Showing papers by "James F. Fries published in 1997"

Patient education in arthritis: randomized controlled trial of a mail-delivered program.

Abstract: Objective. Self-management courses in arthritis have been shown to improve outcomes and to decrease medical resource utilization. We studied the effectiveness of a mail-delivered arthritis self-management program with the potential for extending these effects more broadly. Methods. Randomized controlled trial of 375 program participants and 434 controls over a 6 month period. Baseline and 6 month data were analyzed for each group and between groups by paired 2 sample t test. The intervention consists of health assessment questionnaires at 3 month intervals, with computer processed recommendation letters and reports individualized to age, diagnosis, education level, disability, pain, medication, and other patient-specific variables. Results. At 6 months, outcomes of function 14.7%; 95% confidence limits 2.7, 6.7), decreased pain (9%; 2.8, 15.2), global vitality (7%; 2.8, 11.2), and joint count (28%; 20, 36) were improved in the program group compared with controls (p < 0.01). Exercise (35%; 26, 44) and self-efficacy (14.7%; 9, 20) were increased in the program group but not controls (p < 0.001). Doctor visits/year were decreased by 16% (3, 29) in the program group compared with controls (p < 0.05) and days missed work or confined to home decreased by 52% (-3, 107) in the program group compared with controls (p = 0.06). At one year, patients in the original program group continued to improve, and the control group, provided with the program in the second 6 months, showed improvement similar to the first 6 months of the original program group. Conclusion. A mail-delivered arthritis self-management program can positively affect patient outcomes and can decrease medical resource utilization.

Assessment of quality of life in early stage HIV-infected persons: data from the AIDS Time-oriented Health Outcome Study (ATHOS).

Abstract: The development of new pharmaceutical interventions for persons with human immunodeficiency virus (HIV) infection has resulted in extended survival and a need for valid, reliable and responsive instruments to assess health-related QoL (HRQoL). This paper reviews the reliability and validity of an HRQoL instrument, the AIDS Health Assessment Questionnaire (AIDS-HAQ), among persons participating in an observational database of HIV infection. The AIDS-HAQ includes nine subscales: disability, energy, general health, pain, cognitive functioning, mental health, social functioning, health distress and symptoms. Individuals complete the AIDS-HAQ quarterly. Data are reported for 440 individuals entering the study with early HIV infection. Fifty-nine progressed to symptomatic disease and 109 to AIDS after 1 year. The subscales of the instrument resulted in high internal consistency reliability (range=0.79–0.88). Concurrent validity data reflected the ability to distinguish between patients with increasing disease severity. In all domains, except cognitive functioning, individuals who progressed to AIDS had significant decrements (p<0.01) in HRQoL compared with symptomatic and asymptomatic patients. Significant decrements (p<0.01) were observed for disability, general health, energy and symptoms for patients who progressed to symptomatic disease from an asymptomatic status. Individuals who had decreasing CD4+ counts also had significant declines (p<0.001) in disability, general health, social functioning, pain and symptoms. The AIDS-HAQ is an instrument that can be used when comparing group differences and within group changes in observational databases, naturalistic studies and clinical trials.

"Arthritis specific" global health analog scales assess "generic" health related quality-of-life in patients with rheumatoid arthritis

Abstract: OBJECTIVE Quality-of-life assessment is receiving increased attention as an outcome measure in rheumatoid arthritis (RA). The most widely used instruments use variations on a vertical visual analog scale (VAS). Since the Health Assessment Questionnaire (HAQ), Arthritis Impact Measurement Scales (AIMS), and other instruments have long included a "global" arthritis horizontal VAS (GLOB), we studied whether these 2 approaches assess the same concept. METHODS We studied 663 patients with RA from 4 ARAMIS (Arthritis, Rheumatism, and Aging Medical Information System) centers and had them complete, in different parts of the same HAQ, the GLOB and the Torrance "feeling thermometer" (FT). RESULTS The 2 scales were highly correlated (r = -0.676; p < 0.001). Reliability (estimated by 6 month test-retest) was 0.62 for the FT and 0.83 for the GLOB. The GLOB correlated more strongly than the FT with disability (r = 0.561 vs -0.507) and pain (0.630 vs -0.553). In stepwise regressions, pain and then disability were the dominant predictors of both GLOB and FT, followed weakly by joint count and then other variables. Patients with greater disability placed more emphasis on pain and patients with greater pain appeared to value more the contribution of disability. Change scores over 6 months between GLOB and FT correlated very well (-0.59). CONCLUSION "Health" and "health related quality-of-life" are nearly equivalent terms. Since large longitudinal rheumatology databases contain thousands of global health VAS values, data for longitudinal quality-of-life studies in arthritis are already available, and this dimension may readily be added to longterm outcome assessment. In patients with RA, "generic" and "disease specific" assessments yield very similar results.

The influence of systemic lupus erythematosus on fetal development: Cognitive, behavioral, and health trends

Abstract: In 1985, Gualtieri and Hicks proposed the immunoreactive theory to explain the higher prevalence of childhood neurodevelopmental disorders in males. The theory claimed that male fetuses are more antigenic to mothers, resulting in increased immunologic attack on the developing central nervous system, and increased probability of atypical brain development. Individuals with systemic lupus erythematosus (SLE) provide a unique situation in which to investigate this theory. We evaluated the parent-reported prevalence of five developmental problems (stuttering, other speech problems, hyperactivity, attention deficit, and reading problems) in two groups: 154 individuals ages 8-20 years born to women with SLE, drawn from six cities, and 154 controls of comparable age and sex whose mothers did not have SLE. Controls were drawn from a comparison group ascertained from randomly selected schools in one of the cities. Questions about handedness, immune disorders, and pregnancy and birth complications were also evaluated. Children of SLE mothers were shown to have more evidence of developmental difficulties, immune related disorders, and nonrighthandedness. For developmental problems, these findings were most marked in male children of SLE mothers. These results suggest that maternal immunoreactivity, as represented by women with SLE, may present a special risk factor for subsequent learning difficulties in their children, particularly males.

Response to therapy in rheumatoid arthritis is influenced by immediately prior therapy

Abstract: Objective. Clinicians do not often employ washout periods before prescribing a change in therapy for rheumatoid arthritis (RA). As a result, the observed effectiveness or lack of effectiveness of a new drug actually represents the effectiveness at that drug had the patient been taking placebo minus the residual effectiveness of the old drug. Methods. We studied new starts of selected disease modifying antirheumatic drugs (DMARD) and prednisone in 2898 patients with RA from 8 ARAMIS data bank conters, broken into subgroups on the basis of immediately prior therapy. Therefore we examined the hypothesis that the chances of a treatment being observed effective depend upon the immediately preceding treatment. Using intent-to-treat analysis, we analyzed the effects upon Health Assessment Questionnaire (HAQ) disability and pain scores an average of months after the new drug start. Results. Methotrexate reduced disability significantly except after intramuscular gold or hydroxy-chloroquine and it reduced pain significantly after all prior therapies. Hydroxychloroquine reduced disability significantly after nonsteroidal antiinflammatory drugs (NSAID) only, but disability increased after intramuscular gold; pain was decreased only after NSAID only. Prednisone had no consistent effect upon disability but was consistently associated with decreased pain. Greatest effectiveness was always seen with a new drug start after NSAID only treatment versus after DMARD treatment. Conclusion. The effectiveness of a newly started RA treatment after 9 months may be substantially influenced by immediately prior treatment. This finding provides an additional reason for concern about direct extrapolation of clinical trial data into clinical practice.

Exercise and the Health of the Elderly.

Abstract: Most lifetime morbidity is concentrated in the later years as a consequence of increasing amounts of chronic illness and senescent changes. An ideal society would reduce this large illness burden by focusing upon increasing the incident age of first infirmity and compressing lifetime morbidity between that point and the average age at death; the "Compression of Morbidity." We compared progression of musculoskeletal disability, pain, and medical care costs by a longitudinal study of 537 members of a runners club and 423 community controls over a period of more than 8 years with an average initial age of 59 years, with extensive controls for selection bias. Exercising subjects developed disability at a rate only one-fourth that of the sedentary controls. Musculoskeletal pain was reduced by 20%. Medical care costs of exercisers were 25% less than controls. Mortality was significantly reduced in the exercising groups. These findings have substantial implications for health policies directed at increasing amounts of regular lifetime physical activity to improve the quality of life of our rapidly increasing senior population.

Reducing the need and demand for medical care: implications for quality management and outcome improvement.

Abstract: Reduction in medical need (illness burden) and demand (variability in resource use) can improve health, reduce medical care costs, and move us toward the goal of becoming a healthy society. Health promotion, redefined, works to enhance individual autonomy. The underlying conceptual bases and the abundant empiric documentation of the effectiveness of need and demand reduction are summarized here.

Absenteeism and HIV infection

Abstract: We sought to determine whether employed patients with HIV infection reported more days unable to work than similar patients without HIV infection. We did not consider whether HIV infection resulted in job loss. Cross-sectional data on 884 employed patients from five physician-sites in California were drawn from the AIDS Time-Oriented Health Outcome Study (ATHOS). An econometric 2-part model with a number of covariates including age, race, education, and an instrumental variable reflecting the probability of any employment was constructed to provide a comparison between three categories of patients, HIV -negative; HIV positive but not yet AIDS; and AIDS. The results suggested no statistically significant difference between the comparison patients (HIV -negative) and the patients with HIV but not AIDS for days unable to work. Employed patients with AIDS, however, reported roughly 5.1 (one week) more days unable to work out of the prior three months than either the comparison patients or the patients with HI...