Increasing condom usage for African-American and hispanic young fathers in a community based intervention.

Objectives: This paper investigates a community-based intervention for young fathers, FatherWorks, compared to care-as-usual, 24/7 Dads. We hypothesized that utilizing the FatherWorks intervention (a 15 session parenting intervention, 13 session employment class, paid internship, case management, and access to behavioral health services) will assist in readiness to use condoms and increase condom usage, which may differ by race/ethnicity.Methods: Eligible males (n = 328) were enrolled into a Randomized Control Trial. Participants were 15-24 years old and had fathered one or more children with a female under the age of 21. A survey was taken at baseline and at 15 weeks following the intervention.Results: Analyses of changes indicated that intervention participants improved from the pre-contemplation stage of condom usage towards contemplation, and from preparation to action. The pattern of improvement in the condom use stage of change was different in African-American versus Hispanic participants. Changes in condom use during last intercourse were not significant.Conclusions: Study findings indicate that FatherWorks is successful in increasing the intent to use condoms, with the effect manifesting differently in African-American and Hispanic young fathers. Future work with minority fathers indicates a need for cultural adaptation of the intervention.

Health insurance literacy: disparities by race, ethnicity, and language preference.

OBJECTIVES: To measure Connecticut's Affordable Care Act qualified health plan enrollees' health insurance literacy (HIL) by race, ethnicity, and language preference. STUDY DESIGN: Statewide landline and cell phone telephonic survey. METHODS: Geographically balanced cohort that oversampled black and Hispanic enrollees. Questions tested enrollees' knowledge of basic health insurance terminology and their use. Survey data were supplemented by deidentified administrative data from the state's health insurance exchange. RESULTS: Overall, subjects answered 62% of 13 questions correctly. The percentages of correct answers were 53% for black enrollees, 50% for Hispanic enrollees, 74% for white enrollees, and 45% for Spanish-speaking enrollees. The differences by race, ethnicity, and language preference were statistically significant. Overall, enrollees with a college education scored higher across all demographic groups, but disparities by race and ethnicity persisted. CONCLUSIONS: Health insurance terminology and use rules confuse consumers, especially racial and ethnic minorities. Differences in HIL may be a previously underrecognized source of healthcare disparities because even minor errors can result in delayed care or unanticipated medical bills. Low HIL can diminish the practical value of health insurance and exacerbate perceptions of health insurance as offering insufficient value for premium price. Additional research on ways to improve HIL and investments in insurance navigation support for black and Hispanic enrollees are needed.

Innovations in Payer-Community Partnerships: The EmblemHealth Neighborhood Care Program.

Comprehensive and innovative strategies are needed to address and manage chronic diseases and conditions and to reduce health disparities. EmblemHealth Neighborhood Care (EHNC) sites provide community-based linkages across payers, health providers, and delivery systems and underserved communities using culturally sensitive methods tailored to meet the needs of the community. This article describes this novel initiative and early indicators of its feasibility. Three EHNC sites were established in New York City: Harlem, Cambria Heights, and Chinatown. Each site provides core health and customer services to members and the community. In addition, sites provide tailored services to meet the unique needs of each community. Preliminary data suggest that program and community members are utilizing the sites and returning for follow-up visits. Sites also demonstrate success in cross referral between EHNC teams. The EHNC program is both feasible from the payer's perspective and acceptable to diverse patient populations and settings.

U.S. Dental Specialty Residents' Expectations and Anticipated Benefits of Academic Employment.

The aims of this study were to assess features of an academic career that dental specialty residents, as a group and by gender, find most attractive and to identify what determines their expectations for responsibilities and professional growth in academic employment. In November 2013, an invitation to participate in the study along with a link to an online survey was sent to the 407 U.S. program directors of six of the dental specialties (endodontics, oral and maxillofacial surgery, pediatric dentistry, periodontics, prosthodontics, and orthodontics), asking them to forward the survey to their residents. A total of 287 residents responded (112 [41.3%] female and 159 [58.7%] male) out of 4,400 enrolled in these specialty training programs (6.5% response rate). The female respondents were significantly more interested in joining academia than were the male respondents (female 48%; male 31.5%; p<0.005). Respondents of both genders were attracted to academic dentistry by opportunities for intellectual and professional stimulation, but the lifestyle of academicians was significantly more important for the female respondents. The most important feature of a successful academic career for the female respondents was the ability to have a good balance between career and personal life. While opportunity to conduct research was a positive feature for all residents interested in academia and both male and female respondents agreed strongly on the need for collaboration between faculty members for productive research, male respondents agreed significantly more than female respondents that faculty members should conduct independent research. Faculty members' feedback about academic employment were a significantly positive influence on those planning an academic career compared to those planning to enter private practice. This study found that the female and male residents differed in their expectations of responsibilities and professional growth in academic employment. These results may be useful for academic dental institutions and organizations when developing faculty recruitment and retention programs.

A Review of Graphical Approaches to Common Statistical Analyses: The Omnipresence of Latent Variables in Statistics.

We provide a comprehensive review of simple and advanced statistical analyses using an intuitive visual approach explicitly modeling Latent Variables (LV). This method can better illuminate what is assumed in each analytical method and what is actually estimated, by translating the causal relationships embedded in the graphical models in equation form. We recommend the graphical display rooted in the century old path analysis, that details all parameters of each statistical model, and suggest labeling that clarifies what is given vs. what is estimated. We link in the process classical and modern analyses under the encompassing broader umbrella of Generalized Latent Variable Modeling, and demonstrate that LVs are omnipresent in all statistical approaches, yet until directly 'seeing' them in visual graphical displays, they are unnecessarily overlooked. The advantages of directly modeling LVs are shown with examples of analyses from the ActiveS intervention designed to increase physical activity.

Development and validation of the Medical Home Care Coordination Survey for assessing care coordination in the primary care setting from the patient and provider perspectives.

BACKGROUND: Community health centers are increasingly embracing the Patient Centered Medical Home (PCMH) model to improve quality, access to care, and patient experience while reducing healthcare costs. Care coordination (CC) is an important element of the PCMH model, but implementation and measurability of CC remains a problem within the outpatient setting. Assessing CC is an integral component of quality monitoring in health care systems. This study developed and validated the Medical Home Care Coordination Survey (MHCCS), to fill the gap in assessing CC in primary care from the perspectives of patients and their primary healthcare teams. METHODS: We conducted a review of relevant literature and existing care coordination instruments identified by bibliographic search and contact with experts. After identifying all care coordination domains that could be assessed by primary healthcare team members and patients, we developed a conceptual model. Potentially appropriate items from existing published CC measures, along with newly developed items, were matched to each domain for inclusion. A modified Delphi approach was used to establish content validity. Primary survey data was collected from 232 patients with care transition and/or complex chronic illness needs from the Community Health Center, Inc. and from 164 staff members from 12 community health centers across the country via mail, phone and online survey. The MHCCS was validated for internal consistency, reliability, discriminant and convergent validity. This study was conducted at the Community Health Center, Inc. from January 15, 2012 to July 15, 2014. RESULTS: The 13-item MHCCS - Patient and the 32-item MHCCS - Healthcare Team were developed and validated. Exploratory Structural Equation Modeling was used to test the hypothesized domain structure. Four CC domains were confirmed from the patient group and eight were confirmed from the primary healthcare team group. All domains had high reliability (Cronbach's α scores were above 0.8). CONCLUSIONS: Patients experience the ultimate output of care coordination services, but primary healthcare staff members are best primed to perceive many of the structural elements of care coordination. The proactive measurement and monitoring of the core domains from both perspectives provides a richer body of information for the continuous improvement of care coordination services. The MHCCS shows promise as a valid and reliable assessment of these CC efforts.

Statistical Power of Alternative Structural Models for Comparative Effectiveness Research: Advantages of Modeling Unreliability.

The advantages of modeling the unreliability of outcomes when evaluating the comparative effectiveness of health interventions is illustrated. Adding an action-research intervention component to a regular summer job program for youth was expected to help in preventing risk behaviors. A series of simple two-group alternative structural equation models are compared to test the effect of the intervention on one key attitudinal outcome in terms of model fit and statistical power with Monte Carlo simulations. Some models presuming parameters equal across the intervention and comparison groups were underpowered to detect the intervention effect, yet modeling the unreliability of the outcome measure increased their statistical power and helped in the detection of the hypothesized effect. Comparative Effectiveness Research (CER) could benefit from flexible multi-group alternative structural models organized in decision trees, and modeling unreliability of measures can be of tremendous help for both the fit of statistical models to the data and their statistical power.

Quality and efficiency in small practices transitioning to patient centered medical homes: a randomized trial.

BACKGROUND: There is growing evidence that even small and solo primary care practices can successfully transition to full Patient Centered Medical Home (PCMH) status when provided with support, including practice redesign, care managers, and a revised payment plan. Less is known about the quality and efficiency outcomes associated with this transition. OBJECTIVE: Test quality and efficiency outcomes associated with 2-year transition to PCMH status among physicians in intervention versus control practices. DESIGN: Randomized Controlled Trial. PARTICIPANTS: Eighteen intervention practices with 43 physicians and 14 control practices with 24 physicians; all from adult primary care practices. INTERVENTIONS: Modeled on 2008 NCQA PPC®-PCMH™, intervention practices received 18 months of tailored practice redesign support; 2 years of revised payment, including up to $2.50 per member per month (PMPM) for achieving quality targets and up to $2.50 PMPM for PPC-PCMH recognition; and 18 months of embedded care management support. Controls received yearly participation payments. MAIN MEASURES: Eleven clinical quality indicators from the 2009 HEDIS process and health outcomes measures derived from patient claims data; Ten efficiency indicators based on Thomson Reuter efficiency indexes and Emergency Department (ED) Visit Ratios; and a panel of costs of care measures. KEY RESULTS: Compared to control physicians, intervention physicians significantly improved TWO of 11 quality indicators: hypertensive blood pressure control over 2 years (intervention +23 percentage points, control -2 percentage points, p =0.02) and breast cancer screening over 3 years (intervention +3.5 percentage points, control -0.4 percentage points, p =0.03). Compared to control physicians, intervention physicians significantly improved ONE of ten efficiency indicators: number of care episodes resulting in ED visits was reduced (intervention -0.7 percentage points, control + 0.5 percentage points, p = 0.002), with 3.8 fewer ED visits per year, saving approximately $1,900 in ED costs per physician, per year. There were no significant cost-savings on any of the pre-specified costs of care measures. CONCLUSIONS: In a randomized trial, we observed that some indicators of quality and efficiency of care in general adult primary care practices transitioning to PCMH status can be significantly, but modestly, improved over 2 years, although most indicators did not improve and there were no cost-savings compared with control practices. For the most part, quality and efficiency of care provided in unsupported control practices remained unchanged or worsened during the trial.

A randomized, controlled trial of implementing the patient-centered medical home model in solo and small practices.

BACKGROUND: Transition to a Patient-Centered Medical Home (PCMH) is challenging in primary care, especially for smaller practices. OBJECTIVE: To test the effectiveness of providing external supports, including practice redesign, care management and revised payment, compared to no support in transition to PCMH among solo and small (<2-10 providers) primary care practices over 2 years. DESIGN: Randomized Controlled Trial. PARTICIPANTS: Eighteen supported practices (intervention) and 14 control practices (controls). INTERVENTIONS: Intervention practices received 6 months of intensive, and 12 months of less intensive, practice redesign support; 2 years of revised payment, including cost of National Council for Quality Assurance's (NCQA) Physician Practice Connections(®)-Patient-Centered Medical Home™ (PPC(®)-PCMH™) submissions; and 18 months of care management support. Controls received yearly participation payments plus cost of PPC(®)-PCMH™. MAIN MEASURES: PPC(®)-PCMH™ at baseline and 18 months, plus intervention at 7 months. KEY RESULTS: At 18 months, 5 % of intervention practices and 79% of control practices were not recognized by NCQA; 10% of intervention practices and 7% of controls achieved PPC(®)-PCMH™ Level 1; 5% of intervention practices and 0% of controls achieved PPC(®)-PCMH™ Level 2; and 80% of intervention practices and 14% of controls achieved PPC(®)-PCMH™ Level 3. Intervention practices were 27 times more likely to improve PPC(®)-PCMH™ by one level, irrespective of practice size (p < 0.001) 95% CI (5-157). Among intervention practices, a multilevel ordinal piecewise model of change showed a significant and rapid 7-month effect (p(time7) = 0.01), which was twice as large as the sustained effect over subsequent 12 months (p(time18) = 0.02). Doubly multivariate analysis of variance showed significant differential change by condition across PPC(®)-PCMH™ standards over time (p(time x group)=0.03). Intervention practices improved eight of nine standards, controls improved three of nine (p(PPC1) = 0.009; p(PPC2) = 0.005; p(PPC3) = 0.007). CONCLUSIONS: Irrespective of size, practices can make rapid and sustained transition to a PCMH when provided external supports, including practice redesign, care management and payment reform. Without such supports, change is slow and limited in scope.

Developing culturally congruent weight maintenance programs for African American church members.

OBJECTIVES: Developing community-based and culturally congruent weight loss maintenance programs is an important component of weight reduction interventions in high-risk populations. This qualitative investigation was conducted to guide development of faith-based weight maintenance programs for African American church members. DESIGN: Twenty African American church members who previously participated in a church-based group weight loss program were recruited to participate in focus groups. This qualitative inquiry focused on the role of faith in maintaining healthy lifestyle behaviors, such as healthy eating and regular physical activity. Within these groups, a nominal group process was used to identify activities and language to be included within a faith-based maintenance program. RESULTS: Content analysis identified seven conceptual domains that participants thought were important aspects of a faith-based weight maintenance program: (1) accountability for change targets, (2) programmatic tools, (3) group benefits and support, (4) keys to successful behavior change, (5) keys to church and programmatic level success, (6) addressing barriers, and (7) faith. The faith sub-domains included faith in the Lord, using the body for God, and a spiritual focus. The nominal group process resulted in 11 recommended components for a faith-based weight maintenance program. The top four included scriptures and prayers are 'walk of faith,' healthy diet, exercise, and focusing on God. CONCLUSIONS: The results suggest that integrating faith themes into a weight loss maintenance program may increase its long-term impact on participants' health behavior change.

Improving pediatric asthma control among minority children participating in medicaid: providing practice redesign support to deliver a chronic care model.

BACKGROUND: Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have over-reliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach. OBJECTIVE: The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC). METHODS: In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt. RESULTS: Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315-4.204). In Phase II (the post-enrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients' asthma control. CONCLUSIONS: The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.

Employment and health status changes among women with fibromyalgia: a five-year study.

OBJECTIVE: To assess changes in health status of women with fibromyalgia (FM) over 5 years and determine whether baseline employment status influences health outcomes adjusting for other baseline factors. METHODS: Two hundred eighty-seven women with FM were recruited from a national sample of rheumatologists and interviewed by phone at baseline and annually for 4 years. Data were collected on pain, fatigue, Center for Epidemiologic Studies Depression Scale and Modified Health Assessment Questionnaire (M-HAQ) scores, demographic characteristics, and employment status. At the end of the study, 211 participants remained. Data were analyzed using multilevel modeling techniques. Bootstrap methods adjusted for the cluster sampling. RESULTS: The participants' mean +/- SD age was 47 +/- 11 years, their mean +/- SD education level was 14 +/- 2 years, 90% were white, 50% employed, 64% married, and their median household income was >or=$50,000. Mean +/- SD scores at baseline were 57.2 +/- 24 for pain, 75.4 +/- 22 for fatigue, 22.9 +/- 13 for depression, and 0.73 +/- 0.5 for the M-HAQ. Multilevel modeling indicated that all health status measures declined significantly over time except for pain. Rates of change varied from -1.22 for fatigue to -0.03 for the M-HAQ. Except for pain, patients who were employed at baseline had better health status over time. The employment and time interaction was not significant, indicating that health status changed at the same rate regardless of employment status. Other significant factors were age and income. CONCLUSION: Employed women with FM have better health status at baseline and maintain that advantage over time. Employment does not seem to provide a protective health benefit.

Centers speak up: the clinical context for health information technology in the ambulatory care setting.

BACKGROUND: Clinicians in ambulatory care settings are increasingly called upon to use health information technology (health IT) to improve practice efficiency and performance. Successful adoption of health IT requires an understanding of how clinical tasks and workflows will be affected; yet this has not been well described. OBJECTIVE: To describe how health IT functions within a clinical context. DESIGN: Qualitative study, using in-depth, semi-structured interviews. PARTICIPANTS: Executives and staff at 4 community health centers, 3 health center networks, and 1 large primary care organization. APPROACH: Transcribed audio-recorded interviews, analyzed using the constant comparative method. RESULTS: Systematic characterization of clinical context identified 6 primary clinical domains. These included results management, intra-clinic communication, patient education and outreach, inter-clinic coordination, medication management, and provider education and feedback. We generated clinical process diagrams to characterize these domains. Participants suggested that underlying workflows for these domains must be fully operational to ensure successful deployment of health IT. CONCLUSIONS: Understanding the clinical context is a necessary precursor to successful deployment of health IT. Process diagrams can serve as the basis for EHR certification, to identify challenges, to measure health IT adoption, or to develop curricular content regarding the role of health IT in clinical practice.

Coping with rheumatoid arthritis pain in daily life: within-person analyses reveal hidden vulnerability for the formerly depressed.

This study examined the association between history of depression and day-to-day coping with rheumatoid arthritis (RA) pain. The sample was 188 RA-diagnosed participants, 73 of whom were identified by a structured clinical interview as having a history of major depression. None had current major depression. All participated in a 30-day prospective study in which they made end-of-day ratings of their arthritis pain, the strategies for how they coped with their pain, their appraisals of daily pain, and daily mood. Hierarchical linear models evaluated whether individuals with and without depression history differed in their average pain and the other daily measures; and separately, whether they differed in their within-person associations between pain and the daily measures (e.g., the day-to-day contingency between pain and mood). All analyses controlled for current mild depressive symptoms, neuroticism, and age. Previously depressed individuals were indistinguishable from their never depressed peers in their average pain and the other daily measures; however, the previously depressed exhibited significantly stronger associations between pain and several aspects of their daily emotional experience, suggesting more pain-contingent well-being. For individuals with a history of depression, increases in daily pain corresponded with more frequent efforts to cope with their pain by venting their emotions, significantly stronger impairments in mood, and, if they were also presently distressed, reduced perceptions of control over their pain, compared to the never depressed. Patterns suggest that formerly depressed individuals exhibit a hidden vulnerability in how they manage chronic pain. This vulnerability is best revealed by a daily process approach.

Rate of change in functional limitations for patients with rheumatoid arthritis: effects of sex, age, and duration of illness.

OBJECTIVE: To estimate the rate of change in functional limitations for patients with rheumatoid arthritis (RA) as a function of age, duration of illness, and sex. METHODS: Patients with RA (n = 700) aged 21-65 years in 1988 were interviewed yearly for 6 years in The National Rheumatoid Arthritis Study. Functional limitations scores based on a Rasch measurement model of 20 Health Assessment Questionnaire items were analyzed in mixed-effects models to estimate the rate of change in functional ability as a function of age, duration of illness, sex, and interactions. RESULTS: Models for both patient age and duration of illness significantly predicted limitations in functional ability for men and women. The model for age included a significant cubic effect; the model for duration of illness included a significant linear effect only. Sex was significant in both models and no interactions were significant in either model. The AIC index of fit, an indicator of the information value of the model, favored the model for duration of illness over the model for age. While both models showed higher levels of functional limitations in women than men, the rate of change for women was similar to men. CONCLUSION: Limitation in functional ability in RA progressed in a linear manner with duration of illness and progressed at the same rate for both men and women, but functional limitations were greater for women.

From research to daily clinical practice: what are the challenges in "translation"?

BACKGROUND: Translating research findings into sustainable improvements in clinical and patient outcomes remains a substantial obstacle to improving the quality and safety of care. The Agency for Healthcare Research and Quality funded two initiatives to assess strategies for improvements--Translating Research into Practice (TRIP). The TRIP II initiative supported 13 quality improvement projects. SURVEYING THE TRIP II STUDIES: The principal investigators (PIs) of the 13 projects were surveyed regarding encountered barriers to implementation at 6 months and 18 months (when they were also asked about solutions). RESULTS: Seven of the 13 PIs responded to the survey at both times--6 and 18 months. For each project stage--Select a TRIP focus and develop intervention strategies (Stage 1), Conduct the intervention (Stage 2), and Measure the Impact (Stage 3)--barriers were described, and field-tested solutions were provided. For example, for Stage 2, if the target audience lacked buy-in and would not participate, solutions would be to get up-front buy-in from all staff, not just leaders; address root causes of problems; use opinion leaders and incentives; plan interventions ahead and provide make-up videos; and accept that targets vary in their readiness to change. DISCUSSION: The framework and examples provided should help overcome challenges in any work in which research findings are applied to clinical practice.

History of affective disorder and the experience of fatigue in rheumatoid arthritis.

OBJECTIVE: To evaluate how a prior affective disorder (major depression or generalized anxiety disorder) affects current fatigue among individuals with rheumatoid arthritis (RA). To determine whether that relationship is mediated by self-efficacy expectations. METHODS: Forty-eight RA patients with a prior affective disorder and 74 without a history of affective disorder completed a mailed questionnaire that included the Multidimensional Assessment of Fatigue and indicators of neuroticism and self efficacy. RESULTS: RA patients with a history of affective disorder reported higher levels of fatigue than those with no previous affective disturbance. Controlling for neuroticism and self efficacy, affective disorder history continued to predict current fatigue. Mediational analyses revealed both direct and indirect effects (via self efficacy) of history of affective disorder on the experience of fatigue in RA. CONCLUSION: History of affective disorder independently predicts higher levels of fatigue in RA patients, and self efficacy plays a mediating role in this relationship.

Employment and quality of life outcomes among women with fibromyalgia compared to healthy controls.

The purpose of this study was to assess the effects of paid employment on health related quality of life among women with fibromyalgia compared to a group of women who were otherwise healthy. Participants were recruited from 118 rheumatology practices randomly sampled from the membership of the American College of Rheumatology. Three hundred and sixty-five patients were referred to the study and 287 completed a telephone interview. At the end of each interview, participants were asked to nominate 2 individuals to serve as control subjects. Because of lagging enrollment of control subjects, we initiated an additional method of asking control subjects to nominate controls. Of 381 control subjects nominated for the study, 286 or 75% completed the initial interview. As with patients, controls completed a computer assisted phone interview with a trained interviewer similar to that of the patient. The mean age of women with FMS was 47 years, most were married (59.6%), 87.8% were of white race and non-Hispanic ethnicity, 47.7% were employed, had an average of 14 years of education and household annual incomes generally exceeded $20,000, with 40.4% having incomes in excess of $50,000. There we no significant differences between women with FMS and those without FMS on these characteristics. Women with FMS had significantly worse physical and mental health related quality of life measured by SF-12 Physical (PCS) and Mental (MCS) Component Summary Scores; those who were not employed had significantly worse PCS scores but there were no differences by employment for MCS. Ordinal regression analysis adjusting for demographic characteristics showed that there were significant main effects for condition and employment on PCS in that those with FMS and those who were not employed had worse PCS scores. Initially, we also found an interaction effect between condition and employment in that the beneficial effects of employment was restricted to the FMS cases. However, when adjustments were made for the double nesting design, the interaction effect was no longer significant. For MCS, FMS cases had significantly worse health related quality of life, but there were no main effects for employment and no interactions were significant. Our results concur with findings in community studies that employed women report better quality of life than those not employed, but only for the physical dimension of quality of life. The findings regarding MCS are intriguing in that women with FMS are not very different from controls and that employment has little effect on the mental health component of quality of life.

Do employment and family work affect the health status of women with fibromyalgia?

OBJECTIVE: To assess health status differences of women with fibromyalgia syndrome (FM) who are employed and not employed, and to evaluate whether employment and family work influence the health status of women with FM as it does for women in community studies. METHODS: Participants were 287 women recruited from 118 randomly selected rheumatology practices. They completed telephone interviews that collected data on demographic characteristics, health status, symptoms, family work, and social support. One hundred thirty-seven were employed and 150 were not employed. Formal statistical analysis, including estimation and testing, focused on the relationship between employment and 4 health status measures: Modified Health Assessment Questionnaire (MHAQ), visual analog scale (VAS) for pain on the interview day, number of painful areas, and VAS for fatigue on the interview day. The relationship between employment and these measures was evaluated using analysis of variance, chi-square, linear regression, and ordinal logistic regression. RESULTS: The majority of participants reported high levels of symptoms and poor health status. In the bivariate analyses, employed women reported significantly less pain, less fatigue, and better functional status than those who were not employed. In the multivariate analyses, employment remained a significant factor in explaining number of painful areas, functional status (MHAQ), and fatigue, with employed women reporting better health status than those not employed. Employment was not associated with pain on the day of the interview when other factors were considered in the analysis. The psychological demands of family work were consistently related to all dependent measures of health status, as those with greater psychological demands reported worse health status. CONCLUSION: As in community studies, employed women with FM report better health status than women who are not employed. The demands of family work exert a serious and significant effect on every dimension of health status and should be the focus of greater clinical attention. Further followup will assess whether employment has a protective effect for women with FM as in community studies or whether women with less severe FM tend to remain in the workforce.