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01primer of rheumatological disease

01primer of rheumatological disease

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rheumatological disorders
rheumatological disorders

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1
CHAPTER 1
Public Health and Arthritis:A Growing Imperative
P
ATIENCE
H. W
HITE
, MD, MA
OWLAND
W. C
HANG
, MD, MPH
Forty-six million people have doctor-diagnosedarthritis and by 2030 it is projected to be 67 million,or 25% of the US population.
Arthritis is the number one cause of disability and coststhe United States an estimated 128 billion annually.
Public health focuses on the assessment andreduction of health burden in the population.
Three types of prevention strategies can be appliedto arthritis.
The Merriam-Webster Dictionary defines public healthas “the art and science dealing with the protection andimprovement of community health by organized com-munity effort and including preventive medicine andsanitary and social science.”
 
Until the mid-20th century,the field of public health was primarily concernedwith the prevention and control of infectious diseases.More recently, public health scientists and practitio-ners have also been engaged in the prevention andcontrol of chronic diseases. In the mid-19th century,when the therapeutic armamentarium of physicianswas limited, the relationship between the fields of public health and medicine was very close. Indeed,most public health professionals were physicians.However, as biomedical science led to more and morediagnostic and therapeutic strategies for physiciansin the 20th century, and as separate schools of medicine and public health were established in Ameri-can universities, the fields have developed differentapproaches to solving health problems. Medicine hasbeen primarily concerned with the diagnosis and thepalliative and curative treatments of disease and thehealth of the individual patient. Public health has beenprimarily concerned with the prevention and control of disease and the health of the population. The goal of this chapter is to illustrate the magnitude of the arthri-tis public health problem in the United States and todescribe potential public health approaches to mitigatethis problem. In order to more clearly describe publichealth perspective, science, and intervention, contrastswill be made with the medical approach, but this shouldnot be interpreted to mean that one approach issuperior to the other. In fact, it is likely that arthritispatient–physician encounters will be more effectivewhen arthritis public health efforts are successful andvice versa. It is this synergy for which both fields shouldbe striving.
RATIONALE FOR ARTHRITISPUBLIC HEALTH INITIATIVE
Arthritis and other rheumatic conditions are the lead-ing cause of disability in the United States (1), makingit a major public health problem. Arthritis is one of themost common chronic diseases in the United States.Forty-six million Americans, or one out of every fiveadults, has doctor-diagnosed arthritis, and 300,000children have arthritis (http://www.cdc.gov/arthritis/).Between 2003 and 2004, an estimated 19 million USadults reported arthritis-attributable activity limitationand 8 million reported arthritis affected their work (2).Arthritis is a large clinical burden, with 36 millionambulatory visits and 750,000 hospitalizations (3,4). In2030, due to the aging of the population and thegrowing epidemic of obesity, the prevalence of self-reported, doctor-diagnosed arthritis is projected toincrease to nearly 67 million (25% of the adult popula-tion) and 25 million (9.3% of the adult population) willreport arthritis-attributable activity limitations (Table1-1) (5).In the future, this arthritis-related clinical andhealth care system burden will require a planned
 
2 PATIENCE H. WHITE AND ROWLAND W. CHANG
coordinated approach with increased need for morearthritis specialists, increased need for training of primary care providers in arthritis management, andincreased availability of public health interventions toimprove quality of life through lifestyle changes anddisease self-management.
THE MEDICAL MODELCOMPARED WITH THE PUBLICHEALTH MODEL
There are several differences between medicine andpublic health, but perhaps the most important differ-ence is that of perspective. Medicine focuses on the
diagnosis and treatment 
 
of 
 
individuals
, whereas publichealth focuses on the
assessment and the reduction of health burden in the population
. The diagnostic toolsof the physician includes history, physical examination,and a vast array of diagnostic tests including bloodtests, imaging, and tissue sampling, all performed onthe individual patient. Medical treatment includespharmaceuticals, surgery, and rehabilitation. Theassessment tools of the public health professionalinclude surveys and disease registries for defined popu-lations (local, state, and/or national). Public healthintervention includes community health educationand programs and advocacy for public policy reform.Medical research programs emphasize basic science,drilling down to individual abnormalities at themolecular and genomic level, whereas public healthresearch programs emphasize epidemiology and thesocial sciences, searching out risk factors that pertainto a large proportion of the population. While medicalscience has undeniably improved the individual treat-ment of some forms of arthritis (e.g., rheumatoidarthritis), still much more needs to be done to dealwith the coming increases in arthritis prevalence andarthritis-related disability associated with the aging of the US population. This is perhaps the most importantreason to embrace an arthritis public health initiative:to have a greater impact on the health of thepopulation.
PUBLIC HEALTH’S EMPHASIS ONPREVENTION AND HOW ITRELATES TO ARTHRITIS
Traditionally, public health has been concernedwith the prevention of disease and the preventionof disease consequences (e.g., death and disability).Three types of prevention have been described:primary, secondary, and tertiary. Primary preventionis the prevention of the disease itself. In the infectiousdisease realm, this is made possible by the identifica-tion of the etiologic microorganism and the develop-ment of a vaccine that will protect the host fromdeveloping the infection even when the host is exposedto the microorganism. Primary prevention of a chronicdisease requires the identification of an etiologic factorassociated with the disease and the successful inter-vention (lifestyle change and/or pharmacologic treat-ment) on the risk factor. For example, the reductionof weight by dietary and physical activity interventionhas been successful in the primary prevention of dia-betes, and the pharmacologic treatment of hyperten-sion has proven effective in the prevention of coronaryartery disease. An example of a primary arthritisprevention trial showed that a vaccine for the spiro-chete associated with Lyme disease reduced the riskfor this disease in endemic areas (6). While severaletiologic factors associated with knee osteoarthritis(most notably obesity) have been identified, no trialshave been performed to inform public health practiceregarding the primary prevention of this condition,
TABLE 1-1.
ESTIMATED US POPULATION AND PROJECTED PREVALENCE OF DOCTOR-DIAGNOSED ARTHRITIS ANDACTIVITY LIMITATION FOR ADULTS AGES 18 AND OLDER IN THE UNITED STATES.
PROJECTED PREVALENCE OF PROJECTED PREVALENCE OF ARTHRITIS-ESTIMATED US POPULATION DOCTOR-DIAGNOSED ARTHRITIS ATTRIBUTABLE ACTIVITY LIMITATIONSYEAR IN THOUSANDS IN THOUSANDS IN THOUSANDS
2005 216,096 47,838 17,6102015 238,154 55,725 20,6012030 267,856 66,969 25,043
S
OURCE
: Hootman JM, Helmick CG, Arthritis Rheum 2006;54:226–229, by permission of 
 Arthritis 
 
and 
 
Rheumatism
.
 
CHAPTER 1 • PUBLIC HEALTH AND ARTHRITIS: A GROWING IMPERATIVE 3
1
although data will hopefully be available in the comingyears.Secondary prevention involves the detection of disease in its preclinical (i.e., asymptomatic) phase toallow for early treatment and the prevention of impor-tant consequences, such as death or disability. Forexample, mammography has been shown to preventbreast cancer–related death by detecting breast cancerbefore clinical signs and symptoms develop such thatearly treatment can be initiated. Similarly, screeningfor osteoporosis with dual-energy x-ray absorptiometry(DXA) scanning has been shown to reduce fracturerates and subsequent disability by allowing for earlydetection and treatment of this common condition.Secondary prevention of rheumatoid arthritis is likelyto be successful because of effective medical treatmentthat limits joint destruction and arthritis-related dis-ability. Studies have shown that the earlier the treat-ment, the less the ultimate destruction and disability.The challenge here is to identify a suitable screeningtest.Tertiary prevention involves the treatment of clinicaldisease in order to prevent important consequences,such as death or disability. Thus, tertiary prevention istypically in the realm of medicine. However, publichealth and public policy efforts to make medical, surgi-cal, and rehabilitation treatment more effective andmore accessible are common public health tertiary pre-vention interventions.
ARTHRITIS PUBLIC HEALTHACCOMPLISHMENTS
The Arthritis Foundation has focused its public healthactivities by promoting the health of people with and atrisk for arthritis through its leadership and involvementin the National Arthritis Act, the National ArthritisAction Plan, the arthritis section of Healthy People2010, and the National Committee on Quality Assur-ance (NCQA) to develop an arthritis-related HealthPlan Employer Data and Information Set (HEDIS)measure (2003).
National Arthritis Act
In 1974, the Arthritis Foundation joined in a partner-ship that pushed the US Congress to pass the NationalArthritis Act, which initiated an expanded response toarthritis through research, training, public education,and treatment. The National Arthritis Act called for along-term strategy to address arthritis in the UnitedStates.
National Arthritis Action Plan
The National Arthritis Action Plan (NAAP) broughttogether over 40 partners to create a blueprint for popu-lation-oriented efforts to combat arthritis. The NAAPemphasizes four public health values: prevention, theuse and expansion of the science base, social equity, andbuilding partnerships. The NAAP is now widely utilizedby other public health and professional organizationsas a model program for population-oriented efforts tocombat a chronic disease (see Table 1-2 for the aims andactivities of NAAP). In 2000, the federal governmentfunded the Arthritis Program at the Centers for DiseaseControl (CDC) that provides the infrastructure for theprogram at the CDC, implementation of the arthritispublic health plan through the establishment of arthritis programs in state health departments (seehttp://www.cdc.gov/arthritis/), limited investigator-initi-ated grant program, and a peer-reviewed grant to theArthritis Foundation. With this funding, the CDCArthritis Program and the Arthritis Foundation havecreated effective public education and awareness activi-ties in both English and Spanish and have developedevidence-based programs for people with arthritis,including an arthritis-specific self-help course, an exer-cise program, and a water exercise program (see theLife Improvement Series descriptions at http://www.arthritis.org).The Arthritis Group at the Center for DiseaseControl have developed arthritis data collectionplans through the Behavioral Risk Factor SurveillanceSystem (BRFSS), the National Health Interview Survey
TABLE 1-2.
THE NATIONAL ARTHRITIS ACTIONPLAN.
The overarching aims of the NAAP are:Increase public awareness of arthritis as the leading cause of disability and an important public health problem.Prevent arthritis whenever possible.Promote early diagnosis and appropriate management forpeople with arthritis to ensure the maximum number of years of healthy life.Minimize preventable pain and disability due to arthritis.Support people with arthritis in developing and accessing theresources they need to cope with their disease.Ensure that people with arthritis receive the family, peer, andcommunity support they need.The aims of the NAAP will be achieved through three majortypes of activities:Surveillance, epidemiology, and prevention researchCommunication and educationPrograms, policies, and systems

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