Intern Med 1982; 96:723-7. [PMID: 7091936 DOI: 10.7326/0003-4819-96-6-723] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
To evaluate the informational value of renal biopsy in nephritis of systemic lupus erythematosus, we selected the records of 30 patients who had a renal biopsy done and also had a known clinical outcome. Detailed case histories were prepared, and three distinct randomly chosen cases were given to 197 academic rheumatologists. The rheumatologists estimated the probability of future clinical events (worsened serum creatinine, worsened urine protein, renal death, and aggressive therapy) at 3 and 12 months after the biopsy. Biopsy results were given in detail, and probability estimates were made of the same clinical events using the additional information. The accuracy of each probability estimate was measured using a scoring function that depends on the estimates and the actual outcomes. Knowledge of the renal biopsy failed to improve predictive accuracy scores of estimates of future serum creatinine levels, urine protein levels, and renal death at 3 and 12 months (p less than 0.0001), and for estimates of the probability of the use of aggressive therapy at 12 months (p less than 0.007). The renal biopsy information improved only the accuracy of predictions concerning the use of aggressive therapy at 3 months (p less than or equal to 0.0003). Knowledge of the renal biopsy results failed to add important prognostic information about the future course of treated lupus nephritis to information already obtained from history, physical examination, and laboratory tests.
Collapse
|
24
|
Abstract
We analyzed data for the 12-month period after renal biopsy was done in 130 patients with systemic lupus erythematosus to examine whether renal biopsy provides useful information on the nephritis of systemic lupus erythematosus beyond that clinically available. A stepwise linear regression analysis was used to construct a linear before biopsy model that predicted the change in renal function 12 months after biopsy. The model included serum creatinine, patient age, 24-hour urine protein, a laboratory index of renal activity, antibodies to DNA, urinalysis protein, change in inverse creatinine from 6 weeks before biopsy, and urine light chain protein, and had a squared multiple correlation coefficient (R2) of 0.246. Four prospectively chosen renal biopsy variables (glomerular cell counts, percent of sclerotic glomeruli, percent of glomeruli with crescents, and interstitial fibrosis) resulted in a 0.079 improvement in R2 (p less than or equal to 0.012). Both the percent glomerular sclerosis (p less than or equal to 0.0032) and subendothelial deposits shown by electron microscopy (p less than or equal to 0.0026) added significantly to the predictive power of the before biopsy model. Histologic classification did not add significantly to the before biopsy model. The renal biopsy information increased the power of a linear regression model to predict the effect of 12 months of treatment of active lupus nephritis.
Collapse
|
25
|
Abstract
A description of academic and community rheumatologist practice activities in the United States has been assembled from 826 responses to a 1977 survey of American Rheumatism Association members. Reported work hours and patient load are similar to other medical subspecialists, and three-fourths of the clinical time is devoted to persons with predominantly rheumatic disease problems. Significant differences in activities occur between academic and community practices and among rheumatologists with different training backgrounds. Few characteristics vary significantly across geographic regions containing divergent rheumatologist-population ratios. Descriptive productivity measures such as these are necessary for planning; they provide part of the empirical analysis required to give reality to manpower policies.
Collapse
|
26
|
Abstract
The literature on the fluorescent antinuclear antibody (FANA) test, commonly used in diagnosing systemic lupus erythematosus, was analyzed. The specificity of the test reported in early descriptive studies is much greater than the value obtained when the test is used in clinical practice. The probability of systemic lupus erythematosus in a specific patient was determined when different numbers of the classification criteria developed by the American Rheumatism Association are present. The predictive value of a positive or negative FANA test result was calculated using different pretest probabilities based on clinical criteria. The marginal benefit of the FANA test was determined as minimal at points of very large and very small pretest probability of systemic lupus erythematosus, and as maximal when five clinical criteria are present.
Collapse
|
27
|
Meenan RF, Yelin EH, Nevitt M, Epstein WV. The impact of chronic disease: a sociomedical profile of rheumatoid arthritis. Arthritis Rheum 1981; 24:544-9. [PMID: 7213432 DOI: 10.1002/art.1780240315] [Citation(s) in RCA: 124] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
A large number of individuals with rheumatoid arthritis have been studied in order to better delineate the sociomedical problems experienced by patients with this chronic disease. Two hundred forty-five respondents were surveyed by use of a detailed questionnaire and interview, and the results indicate that major losses in the areas of work, finances, and family structure are extremely common. The majority of workers were totally disabled as a result of their disease. On the average, subjects in the group were earning only 50% of the income predicted for them had they not had arthritis. Sixty-three percent experienced a major change in their psychosocial status as a result of their disease. Work disability appears to be the most important sociomedical impact of rheumatoid arthritis since it is associated with significantly greater income and psychosocial losses. This evidence of numerous and serious sociomedical problems in persons with rheumatoid arthritis raises questions of emphasis and approach for physicians involved in the clinical care of chronic rheumatic disease patients.
Collapse
|
28
|
Abstract
A randomized single-blind experiment was done in a medical subspecialty clinic in order to determine whether a flow-sheet type of summary medical record could validly serve as a means to communicate clinical information in the absence of the traditional medical record. Two groups of outpatient physician-patient encounters were compared: In the 68 study encounters (Group S), physicians were given a flow-sheet summary record with the option to receive the standard medical record if they desired; in the 27 control encounters (Group C), physicians were given the standard medical record plus the flow-sheet summary record. Fifty-nine per cent of study-group physicians did not choose to receive the full medical record. The study group was found not to differ (p = 0.013) from controls significantly with regard to the follow-up of clinical information as measured by pre- and post-encounter chart review. Physician providers in the study group were unable to detect by retrospective chart review overlooked clinical information with greater frequency than control group providers. We conclude that a flow-sheet type of summary medical record can serve as the sole source of clinical information in a substantial number of outpatient follow-up encounters in a medical subspecialty clinic without deterioration in the communication of clinical information.
Collapse
|
29
|
Zulman JI, Talal N, Hoffman GS, Epstein WV. Problems associated with the management of pregnancies in patients with systemic lupus erythematosus. J Rheumatol 1980; 7:37-49. [PMID: 7354468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Eighty-three percent of 24 pregnancies in patients with systemic lupus erythematosus studied retrospectively terminated in normal children. Fifty-four percent of patients had clinical and serological disease exacerbations during pregnancy or in the post-partum period, as contrasted with 4% in the 6 months prior to pregnancy. The presence of significant renal disease and SLE activity in the 6 months prior to pregnancy correlated with exacerbations. A distinction between pre-eclamptic toxemia and lupus exacerbation had to be made in 25% of our patients. There were 2 maternal deaths associated with uncontrolled lupus activity. No potentially viable infants died for reasons directly related to lupus activity.
Collapse
|
30
|
Epstein WV, Henke CJ. Study of internal medicine. Ann Intern Med 1979; 91:649. [PMID: 484973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|
31
|
Epstein WV, Rizk N. Amyloidosis. West J Med 1979; 130:354-9. [PMID: 442628 PMCID: PMC1238622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
32
|
Yelin EH, Feshbach DM, Meenan RF, Epstein WV. Social problems, services and policy for persons with chronic disease: the case of rheumatoid arthritis. Soc Sci Med Med Econ 1979; 13C:13-20. [PMID: 553301 DOI: 10.1016/0160-7995(79)90021-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
33
|
Henke CJ, Epstein WV. The training of United States rheumatologists, 1927-1976. Description and evaluation of the training experience. Arthritis Rheum 1979; 22:187-96. [PMID: 311200 DOI: 10.1002/art.1780220213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
34
|
Meenan RF, Yelin EH, Henke CJ, Curtis DL, Epstein WV. The costs of rheumatoid arthritis. A patient-oriented study of chronic disease costs. Arthritis Rheum 1978; 21:827-33. [PMID: 100122 DOI: 10.1002/art.1780210714] [Citation(s) in RCA: 97] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
To detail the cost for one year of a chronic disease, 50 patients with Stage III rheumatoid arthritis were surveyed. Direct medical costs for this group were three times the national average, and 58% of these costs were covered by insurance. Indirect costs due to lost income were at least three times the direct medical costs, and transfer payments covered only 42% of these costs. Fifty-eight percent of the study group also sustained a major psychosocial loss. Uncovered income losses were the greatest economic burden for individuals with chronic rheumatoid arthritis. This striking ratio of indirect to direct medical costs has important implications for medical practice and health policy.
Collapse
|
35
|
Jamison TH, Cooper NM, Epstein WV. Lichen planus and discoid lupud erythematosus. Overlap syndrome associated with cryoglobulinemia and hypocomplementemia. Arch Dermatol 1978; 114:1039-42. [PMID: 686722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A patient with the discoid lupus erythematosus and lichen planus overlap syndrome has profound depression of serum C4 concentration associated with substantial mixed cryoblobulinemia. A family study failed to disclose evidence of a familial hypocomplementemia, cryoglobulinemia, or a dermatologic condition. Immunologlobulin, but no complement, was detected at the site of the skin abnormality. This case illustrates an immune-complex disorder with a mixed cryoglobulinemia that is related to immunoglobulin deposition in the skin.
Collapse
|
36
|
|
37
|
Yelin EH, Henke CJ, Epstein WV. Rheumatology manpower in California. Approaches to assessment of quantitative sufficiency. Arthritis Rheum 1977; 20:805-10. [PMID: 301026 DOI: 10.1002/art.1780200307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Californian specialists in the treatment of rheumatic diseases were surveyed to determine the spatial distribution of rheumatologic services in the state, the amount of patient care time available for the rhematic diseases in each county, the physicians' capacity to treat all rhemmatic disease patients who seek their care, and their perception of the need for more specialists in their area. The data resulting from the survey are analyzed by four methods to assess the sufficiency of medical manpower resoruces.
Collapse
|
38
|
|
39
|
Henke CJ, Yelin EH, Ingbar ML, Epstein WV. The university rheumatic disease clinic: provider and patient receptions of cost. Arthritis Rheum 1977; 20:751-8. [PMID: 849370 DOI: 10.1002/art.1780200218] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A medical school based rheumatic disease clinic provides patient services and educational activities and conducts clinical research. The patient population and routes of access to one such clinic are described, and the effect of direct and indirect costs influencing patient compliance are analyzed. It was found that the program cost of such a facility greatly exceeds the administrative cost. Alternatives to such high-cost facilitities are considered.
Collapse
|
40
|
Yelin E, Henke C, Epstein WV. Resources for the care of arthritics in a nonmetropolitan community. Redding, California. Arthritis Rheum 1977; 20:45-57. [PMID: 836337 DOI: 10.1002/art.1780200108] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
All professional, institutional, and administrative resources available to persons with musculoskeletal disabilities, including arthritis, were surveyed in a large nonmetropolitan community. Access to such resources and their residual capacity to serve local arthritics was determined. The resources appeared adequate as was the access, but the referral pattern was poorly developed. Most of the physicians in the community did not perceive a need for a trained rheumatologist practicing in the community.
Collapse
|
41
|
Feldmann JL, Becker MJ, Moutsopoulos H, Fye K, Blackman M, Epstein WV, Talal N. Antibody-dependent cell-mediated cytotoxicity in selected autoimmune diseases. J Clin Invest 1976; 58:173-9. [PMID: 6490 PMCID: PMC333168 DOI: 10.1172/jci108447] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Antibody-dependent cell-mediated cytotoxicity mediated by peripheral blood lymphocytes was studied in patients with systemic lupus erythematosus, polyarteritis nodosa. Sjogren's syndrome, and rheumatoid arthritis. The target cells were chicken erythrocytes coated with rabbit anti-chicken erythrocyte antibody. Antibody-dependent cell-mediated cytotoxic activity was normal in Sjogren's syndrome and rheumatoid arthritis but significantly decreased (P is less than 0.001) in active systemic lupus erythematosus and in two patients with polyarteritis nodosa. A partial regeneration of antibody-dependent cell-mediated cytotoxic activity was obtained by treatment with pronase and DNase followed by overnight incubation. Sera from patients with systemic lupus erythematosus inhibited antibody-dependent cell-mediated cytotoxic activity of normal lymphocytes. The inhibitory activity was studied by specific immunoadsorption and sucrose density geadient ultracentrifugation. Removal of IgG but not IgM greatly reduced inhibition. Inhibitory factors were present in 7S and heavier fractions containing IgG. Five systemic lupus erythematosus patients were studied serially to determine if improvement in clinical status could be correlated with a decrease in serum inhibitory factors as studied by inhibition of normal antibody-dependent cell-mediated cytotoxicity. Indeed, a greater serum inhibitory capacity was found in each patient during periods of greater disease activity.
Collapse
|
42
|
Epstein WV, Shearn MA. Letter: Immunosuppressive drugs in lupus nephritis. Ann Intern Med 1976; 84:492-3. [PMID: 1259300 DOI: 10.7326/0003-4819-84-4-492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
|
43
|
Abstract
Two cases of Wegener's granulomatosis are reported in which circulating immunoglobulin complexes detected during the active phase of the disease disappeared during induction of remissions of active pulmonary and renal disease by immunosuppressive agents. Elevated antiglobulin activity, urinary immunoglobulin L-chain concentration and evidence of activated coagulation mechanisms were also present during active disease, and returned toward normal with treatment. Studies showed that the serum complexes did not contain deoxyribonucleic acid (DNA) and demonstrated their immunoglobulin nature. Serum complement concentrations were normal, and no cryoglobulins were present. Immunofluorescent staining and electron microscopy of the kidney biopsy specimen of one patient showed marked fibrin deposition but no immunoglobulin or antigen-antibody deposits. Although the role of circulating immunoglobulin complexes in the pathogenesis of Wegener's granulomatosis remains uncertain, serial changes in the described parameters may provide an objective guide to activity of the disease and its response to treatment.
Collapse
|
44
|
Curtis DL, Epstein WV. Letter: Implications of W27 screening. N Engl J Med 1976; 294:226. [PMID: 1244543 DOI: 10.1056/nejm197601222940420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
45
|
Rudd P, Fries JF, Epstein WV. Irreversible bone marrow failure with chlorambucil. J Rheumatol 1975; 2:421-9. [PMID: 1206673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Two cases of irreversible bone marrow failure are described, one with rheumatoid disease and one with systemic lupus erythematosus. Each case was associated with prior chlorambucil administration, effective in controlling the clinical manifestations (total dosage 398 and 1,764 mg respectively). The irreversibility of the bone marrow depression in the two cases presented stands in contrast to published assurances that chlorambucil-associated leukopenia is dose-related and readily reversible. The cases illustrate that chlorambucil therapy should not be continued after initial leukopenia, until peripheral counts or marrow cellularity has returned to normal. Titration of drug dosage and leukocyte count, as frequently employed with cyclophosphamide and other alkylating agents, must be presumed hazardous. Additional studies are needed to determine if irreversible bone marrow depression is dose-related or idiosyncratic.
Collapse
|
46
|
Epstein WV. Specificity of SLE serum antibody for single-stranded and double-stranded DNA configuration. J Rheumatol 1975; 2:215-20. [PMID: 1151954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The solid phase immunoassay for the measurement of serum antibody to double and single-stranded DNA is described. The technique allows a more accurate definition of the antibody specificity of SLE sera as defined by inhibition techniques. The clinical usefulness of immunologic assays in the management of patients with SLE is described, including measurement of urine light chain protein concentration. A core discussion is provided to illustrate how such a panel of tests is used in management.
Collapse
|
47
|
|
48
|
Epstein WV, Tan M, Wood IS. Formation of "amyloid" fibrils in vitro by action of human kidney lysosomal enzymes on Bence Jones proteins. J Lab Clin Med 1974; 84:107-10. [PMID: 4134506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
49
|
Gelber RH, Drutz DJ, Epstein WV, Fasal P. Clinical correlates of C1Q-precipitating substances in the sera of patients with leprosy. Am J Trop Med Hyg 1974; 23:471-5. [PMID: 4823798 DOI: 10.4269/ajtmh.1974.23.471] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
|
50
|
Epstein WV, Grausz H. Favorable outcome in diffuse proliferative glomerulonephritis of systemic lupus erythematosus. Arthritis Rheum 1974; 17:129-42. [PMID: 4131150 DOI: 10.1002/art.1780170205] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|