Showing papers by "James F. Fries published in 1993"

Reducing Health Care Costs by Reducing the Need and Demand for Medical Services

Abstract: Health care costs in the United States exceed 14 percent of the gross domestic product, far more than in any other nation. Overall costs were $838 billion in 1992, or over $3,000 per person1. Well over 30 million Americans are uninsured, partly because of rising premium costs2,3. We propose an approach to part of this problem that has been neglected, one that focuses on systematically reducing the need and thus the demand for medical services. This approach requires expanding the definitions of “health promotion” and “preventive care,” paying selective attention to strategies that have been found to . . .

Risk factors for physical disability in an aging cohort: the NHANES I Epidemiologic Followup Study.

Abstract: Successful improvement in health in our increasingly aged population will depend in substantial part on reduction of age specific disability levels. In turn, the epidemiologic model suggests that this requires identification of risk factors, development of intervention models, and testing of these models. We attempted to identify risk factors for physical disability among 4,428 50-77-year-olds using baseline data collected in the first National Health and Nutrition Examination Survey (NHANES I) (1971-1975) linked to disability data collected 10 years later in the NHANES I Epidemiologic Followup Study. Results of forward stepwise linear regression analysis showed that the major characteristics contributing to greater disability (explaining at least 1% of the variability in scores) were older age at baseline, less nonrecreational activity, arthritis history, less education, female sex, and greater body mass index at age 40. Other factors associated with greater disability included a history of asthma, cardiovascular disease, abnormal urine test, less recreational activity, higher sedimentation rate, rheumatic fever history, lower caloric intake, positive musculoskeletal findings, histories of polio and allergies, lower family income, elevated blood pressure, lower serum albumin, history of tuberculosis, glucose in the urine, and histories of hip or spine fracture, chronic pulmonary disease, and kidney disease.

The risk of osteoarthritis with running and aging: a 5-year longitudinal study.

Abstract: Our purpose was to determine the 5-year longitudinal effects of running and aging on the development of radiographic and clinical osteoarthritis (OA) of the knees, hands and lumbar spine. Thirty-five running subjects and 38 controls, with a mean age of 63 years, were matched for age (+/- 2 years), years of education, and occupation; 33 matched pairs were constructed. All subjects underwent rheumatologic examination, completed questionnaires, and had radiographs taken of the hands, lateral lumbar spine, and knees in 1984 and in 1989. Five year radiographic results for both the runner and control groups showed OA progression for the knees, hands, and lumbar spine. In 1989, 10 (13%) of the 73 subjects fit American College of Rheumatology (ACR) criteria for clinical OA of the hand, and 9 subjects (12%) fit ACR criteria for OA of the knee. In summary, running did not accelerate the development of radiographic or clinical OA of the knees, but with aging, 13% of all subjects developed OA of the hands and 12% of all subjects developed OA of the knees.

The relative toxicity of disease-modifying antirheumatic drugs

Abstract: Objective. To compare the toxicities of commonly employed disease-modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis (RA). Methods. Toxicity Index scores, computed from symptoms, laboratory abnormalities, and hospitalizations attributable to DMARD therapy, were assessed in 2,747 patients with RA receiving 3,053 courses of 6 DMARDs and 1,309 courses of prednisone over 7,278 patient-years. Results were adjusted for severity of illness and other covariates. Results. Least toxic was hydroxychloroquine (mean ± SEM score 1.38 ± 0.15), followed by intramuscular gold (2.27 ± 0.17) and the closely grouped D-penicillamine (3.38 ± 0.36), methotrexate (3.82 ± 0.35), and azathioprine (3.92 ± 0.39). Auranofin (5.25 ± 0.32) was most toxic, but this toxicity resulted from a high frequency of minor complications. Hospitalizations because of auranofin or hydroxychloroquine therapy were not noted. Prednisone (3.83 ± 0.39) was of comparable toxicity, although it is likely that not all events of prednisone toxicity were captured. For reference, the toxicity of methotrexate and azathioprine was similar to that of the most toxic nonsteroidal antiinflammatory drugs (NSAIDs) (indomethacin 3.99, tolmetin sodium 3.96, and meclofenamate 3.86). Hydroxychloroquine showed less toxicity than the most commonly used prescription NSAIDs. Conclusion. There are substantial differences in toxicity among DMARDs and less important differences in toxicity between specific DMARDs and specific NSAIDs.

Fractures in rheumatoid arthritis: an evaluation of associated risk factors.

Abstract: Objective Our purpose was to identify factors indicative of a high fracture risk during the disease course of rheumatoid arthritis (RA). Methods In 1110 patients (879 women and 231 men) with RA from five Arthritis, Rheumatism and Aging Medical Information System centers, information from history, clinical and laboratory examination, outcome assessment, and therapy was evaluated for association with the 226 first fractures having occurred during the years from 1975 to 1988. Results The mean age of the patients was 54 years, the mean time of observation was 8 years. Multivariate analyses identified the following factors to be associated with fracturing: years taking prednisone, previous diagnosis of osteoporosis, disability, age, lack of physical activity, female sex, disease duration, impaired grip strength, and low body mass. Conclusion We conclude that patients with RA at greatest risk for fracturing are easily identified by using a few clinical variables. These findings support encouragement of active lifestyle habits and avoidance of longterm administration of corticosteroids in patients with RA.

Progression of Functional Disability in Patients With Rheumatoid Arthritis: Associations With Rheumatology Subspecialty Care

Abstract: Background: To determine whether patients with rheumatoid arthritis and their physicians make appropriate decisions regarding referral to rheumatologists and the need for continuing rheumatology care, we examined the relationship between the progression of functional disability in these patients and their use of rheumatology subspecialty care over time. Methods: A cohort of 282 patients with rheumatoid arthritis was followed prospectively for up to 10 years. Participants were categorized into three subgroups based on the pattern of care received from rheumatologists over the study period: patients who were never treated by a rheumatologist; patients treated by a rheumatologist only intermittently; and patients treated by a rheumatologist at least once during each 6-month study period. The outcome was the rate of progression of functional disability, measured using the Health Assessment Questionnaire Disability Index. Results: Among the 52 patients who had not been referred to a rheumatologist, 30 (58%) had rates of progression of functional disability that were stable or improving over time (rate Conclusions: Most patients with rheumatoid arthritis in this community cohort were treated by a rheumatologist, but 42% of those not referred had progressively increasing functional disability. Among patients treated by rheumatologists, those who had continuing care from rheumatologists experienced lower rates of progression of functional disability than those who had only intermittent care. These results suggest that use of rheumatology subspecialty care is associated with better health outcomes in rheumatoid arthritis. (Arch Intern Med. 1993;153:2229-2237)

Quality of Life and Health Service Use Among Hiv-infected Patients with Chronic Diarrhea

Abstract: Health-related quality of life and the utilization of health resources are important components of the evaluation of patient outcome in HIV infection because medical problems are often progressive and debilitating, and treatment is palliative. We evaluated quality-of-life measures and resource utilization of patients with AIDS and/or CD4 lymphocytes < 200 who had symptoms of chronic diarrhea and compared them with similar patients with AIDS and/or CD4 lymphocytes < 200 without diarrheal symptoms. Annual charges were 50% higher for patients with chronic diarrhea ($24,567 versus $14,471 for the comparison group, p < 0.01). Higher charges for the patients with diarrhea were a result of more physician visits and diagnostic testing. Quality-of-life scores were poor for all patients, but deterioration over the year in role functioning (social activity, daily living, energy, cognition) and general health was clearly evident (p < 0.01) for the patients with chronic diarrhea. These patients also suffered significant work loss and reported greater need for assistance in the home. These data suggest that HIV-infected patients with diarrhea experience marked decreases in quality of life and that care for patients with chronic diarrhea is costly. Relatively little attention has been paid to this debilitating syndrome, and current treatment options rarely provide permanent relief. Research and innovation in this area are needed; an estimated 25-50% of HIV-positive individuals suffer from this symptom complex.

A canadian study of the total medical costs for patients with systemic lupus erythematosus and the predictors of costs

Abstract: Objective. We conducted a cost identification analysis on 164 consecutive patients with systemic lupus erythematosus (SLE) who entered the Montreal General Hospital Lupus Registry between January 1977 and January 1990, compared their costs to the population of Quebec, and determined the predictors of cost. Methods. In January 1990 and 1991, participants completed questionnaires on health services utilization and on employment history over the preceding 6 months, as well as on functional, psychological, and social well-being. The societal burden of SLE was determined in terms of direct costs (all resources consumed in patient care) and indirect costs (wages lost due to lack of work force participation because of morbidity). Results. The mean total annual cost for 1989, as assessed in January 1990 and expressed in 1990 Canadian dollars, was $13,094. Although only 44% of the patients were fully employed, indirect costs were responsible for 54% of this total ($7,071). Ambulatory costs, primarily diagnostic procedures, medications, and visits to health care professionals, comprised 55% of direct costs ($3,331). The results of the 1990 cost determination were similar. On average, hospitalizations among SLE patients were 4 times more frequent than among the general population of Quebec (matched for age and sex), and the number of ambulatory visits to physicians was double that for the average resident of Quebec. Higher 1989 values of creatinine and a poorer level of physical functioning were the best predictors of higher 1990 direct costs (R2 = 0.29). A poorer SLE well-being score, a combination of education and employment status, and a weaker level of social support were the best predictors of higher indirect costs (R2 = 0.29). Conclusion. The direct and indirect costs for patients with SLE are substantial, and their respective predictors are distinct. Direct costs arise from organic complications which induce functional disability. Predictors of indirect costs are potentially amenable to psychological or social interventions and may be more easily modified than the determinants of direct costs, thereby improving patient outcome while simultaneously reducing disease costs.

Health status among persons infected with human immunodeficiency virus. A community-based study.

Abstract: This research was supported by the Agency for Health Care Policy and Research (Grant No. HS06211), James F. Fries, Principal Investigator. Presented at the Agency for Health Care Policy Research: HIV-AIDS Health Services Research and Delivery Conference, Miami, Florida, December 4-6, 1991; American Public Health Association Annual Meeting, Atlanta, Georgia, November 10-14, 1991. Address correspondence to: Deborah P. Lubeck, PhD, 1000 Welch Road, Suite 203, Palo Alto, CA 94304.

Seasonal variation in the onset of Wegener's granulomatosis, polyarteritis nodosa and giant cell arteritis.

Abstract: OBJECTIVE The hypothesis of a seasonal pattern in the onset of symptoms for some vasculitides has been raised in previous small studies. METHODS Using the data collected by the American College of Rheumatology (ACR) Subcommittee on Classification of Vasculitis, we specifically tested for a higher proportion of onset of symptoms in winter, lower in summer, and intermediate for the other seasons for polyarteritis nodosa (PAN) and Wegener's granulomatosis. We also tested for a higher proportion of onset of symptoms in the spring-summer months for giant cell arteritis (GCA). RESULTS AND CONCLUSIONS The results of our study support the hypothesis of a seasonal trend for the onset of symptoms of Wegener's granulomatosis (p = 0.04) as described previously. No seasonal pattern was found for the other vasculitides studied (PAN and GCA).

The relationship between spinal and peripheral osteoarthritis and bone density measurements.

Abstract: OBJECTIVE To determine the influence of osteoarthritis (OA) on bone density measurements and whether OA at one site is associated with OA at other sites. METHODS Nonrandomized, cross sectional observational study; secondary analysis of a general population database. Sixty-four subjects derived from a longitudinal study of long distance runners and community controls had a complete peripheral radiographic evaluation for osteoarthritic changes in hands, knees, and lumbar spine. Forty-four of these were studied in 1984 with quantitative computed tomography (QCT) of L1, and 54 were studied in 1988 with 153-Gd dual photon absorptiometry (DPA) in the spine and total body. Thirty-four subjects had all measurements done. RESULTS Total body and lumbar spine DPA were positively correlated with radiological scores of OA in the spine and knees, with coefficients ranging between 0.467 to 0.530 (p < 0.001 in all cases). This correlation was principally associated with spinal spurs and knee sclerosis. Results of stepwise multiple linear regression modeling for QCT included age, spine sclerosis, knee sclerosis and knee spurs as the main predictors of bone mineral density (BMD). For DPA measurements, spine spur score was a useful regressor for all the models. Altogether, the percentage of variance accounted for by individual radiological OA variables was 27.4% for lumbar QCT, 27.3% for lumbar BMD, 7.3% for total spine BMD, and 45.2% for total body BMD. OA scores at different sites were not correlated, although repeated assessment at the same site showed very close correlation. CONCLUSIONS All methods used to determine BMD showed a highly significant positive correlation between lumbar and knee radiological OA and bone mineral content both in the spine and the total body. Thus, our results support the hypothesis that OA is negatively correlated with osteopenia. OA, as seen in this population, was not a generalized condition, but rather, was site specific.

A reevaluation of aspirin therapy in rheumatoid arthritis.

Abstract: Background: Aspirin therapy has been largely superseded by prescription nonsteroidal anti-inflammatory drug (NSAID) therapy in rheumatoid arthritis, in part because of premarketing studies suggesting lesser toxic effects for NSAIDs than for aspirin. This study evaluates these toxic effects in a postmarketing population of patients with rheumatoid arthritis. Methods: We studied 1521 consecutive courses of aspirin and 4860 courses of NSAIDs in patients with rheumatoid arthritis from eight Arthritis, Rheumatism, and Aging Medical Information System Post-marketing Surveillance Centers. Toxicity index scores were generated from symptoms, laboratory abnormalities, and hospitalizations, weighted for variable severity and severity of side effect. Results: The toxicity index was only 1.37 (SE=0.10) for aspirin and 1.87 to 2.90 for selected nonsalicylate NSAIDs. These differences were consistent across centers and remained after statistical adjustment for differing patient characteristics. There was a different toxicity with different aspirin preparations, with a score for plain aspirin of 1.36 (SE=0.23), for buffered aspirin of 1.10 (0.20), and for enteric-coated aspirin preparations of 0.92 (0.14). Most important, there were strong dose effects, with a score of 0.73 (0.09) for 651 to 2600 mg daily, 1.08 (0.17) for 2601 to 3900 mg, and 1.91 (0.38) for more than 3900 mg. The average aspirin dose taken was only 2665 mg/d, approximately eight "tablets," compared with 3600 to 4800 mg/d used in the 16 pivotal premarketing studies reviewed. Average NSAID doses were, on the other hand, lower in premarketing trials (eg, naproxen 500 mg/d vs 773 mg/d in the Arthritis, Rheumatism, and Aging Medical System clinical practices). Conclusions: Aspirin therapy, in doses commonly employed in practice, has an excellent safety profile in rheumatoid arthritis, and it is the least costly NSAID. The safety advantage is explained primarily by a dose effect and secondarily by possible differences between formulations. Newer management strategies for rheumatoid arthritis emphasize NSAID use as symptomatic therapy and use of diseasemodifying anti-rheumatic drug therapy for antiinflammatory objectives. Thus, the original recommendation for "anti-inflammatory" doses of aspirin now is less easily justified. Aspirin therapy merits reconsideration as adjunctive therapy for the management of rheumatoid arthritis. (Arch Intern Med. 1993;153:2465-2471)

Reducing attrition bias with an instrumental variable in a regression model: Results from a panel of rheumatoid arthritis patients

Abstract: This study proposes an econometric technique to reduce attrition bias in panel data. In the simplest case, one estimates two regressions. The first is a probit regression based on sociodemographic and clinical characteristics measured at baseline. The probit regression estimates the probability that subjects stay or leave over the duration of the study. We insert the predicted probabilities from the probit regression into an inverse Mills ratio (IMR) or hazard rate to form an instrumental variable. We use this instrumental variable subsequently as an additional covariate in a second regression model that attempts to explain fluctuations in the dependent variable. The second regression, which is linear, includes only subjects who remained in the study. In alternative models, instrumental variables are created using predicted values from least squares and logit regressions estimating the probability that subjects stay or leave. The use of the instrumental variables reduces the effects of attrition bias in the linear regression model. We applied the technique to a panel of patients with rheumatoid arthritis (RA) enrolled in 1981 and followed through 1990. We attempted to predict values for a measure of functional disability recorded in 1990 with use of covariates measured in 1981. The dependent variable was an index of disability in 1990 and the independent variables (covariates) included the disability index from 1981, the years of duration of RA, gender, marital status, education, and age in 1981. The correction technique suggested that ignoring attrition bias would underestimate the strength of associations between being female and the subsequent disability index, and overestimate the strength of associations between being married spouse present, age, and the initial disability index on the one hand and the subsequent disability index on the other.

Associations among healthy habits, age, gender, and education in a sample of retirees

Abstract: In this exploratory and descriptive study, data are drawn from a sample of 1,864 Bank of America retirees collected in 1987 to investigate correlations among healthy habits, age, gender, and education. Findings include: 1) Health habits are strongly and positively associated with each other and negatively associated with unhealthy habits. 2) Age is statistically significant and positively associated with fiber, fat consumption, and lack of exercise, but negative associated with cigarette use. 3) Women are more likely than men to smoke, use seat belts, and eat foods high in fiber. Men are more likely than women to exercise and drink excessively. 4) Education is statistically significant and positively associated only with fiber in the diet and no other habit. 5) Fiber consumption emerges as the healthy habit most consistently associated with all other habits.

Unilateral ptosis as an initial manifestation of D-penicillamine induced myasthenia gravis.

Abstract: We describe 2 patients presenting with isolated unilateral ptosis without other signs of cranial or peripheral nerve involvement or sympathetic denervation Both patients (one case of progressive systemic sclerosis and one of rheumatoid arthritis) were currently taking D-penicillamine In these cases, the ptosis was reversed a few minutes after a Tensilon test, hallmark of myasthenia gravis Antibodies to acetylcholine receptors were present Myasthenia gravis should be suspected with ptosis without other cranial nerve involvement or miosis, even if the ptosis is unilateral Thus, unilateral ptosis can be the first manifestation of a toxic side reaction to D-penicillamine

Detecting treatment effects in patients with rheumatoid arthritis: the advantage of longitudinal data.

Abstract: Assessment of therapy in patients with rheumatoid arthritis is important but difficult. We examined 4 different methods of analyzing pretreatment data and assessed the difference that each made in detecting a positive effect of intramuscular gold on the patient's overall disability. The methods were (1) calculating the arithmetic mean of prior data points, (2) taking the last data point pretreatment, (3) fitting a straight line to pretreatment points and (4) fitting the pretreatment points with a quadratic equation. After comparison with matched controls (not taking remittive agents) the most significant difference was found by fitting a straight line to pretreatment data

Effects of New 1993 Criteria for Classification of AIDS

Abstract: To the Editor. —On January 1,1993, the revised classification system for human immunodeficiency virus (HIV) infection and expanded surveillance case definition for acquired immunodeficiency syndrome (AIDS) went into effect. 1 With the new criteria, individuals with a CD4 cell count of less than 0.20×10 9 /L (200/μL) or a CD4 percentage of less than 14% are classified as having AIDS even in the absence of a defining opportunistic infection or indicator disease. The list of defining conditions was augmented by inclusion of pulmonary tuberculosis, bacterial pneumonia, and cervical cancer. Many implications for insurance coverage, clinic eligibility, and other social factors, as well as medical ones, result from this change. For example, it may be anticipated that survival for AIDS patients will artificially increase, and the point prevalence of disability and decreased quality of life in AIDS patients will become somewhat less. It is important to recognize the magnitude of these

Estimating lumbar bone mineral density from routine radiographs of the lumbar spine

Abstract: To evaluate the information content of lateral lumbar films with respect to bone mineral content, we compared reading criteria with values obtained by quantitative computed tomography (CT) of L1 at baseline and after 5 years. The highest correlations with mineral content were found for the criteria “overall assessment of the vertebra”, “vertebral body density versus soft tissue”, and “amount of trabeculations”. These three reading criteria yielded higher correlations with CT scores in subjects with lower body mass index. Changes in mineral content over the 5-year period could not be read adequately, the average difference representing only a loss of about 10% in the study subjects. We conclude that a rough estimate of bone density can be obtained from lateral radiographs which, in the presence of eventual risk factors for osteoporosis, may serve as an additional indication to timely bone densitometry with methods which allow precise short-term follow-up measurements.