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ABSTRACT: Work disability is a common outcome of inflammatory arthritis (IA), yet few services address employment. We conducted a proof-of-concept study of the "Employment and Arthritis: Making It Work" self-management program aimed at preventing work disability and maintaining at-work productivity in employed people with IA.
The program was developed using the precede-proceed model and self-management concepts. Program goals included modifying risk factors for work disability and enhancing self-management of work problems due to IA, as identified in initial focus groups. The program included a self-learning manual, 5 group sessions, and individual visits with an occupational therapist for an ergonomic assessment and a vocational rehabilitation counselor. It was pilot tested in 2 groups (n = 19) and evaluated over 12 months of followup.
Participants consisted of 19 employed women with IA. Process evaluation demonstrated feasibility and excellent attendance and use of the self-learning manual. By 1 year, 80% reported increased confidence in requesting job accommodations, 74% had requested an accommodation, and 71% of requested accommodations were implemented. The occupational therapist and vocational rehabilitation counselor visits resulted in recommendations for change in 100% and 74% of participants, respectively, with implementation of some recommended changes in 89% and 63%, respectively. Improvements were observed in self-confidence in managing problems at work, fatigue interference with work, measures of limitations, and at-work productivity.
We developed a novel intervention to prevent work disability in patients with IA, combining self-management group sessions and professional assessments aimed at job retention, which resulted in people making changes to adapt their work to their arthritis, and improved fatigue, self-efficacy, and at-work productivity.
Arthritis & Rheumatism 12/2008; 59(11):1647-55. · 7.87 Impact Factor
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ABSTRACT: To prospectively examine arthritis-related productivity losses, work changes, and leaving employment, the relationships among these work transitions, and the factors associated with them.
Participants with inflammatory arthritis or osteoarthritis were interviewed at 4 time points, 18 months apart, using a structured questionnaire. At baseline (T1), all participants (n = 490; 381 women, 109 men) were employed. At T2, T3, and T4, the sample decreased to 413, 372, and 349 participants, respectively. Respondents were recruited using community advertising and from rheumatology and rehabilitation clinics. Work transitions considered were productivity losses (absenteeism, job disruptions), work changes (reduced hours, changing jobs), and leaving employment. Also measured were demographic, illness, work context, and psychological variables. Generalized estimation equations modeled predictors of work transitions over time.
Although 63.1% of respondents remained employed throughout the study, work transitions were common (reported by 76.5% of participants). Productivity losses, especially job disruptions such as being unable to take on extra work, were the most frequently reported. Work transitions were related to subsequently making other work transitions, including leaving employment. Age, sex, education, activity limitations, control, depression, and arthritis-work spillover were also associated with work transitions.
This study sheds light on a process of diverse employment changes that may occur in the lives of many individuals with arthritis. It emphasizes the interrelationships among work transitions, as well as other factors in predicting work transitions, and it provides insight into work changes that may signal impending difficulties with remaining employed.
Arthritis & Rheumatism 12/2008; 59(12):1805-13. · 7.87 Impact Factor
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ABSTRACT: To determine the magnitude of risk of cardiovascular mortality in patients with rheumatoid arthritis (RA) compared with the general population through a meta-analysis of observational studies.
We searched Medline, EMBase, and Lilacs databases from their inception to July 2005. Observational studies that met the following criteria were assessed by 2 researchers: 1) prespecified RA definition, 2) clearly defined cardiovascular disease (CVD) outcome, including ischemic heart disease (IHD) and cerebrovascular accidents (CVAs), and 3) reported standardized mortality ratios (SMRs) and 95% confidence intervals (95% CIs). We calculated weighted-pooled summary estimates of SMRs (meta-SMRs) for CVD, IHD, and CVAs using the random-effects model, and tested for heterogeneity using the I(2) statistic.
Twenty-four studies met the inclusion criteria, comprising 111,758 patients with 22,927 cardiovascular events. Overall, there was a 50% increased risk of CVD death in patients with RA (meta-SMR 1.50, 95% CI 1.39-1.61). Mortality risks for IHD and CVA were increased by 59% and 52%, respectively (meta-SMR 1.59, 95% CI 1.46-1.73 and meta-SMR 1.52, 95% CI 1.40-1.67, respectively). We identified asymmetry in the funnel plot (Egger's test P = 0.002), as well as significant heterogeneity in all main analyses (P < 0.0001). Subgroup analyses showed that inception cohort studies (n = 4, comprising 2,175 RA cases) were the only group that did not show a significantly increased risk for CVD (meta-SMR 1.19, 95% CI 0.86-1.68).
Published data indicate that CVD mortality is increased by approximately 50% in RA patients compared with the general population. However, we found that study characteristics may influence the estimate.
Arthritis & Rheumatism 12/2008; 59(12):1690-7. · 7.87 Impact Factor
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ABSTRACT: To assess the potential benefits of methotrexate in patients with systemic lupus erythematosus (SLE).
A 12-month, double-blind, placebo-controlled trial of methotrexate with folic acid was conducted. Intent-to-treat analyses were performed with mixed linear models and alpha = 0.04 (96% confidence interval [96% CI]) to account for interim analysis of longitudinal data to assess the treatment effects on lupus disease activity and daily steroid dose across monthly measurements, and to test if the treatment effects depended on selected participant characteristics.
Of 215 participants screened, 94 were excluded, 35 declined, and 86 were randomized (methotrexate = 41, placebo = 45). The groups were balanced for demographic and disease characteristics. Antimalarial use was more frequent in the placebo group, which was adjusted for in multivariable analyses. Sixty participants (27 methotrexate, 33 placebo) completed the study and 26 terminated early. Among participants who had the same baseline prednisone dose, those taking methotrexate received, on average, 1.33 mg/day less prednisone during the trial period (96% CI 0.06, 2.72 mg/day; a 22% reduction of their average-during-trial daily dose) compared with those in the placebo group. For the primary measure of disease activity (revised Systemic Lupus Activity Measure), methotrexate use was also associated with a marginally significant reduction in the mean during-trial score of 0.86 units (96% CI 0.01, 1.71; P = 0.039). A significant interaction between treatment and baseline damage was found (P = 0.001).
Methotrexate conferred a significant advantage in participants with moderately active lupus by lowering daily prednisone dose and slightly decreasing lupus disease activity. As a therapeutic option in moderate SLE, methotrexate can be considered to be steroid sparing.
Arthritis & Rheumatism 12/2008; 59(12):1796-804. · 7.87 Impact Factor
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ABSTRACT: Ergonomic assessment and recommendations may help people with arthritis maintain employment; however, most ergonomic tools are designed to assess injury risk in the general population and are not specific to the needs of people with inflammatory arthritis (IA). Our objectives were to design and pilot test an ergonomic assessment tool for people with IA and to propose ergonomic modifications to prevent work loss and maintain at-work productivity.
Relevant content was identified in a literature review by an interdisciplinary team. Respecting some clients' reluctance to disclose arthritis to employers, no work site visit was required. An initial assessment tool was reviewed by a 4-person expert panel, revised and pretested with 13 adults with IA by 3 occupational therapists (OTs). The final tool, comprised of a self-assessment, an interview guide, and a solutions summary, was used in a pilot test of a multifaceted program designed to prevent work loss and maintain at-work productivity. One OT conducted all ergonomic consultations and followed up with phone calls at 1 month. Implementation of recommendations was evaluated at 3, 6, and 12 months.
Nineteen women (mean age 51 years) with IA (mean disease duration 12 years) completed ergonomic assessments. A range of risks were identified and 87 recommendations were made (mean 4.5 per participant). At 1 year, 85% of recommendations had been implemented by 74% of the participants.
The Ergonomic Assessment Tool for Arthritis is a feasible and comprehensive process for identifying ergonomic job accommodations.
Arthritis & Rheumatism 11/2008; 59(10):1495-503. · 7.87 Impact Factor
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ABSTRACT: Rheumatoid arthritis (RA) is associated with increased frequency of and mortality from infections, which may be related to host factors, RA itself, inflammation, or medication side effects. This study was undertaken to determine the effect of nonbiologic disease-modifying antirheumatic drugs (DMARDs) on infection risk in RA.
We performed a retrospective, longitudinal study of a population-based RA cohort in British Columbia, Canada, followed from January 1996 to March 2003 using administrative data. We evaluated mild infections (requiring a physician visit or antibiotics) and serious infections (requiring or complicating hospitalization). Adjusted risk of mild and serious infections associated with DMARD exposure was estimated using generalized estimating equation extension of multivariate Poisson regression models, after adjusting for baseline covariates (age, sex, RA duration, socioeconomic status) and time-dependent covariates (corticosteroids, comorbidity, prior infections).
A total of 27,710 individuals with RA provided 162,710 person-years of followup. Of these, 25,608 (92%) had at least 1 mild infection and 4,941 (18%) had at least 1 serious infection. Use of DMARDs without corticosteroids was associated with a small decrease in mild infection risk of statistical significance but unclear clinical significance (adjusted rate ratio [RR] 0.90, 95% confidence interval [95% CI] 0.88-0.93 relative to no corticosteroid or DMARD use). Use of DMARDs without corticosteroids was not associated with increased serious infection risk (adjusted RR 0.92, 95% CI 0.85-1.0). Use of corticosteroids increased the risk of mild and serious infections.
Our results indicate that use of nonbiologic DMARDs, including methotrexate, does not increase the risk of infection in RA, whereas use of corticosteroids does. This has important implications for counseling individuals with RA concerning risks and benefits of DMARDs.
Arthritis & Rheumatism 09/2008; 59(8):1074-81. · 7.87 Impact Factor
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ABSTRACT: To estimate the minimal clinically important difference (MCID) of seven measures of fatigue in rheumatoid arthritis.
A cross-sectional study design based on interindividual comparisons was used. Six to eight subjects participated in a single meeting and completed seven fatigue questionnaires (nine sessions were organized and 61 subjects participated). After completion of the questionnaires, the subjects had five one-on-one 10-minute conversations with different people in the group to discuss their fatigue. After each conversation, each patient compared their fatigue to their conversational partners on a global rating. Ratings were compared to the scores of the fatigue measures to estimate the MCID. Both nonparametric and linear regression analyses were used.
Nonparametric estimates for the MCID relative to "little more fatigue" tended to be smaller than those for "little less fatigue." The global MCIDs estimated by linear regression were: Fatigue Severity Scale, 20.2; Vitality scale of the MOS-SF36, 14.8; Multidimensional Assessment of Fatigue, 18.7; Multidimensional Fatigue Inventory, 16.6; Functional Assessment of Chronic Illness Therapy-Fatigue, 15.9; Chalder Fatigue Scale, 9.9; 10-point numerical Rating Scale, 19.7, for normalized scores (0-100). The standardized MCIDs for the seven measures were roughly similar (0.67-0.76).
These estimates of MCID will help to interpret changes observed in a fatigue score and will be critical in estimating sample size requirements.
Journal of Clinical Epidemiology 08/2008; 61(7):705-13. · 4.27 Impact Factor
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ABSTRACT: To assess the importance of different social roles in the lives of people with osteoarthritis (OA), and satisfaction with time spent in roles and role performance, as well as the relationship of demographic, health, and psychological factors to role perceptions.
Sixty women and 27 men (age 42-86 yrs) with hip or knee OA were recruited from rehabilitation programs and community advertising. Participants completed interview-administered questionnaires measuring demographics, OA symptoms, activity limitations, and well-being (e.g., depression). They also completed the Social Role Participation Questionnaire (SRPQ) assessing the influence of arthritis on role salience and satisfaction across diverse role domains (e.g., close relationships, employment).
Participants reported many salient roles, but low to moderate satisfaction with them related to OA. SRPQ dimensions of salience and satisfaction were distinct; satisfaction with time spent in roles and with role performance was highly correlated (r = 0.83). Lower role salience was associated with being older, having less education and income, and greater illness intrusiveness. Less satisfaction with time spent in roles due to OA was associated with being younger, greater pain, and greater illness intrusiveness, whereas less satisfaction with role performance was associated with greater illness intrusiveness and depression.
This study addresses a gap -- the influence of OA on social role participation. It underscores the importance of taking into account individual perceptions of roles, and that these perceptions are multifaceted. Understanding diverse factors related to social roles may help identify individuals at risk for role difficulties and provide targets for interventions to improve role participation.
The Journal of Rheumatology 07/2008; 35(8):1655-63. · 3.69 Impact Factor
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Ewan C Goligher,
Jacques Pouchot,
Rollin Brant,
Raheem B Kherani,
J Antonio Aviña-Zubieta, Diane Lacaille,
Allen J Lehman,
Stephanie Ensworth,
Jacek Kopec,
John M Esdaile,
Matthew H Liang
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ABSTRACT: To determine the minimal clinically important difference (MCID) for 7 measures of fatigue in patients with systemic lupus erythematosus (SLE).
Study subjects completed 7 fatigue instruments [Fatigue Severity Scale (FSS), Multidimensional Assessment of Fatigue (MAF), Multidimensional Fatigue Inventory (MFI), Vitality scale of the MOS-SF-36, Chalder Fatigue Scale (CFS), Functional Assessment of Chronic Illness Therapy-Fatigue, and a global Rating Scale (RS)] and then participated in a series of interviews with other study participants comparing their fatigue with one another. Each interview participant rated the difference in their fatigue levels on a 7-point transition scale. The MCID was estimated from the mean difference in fatigue scores between each pair of interview participants based on their subjective rating of fatigue contrast. The MCID was also estimated using linear regression modeling.
Eighty patients with SLE participated. Patients reported significant levels of fatigue [mean normalized (0 = none, 100 = maximum) fatigue scores for the 7 instruments ranged from 49.8 (CFS) to 71.1 (FSS)]. The MCID of "a little more" fatigue tended to be greater than the MCID for a "little less fatigue" and differed significantly for FSS and MAF. The MCID of normalized scores estimated by linear regression ranged from 7.0 (CFS) to 14.3 (MFI).
Fatigue is a common and debilitating component of SLE. Estimates of MCID will help to interpret changes observed in a fatigue score and will be critical in estimating sample size requirements for clinical trials including fatigue as an outcome.
The Journal of Rheumatology 05/2008; 35(4):635-42. · 3.69 Impact Factor
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ABSTRACT: Inflammatory arthritis (IA) is a leading cause of work disability, especially for those with jobs involving repetitive, hand-intensive or manual work. Ergonomic interventions may mediate against job loss. Our objective was to identify desirable features of an ergonomic tool for use in providing job accommodation for people with IA, and to evaluate a selection of ergonomic and rehabilitation tools against these features. Eight desirable features were compared across 16 assessment tools. None of the tools met all the pre-determined features. Ergonomic assessment tools should incorporate objective assessment of risk factors together with subjective perceptions of symptom aggravation, and identify risk factors that may not currently be causing problems, but may increase risk of aggravation or injury in the future. To accommodate the needs of people with IA, the tool should allow for evaluation of risks and generation of solutions without a worksite visit in situations where the client does not want to disclose their illness. Finally, an assessment tool needs to be applicable to a wide range of worksites, easy to use, valid, and reliable. Against these criteria, it appears that there is a lack of appropriate ergonomic assessment tools for use in people with IA.
Work 02/2008; 31(2):145-57. · 0.52 Impact Factor
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ABSTRACT: A qualitative study was conducted to better understand patients' perspective on their experience at work in relation to their inflammatory arthritis (IA). Objectives were to identify the problems and barriers to employment that persons with IA face at work because of arthritis, understand why these issues are problematic, and identify strategies helpful for maintaining employment.
Five focus groups were conducted with 36 employed adults with IA (75% rheumatoid arthritis) recruited from rheumatology practices and outpatient arthritis treatment programs. Script design used brainstorming techniques to identify problems and helpful strategies, and root cause analysis to capture in-depth information about underlying causes of problems. Descriptive qualitative analysis of transcripts was performed by 2 researchers independently to identify problems and organize them into topics and broad categories.
Problems clustered around 4 categories: arthritis symptoms, working conditions, interpersonal difficulties at work, and emotional challenges. New insights gained included identifying fatigue as the aspect of IA most limiting employment; challenges posed by invisibility, fluctuation, and unpredictability of arthritis; complexity of interpersonal relationships at work; reluctance to disclose or draw attention to arthritis; numerous barriers to using available supports and requesting job accommodations, including fear of disclosure and concern it could be perceived by coworkers as favoritism; loss of self-efficacy at work; and many emotional challenges.
This research identified new issues that are meaningful to individuals working with arthritis and that deserve greater attention by professionals counseling people on employment, in intervention efforts to help maintain employment, and in arthritis employment studies.
Arthritis & Rheumatism 11/2007; 57(7):1269-79. · 7.87 Impact Factor
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ABSTRACT: To estimate healthcare demand elasticity and evaluate the impact of deductible/co-payment policy changes for prescription drugs on the use of drugs and physician visits among seniors with rheumatoid arthritis (RA) in British Columbia (BC), Canada.
According to the BC drug insurance program, prior to 2002, seniors co-paid the dispensing fee of each prescription to an annual maximum of CAN$ 200 (plan A). Starting in 2002, this plan was split into plan A and plan A1 (Premium Assistance) such that the co-payment amount equaled a maximum of CAN$ 25 and CAN$ 10 per prescription to an annual maximum of CAN$ 275 and CAN$ 200, respectively. Because of the endogeneity of the beneficiary price in the presence of a non-linear price schedule resulting from the cost-sharing policy, we implemented the method of instrumental variables to estimate price elasticities. The instrument was based on the price an individual would face under the new cost-sharing policy if their consumption remained at the pre-policy level.
A total of 8017 patients were included. The estimated own-price elasticity of demand for prescription drugs and the cross-price elasticity of demand for physician visits were found to be negative and positive, respectively. The implications of our findings were that when cost sharing for prescription drugs increased, the demand for prescription drugs decreased and the demand for physician visits increased.
In a predominantly publicly funded health care system, the selective introduction of market driven cost containment concepts such as patient cost-sharing might have the unintended impact of increasing overall health utilization for seniors with RA.
Health Policy 09/2007; 82(3):340-7. · 1.51 Impact Factor
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ABSTRACT: To evaluate alternative approaches to correct for bias due to inaccurate diagnostic criteria in database studies of associations.
A simulation study of a hypothetical cohort of 10,000 subjects selected based on database-derived diagnostic criteria with positive predictive value (PPV) of either 53% or 80%. Analyses focus on the putative association between a drug and the time to a negative outcome. The association is confounded for "false positive" subjects, where the drug acts as a marker for unobserved frailty. First, we estimate the conventional multivariable Cox's Model 1. We then assume having in-depth evaluation of a fraction of subjects, which permits estimating the probabilities of having the disease for all subjects in the cohort. Alternative correction methods use the estimated probability as a confounder (Model 2), a modifier of the drug effect (Model 3), or an importance weight (Model 4).
With a PPV of 53%, Models 1 and 2 induced about 50% underestimation bias for the drug effect. Interaction-based Model 3 yielded the least biased estimates (25% bias), whereas weighting by probability (Model 4) resulted in slightly more biased (33%), but more stable estimates.
Proposed methods help reducing bias due to sample contamination.
Journal of Clinical Epidemiology 07/2007; 60(6):600-9. · 4.27 Impact Factor
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ABSTRACT: Arthritis is a leading cause of work disability and makes up a significant amount of the socioeconomic cost and health burden to the working age population. We discuss the measurement of worker productivity: that is, absenteeism and presenteeism. Absenteeism refers to the time missed from work due to health reasons and presenteeism refers to the time of impaired performance while at work due to health reasons resulting in productivity loss. While the term absenteeism is commonly used and has several definitions by itself, the current arthritis literature lacks the use of presenteeism as a work outcome measure in describing health states of the workers and for economic costing. Due to advanced medical management and job accommodations that allow workers to stay at work, absenteeism alone may not be enough to give us a complete picture of worker productivity. From our review, we found that the conceptualization and measurement of absenteeism and presenteeism differ. Our research agenda was to carry forward a work outcome measurement that can be used for cost calculation and that can determine levels or states of productivity loss so we can accurately measure the influence of arthritis and advance arthritis care. We recognize the need to perform psychometric testing of work outcome measures and to improve our ability to identify transitions (i.e., move in and out of a productivity state over time) made by workers with arthritis.
The Journal of Rheumatology 07/2007; 34(6):1372-80. · 3.69 Impact Factor
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ABSTRACT: Previous research has shown that patient cost-sharing leads to a reduction in overall health resource utilization. However, in Canada, where health care is provided free of charge except for prescription drugs, the converse may be true. We investigated the effect of prescription drug cost-sharing on overall health care utilization among elderly patients with rheumatoid arthritis.
Elderly patients (> or = 65 years) were selected from a population-based cohort with rheumatoid arthritis. Those who had paid the maximum amount of dispensing fees (200 dollars) for the calendar year (from 1997 to 2000) were included in the analysis for that year. We defined the period during which the annual maximum co-payment had not been reached as the "cost-sharing period" and the one beyond which the annual maximum co-payment had been reached as the "free period." We compared health services utilization patterns between these periods during the 4 study years, including the number of hospital admissions, the number of physician visits, the number of prescriptions filled and the number of prescriptions per physician visit.
Overall, 2968 elderly patients reached the annual maximum cost-sharing amount at least once during the study periods. Across the 4 years, there were 0.38 more physician visits per month (p < 0.001), 0.50 fewer prescriptions filled per month (p = 0.001) and 0.52 fewer prescriptions filled per physician visit (p < 0.001) during the cost-sharing period than during the free period. Among patients who were admitted to the hospital at least once, there were 0.013 more admissions per month during the cost-sharing period than during the free period (p = 0.03).
In a predominantly publicly funded health care system, the implementation of cost-containment policies such as prescription drug cost-sharing may have the unintended effect of increasing overall health utilization among elderly patients with rheumatoid arthritis.
Canadian Medical Association Journal 11/2005; 173(11):1335-40. · 8.22 Impact Factor
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ABSTRACT: Treatment guidelines for rheumatoid arthritis (RA) now recommend early, aggressive, and persistent use of disease-modifying antirheumatic drugs (DMARDs) to prevent joint damage in all people with active inflammation, and evaluation by a rheumatologist, when possible. This research assesses whether care for RA, at a population level, is consistent with current treatment guidelines.
Using administrative billing data from the Ministry of Health in 1996-2000, all prevalent RA cases in British Columbia, Canada were identified. Data were obtained on all medications and all provincially-funded health care services.
We identified 27,710 RA cases, yielding a prevalence rate of 0.76%, consistent with epidemiologic studies. DMARD use was inappropriately low. Only 43% of the entire RA cohort received a DMARD at least once over 5 years, and 35% over 2 years. When used, DMARDs were started in a timely fashion, but were not used consistently. Care by a rheumatologist increased DMARD use 31-fold. Yet, only 48% and 34% saw a rheumatologist over 5 and 2 years, respectively. DMARD use was significantly more frequent, persistent, and more often used as combination therapy with continuous rheumatologist care. DMARDs were used by 84% and 73%, 40%, and 10% of people followed by rheumatologists continuously and intermittently, internists, and family physicians, respectively (P < 0.001). NSAID use, physiotherapy, and orthopedic surgeries were similar across these 4 care groups.
RA care in the British Columbia population was not consistent with current treatment guidelines. Efforts to educate family physicians and consumers about the shift in RA treatment paradigms and to improve access to rheumatologists are needed.
Arthritis & Rheumatism 04/2005; 53(2):241-8. · 7.87 Impact Factor
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Diane Lacaille
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ABSTRACT: Studies of work disability among individuals with arthritis reveal that loss of employment is a common, important, and costly problem. Arthritis and musculoskeletal conditions are the leading cause of longterm work disability in Canada and the US, with an estimated yearly cost of 13.7 billion dollars in Canada. In rheumatoid arthritis, reported rates of work disability are remarkably high, ranging from 32% to 50% 10 years after RA onset, and increasing to 50% to 90% after 30 years. Studies have shown that work disability starts early in the course of RA, emphasizing the need for early intervention. To date, research in the area of arthritis and employment has mostly focused on measuring the extent of the problem and on identifying predictors of work loss. Despite the importance of the problem, there has been little intervention research assessing the effectiveness of medical treatment and few interventions specifically aimed at employment, reducing work loss, or improving ability to work. Research needed includes evaluating the effect of current therapies on employment outcomes, and studying interventions specifically aimed at employment, as well as addressing methodological issues in employment research.
Journal of Rheumatology Supplement 02/2005; 72:42-5.
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ABSTRACT: To understand arthritis-related workplace changes, including occasional work loss and changes to the type and hours of work, and the factors associated with them using theories of adaptation and behavior change as a framework.
Participants were 492 employed individuals with rheumatoid arthritis or osteoarthritis. They completed an interview-administered, structured questionnaire assessing demographic, workplace, and psychosocial variables, as well as such work transitions as changes to the hours, type, and nature of work. Hypotheses were examined using multiple linear regression.
Seventy percent of respondents made at least 1 work change. Younger participants and those with greater workplace activity limitations reported more changes. Work changes were associated with greater depression. A hypothesized 3-way interaction among people's perceptions of their capacity, their future job expectations, and whether they had told their employer about their arthritis was significant.
This study extends arthritis employment research by examining a range of work changes. It highlights the dynamic interplay among arthritis, workplace, and psychosocial variables to understand adaptation to arthritis disability.
Arthritis & Rheumatism 01/2005; 51(6):909-16. · 7.87 Impact Factor
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ABSTRACT: To define work-related factors associated with increased risk of work disability (WD) in people with rheumatoid arthritis (RA).
Questionnaires were mailed to all RA patients who used a province-wide arthritis treatment program between 1991 and 1998 (n = 1,824). The association between risk factors and WD (defined as no paid work due to RA for at least 6 months) was assessed using multiple logistic regression analysis, controlling for significant sociodemographic and disease-related variables.
Of the original 1,824 patients, 581 were eligible and responded to the questionnaire. Work survival analysis revealed a steady rate of WD starting early, with 7.5%, 18%, and 27% work disabled at 1, 5, and 10 years, respectively. Significant determinants in multiple logistic regression were physical function (Health Assessment Questionnaire), pain (visual analog scale), and 6 work-related factors: self employment, workstation modification, work importance, family support toward employment, commuting difficulty, and comfort telling coworkers about RA.
Work disability occurs early in RA. Novel work-related factors were identified, which are potentially modifiable, to help RA patients stay employed.
Arthritis & Rheumatism 11/2004; 51(5):843-52. · 7.87 Impact Factor
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ABSTRACT: To examine the relationship between disease severity in patients with confirmed rheumatoid arthritis (RA) and the carriage of alleles expressing the high risk epitope (HRE) QK/QR/RRRAA or the low risk epitope (LRE) DERAA at positions 70-74 of the third hypervariable region of HLA-DRB1.
A case-control design to compare allele carriage rates in 204 Caucasian subjects with severe RA and mild RA and healthy controls. Patients had a mean disease duration of 12-18 years and severity of RA was defined using clinical and therapeutic criteria. Molecular typing at the HLA-DRB1 locus was performed using a polymerase chain reaction method.
Eighty-seven percent of patients (52/60) with severe RA had one or more of the alleles bearing the QK/QR/RRRAA motif or HRE, compared with 54% (21/39) with mild RA (OR 5.57, p = 0.0007) and 39% (41/105) of controls (OR 10.15, p < 0.0001). Twenty-five percent of patients (15/60) with severe disease expressed 2 disease associated HRE DRB1 alleles, compared with 13% of patients (5/39) with mild disease (OR 2.3, p = NS) and 5% (5/105) of controls (OR 6.67, p = 0.0003). In contrast, only 5% of patients (3/60) with severe RA expressed one of the LRE alleles that carry the DERAA motif at positions 70-74, compared with 31% of patients (12/39) with mild RA (OR 0.12, p = 0.0013) and 22% of controls (23/105) (OR 0.19, p = 0.0082). No patient or control was homozygous for LRE alleles. Eighty-three percent (50/60) of patients with severe RA expressed the HRE without the LRE, compared with 44% (17/39) of those with mild disease (OR 6.47, p < 0.0001) and 35% (37/105) of controls (OR 9.19, p < 0.0001). In contrast, only one patient (2%) with severe disease expressed the LRE without the HRE, compared with 20% (8/39) of those with mild disease (OR 0.07, p = 0.0047) and 16% (17/105) of controls (OR 0.09, p = 0.009). There was no significant difference between the 3 groups in the frequency of patients who expressed both or neither epitope. Logistic regression showed that age at disease onset (p = 0.0009), duration of disease (p = 0.007), positive rheumatoid factor status (p = 0.003), and presence of the HRE or LRE (p = 0.00005) were significantly associated with the presence of severe disease.
HLA-DRB1 alleles appear to confer an important bidirectional influence on the risk of disease severity in RA, with 20-fold difference in OR between those associated with the highest (HLA-DRB1*0401) and lowest (HLA-DRB1*1301/02) risk. The HRE and LRE exhibit diametrically opposed effects, which may be mutually antagonistic. These data support a multistep pathogenesis in which MHC class II genes are one component of a coordinate genetic and environmental interaction leading to immunological injury and joint destruction.
The Journal of Rheumatology 07/2002; 29(7):1358-65. · 3.69 Impact Factor
