Osteoarthritis: new insights. Part 1: the disease and its risk factors.

Osteoarthritis is the most common form of arthritis, affecting millions of people in the United States. It is a complex disease whose etiology bridges biomechanics and biochemistry. Evidence is growing for the role of systemic factors (such as genetics, dietary intake, estrogen use, and bone density) and of local biomechanical factors (such as muscle weakness, obesity, and joint laxity). These risk factors are particularly important in weight-bearing joints, and modifying them may present opportunities for prevention of osteoarthritis-related pain and disability. Major advances in management to reduce pain and disability are yielding a panoply of available treatments ranging from nutriceuticals to chondrocyte transplantation, new oral anti-inflammatory medications, and health education. This article is part 1 of a two-part summary of a National Institutes of Health conference. The conference brought together experts on osteoarthritis from diverse backgrounds and provided a multidisciplinary and comprehensive summary of recent advances in the prevention of osteoarthritis onset, progression, and disability. Part 1 focuses on a new understanding of what osteoarthritis is and on risk factors that predispose to disease occurrence. It concludes with a discussion of the impact of osteoarthritis on disability.

Health status measurement performance and health status differences by age, ethnicity, and gender: assessment in the medical outcomes study.

The comparative measurement performance of self-reported health status instruments for African American and Hispanic elderly has rarely been studied, despite evidence of their poor health status. This study examined psychometric performance and health status differences by age, ethnicity, and gender among 10,569 ethnically diverse patients who completed the Short-Form General Health Survey in the Medical Outcomes Study (MOS). Hispanics and African Americans tended to have slightly lower measurement performance than other ethnic groups. Compared with whites, health status scores for African American and Hispanic women were slightly but significantly lower. The small differences in health status by ethnicity may be due to the MOS sampling strategy, which excluded low-socioeconomic status minorities with poor education and no regular medical care. The psychometric performance of MOS health status measures should be examined in studies of ethnically diverse, community-dwelling, elderly populations who have poor access to care, poor education, and/or low socioeconomic status.

Frailty, family, and church support among urban African American elderly.

A community-based survey of 507 African Americans aged 60 and older from South Central Los Angeles was conducted to estimate the prevalence of frailty and describe the correlation between frailty, social support from family and church, and use of community services. Persons were considered frail if they met criteria for any of four conditions: functional impairment, depression, urinary incontinence, falls. Sixty-seven percent met criteria for frailty. Analyses revealed that frail elderly were significantly less likely to report feeling very close to family. Family contact, feeling that church was important, and receiving church support were similar for the frail and nonfrail. Frail elderly were more likely to use community services. These findings suggest that frail elderly in this population may not receive more support from family and church than nonfrail elderly. There is a need for caution when assuming families and churches in urban African American communities are able to support the most vulnerable elderly.

Primary care of long-stay nursing home residents: approaches of three health maintenance organizations.

OBJECTIVE: To describe the innovative programs of three health maintenance organizations (HMOs) for providing primary care for long-stay nursing home (NH) residents and to compare this care with that of fee-for-service (FFS) residents at the same NHs. DESIGN: Cross-sectional interviews and case-studies, including retrospective chart reviews for 1 year. SETTING: The programs were based in 20 community-based nursing homes in three regions (East, West, Far West). PARTICIPANTS: Administrative and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse practitioner/physician's assistants (NP/PA), but the structural configuration of physicians' (MD) practices differed substantially. At nursing homes within each region, all three HMO programs provided more total (MD plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4 vs .8 visits per month; all P < .05). The HMO that provided the most total visits had a significantly lower percentage of residents transferred to EDs (6% vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P = .027), and fewer hospitalizations per resident (0.1 vs .5 per year, P = .038) than FFS residents; these differences remained significant in multivariate analyses. However, the other two programs did not achieve the same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents provide more primary care and have the potential to reduce ED and hospital use compared with FFS care. However, not all programs have been associated with decreased ED and hospital utilization, perhaps because of differences in structure or implementation problems.

The associations between self-rated vision and hearing and functional status in middle age.

OBJECTIVES: To describe the associations between self-reported visual and hearing impairment and an index of global functional status among community-dwelling, middle-aged Americans. DESIGN: Cross-sectional. PARTICIPANTS: A total of 9744 U.S. community-dwelling persons 51 to 61 years of age participated. METHODS: Multivariate analyses of functional status based on cross-sectional data from Wave I (1992) of the Health and Retirement Study (HRS), controlling for demographic and socioeconomic status, common chronic medical conditions, and general health status, were performed. MAIN OUTCOME MEASURE: A global index of functional status based on self-reported limitations in 17 activities was measured. RESULTS: Approximately 3% of respondents in the HRS rated their vision or hearing as poor. Even after controlling for demographic factors, socioeconomic status, medical conditions, and general health status, limitations in both vision and hearing were independently correlated with worse functional status. In addition, controlling for income, wealth, and education reduced the strength of the associations between vision and hearing impairment and function, but did not eliminate them. The magnitude of effect of poor vision exceeded all medical conditions except stroke. CONCLUSIONS: Visual and hearing impairment appear to have a significant relationship with overall functional status, among even community-dwelling, middle-aged Americans and even after controlling for general health status, medical comorbidities, and socioeconomic status.

Two-year follow-up of AIDS education programs for impoverished women.

The long-term effects of two culturally competent AIDS education programs with different content on the risk behavior and AIDS-related knowledge of 410 homeless African American women 2 years after program completion were examined. Participants were members of a larger cohort of impoverished African American and Latina women recruited in Los Angeles from 1989 to 1991. Of a subsample of 527 African American women selected randomly for a 2-year follow-up interview, 410 (78%) were located and agreed to participate. Women participating in both AIDS education programs reported reduced HIV risk behaviors and demonstrated greatly improved AIDS knowledge at 2-year follow-up (p < .001). Women in a specialized program were less likely than those in a traditional program to report noninjection drug use at 2 years. Women in the traditional program had significantly better AIDS knowledge at follow-up (p < .001). These findings suggest that educational programs can produce sustained benefits among impoverished women.

Use of relevancy ratings by target respondents to develop health-related quality of life measures: an example with African-American elderly.

BACKGROUND: Health-related quality of life (HRQOL) instruments assess functioning and well-being. Generic HRQOL measures are intended to be relevant to everyone whereas population-targeted measures are designed to be relevant to a particular population. METHODS: We asked 99 African-American elderly (mean age 72, 33% female, 47% less than high school education) to rate the relevancy of 33 HRQOL items drawn largely from existing instruments. We assessed the reliability of the relevancy ratings across respondents, rank-ordered the items by relevancy, and tested the significance of difference in relevancy ratings for each item compared to the average of all other items. We also examined the associations of the relevancy ratings with sociodemographic and clinical characteristics. RESULTS: The relevancy ratings were reliable (intraclass correlation = 0.71) and relevancy was generally distinct from HRQOL and demographic characteristics. Items assessing spirituality and weight-related health status were rated as significantly more relevant than other types of items. Generic HRQOL items were not rated as highly relevant. CONCLUSIONS: HRQOL measures assessing spirituality and weight-related concepts are important for future studies of HRQOL in African-American elderly. The method of identifying these concepts used in this study should be valuable in developing new measures targeted to other sociodemographically or clinically defined subgroups.

The persistence of race and ethnicity in the use of long-term care.

We examine the use of nursing homes, formal personal care, informal Activities of Daily Living (ADL) assistance, and no care to identify racial differences in their use. Using the 1987 National Medical Expenditure Survey of both nursing homes and the community, multinominal logistic regressions controlled for predisposing, enabling, and need variables as well as other types of service use. Additional state-level variables make few changes in race/ethnicity parameters, indicating that race/ethnicity are not simply proxies for state-level variables. Older African Americans are less likely to use nursing homes than similar whites, with the lower institutionalization replaced by a higher use of paid home care, informal-only care, and no care. This suggests that formal in-home community care is not fully compensating for the racial differences in nursing home use. Persistent effects of race/ethnicity could be the result of culture, class, and/or discrimination that may impair equitable access to services.

Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases.

OBJECTIVES: This study examined the relationships between wealth and income and selected racial and ethnic differences in health. METHODS: Cross-sectional data on a national sample of 9744 men and women aged 51 through 61 from the 1992 Health and Retirement Survey were analyzed to examine the association between socioeconomic status and racial and ethnic differences in functional status among those with hypertension, diabetes, a heart condition, and arthritis. RESULTS: Compared with Whites, African Americans report higher rates of hypertension, diabetes, and arthritis, while Hispanics report higher rates of hypertension and diabetes and a lower rate of heart conditions. Accounting for differences in education, income, and wealth had little effect on these prevalence differences. In general, among those with chronic diseases, African Americans and Hispanics reported worse function than Whites. This disadvantage was eliminated in every case by controlling for socioeconomic status. CONCLUSIONS: While socioeconomic status, including wealth, accounts for much of the difference in functional status associated with these chronic diseases. It plays a relatively small role in explaining differences in the prevalence of chronic disease, possibly reflecting different causal pathways.

Barriers to cancer prevention in the older person.

Barriers to cancer screening are numerous and include both immutable barriers, such as a patient's low income, as well as more mutable barriers; fortunately, most barriers are potentially mutable ones. These encompass, among others, doctor patient communication patterns, inadequate and inaccurate health information, at attitudinal barriers such as patient anxiety, and community barriers, such as the lack of a provider reminder system to patients that prompts compliance. One of the easiest enablers of patient screening to implement is for clinicians to communicate their enthusiastic belief in screening to their older patients. Numerous studies now have documented the effectiveness of the physician's role in increasing patient compliance with screening guidelines.

The impact by race of changing long-term care policy.

Long-term care policy has evolved with little attention to racial differences in the need for and use of services. Using 1987 National Medical Expenditure Survey data on nursing home care, formal in-home personal care, and informal-only help, a model was created to show how different races would use each type of care if: (1) a universal home-care benefit was established, (2) existing Medicaid home-care benefits were ended, or (3) the income level for Medicaid eligibility was substantially reduced. Expanded community care benefits would primarily serve severely disabled older whites. Reductions in long-term care benefits or eligibility would disproportionately impede access to long-term care for severely disabled older African-Americans. These differences indicate that race must be taken into account in long-term care policy initiatives.

Geriatric home assessment after hospital discharge.

OBJECTIVES: To evaluate the feasibility of an intervention involving post-discharge geriatric home assessment and follow-up and to describe the spectrum of significant clinical problems identified during the home assessment. DESIGN: Prospective observational study nested within a randomized controlled trial. SETTING: Inpatient service of a large academic medical center in Southern California. PATIENTS: There were 152 adults aged 65 or greater who had one or more specific risk factors for functional decline or increased mortality, who were awaiting discharge from the hospital, and who were assigned to the intervention arm of a randomized controlled trial of post-discharge comprehensive geriatric home assessment. MAIN RESULTS: During the home assessment, the gerontologic nurse practitioner (GNP) identified new or worsening problems in 150 patients (99%); 61 problems (eg, serum sodium 125 mg/dL; severe orthostatic hypotension) were considered by a reviewing physician to require urgent medical attention. Older age, non-white race, and new incontinence were associated independently with a greater number of findings (P < 0.05). Based on the findings, an interdisciplinary team made an average of 3.4 recommendations per patient; only two of 111 requests for written approval of recommendations were rejected. CONCLUSIONS: Post-discharge visitation by a GNP to patients at high risk is capable of detecting a high yield of important and potentially reversible clinical problems. This multidisciplinary approach is acceptable to physicians. Research is needed to identify additional links between short hospital stays, impairment or instability at discharge, and adverse outcomes.