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R F Meenan

Publications and source records attributed to R F Meenan.

At least 37 records · Page 2Linked to original sources
PubMed1991

Subspecialty training: is it financially worthwhile?

OBJECTIVE: To determine the financial return of additional training in a cognitive-oriented medical subspecialty (rheumatology) and in a procedure-oriented medical subspecialty (gastroenterology) relative to general internal medicine. DESIGN: Analysis of existing data to compare lifetime discounted earnings of physicians in different medical specialties. PARTICIPANTS: General internists, gastroenterologists, and rheumatologists were surveyed. MAIN OUTCOME MEASURES: Using data from surveys conducted by Medical Economics and the American College of Rheumatology, we constructed lifetime earnings streams that allowed the calculation of the net present values of discounted lifetime earnings in general internal medicine, gastroenterology, and rheumatology. Net present values of lifetime earnings were calculated for each group at two discount rates. Sensitivity analyses were done to estimate how changes in relative income would affect calculations of the net present values. MAIN RESULTS: The average net incomes before taxes for general internists, gastroenterologists, and rheumatologists in 1988 were $115,825, $201,875, and $118,056, respectively. At 5% and 10% discount rates, the net present values of the estimated career earnings stream for additional training in gastroenterology relative to general internal medicine were + $1,101,863 and + $512,952, respectively; for additional training in rheumatology relative to general internal medicine, the respective values were - $84,748 and - $92,467. If the incomes of general internists were decreased by 3% and the incomes of gastroenterologists were decreased by 25% to reflect the effect of potential changes due to the resource-based relative value scale (RBRVS), or if gastroenterology training were increased to 3 years and rheumatology fellowship stipends were increased by 30%, large differences would still exist between the groups. CONCLUSION: Gastroenterologists have an extremely large return on their additional investment in training, but rheumatologists have a negative return. When considered exclusively as a financial decision, fellowship training in a cognitive-oriented medical subspecialty such as rheumatology is a poor investment. Even major changes in reimbursement policies will not affect the relative pecuniary attractiveness of procedure-oriented medical subspecialties.

Economics, Medical↗
PubMed1991

The impact of rheumatoid arthritis on the household work performance of women.

We conducted a study to assess whether and to what degree household work disability exists in women with rheumatoid arthritis (RA) and to examine the role of health versus family and personal factors as predictors of household work disability. In addition, the participation of other family members and paid employees in household work was evaluated. One hundred forty-two women with RA and 58 female friends/neighbors completed questionnaires which assessed household work performance and health, family, and personal variables. Performance was measured in 4 ways: the current amount of time spent on household work, the proportion of the household work done, and the changes in time and proportion since just before the onset of RA. Functional status was measured via the Health Assessment Questionnaire. Pain, anxiety and depression, and general health perception were measured via the Arthritis Impact Measurement Scales. The results indicate that household work disability exists in women with RA, but is substantial only in women with moderate-to-severe disease. In families in which the wife/mother has moderate-to-severe RA, the other family members spend 7 hours more per week on household work than in control families, but there was no increase in the use of paid household employees. Health factors were the strongest predictors of household work disability, but family and personal factors also had significant effects. Household work disability in women with moderate or severe RA merits more attention because of the importance of household work to family functioning and the negative effects that changes in this area can produce.

Activities of Daily Living↗
PubMed1991

The clinical and health status of patients with recent-onset rheumatoid arthritis.

This study was designed to document the clinical and health status of patients with recent-onset rheumatoid arthritis (RA). Three groups were studied: 108 patients who had had RA for greater than 1 year (established RA group), 313 patients who had had RA for less than or equal to 1 year (recent-onset RA group), and 188 healthy friend of the patients with recent-onset RA (no RA group). Clinical status was measured using tender joint count, erythrocyte sedimentation rate, and overall physician assessment. Health status was measured using the physical, psychological, pain, and arthritis impact scores of the Arthritis Impact Measurement Scales. Scores on all clinical and health status measures indicated substantial disease effects in the group with recent-onset RA. For most of these measures, effect size analysis indicated that clinical and health status impacts in the recent-onset RA group were similar in magnitude to those found in the groups with more established disease, with scores in both groups being substantially different from those found in the no RA group. These results document the magnitude of the clinical and health status impacts in recent-onset RA. They lend support to recent arguments advocating aggressive therapy earlier in the course of this frequently disabling disease.

Arthritis, Rheumatoid↗
PubMed1991

Secular changes in published clinical trials of second-line agents in rheumatoid arthritis.

The present investigation was undertaken to explore changes over time in the design and reporting of trials of second-line drugs in rheumatoid arthritis, in the characteristics of patients included in the trials, and in the sources of funding. We studied 105 trials of second-line agents for the treatment of rheumatoid arthritis, including placebo-controlled and comparative trials involving 8 different agents. Three time periods, 1945-1969, 1970-1979, and 1980-1989, were compared. We found little change in the standards for reporting on the design of trials or for reporting information on patient dropout and drug side effects, some increase in the complexity of the statistical methods used, but no increase in the use of power analysis (reported in only 13% of trials). The average age of patients in clinical trials has increased. In recent years, there has been a substantial shift from placebo-controlled to comparative trials, and it is increasingly common for trials to be financially supported by pharmaceutical companies. The possible effects of secular trends should be considered when combining or comparing results of trials conducted in different years.

Age Factors↗
PubMed1990

Time for changes in the design, analysis, and reporting of rheumatoid arthritis clinical trials.

We have proposed a set of changes in the design, analysis, and reporting of RA clinical trials which emphasizes the standardization of trials. We have suggested limiting the number of outcome measures used to those most sensitive to change and using uniform measurements of the same outcome measures in all clinical trials. We have also suggested that investigators focus on enumerating which patients improve in a trial, rather than on the mean level of improvement in treated patients versus the control patients. Finally, we have suggested the reporting of confidence intervals rather than simply stating P values. With the inauguration of these changes and more attention to other issues relevant to the quality of clinical trials, we hope that drug treatments of rheumatoid arthritis can be more easily compared with respect to effectiveness.

Arthritis, Rheumatoid↗
PubMed1990

The comparative efficacy and toxicity of second-line drugs in rheumatoid arthritis. Results of two metaanalyses.

We performed 2 metaanalyses of placebo-controlled and comparative clinical trials to examine the relative efficacy and toxicity of methotrexate (MTX), injectable gold, D-penicillamine (DP), sulfasalazine (SSZ), auranofin (AUR), and antimalarial drugs, the second-line drugs most commonly used to treat rheumatoid arthritis (RA). For the efficacy study, we applied a set of inclusion criteria and focused on trials which provided information on tender joint count, erythrocyte sedimentation rate, or grip strength. We found 66 clinical trials that contained 117 treatment groups of interest, and for each drug, we combined the treatment groups. For each outcome, results showed that AUR tended to be weaker than other second-line drugs. The results of the 3 outcome measures were synthesized into a composite measure of outcomes, and AUR was significantly weaker than MTX (P = 0.006), injectable gold (P less than 0.0001), DP (P less than 0.0001), and SSZ (P = 0.009) and was slightly, but not significantly, weaker than antimalarial agents (P = 0.11). We also found heterogeneity among antimalarial agents, in that patients treated with chloroquine did better than those treated with hydroxychloroquine. We found little difference in efficacy between MTX, injectable gold, DP, and SSZ. A power analysis showed that a trial should contain at least 170 patients per treatment group to successfully differentiate between more effective and less effective (e.g., AUR) second-line drugs. None of the reported interdrug comparative trials we reviewed were this large. For the toxicity study, our inclusion criteria captured RA trials which reported the proportion of patients who discontinued therapy because of drug toxicity and the total proportion who dropped out. We found 71 clinical trials that contained 129 treatment groups. The average proportion who dropped out and the average proportion who dropped out because of drug toxicity were computed for each drug. Overall, 30.2% of the patients in these trials dropped out; 50% of them did so because of drug toxicity. Injectable gold had higher toxicity rates (P less than 0.05) and higher total dropout rates (P less than 0.01) than any other drug; 30% of gold-treated patients dropped out because of side effects versus 15% of all trial patients. Antimalarial drugs and AUR had relatively low rates of toxicity; the rate for MTX was imprecise because of discrepancies between trials. Thus, of the commonly used second-line drugs, AUR is the weakest, and injectable gold is the most toxic. Agents introduced in the future will be compared with these drugs.(ABSTRACT TRUNCATED AT 400 WORDS)

Antimalarials↗
PubMed1990

Health status reports in the care of patients with rheumatoid arthritis.

We examined the use of formal health status reports every 3 months over 1 year in the clinical care of patients with rheumatoid arthritis (RA). The reports consisted of single-page, computer-generated summaries of scores derived from either the AIMS (Arthritis Impact Measurement Scales) or the MHAQ (Modified Health Assessment Questionnaire) health status questionnaires. A total of 1920 subjects from 27 community practice sites were randomly assigned to three study groups in each practice: intervention, attention placebo and control. Results showed that 55% of the physicians found the reports to be at least moderately useful as an aid to patient management, primarily for improving the doctor-patient relationship. However, no detectable differences among the three groups were seen in terms of medication compliance, number of physician visits, number of referrals, frequency of major medication changes, attitudes towards the physician, patient satisfaction or change in health status over 1 year. The failure to demonstrate objective benefits of health status reports in this study may be due to physician unfamiliarity with health status scores, failure to link the report with an office visit, the relative stability of clinical status in the subjects over 1 year and the relatively short time-frame of the study.

Activities of Daily Living↗
PubMed1990

Health status as a predictor of mortality in rheumatoid arthritis: a five-year study.

We examined the utility of health status scores as predictors of mortality in a 5-year study of patients with rheumatoid arthritis (RA). Of 279 patients with a known outcome after an average of 5 years of followup, 37 had died. Scores derived from the Arthritis Impact Measurement Scales indicated that mobility and general health perception were significant predictors of mortality with odds ratios (95% confidence interval) of: 1.19 (1.05, 1.33) and 1.27 (1.04, 1.55), respectively. These measures were particularly predictive of dying at worse levels of health status with a significant linear trend for mobility (p less than 0.05) and general health perception (p less than 0.01). Even after controlling for physical function, poorer levels of general health perception were significantly associated with mortality, (p less than 0.01 for linear trend). Our results confirm that certain health status measures are related to subsequent mortality in patients with RA.

Adult↗
PubMed1989

Sensitivity, specificity, and predictive value of abdominal fat aspiration for the diagnosis of amyloidosis.

Samples of abdominal fat aspirates from 73 patients were sent to us for staining and interpretation. Ten samples were positive for amyloid. We calculated the sensitivity, specificity, and predictive value of the procedure based on the findings and the clinical information and other biopsy data about these patients. Using the results from more traditional biopsies as the "gold standard," sensitivity was 57%, specificity was 100%, and the predictive value was 100% for positive findings in the abdominal fat aspirate. Although the sample size in this study was relatively small, the procedure was found to be a minimally invasive test of high clinical utility.

Abdomen↗
PubMed1989

Does smoking protect against osteoarthritis?

While studying knee osteoarthritis (OA) in the first Health and Nutrition Examination Survey, we unexpectedly found a protective association between smoking and OA. After adjustment for age, sex, and weight, smokers had a significantly lower rate of OA than did nonsmokers, and heavier smokers were less likely to have the disease than were light smokers. To test this association in a separate study and see if it was due to confounding factors, we looked at the Framingham Osteoarthritis Study, a study of elderly members of the Framingham Heart Study cohort. We evaluated whether the presence of knee OA in 1983-1985 was related to smoking status at the first Framingham examination, 36 years earlier. Subjects who had been smokers at examination 1 had a lower rate of OA (190 of 679, 28%) than did nonsmokers (276 of 736, 37.5%). In an analysis adjusted for age, sex, and weight, heavy smokers had a modestly lower risk of developing knee OA than did nonsmokers (relative risk 0.81). Also, the adjusted risk of severe OA was less in heavy smokers than in nonsmokers (relative risk 0.73). The negative association with OA persisted when we examined the average cigarette consumption over the first 10 years of the Framingham study. Furthermore, after controlling for age, sex, weight, knee injury history, sports activity history, physical activity level, coffee and alcohol consumption, and weight change after examination 1, and after modeling weight and age in a nonlinear manner, smoking remained a significant protector against later knee OA. It appears that smoking or some unidentified factor correlated with smoking modestly protects against the development of knee OA.

Adult↗
PubMed1989

Which traditional measures should be used in rheumatoid arthritis clinical trials?

It is standard practice to use multiple outcome measures in rheumatoid arthritis (RA) clinical trials. Because of this, multiple testing is usually done, and there is confusion in the interpretation of the results. It is not clear which measures are the most sensitive to detecting improvement and which provide independent information. To address these questions, we conducted an analysis of pooled raw data from 3 placebo-controlled RA trials: one of methotrexate, another of oral and injectable gold, and the third of low-dose and high-dose D-penicillamine. The results show that the joint tenderness count, erythrocyte sedimentation rate, grip strength, and physician assessment of disease activity perform best in RA clinical trials and cover the domain of change measured by traditional outcome measures. Other clinical measures may provide little additional useful information for a standard therapeutic trial of up to 6 months duration, and some measures, such as the proximal interphalangeal joint circumference, hemoglobin level, and 50-foot walking time, can be eliminated from such trials.

Administration, Oral↗
PubMed1989

Arthritis in nursing home residents. A validation of its prevalence and examination of its impact on institutionalization and functional status.

We studied nursing home residents to validate the method used in national surveys for estimating the prevalence of arthritis, and to examine the impact of arthritis on institutionalization and on the physical function of residents. Five homes were studied using a 3-phase approach. Directors of nursing in each home classified residents (n = 629) with respect to the presence of arthritis and senile dementia. The presence of osteoarthritis or rheumatoid arthritis and their impacts on a resident's initial placement were separately assessed by a physician through a chart review of a stratified subsample. The physician also rated a resident's likelihood of returning to community living. Finally, the functional impact of arthritis was assessed by a physical therapist. The nurses' estimate of the prevalence of arthritis in this population was 23.33%, while the physician estimate was 23.03%. These results are consistent with the 24.6% prevalence found in a 1977 national survey. Arthritis itself was a major cause of nursing home placement in 15% of all residents without dementia. Among those without dementia who also had arthritis, arthritis was a major cause of institutionalization in 31%. None of the residents without dementia showed substantial potential for reintegration into the community. Controlling for age, residents with arthritis had more pain, were more likely to require assistance in functional tasks, and were more likely to use a wheelchair daily than were their fellow residents. Nevertheless, our results suggest that arthritis, despite its impact on function, in and of itself is not a major cause of nursing home placement or ongoing institutionalization.

Activities of Daily Living↗
PubMed1989

Applicability of a health status model to osteoarthritis.

A five-component model of health status has been operationalized by the Arthritis Impact Measurement Scales (AIMS) to serve as a core for the health status assessment of individuals with rheumatoid arthritis (RA). These five components of health status are Lower Extremity Function, Upper Extremity Function, Affect, Symptom, and Social Interaction. To test the utility of this model, this study examines the stability and the applicability of the five-component model in a different rheumatic disease, osteoarthritis (OA). The model displays similar characteristics between OA and RA for Upper Extremity Function, Affect, and Social Interaction. Pain, however, appears to be more strongly associated with Physical Activity in the OA sample, suggesting that pain as a measured symptom of OA is closely related to ambulation, while pain as a symptom of RA may be more a manifestation of joint involvement and less dependent upon walking and climbing. This study presents the AIMS as a means of assessing five components of health status in either OA or RA.

Aged↗