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Biomedical subjects

Michael M Ward

Publications and source records attributed to Michael M Ward.

At least 19 recordsLinked to original sources
PubMed2006

Are there gender differences in severity of ankylosing spondylitis? Results from the PSOAS cohort.

OBJECTIVE: To examine the clinical and radiographic features in men and women in the Prospective Study of Outcomes in Ankylosing Spondylitis cohort, a large well-defined cross-sectional study of patients with AS, in order to understand the influence of gender in determining the severity of ankylosing spondylitis. METHODS: Extensive clinical assessments and spine radiographs were performed in 302 men and 100 women with AS of > or = 20 years duration. Radiographs were scored using the Bath Ankylosing Spondylitis Radiographic Index Spine (BASRI-spine) score (range 2-12). Functional impairment was measured by the Bath Ankylosing Spondylitis Functional Index (BASFI) and the Health Assessment Questionnaire for the Spondyloarthropathies (HAQ-S). RESULTS: Radiographic severity was worse among men. The unadjusted median BASRI-spine score for men was 10, compared with 6.5 for women (p<0.001). Functional disability, as measured by the BASFI and HAQ-S, was not different between men and women. However, after adjusting for radiographic spinal damage, women were found to report worse functioning than men at any given level of radiographic damage. Women had a slightly earlier age of disease onset; however, disease duration was identical in both groups. Women more frequently reported family histories of AS in first-degree relatives and were more likely to be treated with intra-articular steroids, sulphasalazine and prednisone. CONCLUSIONS: Among patients with longstanding AS, men have more severe radiographic changes; findings of treatment differences suggest that women may have more peripheral arthritis. At any given level of radiographic damage, self-reported functional limitations were worse for women.

Age of Onset↗
PubMed2006

The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH.

BACKGROUND: The 30-item disabilities of the arm, shoulder and hand (DASH) questionnaire is increasingly used in clinical research involving upper extremity musculoskeletal disorders. From the original DASH a shorter version, the 11-item QuickDASH, has been developed. Little is known about the discriminant ability of score changes for the QuickDASH compared to the DASH. The aim of this study was to assess the performance of the QuickDASH and its cross-sectional and longitudinal validity and reliability. METHODS: The study was based on extracting QuickDASH item responses from the responses to the full-length DASH questionnaire completed by 105 patients with a variety of upper extremity disorders before surgery and at follow-up 6 to 21 months after surgery. The DASH and QuickDASH scores were compared for the whole population and for different diagnostic groups. For longitudinal construct validity the effect size and standardized response mean were calculated. Analyses with ROC curves were performed to compare the ability of the DASH and QuickDASH to discriminate among patients classified according to the magnitude of self-rated improvement. Cross-sectional and test-retest reliability was assessed. RESULTS: The mean DASH score was 34 (SD 22) and the mean QuickDASH score was 39 (SD 24) at baseline. For the different diagnostic groups the mean and median QuickDASH scores were higher than the corresponding DASH scores. For the whole population, the mean difference between the QuickDASH and DASH baseline scores was 4.2 (95% CI 3.2-5.3), follow-up scores was 2.6 (1.7-3.4), and change scores was 1.7 (0.6-2.8). The overall effect size and standardized response mean measured with the DASH and the QuickDASH were similar. In the ROC analysis of change scores among patients who rated their arm status as somewhat or much better and those who rated it as unchanged the difference in the area under the ROC curve for the DASH and QuickDASH was 0.01 (95% CI -0.05-0.07) indicating similar discriminant ability.Cross-sectional and test-retest reliability of the DASH and QuickDASH were similar. CONCLUSION: The results indicate that the QuickDASH can be used instead of the DASH with similar precision in upper extremity disorders.

Adolescent↗
PubMed2006

Short-term prediction of mortality in patients with systemic lupus erythematosus: classification of outcomes using random forests.

OBJECTIVE: To identify demographic and clinical characteristics that classify patients with systemic lupus erythematosus (SLE) at risk for in-hospital mortality. METHODS: Patients hospitalized in California from 1996 to 2000 with a principal diagnosis of SLE (N = 3,839) were identified from a state hospitalization database. As candidate predictors of mortality, we used patient demographic characteristics; the presence or absence of 40 different clinical conditions listed among the discharge diagnoses; and 2 summary indexes derived from the discharge diagnoses, the Charlson Index and the SLE Comorbidity Index. Predictors of patients at increased risk of mortality were identified and validated using random forests, a statistical procedure that is a generalization of single classification trees. Random forests use bootstrapped samples of patients and randomly selected subsets of predictors to create individual classification trees, and this process is repeated to generate multiple trees (a forest). Classification is then done by majority vote across all trees. RESULTS: Of the 3,839 patients, 109 died during hospitalization. Selecting from all available predictors, the random forests had excellent predictive accuracy for classification of death. The mean classification error rate, averaged over 10 forests of 500 trees each, was 11.9%. The most important predictors were the Charlson Index, respiratory failure, SLE Comorbidity Index, age, sepsis, nephritis, and thrombocytopenia. CONCLUSION: Information on clinical diagnoses can be used to accurately predict mortality among hospitalized patients with SLE. Random forests represent a useful technique to identify the most important predictors from a larger (often much larger) number and to validate the classification.

Adult↗
PubMed2006

Measuring function in rheumatoid arthritis: Identifying reversible and irreversible components.

OBJECTIVE: Measurement of physical function at one point in time cannot distinguish impairment caused by the active disease process from chronic irreversible impairment. We aimed to dissect these two components of functional limitation in rheumatoid arthritis (RA) by using the disability index of the Health Assessment Questionnaire (HAQ) as the measure of function. METHODS: We performed a secondary analysis of data from 6 contemporary clinical trials of RA (2,763 patients). Patients in whom remission was achieved in the trials, based on a simplified disease activity index, were identified. In an individual patient, HAQ scores at trial entry represented both reversible and irreversible impairments, while HAQ scores at the time of RA remission represented the mostly irreversible component, and the difference between these corresponded to the component related to disease activity. We tested the concept that the HAQ has a reversible and an irreversible component by associating the HAQ score during remission with 2 measures associated with the degree of accrued damage: duration of RA and radiographic severity. RESULTS: Among patients in whom clinical remission was achieved (n = 295), average HAQ scores despite clinical remission increased progressively with the duration of RA, from 0.19 (<2 years of RA) to 0.36 (2-<5 years) to 0.38 (5-<10 years) to 0.55 (>/=10 years) (P < 0.001). The reversibility of HAQ scores decreased with the duration of RA (median 100%, 83.3%, 81.9%, and 66.7%, respectively; P < 0.001). Findings were similar in patients subgrouped by quartile of radiographic scores. CONCLUSION: Differences in the sources of functional limitations should be considered in the interpretation of functional measures, and in their use for prediction and in cost analyses.

Adult↗
PubMed2006

Inter-hospital transfers of patients with systemic lupus erythematosus: characteristics, predictors, and outcomes.

OBJECTIVE: To describe the reasons for inter-hospital transfers of patients with systemic lupus erythematosus (SLE), to identify predictors of transfers, and to compare the risk of in-hospital mortality between patients who were transferred and those not transferred. METHODS: Data on acute care hospitalizations of patients with SLE in New York and Pennsylvania in 2000-2002 were obtained from state health planning agencies. We identified inter-hospital transfers from discharge and admission codes, and categorized the major reason for transfer (rehabilitation, procedure, or continued medical care). Patient and hospital characteristics were examined as predictors of transfers. We used a matched cohort design with propensity adjustment to compare in-hospital mortality between patients transferred for continued medical care and those who were not transferred. RESULTS: We identified 533 inter-hospital transfers in 490 patients, 524 of which involved one transfer per hospitalization episode. Of these 524 transfers, 122 (23.3%) were for rehabilitation, 158 (30.1%) were for procedures, and 244 (46.6%) were for continued medical care. Patient characteristics and transfer destinations varied among these groups. Transfers for continued medical care were more common among younger patients, those who were more severely ill, had an emergency or urgent admission, or were hospitalized in a smaller, rural or non-teaching hospital, or in Pennsylvania, and were less common among those at proprietary hospitals. In the matched cohort analysis, the risk of in-hospital mortality was 2.25 times higher (95% confidence interval 1.31, 3.85; p = 0.004) among those transferred compared with those who were not transferred. This risk differed with the experience of the attending physician at the receiving hospital: among patients of physicians who treated 3 or fewer patients with SLE per year, this risk was 2.5 times higher (95% CI 1.42, 4.36; p = 0.002), while among patients of physicians who treated more than 3 patients with SLE per year, this risk was 0.56 times (95% CI 0.06, 5.12; p = 0.62) that of matched controls. CONCLUSION: Patient and transferring hospital characteristics vary with the reason for transfer. Transfers for continued medical care are associated with higher risks of in-hospital mortality, but these risks may differ with the SLE-related experience of the attending physician at the receiving hospital.

Comorbidity↗
PubMed2005

Risk factors for functional limitations in patients with long-standing ankylosing spondylitis.

OBJECTIVE: To identify risk factors for functional limitations in patients with ankylosing spondylitis (AS) of at least 20 years' duration. METHODS: Patients with AS for > or =20 years were enrolled in the cross-sectional component of the Prospective Study of Outcomes in AS. All patients had clinical evaluations and completed questionnaires on functional limitations and potential risk factors. Functional limitations were assessed using the Bath Ankylosing Spondylitis Functional Index (BASFI; score range 0-100, higher scores indicate more limitations) and the Health Assessment Questionnaire for the Spondylarthropathies (HAQS). Risk factors included demographic characteristics, duration of AS, smoking status, number of comorbid medical conditions, recalled level of recreational activity in teens and twenties, occupational physical activity throughout life (rated 1 = little, 2 = moderate, 3 = heavy, and weighted by the number of years in each job), and history of AS in a first-degree relative. RESULTS: The 326 patients (74% men) had a mean +/- SD age of 55.0 +/- 10.7 years, a mean duration of AS symptoms of 31.7 +/- 10.2 years, and a mean BASFI score of 40.7 +/- 25.6. BASFI scores increased with higher lifetime occupational physical activity (r = 0.31; P < 0.0001), the number of comorbid conditions (r = 0.25; P < 0.0001), and the duration of AS (r = 0.12; P = 0.04). BASFI scores were higher among current smokers compared with former/nonsmokers (55.5 versus 38.9; P = 0.0002), and among nonwhites compared with whites (49.9 versus 39.3; P = 0.02). In multivariable analyses, lifetime occupational physical activity, current smoking, education level, number of comorbid conditions, and family history were significantly associated with BASFI scores. The same risk factors were associated with the HAQS. CONCLUSION: Functional limitations in patients with AS for >/=20 years are greater among those with a history of more physically demanding jobs, more comorbid conditions, and among smokers, and are less severe among those with higher levels of education and a family history of AS.

Age of Onset↗
PubMed2005

Association between physician volume and in-hospital mortality in patients with systemic lupus erythematosus.

OBJECTIVE: Systemic lupus erythematosus (SLE) is an uncommon, clinically complex disease for which prior experience treating similar patients may be particularly important. This study was undertaken to determine if physician volume is associated with the outcome of hospitalization of patients with SLE. METHODS: Data on in-hospital mortality in a population-based sample of 15,509 patients with SLE ages 18 years or older who were hospitalized in 2000, 2001, or 2002 in New York or Pennsylvania were obtained from state health planning agencies. Risks of in-hospital mortality were examined in relation to the average annual number of patients with SLE hospitalized by the admitting physician. RESULTS: Physician volume was inversely associated with mortality. Mortality was 4.1% among patients of physicians who treated <1 hospitalized patient with SLE per year, 3.5% among patients of physicians who treated 1-3 patients per year, and 2.5% among patients of physicians who treated >3 patients per year. After adjustment for demographic characteristics, severity of illness, and hospital characteristics, the mortality risk was 20% lower among patients in the middle category of physician volume (odds ratio 0.80, 95% confidence interval 0.66-0.96, P =0.02), and 42% lower among patients in the highest category of physician volume (odds ratio 0.58, 95% confidence interval 0.42-0.82, P = 0.002), compared with patients in the lowest category. The association was stronger among patients with nephritis (n = 2,673), for whom the adjusted odds of mortality were approximately 60% lower among those in the highest category of physician volume. CONCLUSION: Our findings indicate that higher disease-specific physician volume is associated with lower risks of in-hospital mortality in patients with SLE.

Female↗
PubMed2005

Remission and active disease in rheumatoid arthritis: defining criteria for disease activity states.

OBJECTIVE: Several composite scores are available to assess the activity of rheumatoid arthritis (RA). Criteria for remission and active RA based on these continuous scores are important for use in clinical practice and clinical trials. We aimed to reevaluate or to define such criteria for the Disease Activity Score in 28 joints (DAS28) and the Simplified Disease Activity Index (SDAI). METHODS: We sampled patient profiles from an observational RA database that included clinical and laboratory variables. Thirty-five rheumatology experts classified these profiles into 1 of 4 categories: remission, low, moderate, or high disease activity. Cutoff values were estimated by mapping scores on the DAS28 and SDAI to these ratings, and analyses of agreement (kappa statistics) and a diagnostic testing approach (receiver operating characteristic curves) were used to validate the estimates. The final criteria were validated using 2 observational cohorts (a routine cohort of 767 patients and an inception cohort of 91 patients). RESULTS: Results from the 3 analyses were very similar and were integrated. The criteria for separating remission, low, moderate, and high disease activity based on the SDAI were scores of 3.3, 11, and 26, respectively; those based on the DAS28 were scores of 2.4, 3.6, 5.5, respectively. In the routine cohort, these cutoff values showed substantial agreement (weighed kappa = 0.70) and discriminated between groups of patients with clearly different functional capacities (P < 0.001). In the inception cohort, these cutoff scores differentiated responders (those with a 20% response on the American College of Rheumatology improvement criteria) from nonresponders (P < 0.01), as well as patients with and without radiologic progression (P < 0.05). CONCLUSION: New criteria for levels of RA disease activity were determined and internally validated. These criteria, which are based on current and explicit expert judgment, are valuable in this era of rapidly advancing therapeutic approaches.

Arthritis, Rheumatoid↗
PubMed2005

Ethnic and socioeconomic disparities in health among patients with rheumatic disease.

PURPOSE OF REVIEW: To describe recent studies of differences in the occurrence and outcomes of rheumatic diseases and differences in treatment by ethnic group or socioeconomic status. RECENT FINDINGS: African Americans and Hispanics in the United States have consistently been found to have higher prevalences of arthritis and other rheumatic conditions than whites, and also generally have more activity limitations in the setting of rheumatic disease. Variations in disease occurrence by socioeconomic status have not been studied extensively. African Americans with osteoarthritis were less likely than whites to be treated with narcotic analgesics. Rates of total knee or hip arthroplasty were found to be substantially lower among African Americans and Hispanics than among whites in the United States, and lower among those of low socioeconomic status in the United Kingdom. Ethnic differences in use of arthroplasty have been associated with less willingness of African Americans to have surgery, which has been related to perceptions of uncertain benefits of surgery. Poverty and ethnicity had important associations with the activity of systemic lupus erythematosus, whereas socioeconomic status was a more important predictor of mortality in these patients. Treatment adherence was similar in African American and white patients with systemic lupus erythematosus, but barriers to adherence differed by ethnic group. SUMMARY: Ethnic disparities in health have been more extensively studied than socioeconomic disparities. Most studies only describe the disparities, but several studies have begun to investigate potential reasons for the disparities.

Delivery of Health Care↗
PubMed2005

Patient participation in medical consultations: why some patients are more involved than others.

BACKGROUND: Patients vary in their willingness and ability to actively participate in medical consultations. Because more active patient participation contributes to improved health outcomes and quality of care, it is important to understand factors affecting the way patients communicate with healthcare providers. OBJECTIVES: The objectives of this study were to examine the extent to which patient participation in medical interactions is influenced by 1) the patient's personal characteristics (age, gender, education, ethnicity); 2) the physician's communication style (eg, use of partnership-building and supportive talk); and 3) the clinical setting (eg, the health condition, medical specialty). RESEARCH DESIGN AND SUBJECTS: The authors conducted a post hoc cross-sectional analysis of 279 physician-patient interactions from 3 clinical sites: 1) primary care patients in Sacramento, California, 2) patients with systemic lupus erythematosus (SLE) from the San Francisco Bay area, and 3) patients with lung cancer from a VA hospital in Texas. MAIN OUTCOME MEASURES: The outcome measures included the degree to which patients asked questions, were assertive, and expressed concerns and the degree to which physicians used partnership-building and supportive talk (praise, reassurance, empathy) in their consultations. RESULTS: The majority of active participation behaviors were patient-initiated (84%) rather than prompted by physician partnership-building or supportive talk. Patients who were more active participants received more facilitative communication from physicians, were more educated, and were more likely to be white than of another ethnicity. Women more willingly expressed negative feelings and concerns. There was considerable variability in patient participation across the 3 clinical settings. Female physicians were more likely to use supportive talk than males, and physicians generally used less supportive talk with nonwhite compared with white patients. CONCLUSIONS: Patient participation in medical encounters depends on a complex interplay of personal, physician, and contextual factors. Although more educated and white patients tended to be more active participants than their counterparts, the strongest predictors of patient participation were situation-specific, namely the clinical setting and the physician's communicative style. Physicians could more effectively facilitate patient involvement by more frequently using partnership-building and supportive communication. Future research should investigate how the nuances of individual clinical settings (eg, the health condition, time allotted for the visit) impose constraints or opportunities for more effective patient involvement in care.

Adult↗
PubMed2005

Severity of illness in patients with systemic lupus erythematosus hospitalized at academic medical centers.

OBJECTIVE: To compare the severity of illness of patients with systemic lupus erythematosus (SLE) between those hospitalized at academic medical centers and those hospitalized at community hospitals. METHODS: In this population based cross-sectional survey, data on all hospitalizations of patients with SLE in California, New York, and Pennsylvania in 2000 were obtained from discharge abstracts submitted by acute care hospitals to state health planning agencies. Patients hospitalized at one of 36 academic medical centers in these states (N = 2072) were compared to patients hospitalized at community hospitals (N = 9373). The primary measures of severity of illness were the SLE Comorbidity Index, a weighted index of SLE manifestations and comorbid medical conditions based on discharge diagnoses, and long lengths of stay, defined as stays that exceeded the 90th percentile of hospital stays in the same diagnosis-related group in the United States. RESULTS: Compared to patients at community hospitals, patients at academic medical centers had substantially higher scores on the SLE Comorbidity Index (odds ratio for each 1-point increase 1.27, 95% confidence interval 1.15-1.40, p < 0.0001) and were more likely to have long lengths of stay (OR 1.65, 95% CI 1.42-1.91, p < 0.0001). Patients at academic medical centers also had higher scores on the SLE Comorbidity Index (OR for each 1-point increase 1.16, 95% CI 1.07-1.27, p = 0.0002) and were more likely to have long lengths of stay (OR 1.27, 95% CI 1.08-1.49, p = 0.004) compared to patients at large (> or = 300 beds) community hospitals in the same metropolitan areas. Results for the SLE Comorbidity Index were similar in the subset of patients with SLE as the primary discharge diagnosis. CONCLUSION: Patients with SLE hospitalized at academic medical centers are generally more severely ill than those hospitalized at community hospitals, including large community hospitals in the same area.

Adult↗
PubMed2004

Education level and mortality in systemic lupus erythematosus (SLE): evidence of underascertainment of deaths due to SLE in ethnic minorities with low education levels.

OBJECTIVE: To determine if socioeconomic status, as measured by education level, is associated with mortality due to systemic lupus erythematosus (SLE), and to determine if these associations differ among ethnic groups. METHODS: Sex- and race-specific mortality rates due to SLE by education level were computed for persons age 25-64 years using US Multiple Causes of Death data from 1994 to 1997. SLE-specific mortality rates were compared with all-cause mortality rates in 1997 to determine if the association between education level and mortality in SLE was similar to that in other causes of death. RESULTS: Among whites, the risk of death due to SLE was significantly higher among those with lower levels of education, and the risk gradient closely paralleled the 1997 all-cause mortality risks by education level. However, in African American women and men and Asian/Pacific Islander women, the risk of death due to SLE was lower among those with lower education levels, contrary to the associations between education level and all-cause mortality in these groups. Comparing the distribution of education levels among deaths due to SLE and all deaths in 1997, persons with lower education levels were underrepresented among deaths due to SLE in African Americans and Asian/Pacific Islanders. CONCLUSION: Among whites, higher education levels are associated with lower mortality due to SLE. These associations were not present in ethnic minorities, likely due to underascertainment of deaths due to SLE in less-well educated persons. This underascertainment may be due to underreporting of SLE on death certificates, but may also represent underdiagnosis of SLE in ethnic minorities with low education levels.

Adult↗
PubMed2004

Decreases in rates of hospitalizations for manifestations of severe rheumatoid arthritis, 1983-2001.

OBJECTIVE: To determine whether the rates of hospitalization for 4 manifestations of severe rheumatoid arthritis (RA), which are used as indicators of long-term health outcomes, have changed from 1983 to 2001. METHODS: Data on all patients with RA who were hospitalized with rheumatoid vasculitis or to undergo splenectomy for Felty's syndrome, cervical spine fusion for myelopathy, or total knee arthroplasty at hospitals in California were abstracted from a state hospitalization database. Changes in rates of hospitalization from 1983 to 2001 were examined in this serial cross-sectional study. RESULTS: Rates of hospitalization for rheumatoid vasculitis and splenectomy in Felty's syndrome decreased progressively over time. The risk of hospitalization for rheumatoid vasculitis was one-third lower in 1998-2001 than in 1983-1987. The risk of hospitalization for splenectomy in Felty's syndrome was 71% lower in 1998-2001 than in 1983-1987. There were no significant decreases in the rates of hospitalization for cervical spine surgery or total knee arthroplasty (primary and revision), although in 1998-2001 there was a reversal of the trend of increasing rates of total knee arthroplasty. The risk of hospitalization for primary total knee arthroplasty was significantly lower in 1998-2001 than in 1990-1993 (rate ratio 0.90, 95% confidence interval 0.86-0.95; P < 0.0001). CONCLUSION: Rates of hospitalization for rheumatoid vasculitis and splenectomy in Felty's syndrome have decreased over the past 19 years, and there has been a recent decrease in the rates of primary total knee arthroplasty in patients with RA. Although several factors may account for these decreases, these findings suggest that since the early 1980s, the long-term health outcomes of patients with RA have improved.

Adult↗