Juan A. Jover

Multimorbidity: Prevalence, Effect on Quality of Life and Daily Functioning, and Variation of This Effect When one Condition Is a Rheumatic Disease

OBJECTIVESnTo examine the prevalence and effect of multimorbidity on health-related quality of life (HRQoL) and daily functioning in the general population, and to analyze the influence on HRQoL and daily functioning of multimorbidity including a rheumatic disease.nnnMETHODSnA national health survey was conducted on 2192 randomly selected adults in Spain. Multimorbidity was defined as the co-occurrence of at least 2 chronic diseases, as defined by self-report. All subjects completed the 12-item short form (SF-12) health survey and the Health Assessment Questionnaire (HAQ). Estimates and 95% confidence intervals (CI) of the prevalence of multimorbidity were obtained. The effect on HAQ and SF-12 scores is presented as beta-coefficients obtained from multiple linear regressions.nnnRESULTSnThe estimated prevalence of multimorbidity was 30% (95% CI 25 to 34), and the prevalence of multimorbidity including a rheumatic disease was 17% (95% CI 13 to 20). Multimorbidity was associated with impaired daily functioning [HAQ beta = 0.07 (95% CI 0.02 to 0.11)], and lower HRQoL [SF-12(physical component) beta = -4.2 (95% CI -5.2 to -3.22); SF-12(mental dimension) beta = -3.3 (95% CI -4.5 to -2.2)]. Subjects with multimorbidity including a rheumatic disease reported worse scores than those without a rheumatic disease: HAQ beta 0.13 (95% CI 0.07 to 0.18) versus -0.03 (95% CI -0.08 to 0.02), and SF-12(physical component) beta -6.5 (95% CI -5.2 to -3.2) versus 0.5 (95% CI -0.7 to 1.7).nnnCONCLUSIONSnMultimorbidity is frequent in the general population and can considerably impair daily functioning and HRQoL. Having a rheumatic disease worsens these outcomes.

A Health System Program To Reduce Work Disability Related to Musculoskeletal Disorders

Context Nonoccupational musculoskeletal disorders account for a large proportion of work disability and represent a major financial burden on society. Contribution A voluntary, randomized, controlled intervention study consisted of avoidance of bed rest, early mobilization, avoidance of splints, stretching exercises, ergonomic training, provision of educational booklets, and suggestions for optimal levels of physical activity. Although return to work was never forced, temporary work disability, long-term disability, and costs were significantly decreased in the intervention group. Implications The personal and financial impact of work disability due to musculoskeletal disorders (not related to work injury) may be mitigated by a voluntary program of education and rehabilitation. The Editors Musculoskeletal disorders (MSDs) are prevalent and potentially disabling conditions (1) that consume a large proportion of health care resources (2-4) and together are the leading cause of functional loss in adults (3-8). The social costs of MSDs are enormous, often overshadowing those of other chronic conditions (9, 10). In industrialized societies, MSDs are one of the most common causes of temporary work disability and the chief cause of permanent work disability (11), accounting for productivity losses equivalent to 1.3% of the U.S. gross national product (12). Work disability related to MSDs is a challenge to employability, business productivity, and the capacity of health and social security systems. Various strategies for addressing MSD-related work disability have been promoted in the field of occupational health, including strategies involving legislation, risk management, ergonomics, prevention, education, and social work (13). However, the role of health systems remains ill-defined in this field. The purpose of this study was to evaluate whether an intervention program, integrated into the health system and offered to the working population, could reduce the impact of recent-onset MSD-related temporary work disability. Methods Setting Of the 5.5 million persons in Madrid, Spain, 98% receive health coverage from the Instituto Madrileo de Salud. Care is organized into 11 health districts. Patients have direct access to primary care physicians, who refer patients to specialized care if needed. Disability compensation payments are made by the Instituto Nacional de la Seguridad Social (INSS), a division of the Ministry of Work. Any worker who requires sick leave is given a temporary work disability initiation form that states the diagnosis made by the primary care physician and entitles the worker to receive INSS compensation payments. The form is renewed weekly by the primary care physician until the worker 1) recovers and receives an ending form, 2) reaches a maximum of 18 months of temporary work disability, or 3) receives a proposal for evaluation for permanent work disability. Proposals for permanent work disability are evaluated by the INSS, which determines the need for and type of long-term compensation. Inspection services in each health district oversee all administrative aspects of these processes. Design We did a randomized, controlled study, unblinded for both patients and physicians, to test whether a clinical intervention could improve the outcome of patients with recent-onset MSD-related temporary work disability. The study began in March 1998 in health district 7 and in March 1999 in health districts 4 and 9. Selection and randomization of patients was done during the first year of the study in each district. Follow-up lasted for another year. Patients and Selection Criteria Health districts 4, 7, and 9 were chosen. Health district 4 had a total population of 508249 persons and an active working population of 192939 persons; health district 7 had a total population of 522742 persons and an active working population of 179155 persons; and health district 9 had a total population of 371294 persons and an active working population of 135475 persons (14). The inclusion criterion was the issue of a common diseases temporary work disability initiation form, with an MSD-related cause reported by the primary care physician, within the inclusion period. The MSD-related causes included all arthropathies, connective tissue disorders, back disorders, soft-tissue rheumatisms, bone and cartilage disorders, musculoskeletal pain not caused by cancer, and nerve entrapment syndromes. Patients were excluded if they had a common diseases temporary work disability form with an MSD-related cause resulting from trauma or surgery. They were also excluded if they had work accidents or professional diseases noted on the temporary work disability initiation form. Work accidents are primarily sudden, external, violent causes of disease occurring at work or during travel to work, and they represent less than 27% of cases of temporary work disability. Professional diseases include silicosis, asbestos-related mesothelioma, and noise-induced hearing loss, and they represent less than 1% of cases of temporary work disability. Randomization All temporary work disability initiation forms meeting the selection criteria were collected daily by a study rheumatologist and coded. The patients associated with the forms were randomly assigned to either the intervention group, which received a specific care program, or the control group, which received standard care (Figure 1). Computer-generated lists of pseudorandom numbers were produced for each district. Group assignments were randomly done in blocks of 50 patients with intervention:control ratios of 1:1 in district 7 and 2:3 in districts 4 and 9. This was done so that similar numbers of patients would be seen by the rheumatologists in all areas. The ratios were based on the number of episodes of MSD-related temporary work disability registered in previous years. Patients maintained their group assignments in successive episodes of MSD-related temporary work disability during follow-up. Figure 1. Flow diagram of the study. Care in the Intervention Group A secretary contacted all patients assigned to the intervention group by telephone or mail as soon as possible after the initiation form was issued, offering them an appointment in the program. Patients who voluntarily decided to enter the program were attended by 2 rheumatologists in each district who worked full-time for the study. Patients were seen as often as necessary until the episode of temporary work disability was resolved or recovery was deemed unrealistic. Patients who were assigned to the intervention group but were unable or unwilling to participate, were already working, or could not be located were considered to be assigned to the intervention group throughout the study for statistical purposes. Within the intervention program, care was delivered in regular visits and included education, clinical management, and administrative duties. Education At the first 45-minute visit, patients received a specific diagnosis, reassurance that no serious disease was present, instructions on self-management, instructions on taking medications on a fixed schedule, and information on indications for return to work before complete symptom remission. Return to work was negotiated with patients and was never forced on them. Instructions on self-management included instructions to avoid bed rest, instructions to promote early mobilization of the painful regions, restrictions on the use of splint and neck collars, training in stretching and strengthening exercises (15-18), teaching of ergonomic care (19), delivery of booklets in instances of back or neck pain (19), and information on optimal levels of physical activity (20). Patients with higher degrees of disability or abnormal pain behavior received immediate extra reassurance, information on pain-relieving positions, and a telephone call or second visit within 72 hours. Specific protocols were created for low-back (21), neck, shoulder, arm and hand, knee, and foot pain (19, 22-25) and included the 3-level clinical-management system described later. Moving a patient from the lower to the upper levels of the system implied the need for further diagnostic or therapeutic procedures and was indicated 1) after a patient spent a predefined period at the lower level without return to work or substantial clinical improvement or 2) by the clinical judgment of the rheumatologist. At the first level of the system, patients received the clinical management started at the first visit, including a diagnosis based on clinical criteria, pharmacologic treatment of pain and inflammation, pharmacologic treatment of anxiety and depression, peripheral intra- and periarticular injections (26), and education. Time spent at the first level averaged 2 to 6 weeks. At the second level, patients received maintenance of therapy plus referral for formal rehabilitation and laboratory tests, radiography, computerized tomography, magnetic resonance imaging, and electromyography. After 4 to 8 weeks with no improvement at the second level, patients were moved to the third level and received further diagnostic procedures or referral for surgical or other specialized care. Red flags were defined, including age older than 50 years for patients with axial pain, previous trauma, cancer, serious medical illness, inflammatory pain, night pain, drug abuse, corticosteroid use, fever, weight loss, progressively deteriorating function, and progressive neurologic deficit. The presence of a red flag precluded the use of the level system, and the patient in question was managed according to clinical criteria, with a focus on excluding serious illness. Treatment Failures Patients who did not respond to interventions at the second level of the system were examined for the presence of yellow flags, which included psychiatric illness, family problems, sociolabor conflicts, unemployment, and occupational causes of disability. The presence of a yell

Early lymphocyte activation in the synovial microenvironment in patients with osteoarthritis: comparison with rheumatoid arthritis patients and healthy controls

Osteoarthritis (OA) is largely considered to be a non-inflammatory disease, although there is compelling evidence that subclinical inflammation is a common event, even in the absence of acute inflammatory flares. In this study we analyze, by means of CD5 and CD69 expression, the infiltration and early activation of CD5+cells, mostly lymphocytes, in both synovial membrane and synovial fluid from advanced OA patients and compare them with samples from patients with rheumatoid arthritis and healthy controls. The number of infiltrating CD5+ cells in both synovial membrane and synovial fluid from patients with advanced OA was significantly reduced as compared with rheumatoid arthritis patients. However, synovial membrane and synovial fluid CD5+ cells on OA exhibited a phenotype with evidence of recent activation comparable to that observed in RA.

Prognostic factors in short-term disability due to musculoskeletal disorders.

OBJECTIVEnTo identify factors associated with poor outcome in temporary work disability (TWD) due to musculoskeletal disorders (MSDs).nnnMETHODSnWe conducted a secondary data analysis of a 2-year randomized controlled trial in which all patients with TWD due to MSDs in 3 health districts of Madrid (Spain) were included. Analyses refer to the patients in the intervention group. Primary outcome variables were duration of TWD and recurrence. Diagnoses, sociodemographic, work-related administrative, and occupational factors were analyzed by Cox proportional hazards models.nnnRESULTSnWe studied 3,311 patients with 4,424 TWD episodes. The following were independently associated with slower return to work: age (hazard ratio [HR] 0.99, 95% confidence interval [95% CI] 0.98-0.99), female sex (HR 0.84, 95% CI 0.78-0.90), married (HR 0.90, 95% CI 0.83-0.97), peripheral osteoarthritis (HR 0.77, 95% CI 0.6-0.9), sciatica (HR 0.59, 95% CI 0.54-0.65), self-employment (HR 0.56, 95% CI 0.48-0.65), unemployment (HR 0.41, 95% CI 0.28-0.58), manual worker (HR 0.86, 95% CI 0.79-0.94), and work position covered during sick leave (HR 0.84, 95% CI 0.77-0.92). The factors that better predicted recurrence were peripheral osteoarthritis (HR 1.75, 95% CI 1.14-2.6), inflammatory diseases (HR 1.66, 95% CI 1.009-2.72), sciatica (HR 1.30, 95% CI 1.08-1.56), indefinite work contract (HR 1.43, 95% CI 1.14-1.75), frequent kneeling (HR 1.39, 95% CI 1.15-1.69), manual worker (HR 1.19, 95% CI 1.003-1.42), and duration of previous episodes (HR 1.003, 95% CI 1.001-1.005).nnnCONCLUSIONnSociodemographic, work-related administrative factors, diagnosis, and, to a lesser extent, occupational factors may explain the duration and recurrence of TWD related to MSD.

A meta-analysis of mortality in rheumatic diseases

INTRODUCTIONnData reporting mortality in rheumatic diseases vary widely. The objective of this systematic review and meta-analysis of published data is to provide an accurate overview of the current risk of mortality in rheumatic diseases.nnnMETHODSnSystematic review and meta-analysis of published studies identified by a sensitive search using free text and MeSH synonyms of mortality and of rheumatic diseases, in general and by specific diagnoses. Eligibility criteria were (1) study population with rheumatoid arthritis, systemic lupus erythemathosus, systemic sclerosis, vasculitis, osteoarthritis, osteoporosis, dermatomyositis, or spondyloarthritis; (2) outcome of interest mortality, reported as an standardized mortality ratio (SMR), or easily calculated from data reported; and (3) cohorts or longitudinal observational studies. Assessment of risk of bias relied on the New Castle-Ottawa scale for cohorts; only moderate to high quality studies were included. Separate meta-SMRs were calculated for specific diagnoses. Heterogeneity was studied with meta-regression.nnnRESULTSnA total of 32 studies were included, none in spondyloarthritis or osteoarthritis. The overall pooled SMR was 2.03 (95% confidence interval (CI) 1.79-2.29), ranging from 1.36 in psoriatic arthritis to 4.80 in vasculitis. The largest individual overall SMR came from studies on inflammatory diseases, and the specific SMR were very high for infections and pulmonary events. Heterogeneity between studies was large; however, the analysis of such heterogeneity within diseases did not provide any association with the collected variables.nnnCONCLUSIONSnBased on our results and on the good quality of the included studies, we can conclude that rheumatic diseases increase in general the risk of death, and especially inflammatory diseases.

Observed and expected frequency of comorbid chronic diseases in rheumatic patients

Objective: To estimate and compare the observed and expected prevalence of the co-existence of rheumatic diseases (RD) with other chronic conditions. Methods: The self-reported diagnosis of chronic conditions was obtained from the 2192 participants in a national health survey (Spain, 1999–2000) We compared the estimated prevalence of the co-existence of a RD with other chronic conditions, to the expected prevalence using two-sample test of proportion. Results: The observed (O) prevalence was significantly higher than expected (E) in the following combination of self-reported diseases: RD+arterial hypertension (O/E ratiou200a=u200a1.88), RD+diabetes mellitus (O/E ratiou200a=u200a2.07), RD+hypercholesterolemia (O/E ratiou200a=u200a1.87), RD+cardiological (O/E ratiou200a=u200a1.83), and RD+digestive diseases (O/E ratiou200a=u200a2.07). The prevalence of selected co-existent pairs of diseases is more frequent with increasing age and differs between women and men. Conclusions: The excess in prevalence of some combinations of diseases may serve as a reminder to the rheumatologists that many of their patients will have co-existent disease of which they need to be aware to properly plan their management. It may also be a sign of common risk factors between diseases or of adverse events.

Consensus statement on a framework for the management of comorbidity and extra-articular manifestations in rheumatoid arthritis.

The objective of the study was to develop evidence-based and practical recommendations for the detection and management of comorbidity in patients with rheumatoid arthritis (RA) in daily practice. We used a modified RAND/UCLA methodology and systematic review (SR). The process map and specific recommendations, based on the SR, were established in discussion groups. A two round Delphi survey permitted (1) to prioritize the recommendations, (2) to refine them, and (3) to evaluate their agreement by a large group of users. The recommendations cover: (1) which comorbidities should be investigated in clinical practice at the first and following visits (including treatments, risk factors and patient’s features that might interfere with RA management); (2) how and when should comorbidities and risk factors be investigated; (3) how to manage specific comorbidities, related or non-related to RA, including major adverse events of RA treatment, and to promote health (general and musculoskeletal health); and (4) specific recommendations to assure an integral care approach for RA patients with any comorbidity, such as health care models for chronic inflammatory patients, early arthritis units, relationships with primary care, specialized nursing care, and self-management. These recommendations are intended to guide rheumatologists, patients, and other stakeholders, on the early diagnosis and management of comorbidity in RA, in order to improve disease outcomes.

IL23R and IL12B genes: susceptibility analysis in rheumatoid arthritis

The identification of additional genetic risk factors is an ongoing process that will aid in the understanding of rheumatoid arthritis (RA) aetiology. A genome-wide association scan in Crohn’s disease highlighted the IL23R gene as a susceptibility factor.1 The IL-23 receptor is a heterodimer formed by the products of two different genes: IL23R and IL12RB . Our aim was to analyse whether polymorphisms within the genes coding for the specific chain of the IL-23 receptor ( IL23R ) and for its p40 ligand ( IL12B ) and interacting in psoriasis2 are also associated with an altered risk of RA.nnIn agreement with previously published data,3–6 no statistically significant association was found with the IL12B polymorphisms (table 1).nnView this table:nnTable 1 Association of IL23R (rs7517847 and rs11209026) and IL12B (rs6887695 and rs322227) SNP with RAnnThe minor alleles of the IL23R polymorphisms were associated with increased predisposition to …

Prognostic factors for long-term work disability due to musculoskeletal disorders

The objective of this study is to identify risk factors for permanent work disability (PWD) related to musculoskeletal disorders (MSDs). This is a secondary data analysis of a randomized controlled intervention study in Temporary Work Disability (TWD) due to MSDs. The association of PWD (claim submission and status recognition) with baseline clinical, sociodemographic, work-related administrative and occupational factors was analyzed by Cox proportional hazards models. Of 3,311 patients with TWD, 47 submitted a PWD claim, of whom 32 achieved PWD status. The main alleged causes of the PWD were back pain, sciatica, and inflammatory diseases. The following factors were independently associated with an increased probability of PWD claim submission: age (odds ratio (OR) 5.1), being woman (OR 2.1), self-employment (OR 3.4), unemployment (OR 13.8), previous musculoskeletal surgery (OR 16), repeated TWD (OR 3.4), sitting (OR 2.8), and raising arms frequently (OR 3.1). Patients with inflammatory disease were more likely to file PWD claims (OR 10.4) while tendonitis was associated with lower probability (OR 0.3). The sociodemographic factors that better predicted PWD status recognition were age (OR 5.7), low educational level (OR 4.2), previous musculoskeletal surgery (OR 14.9), unemployment (OR 17.6), sitting (OR 2.6), and raising arms frequently (OR 2.7). Inflammatory diseases were the diagnoses associated with a higher rate of PWD status recognition (OR 6.1). Inflammatory diseases have a high chronic disability potential in active workers. Sociodemographic, work-related, occupational factors, and other clinical factors, some of which are modifiable, may explain the development of long-term work disability related to MSDs.

Orthopedic Surgery in Rheumatoid Arthritis in the Era of Biologic Therapy

Objective. To analyze sociodemographic and clinic-related factors associated with the use of orthopedic surgical procedures in rheumatoid arthritis (RA), focusing on the potential role of new biologic therapies. Methods. A retrospective medical record review was performed in a probability sample of 1272 patients with RA from 47 units distributed in 19 Spanish regions. Sociodemographic and clinical features, use of drugs, and arthritis-related joint surgeries were recorded following a standardized protocol. Results. A total of 94 patients (7.4%) underwent any orthopedic surgery during their disease course, with a total of 114 surgeries; 47 (41.2%) of these surgeries were total joint replacement (TJR). The median time to first orthopedic procedure was 7.9 years from the onset of RA symptoms, and the rate of orthopedic surgery (excluding TJR) was 4.5 procedures per 100 person-years from the beginning of RA, while the rate of TJR was 2.25 interventions per 100 person-years. A higher risk of undergoing an orthopedic surgical procedure was associated with taking nonsteroidal antiinflammatory drugs (NSAID) in the previous 2 years, female sex, longterm disease, and the presence of extraarticular complications. The risk factors for undergoing a TJR were being old, having a longterm disease, and taking biologic therapies. Conclusion. In the era of biologics, our national audit found a low percentage of patients who underwent orthopedic surgery, probably reflecting a thorough management of the RA. Sociodemographic factors, longterm RA, extraarticular complications, and NSAID were associated with orthopedic surgery.