THE BURDEN OF ARTHRITIS IN WEST VIRGINIA

Joe Manchin III Governor

Martha Yeager Walker Secretary Department of Health and Human Resources

February 2006

Chris Curtis, MPH Acting Commissioner West Virginia Bureau for Public Health Catherine Slemp, MD, MPH Acting Medical Officer West Virginia Bureau for Public Health Joe Barker, MPA Director Office of Epidemiology and Health Promotion

Daniel M. Christy, MPA Director, Health Statistics Center James C. Doria, Program Manager Statistical Services Unit, Health Statistics Center

Report Written By Eugenia Thoenen

Health Statistics Center Statistical Staff Fred King, BRFSS Coordinator Thomas A. Leonard, MS, Programmer/Analyst Tom Light, Programmer Philip Simmons, MS, Programmer/Analyst Amy Wenmoth, MA, Data Analyst Additional Acknowledgments Dina L. Jones, PhD, PT Director of Clinical Research, Department of Orthopaedics West Virginia University Robin A. Ryder, MBA West Virginia Health Care Authority Germaine Weis, MA, MDiv Manager, Osteoporosis Prevention Education Program

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EXECUTIVE SUMMARY General Facts ● Arthritis, the leading cause of disability in the United States, actually comprises more than 100 diseases that involve the joints, the tissues that surround the joints, and other connective tissue. ●

Arthritis affects approximately 43 million Americans, including 300,000 children.

● The Arthritis Foundation estimates that arthritis costs society about $125 billion annually, $43 billion in direct medical costs and $82 billion in indirect costs. ● The most common form of arthritis is osteoarthritis, or degenerative arthritis, which affects approximately 10% of Americans, rising to 70% to 90% of people older than 75. Other types of arthritis include rheumatoid arthritis, juvenile rheumatoid arthritis, lupus, gout, and fibromyalgia. ● Risk factors for arthritis include female gender, older age, obesity, physical inactivity, sports and other injuries to a joint, and occupational lifting.

West Virginia Statistics ● In 2003, 37% of West Virginia adults reported that they had been diagnosed with arthritis. This rate was the highest in the United States. Thirty-five percent (35%) of men and 39% of women reported having arthritis. ● The CDC estimates that a total of $750 million was expended in West Virginia in 1997 on arthritis-related conditions. ● West Virginia adults with arthritis are significantly more likely than those without arthritis to be obese (34% vs. 24%, respectively) and physically inactive (36% vs. 23%, respectively). ● People with arthritis in West Virginia are also more likely to report high blood pressure, high cholesterol, diabetes, and asthma than are people without arthritis. ● Arthritis-related hospitalization charges for West Virginia residents in West Virginia hospitals increased 119% from 1996 to 2003. ● Average charges for 2003 arthritis-related hospitalizations were highest for rheumatoid arthritis, followed by osteoarthritis of the spine and lupus.

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TABLE OF CONTENTS

Executive Summary……………………………………………………………………..iii

The West Virginia Arthritis Coalition……………………………………………...……1 The Prevalence of Arthritis in West Virginia………….……………………………..…..2 The Financial and Societal Costs of Arthritis……………………………………………5 Types of Arthritis……………………………………………………….………………..8 Risk Factors for Arthritis……………………………………………………………..…13 Arthritis and Comorbidities………………………………………...……………………17 Treating Arthritis………………………………………………………………...………18 Arthritis Hospitalizations…………………………………………………………..……21 Arthritis Self-Management…………………………………………………...………….25 National Resources…………………………………………………………………...….26 References………………………………………………………………………….…….27

Appendix A: Arthritis Prevalence by County……………………………………………30 Appendix B: Arthritis Hospital Discharge Rates by County………………….……...…32 Appendix C: Licensed Rheumatologists in West Virginia………………..…………….33

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THE WEST VIRGINIA ARTHRITIS COALITION development of the West Virginia Arthritis Coalition. This statewide council, which held its first meeting in February 2005, is open to all organizations and individuals that are committed to improving the quality of life for people with arthritis. The coalition will initially focus on three primary areas: (1) public awareness of arthritis, (2) defining the burden of arthritis in the state, and (3) educating primary care practitioners.

Arthritis is the leading cause of disability in the United States, affecting some 43 million people nationwide, including 300,000 children (1). Although arthritis affects people of all ages, the prevalence increases with age; thus, West Virginia, with its older population, faces a serious problem both in terms of individual suffering and societal and economic costs. While the focus of the medical community is on treating arthritis in the individual patient, the public health approach targets the entire population. In order to impact the burden of arthritis in West Virginia, further definition of the problem in the state, i.e., identifying the needs of those residents who suffer from, or at risk for, arthritis, is of the highest priority. Awareness of the condition and the fact that prevention strategies do exist, e.g., weight control, exercise, injury prevention in the workplace and in sports activities, and protection from tick bites and the potential for Lyme disease, must be emphasized, both to the general public and to health care providers. The importance of early diagnosis must also be stressed, for it is estimated that 2,000,000 people nationwide do not see a doctor even when arthritis is limiting their usual activities.

This report describes the impact of arthritis in West Virginia and can educate both health care professionals and the public about the disease itself and the profound effects of arthritis upon the state’s residents. As such, this report represents a significant step toward fulfilling each part of the Coalition’s mission.

For information on the Coalition, contact: Germaine Weis, MA, MDiv Bureau for Public Health Office of Epidemiology and Health Promotion (304) 558-0644 [email protected]

To this end, the West Virginia Bureau for Public Health and the Arthritis Foundation, Ohio River Valley Chapter, are collaborating in the

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THE PREVALENCE OF ARTHRITIS IN WEST VIRGINIA Arthritis, one of the most common chronic conditions reported by the American population, actually comprises more than 100 diseases that involve the joints, the tissues that surround the joints, and other connective tissue. Affecting approximately 43 million Americans, including 300,000 children, it is the leading cause of disability in the United States, causing some level of activity limitation in nearly one in six affected, or more than 7 million people (1).

Virginia residents aged 65 and older will be affected by arthritis by 2025 (4).

More than 6 out of every 10 West Virginia residents aged 65 and older will be affected by arthritis by 2025. U.S. Centers for Disease Control and Prevention

Arthritis affects people of all ages, but prevalence increases with age, striking nearly one-half of all people over the age of 65. Because of a decline in fertility and increases in life expectancy, the American population is aging, with a growing percentage of people in the upper age brackets, and this proportion will continue to grow during the twenty-first century. According to the U.S. Census Bureau, the proportion of people aged 65 and older in the United States is expected to increase from 12.4% in 2000 to 19.6% in 2030 (2). In West Virginia, the proportion of older residents is projected to be even larger, an increase from 15.3% to 24.8% (3). In fact, the Census Bureau has projected that West Virginia will rank 7th in 2030 among all 50 states and the District of Columbia in the proportion of its population that is 65 or older.

PREVALENCE. The current prevalence of arthritis in West Virginia was estimated using data from the Behavioral Risk Factor Surveillance System (BRFSS), a random sample telephone survey designed to measure selected behaviors and health problems in the adult population (18 years of age and older). The BRFSS is conducted in a total of 54 governmental entities, including all 50 states, the District of Columbia, and three U.S. territories. The 2003 West Virginia BRFSS (WVBRFSS) survey included several questions on arthritis and other rheumatic conditions (AORC). Over half of the respondents (55.9%) reported that they had had symptoms of pain, aching, or stiffness in or around a joint (not including neck or back) during the previous 30 days. Of those, 84.5% reported that their symptoms had begun more than three months prior to the interview.

In a 2003 study, the U.S. Centers for Disease Control and Prevention (CDC) estimated that 61.4% of West

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Respondents were then asked “Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?”

(27.1%; 95% CI: 26.8, 27.4). No significant difference was reported in the state by gender; 34.9% of men had AORC, compared with 39.3% of women. The rate of being diagnosed with AROC increased with age, from 7.4% of respondents aged 18-24 to 62.2% of those aged 65 and older. Adults with less education and lower incomes were more likely than others to have AORC. Table 1 below presents the prevalence of AORC by gender, age, education, and income.

Thirty-seven percent (37.2%) of West Virginia adults (an estimated 529,169 individuals) answered “yes” to this question, the highest rate among the 54 participants in the 2003 BRFSS. The state rate was significantly higher than that for the United States as a whole

Table 1. Prevalence (%) of Arthritis by Sex, Age, Education, and Income West Virginia Behavioral Risk Factor Surveillance System, 2003 Characteristic Men Women Total % at risk 95% CI % at risk 95% CI % at risk 95% CI Total

34.9

32.1-37.8

39.3

37.0-41.7

37.2

35.4-39.0

Age 18-24 25-34 35-44 45-54 55-64 65+

6.4 20.4 30.0 41.0 49.7 56.3

0.8-12.1 14.0-26.9 23.6-36.3 34.7-47.2 43.0-56.4 50.0-62.6

8.3 15.3 27.1 40.5 60.4 66.3

2.9-13.8 10.6-20.0 21.7-32.6 35.3-45.8 55.2-65.6 61.9-70.7

7.4 17.9 28.5 40.8 55.1 62.2

3.4-11.3 13.9-21.8 24.3-32.7 36.7-44.8 50.9-59.4 58.6-65.9

Education Less than H.S. H.S. or G.E.D. Some Post-H.S. College Grad.

46.0 34.4 31.0 29.1

38.7-53.3 30.0-38.8 25.0-37.0 23.5-34.8

55.0 40.0 35.0 27.3

49.5-60.5 36.2-43.7 30.3-39.8 22.4-32.1

50.6 37.3 33.3 28.2

46.0-55.2 34.4-40.2 29.5-37.0 24.5-32.0

Income < $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000-$74,000 $75,000+

51.1 43.6 38.4 34.1 29.2 21.6

42.3-59.9 37.0-50.2 31.0-45.9 27.2-41.0 21.8-36.5 15.0-28.2

50.6 44.2 37.8 36.2 24.4 21.5

44.6-56.5 39.2-49.3 31.5-44.1 30.0-42.4 18.4-30.5 14.8-28.3

50.8 43.9 38.1 35.1 26.8 21.6

45.7-55.9 39.9-48.0 33.3-42.9 30.4-39.8 22.0-31.6 16.7-26.4

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Arthritis prevalence data from the 1999, 2001, and 2003 BRFSS surveys were aggregated to provide sample sizes large enough to allow the generation of county prevalence estimates. For those three years, McDowell County had the highest rate at 48.1%, or nearly half of all adults, while Monongalia County had the lowest rate (18.7%). The map below (Figure 1) illustrates the prevalence of arthritis and

other rheumatic conditions by county, showing how each county compares with the United States prevalence. (Individual county rates and ranks can be found in Appendix A.)

Figure 1

Arthritis Prevalence by County: WVBRFSS 1999, 2001, 2003

Hancock

2001 Estimated U.S. Prevalence - 23.0%

Brooke Ohio

1999-2003 WV Average - 33.5% (Significantly Higher)

Marshall Monongalia

Wetzel Pleasants

Wood

Ritchie

Preston

Dodd- Harrison ridge

Roane

Putnam

Upshur

Grant

Randolph Pendleton

Nicholas

Pocahontas

Lincoln

Significantly Higher than U.S. Prevalence Boone

Fayette Greenbrier

Mingo

Jefferson

Webster

Kanawha Wayne

Tucker

Berkeley

Hardy

Braxton

Clay

Cabell

Hampshire

Lewis

Cal- Gilmer houn

Jackson

Mineral

Taylor Barbour

Wirt

Mason

Morgan

Marion

Tyler

Logan

Lower than U.S. Prevalence but not Significant

Raleigh Wyoming

McDowell

Higher than U.S. Prevalence but not Significant

Summers

Monroe

Mercer

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THE FINANCIAL AND SOCIETAL COSTS OF ARTHRITIS In 2003, the Arthritis Foundation released new estimates of the economic impact of arthritis. The study, published in the February 2003 issue of Arthritis Care & Research, estimated the cost to society at $124.8 billion annually in 2000 dollars (5). Of the total, $42.6 billion were direct medical costs and $82.2 billion represented indirect costs (lost productivity among persons aged 18-64).

medical care for RA averaged $7337 per year, compared with $3250 among people without RA (8). Nearly 70% of the medical costs attributed to RA were for hospitalizations and home nursing care (9). It is estimated that RA patients account for more than nine million doctor visits and 250,000 hospitalizations annually. Estimated Annual Costs of Arthritis in West Virginia, 1997

A previous study by the Centers for Disease Control and Prevention (CDC) generated state-specific estimates of arthritis costs using 1995 dollars to estimate 1997 costs: In West Virginia a total of $750 million was expended in 1997 on arthritis and other rheumatic conditions, $445 million in direct medical costs and $305 million in indirect costs (6). Arthritis-related inpatient hospitalization costs among West Virginia residents in West Virginia hospitals increased 119% from 1996 to 2003. Additional information on arthritis-related hospitalizations in West Virginia can be found on pages 21 through 24 of this report.

Direct Medical Costs: $445 million Indirect Costs: $305 million Total: $750 million Arthritis is the most commonly reported cause of disability in the United States (10), as well as being second only to heart disease as a cause of work disability (11). Labor force participation is lower among people with arthritis; according to the National Academy on an Aging Society, 1.8 million workingage people are not working because of arthritis-related limitations (12). Workers with arthritis earn less than those without arthritis, and premature retirement is more common among persons with arthritis (12). Again, RA results in the most serious limitations. Up to 85% of patients with RA are unable to work by the 11th year of the onset of their disease, with nearly 30% of these becoming disabled within 3 years (9). RA patients lose, on average, 50% of their potential earnings due to disability (9).

Researchers from Northwestern University used data from the 1999-2000 Medical Expenditure Panel Survey to generate expenditures for arthritis patients aged 45 and older. Overall, people with arthritis (all types) had over twice the total health care expenditures as did with people without arthritis (7). Rheumatoid arthritis (RA) incurred the highest costs among the different types of arthritis. Data from the same study, released at the Rheumatology Congress held in Vienna in 2004, indicated that

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significant. Table 2 on the following page presents the prevalence of arthritisrelated limitations by gender, age, education, and income level in the state.

The Chartbook on Work and Disability, 1998 released data showing that West Virginia ranked first among the 50 states in the overall percentage of working-age persons with disabilities (12.6%) (11).

In general, activity and work limitations increased with age and decreased with increasing education and income. Respondents with less than a high school education or its equivalent were significantly more likely to report activity and work limitations than were their better-educated peers. Persons with household incomes of less than $25,000 were significantly more likely to report limitations than those with incomes of $35,000 or greater.

The 2003 WVBRFSS survey included questions on arthritis-related activity limitations. Thirty-six percent (36.3%) of WVBRFSS respondents who reported having had joint pain for at least three months and/or having been diagnosed with arthritis by a health professional answered “yes” to the question “Are you now limited in any way in your usual activities because of arthritis or joint symptoms?” This was the fourth highest rate among the 54 BRFSS participants and significantly higher than the national rate of 29.7% (95% CI: 29.3, 30.2).

West Virginians are significantly more likely to report arthritis-related activity and work limitations than the national average. 2003 BRFSS

Thirty-two percent (31.6%) of WVBRFSS respondents who reported joint pain for at least three months and/or had been diagnosed with arthritis by a health professional and were aged 18 through 64 said “yes” when asked “Do arthritis or joint symptoms now affect where you work, the type of work you do, or the amount of work you do?” This rate was the fifth highest in the nation and again significantly higher than the national average of 26.0% (95% CI: 25.5, 26.6).

Because people who have arthritis have more activity and work limitations than people who do not have arthritis, they have more concerns about health and financial issues. The National Academy on an Aging Society found that persons aged 51 to 61 surveyed in the 1992 Health and Retirement Study (HRS) were markedly more likely to be dissatisfied with their health conditions and financial situations if they had arthritis (12). Nearly one-fourth (24%) of those surveyed with arthritis were dissatisfied with their health, compared with only 9% of their counterparts without arthritis; 31% of those with arthritis expressed dissatisfaction with their financial situation versus 20% of those without arthritis.

Thirty-five percent (35.0%) of state men reported activity limitation, compared with 37.5% of women; 32.4% of men had some work limitation, compared with 30.8% of women. These differences were not statistically 6

Nationally, one-third of the population with arthritis reported having only fair or poor health, compared with just 7% of people without arthritis, according to data from the HRS (12). West Virginia adults were asked to rate their health in the 2003 BRFSS. Among those with arthritis, 41.7% reported that their health was only fair or poor versus 15.5% of those without arthritis.

In West Virginia, only 58% of people with arthritis consider their health to be good, very good, or excellent, compared with 84% of people without arthritis. 2003 BRFSS

Table 2. Prevalence of Arthritis-Related Limitations among Adults West Virginia Behavioral Risk Factor Surveillance System, 2003 Characteristic Arthritis or joint Arthritis or joint symptoms limit usual symptoms affect place of activities* work, type of work, or amount of work** % at risk 95% CI % at risk 95% CI Total

36.3

34.0-38.7

31.6

28.8-34.3

Gender Male Female

35.0 37.5

31.1-38.7 34.5-40.4

32.4 30.8

28.2-36.7 27.3-34.2

Age 18-24 25-34 35-44 45-54 55-64 65+

21.7 28.2 37.7 36.5 42.7 37.8

9.8-33.7 21.1-35.4 31.4-44.1 31.6-41.4 37.7-47.8 33.6-42.1

21.2 30.7 31.9 33.1 33.3 --

9.5-32.8 23.4-38.0 25.8-38.1 28.3-38.0 28.5-38.0 --

Education Less than H.S. H.S. or G.E.D. Some Post-H.S. College Graduate

49.7 36.0 30.3 26.0

44.5-55.0 32.3-39.7 25.5-35.0 20.8-31.2

50.3 34.3 23.0 16.9

43.0-57.6 29.9-38.7 18.1-28.0 11.9-21.9

Income