Wallace V. Epstein

Correlates of fatigue in older adults with rheumatoid arthritis.

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.

Work Disability in Rheumatoid Arthritis: Effects of Disease, Social, and Work Factors

We explore here the relative contribution of selected disease, social, and work-related factors to disability status in a population of persons with rheumatoid arthritis. Our study differs from previous studies in that it is limited to one diagnostic entity, yet at the same time evaluates a broad range of social and work-related factors in disability. One hundred-eighty persons with rheumatoid arthritis sampled from 19 socially diverse practice settings were given a structured survey about their medical and work histories and social backgrounds. We found significant effects of stage and duration of illness on continued employment but no positive effect of selected therapies. Social and work factors combined had a far larger effect on work disability than all disease factors. Among work factors, control over the pace and activities of work and self-employment status had the greatest effect on continued employment, suggesting that time control issues are crucial to the maintenance of ones job after onset of this illness.

A Comparison of the Treatment of Rheumatoid Arthritis in Health Maintenance Organizations and Fee-for-Service Practices

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.

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.

Mixed Cryoglobulins and Glomerulonephritis

Abstract The serum of a patient with rapidly progressive glomerulonephritis associated with mixed cryoglobulins showed sustained high levels of rheumatoid factors. Immunoglobulin (Ig) G, M, and bet...

Health Outcomes for a Chronic Disease in Prepaid Group Practice and Fee for Service Settings: The Case of Rheumatoid Arthritis

The authors compare health care use and outcomes of a panel of persons with rheumatoid arthritis receiving health care in prepaid group practice and feefor- service settings. In 1982, they randomly sampled one half of all 114 boardcertified 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 feefor- 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 followup 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.

Is health care use equivalent across social groups? A diagnosis-based study.

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.

Serum Antibody to Double-Stranded RNA and DNA in Patients with Idiopathic and Secondary Uveitis

Abstract To determine whether products of the reaction of uveitis appear in the circulation, serums from 150 patients were examined for antibody to double-stranded RNA and DNA. With the use of an a...

Effect of Parenterally Administered Gold Therapy on the Course of Adult Rheumatoid Arthritis

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.

Utility of the Fluorescent Antinuclear Antibody Test in a Single Patient

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.