ABurrdetnhof ritis ReportGeorgia, 2006 1 ACKNOWLEDGEMENTS Georgia Department of Human Resources B.J. Walker, Commissioner Division of Public Health Stuart T. Brown, M.D., Director Chronic Disease Prevention and Health Promotion Branch Kimberly Redding, M.D., M.P.H., Director Population Services Section Vicki Pilgrim, M.Ed., Director Arthritis Program Pam Snow, Manager Epidemiology Branch Susan Lance, D.V.M., Ph.D., Director Chronic Disease, Injury, and Environmental Epidemiology Section John M. Horan, M.D., M.P.H., Chief Visit http://www.health.state.ga.us/epi/cdiee/arthritis.asp for more information about arthritis in Georgia. This publication was supported by Grant Number U58/CCU422885 from the Centers for Disease Control and Prevention (CDC). Its content are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. Graphic Design: Jimmy Clanton, Jr. Suggested Citation: Patel M.D. 2006 Georgia Burden of Arthritis Report. Georgia Department of Human Resources, Division of Public Health, Epidemiology Branch, Chronic Disease, Injury, and Environmental Epidemiology Section, January 2007. Publication number: DPH07/010HW. 2 TABLE OF CONTENTS Highlights ............................................................................................................................................................. 2 Introduction.......................................................................................................................................................... 3 Background............................................................................................................................................. 3 Content of Report.................................................................................................................................. 3 What is Arthritis? ................................................................................................................................... 4 Source of Information ........................................................................................................................... 4 Burden of Arthritis in Georgia......................................................................................................5 Overall Prevalence of Arthritis........................................................................................................... 5 Arthritis Prevalence by Demographics .............................................................................................. 6 Arthritis Prevalence by Geography................................................................................................... 8 Quality of Life ....................................................................................................................................... 9 Impact of Arthritis.................................................................................................................................. 10 Inactivity & Obesity .............................................................................................................................. 11 Access to Medical Care ....................................................................................................................... 12 Falls & Disability.................................................................................................................................... 12 Comorbid Health Conditions ............................................................................................................... 13 Hospitalizations...................................................................................................................................... 13 Conclusions ..................................................................................................................................14 Appendices ...................................................................................................................................15 Appendix A: Definitions........................................................................................................................ 15 Appendix B: Technical Notes............................................................................................................... 17 Appendix C: Data Tables .................................................................................................................... 18 1 HIGHLIGHTS Prevalence1 Nearly 1.7 million (about 1 in 4) adult Georgians report having doctor-diagnosed arthritis. Doctor-diagnosed arthritis is more common in women (29%) than men (22%). Doctor-diagnosed arthritis is more common in whites (27%) and blacks (25%) than Hispanics (11%). The prevalence of doctor-diagnosed arthritis increases with age, from about 4% among 18-24 year olds to 57% among those 65 years and older. The metropolitan Atlanta area has the lowest prevalence of doctor-diagnosed arthritis while the southcentral region of Georgia has the highest. Adults with doctor-diagnosed arthritis report being physically inactive and being obese more than others. Adults with doctor-diagnosed arthritis are more likely to report fair or poor health, days of poor physical health, and/or days of poor mental health than others. Almost half of adults with doctor-diagnosed arthritis report limitations in usual activities due to joint symptoms. Almost half of those reporting chronic joint symptoms, but who have not been clinically diagnosed with arthritis, have not seen a doctor for their joint symptoms. Almost 1 in 4 adults with doctor-diagnosed arthritis needed to see a doctor in the past 12 months but could not because of costs. Among obese adults with doctor-diagnosed arthritis, only 65% were recommended by a doctor to lose weight to manage their arthritis, and only 55% were recommended both weight loss and exercise. Among adults with normal weight and doctor-diagnosed arthritis, only 49% were recommended to exercise to manage their arthritis. Hospitalizations2 There were 22,451 hospitalizations with a primary diagnosis of arthritis for Georgians. Osteoarthritis accounted for 62% of these hospitalizations. The average length of stay for these hospitalizations was 4.4 days. Total hospital charges for arthritis exceeded $680 million. 1 2005 Georgia Behavioral Risk Factor Surveillance System 2 2004 Georgia Hospital Discharge Data 2 INTRODUCTION Background In 1999, Georgia began receiving funding from the Centers for Disease Control and Prevention to address the burden of arthritis. The grant was awarded to the Division of Public Health's Chronic Disease Prevention and Health Promotion Branch to develop an Arthritis Program for the state. The major activities of the Georgia Arthritis Program are: Establish partnerships to develop and implement a plan to address arthritis. Conduct arthritis surveillance. Promote awareness of the burden and impact of arthritis. Increase availability of community-based physical activity and self-management education programs for people with arthritis. The 2000 Georgia Arthritis Report was jointly published by the Georgia Department of Human Resources and the Arthritis Foundation, Georgia Chapter and was the first report in the nation to present state-specific surveillance data on arthritis. The Georgia Arthritis Report was released in 2002 and included "The Burden of Arthritis in Georgia" and "The Georgia Arthritis Action Plan." Georgia continues to conduct surveillance for arthritis and its impact on an ongoing basis. The Georgia Arthritis Program works with partners like the Arthritis Foundation, Georgia Chapter, the Division of Aging, and district public health staff to provide resources for physical activity and self-management for people living with arthritis. In 2003, the Georgia Arthritis Program introduced the Arthritis Foundation Exercise Program (formerly known as People with Arthritis Can Exercise, or PACE) in underserved southern Georgia. Since implementing the program, 75 new instructors have been trained and over 700 participants have benefited from the program. Content of Report This report presents the estimated prevalence of arthritis in Georgia by age, race/ethnicity, sex, and across the 18 public health districts. Adults who have been clinically diagnosed with arthritis, those who report chronic joint symptoms but have not been diagnosed with arthritis, and adults who were neither clinically diagnosed with arthritis nor chronic joint symptoms are compared on modifiable risk factors, health-related quality of life, impact of arthritis, arthritis management, and comorbid health conditions. Information on hospitalizations due to arthritis is also reported. 3 What is Arthritis? The term arthritis refers to more than 100 rheumatic diseases and conditions that affect joints, the tissues which surround the joint, and other connective tissue. The pattern, severity, and location of symptoms can vary depending on the specific form of the disease. Osteoarthritis is the most common type of arthritis; other common forms include rheumatoid arthritis, gout, lupus, and fibromyalgia. Arthritis and related conditions affected nearly 46 million adults in the United States in 2003 with approximately 1 in 5 adults (22%) reporting doctor-diagnosed arthritis.3 In addition, arthritis and other rheumatic conditions remained the leading cause of disability in the United States resulting in limitations in daily activities for 16 million Americans. In 1997, $51 billion in direct costs and $35 billion in indirect costs from lost wages were attributed to arthritis and other rheumatic conditions. The economic costs in Georgia totaled $2.5 billion for that year.4 Proper diagnosis and disease management recommendations are important in helping adults with arthritis or joint problems to understand their condition and actively participate in the management of their own disease. For most adults with arthritis, regular physical activity and reaching and maintaining a healthy body weight can help reduce or prevent arthritis-related disability and improve quality of life. Source of Information The Behavioral Risk Factor Surveillance System (BRFSS) is a telephone survey used by Georgia and other states to collect information on health indicators among the state's adult, non-institutionalized population. The following flowchart summarizes how arthritis status is defined using questions about arthritis on the Georgia BRFSS.5 Yes Have you ever been told by a doctor that you have arthritis? No Doctor-diagnosed Arthritis Yes Have you had joint pain or stiffness during the past 30 days? No Yes Did your joint symptoms first begin more than 3 months ago? No Neither Doctordiagnosed Arthritis nor Chronic Joint Symptoms Chronic Joint Symptoms Neither Doctordiagnosed Arthritis nor Chronic Joint Symptoms Before 2002, the case definition of arthritis included those reporting doctor-diagnosed arthritis and those reporting chronic joint symptoms but who have not been diagnosed with arthritis. Adults with doctor-diagnosed arthritis are the current focus of surveillance because these adults are more certain to have arthritis and tend to have a more severe condition, making them the main target population for programmatic interventions. Also, the new surveillance case definition is more comparable to the case definitions used for other chronic diseases such as diabetes and heart disease. 3 Hootman J, Langmaid G, Helmick C, Bolen J, Shih M, Brady T, Sniezek J., Monitoring progress in arthritis management -- United States and 25 states, 2003. MMWR 2005:54;484-488. 4 Murphy L, Cisternas M, Yelin E, Trupin L, Helmick CG. Update: Direct and Indirect Costs of Arthritis and Other Rheumatic Conditions -- United States, 1997. MMWR 2004:53;388389. 5 Definitions based on the BRFSS are explained in Appendix A. 4 BURDEN OF ARTHRITIS IN GEORGIA Overall Prevalence of Arthritis More than one in four (26%) adult Georgians had doctordiagnosed arthritis and about one in seven (14%) reported chronic joint symptoms (Figure 1). These results show that arthritis or joint symptoms affect a large portion of the adult population and pose a major public health issue in this state. Figure 1. Percent of Adults with Arthritis, Georgia, 2005 Doctor-diagnosed Arthritis 26% Neither Doctordiagnosed Arthritis nor Chronic Joint Symptoms 60% 14% Chronic Joint Symptoms Source: GA BRFSS Seniors participating in an Arthritis Foundation Exercise Program class in Dublin, GA. 5 Arthritis Prevalence by Demographics Arthritis affects males and females, all race and ethnicity groups, and all ages, but some groups are more likely to have arthritis than others. Women (29%) were significantly more likely to report doctor-diagnosed arthritis than men (22%). Men and women report the same prevalence of chronic joint symptoms (14%) (Figure 2). Percent Figure 2. Percent of Adults with Arthritis by Sex, Georgia, 2005 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 50 40 30 22 20 14 10 29 14 0 Male Female Sex Source: GA BRFSS Among racial and ethnic groups, whites and blacks have the highest prevalence of doctor-diagnosed arthritis (27% and 25%, respectively), compared to 11% in Hispanics (Figure 3). Percent Figure 3. Percent of Adults with Arthritis by Race/Ethnicity, Georgia, 2005 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 50 40 30 27 20 15 10 25 12 11 13 18 8 0 White Black Hispanic Race/Ethnicity Other Source: GA BRFSS Among race and sex groups, white females (32%) were most likely to report doctor-diagnosed arthritis while white males were least likely (23%) (Figure 4). Percent Figure 4. Percent of Adults with Arthritis by Race and Sex, Georgia, 2005 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 50 40 30 23 20 17 10 25 10 32 13 25 13 0 White Male Black Male White Female Race and Sex Black Female Source: GA BRFSS 6 Percent Percent Figure 5. Percent of Adults with Arthritis by Age, Georgia, 2005 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 57 50 46 40 30 20 13 10 4 0 18-24 14 7 25-34 21 15 32 16 35-44 45-54 Age 14 9 55-64 65+ Source: GA BRFSS Figure 6. Percent of Adults with Arthritis by Education, Georgia, 2005 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 50 40 40 30 20 15 10 24 13 28 13 20 14 0 Did not Graduated high Some college or graduate high school technical school school Graduated college Education Source: GA BRFSS Figure 7. Percent of Adults with Arthritis by Annual Household Income, Georgia, 2005 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 50 46 40 30 30 26 24 22 20 16 17 11 15 12 18 14 10 0 Less than $15,000 - $25,000 - $35,000 - $50,000 - $75,000 or $15,000 $24,999 $34,999 $49,999 $74,999 more Annual Household Income Source: GA BRFSS Figure 8. Percent of Adults with Arthritis by Health Insurance Status, Georgia, 2005 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 50 40 30 27 20 13 10 19 19 0 Health Insurance No Health Insurance Health Insurance Status Source: GA BRFSS Doctor-diagnosed arthritis is more common among older age groups. The prevalence increased from 4% among 18-24 year olds to 57% among those 65 years and older. The oldest age group, 65 years and older, was least likely to be affected by chronic joint symptoms (9%) (Figure 5). Those who did not graduate high school (40%) were most likely to report having doctor-diagnosed arthritis while those who graduated college (20%) were least likely (Figure 6). Adults with a household income of less than $15,000 per year had the highest prevalence of doctordiagnosed arthritis (46%). The prevalence decreased with higher income levels. (Figure 7). Adults with health insurance (27%) were more likely to report doctor-diagnosed arthritis than adults without health insurance (19%), while adults without health insurance were more likely to report chronic joint symptoms (19%) than adults with health insurance (13%) (Figure 8). Percent Percent 7 Arthritis Prevalence by Georgraphy The prevalence of doctor-diagnosed arthritis across The prevalence of doctor-diagnosed arthritis is generally Georgia health districts ranged from about 17% lowest in the metropolitan Atlanta area and highest in the (District 3-5: DeKalb) to 33% (District 5-1: Dublin). south-central region of the state. Figure 9. Prevalence of Adults with Doctor-diagnosed Arthritis by Health District, Georgia, 2003 & 2005 Source: GA BRFSS 1-1 Rome 1-2 Dalton 2-0 Gainesville 3-1 Cobb 3-2 Fulton 3-3 Clayton 28.2% 26.9% 28.8% 20.7% 19.3% 18.5% 3-4 Lawrenceville 3-5 DeKalb 4-0 LaGrange 5-1 Dublin 5-2 Macon 6-0 Augusta 22.9% 16.7% 27.0% 32.6% 28.9% 29.1% 7-0 Columbus 8-1 Valdosta 8-2 Albany 9-1 Savannah/Brunswick 9-2 Waycross 10-0 Athens 26.7% 26.7% 29.6% 24.6% 29.2% 25.3% 8 Quality of Life Health-related quality of life refers to the overall physical, mental, and social well-being of an individual. The findings in this section compare how arthritis impacts quality of life. Among adults with doctor-diagnosed arthritis, the ageadjusted prevalence of reporting fair or poor health (versus good, very good, or excellent health) was 30%. This was about three times greater than the prevalence in adults with neither doctor-diagnosed arthritis nor chronic joint symptoms (10%). The age-adjusted prevalence of reporting days of poor physical health was the highest for adults with doctor-diagnosed arthritis (56%), lower for adults with chronic joint symptoms (45%), and the lowest for adults with neither condition (25%). Adults with doctor-diagnosed arthritis (43%) and adults with chronic joint symptoms (42%) were more likely to report days of poor mental health than adults with neither condition (26%). Furthermore, 51% of adults with doctor-diagnosed arthritis reported days when poor health kept them from doing usual activities, such as self-care, work, or recreation compared to 38% of adults with chronic joint symptoms and 31% of adults with neither condition (Figure 10). These data suggest that adults with doctor-diagnosed arthritis experience a poor quality of life and their symptoms may have more severe impact than the symptoms in adults reporting chronic joint symptoms but no diagnosis of arthritis. Age-adjusted Percent* Figure 10. Age-adjusted Prevalence of Health-related Quality of Life Measures Among Adults by Arthritis Status, Georgia, 2005 80 Doctor-diagnosed Arthritis 70 Chronic Joint Symptoms Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms 60 50 40 30 30 25 56 45 25 43 42 26 51 38 31 20 10 10 0 Fair/Poor Health Reported Days of Poor Reported Days of Poor Reported Days when Physical Health Mental Health Poor Health Kept from Doing Usual Activities * Age-adjusted to U.S. 2000 standard Source: GA BRFSS 9 Impact of Arthritis Arthritis and chronic joint symptoms have an impact on daily activities. Adults with doctor-diagnosed arthritis (31%) were twice as likely to report being able to do some things or hardly anything (versus everything or most things) as adults with chronic joint symptoms (16%) (Figure 11). Age-adjusted Percent* Figure 11. Age-adjusted Prevalence of Impact of Arthritis or Joint Symptoms Among Adults by Arthritis Status, Georgia, 2005 Every/Most Things Some/Hardly Anything 100 90 16 31 80 70 60 50 40 84 69 30 20 10 0 Doctor-diagno1sed Arthritis * Age-adjusted to U.S. 2000 standard population Chronic Joint Symptoms Which of the following best describes what you can do d? Source: GA BRFSS Among adults with doctor-diagnosed arthritis, 42% reported limitations in their daily activities, and 41% reported limitations in their work-related activities. Among adults reporting chronic joint symptoms, only 22% were limited in their daily activities, and only 15% were limited in their work-related activities (Figure 12). Females with doctor-diagnosed arthritis (49%) were more likely to report limitations in daily activities than males with doctor-diagnosed arthritis (34%). Age-adjusted Percent* Figure 12. Age-adjusted Prevalence of Daily and Workrelated Activity Limitations Due to Arthritis or Joint Symptoms Among Adults by Arthritis Status, Georgia, 2005 80 70 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 50 42 41 40 30 22 20 15 10 0 Daily Activity Limitations * Age-adjusted to U.S. 2000 standard population Work-related Activity Limitations Adults aged 18-64 years Source: GA BRFSS South GA seniors participating in fun activity during an Arthritis Foundation Exercise Program graduation. 10 Inactivity & Obesity Age-adjusted Percent* Figure 13. Age-adjusted Prevalence of Inactivity and Obesity Among Adults by Arthritis Status, 80 Georgia, 2005 70 Doctor-diagnosed Arthritis 60 Chronic Joint Symptoms Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms 50 40 30 22 19 20 14 10 35 28 22 0 Inactivity Obesity * Age-adjusted to U.S. 2000 standard population Source: GA BRFSS Obesity, injury, and family history are considered risk factors for most types of arthritis. Appropriate, regular physical activity can prevent the onset of arthritis and reduce arthritis-related disability. Adults with doctor-diagnosed arthritis and adults with chronic joint symptoms were more likely to be inactive than adults with neither condition (22% and 19% versus 14%, respectively). The age-adjusted prevalence of obesity among those with doctor-diagnosed arthritis (35%) was significantly higher than among adults with neither doctor-diagnosed arthritis nor chronic joint symptoms (22%) (Figure 13). Age-adjusted Percent* Figure 14. Age-adjusted Prevalence of Doctor's Recommendations to Manage Arthritis or Joint Symptoms Among Obese or Normal Weight Adults by Arthritis Status, 80 Georgia, 2005 70 65 Doctor-diagnosed Arthritis Chronic Joint Symptoms 60 55 51 49 50 41 40 30 26 20 10 0 Losing weight Losing weight + exercise Exercise Obese * Age-adjusted to U.S. 2000 standard population Normal Wt. Source: GA BRFSS Reaching and maintaining a healthy weight and regular physical activity can be helpful in reducing complications due to arthritis or joint symptoms. Among obese adults with doctor-diagnosed arthritis, 65% reported recommendations by a doctor to lose weight to help manage their condition while 55% received recommendations to both lose weight and exercise. For obese adults reporting chronic joint symptoms, 51% received recommendations by a doctor to lose weight, and 41% received recommendations to lose weight and exercise. Among adults with normal weight, 49% of those with doctor-diagnosed arthritis received recommendation by a doctor to exercise to manage their arthritis while only 26% of adults with chronic joint symptoms were given the same recommendation (Figure 14). These results suggest that some physicians and healthcare providers are missing opportunities to initiate positive behavior change in patients who could benefit from it. 11 Access to Medical Care Almost one in four (24%) adults with doctor-diagnosed arthritis reported needing to see a doctor but could not because of cost (Figure 15). About half (48%) of those reporting chronic joint symptoms did not see a doctor for their condition. Also, 26% of adults with chronic joint symptoms report needing to see a doctor in the past 12 months but could not afford the cost of medical care. This suggests that some adults diagnosed by a doctor with arthritis are not receiving adequate health care. Also, some adults may have arthritis but are not able to see a doctor to get diagnosed, which may be causing unnecessary pain and disability that could be prevented. Age-adjusted Percent* Figure 15. Age-adjusted Prevalence of Adults Who Needed to See a Doctor in the Past 12 Months But Could Not Due to Cost by Arthritis Status, Georgia, 2005 80 Doctor-diagnosed Arthritis 70 Chronic Joint Symptoms Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms 60 50 40 30 24 26 20 11 10 0 * Age-adjusted to U.S. 2000 standard population Source: GA BRFSS Falls & Disability Adults aged 45 years and older with doctor-diagnosed arthritis (17%) and with chronic joint symptoms (14%) were more likely to experience a fall compared to adults with neither condition (7%). Furthermore, among those reporting a fall within the past 3 months, 44% of adults with doctor-diagnosed arthritis, 31% of adults with chronic joint symptoms, and 21% of those with neither were injured (Figure 16). This indicates that not only were adults with doctor-diagnosed arthritis and chronic joint symptoms more likely to experience a fall, if they did fall they were more likely to be injured. Age-adjusted Percent* Figure 16. Age-adjusted Prevalence of Falls and Injuries due to Falls Among Adults by Arthritis Status, Georgia, 2003 80 Injured Due to Fall Fall in Past 3 Months 70 60 50 40 30 20 17 14 10 7 0 Doctor-diagnosed Arthritis Chronic Joint Symptoms Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms * Age-adjusted to U.S. 2000 standard population Adults aged 45+ years Source: GA BRFSS Adults with doctor-diagnosed arthritis (47%) were more likely to have a disability than adults with chronic joint symptoms (27%) and those with neither condition (9%) (Figure 17). Age-adjusted Percent* Figure 17. Age-adjusted Prevalence of Disability Among Adults by Arthritis Status, Georgia, 2005 80 Doctor-diagnosed Arthritis Chronic Joint Symptoms 70 Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms 60 50 47 40 30 27 20 9 10 0 Disability * Age-adjusted to U.S. 2000 standard population Source: GA BRFSS 12 Comorbid Health Conditions Adjusted Percent* Figure 18. Adjusted Prevalence of Selected Health Conditions Among Adults by Arthritis Status, 80 Georgia, 2005 Doctor-diagnosed Arthritis 70 Chronic Joint Symptoms Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms 60 50 40 35 34 35 32 30 29 28 25 24 20 19 10 0 High High Blood Cholesterol Pressure Smoking 12 65 Asthma 12 76 Diabetes 6 4 2 544 5 33 Stroke Heart Attack Angina/CHD *Adjusted by age, sex, and BMI to 2000 national BRFSS d Source: GA BRFSS Hospitalizations Adults with doctor-diagnosed arthritis were more likely to have other health conditions compared to adults with chronic joint symptoms or adults with neither doctordiagnosed arthritis nor chronic joint symptoms. The age, sex, and BMI-adjusted prevalence of high cholesterol was 40% higher for adults with doctor-diagnosed arthritis (35%) than adults with neither condition (25%). Similarly, high blood pressure was more prevalent among adults with doctor-diagnosed arthritis (35%) than adults with neither condition(24%). About 1 in 8 adults with doctor-diagnosed arthritis (12%) also had asthma, which was twice the prevalence among the adults reporting neither doctor-diagnosed arthritis nor chronic joint symptoms (5%). Other chronic conditions like diabetes and smoking were also reported by adults with doctor-diagnosed arthritis (Figure 18). Overall, 76% of adults with doctor-diagnosed arthritis and 66% of adults with chronic joint symptoms reported at least one of the selected health conditions6 while that prevalence was 52% among adults with neither condition. There were 22,451 hospitalizations with a primary diagnosis of arthritis for adult Georgians at non-federal acute care hospitals in Georgia in 2004. Total charges for these hospitalizations exceeded $680 million, with the average length of stay lasting about 4.4 days. Of all adult Georgians hospitalized for arthritis or other related conditions, 61% were female, three-fourths (75%) were white, and nearly half (47%) were 65 years of age and older. Among the five most common types of arthritis (osteoarthritis, rheumatoid arthritis, gout, systemic lupus erythematosus, and fibromyalgia), hospitalizations due to osteoarthritis were the most frequent, accounting for 62% of all arthritis hospitalizations. However, arthritis hospitalizations among 18-24 year olds and 25-34 year olds were most commonly due to systemic lupus erythematosus (29% and 21%, respectively). 6High cholesterol, high blood pressure, smoking, asthma, diabetes, heart attack, angina/coronary heart disease, and stroke 13 CONCLUSIONS Results from the 2005 Georgia BRFSS confirm that arthritis and related conditions are a major public health problem. Nearly 1.7 million (approximately 1 in 4) adult Georgians reported doctor-diagnosed arthritis, and about 680,000 reported activity limitations attributable to arthritis or joint symptoms. Furthermore, with obesity rates increasing and the general population aging, this problem is likely to grow worse. The data in this report also describe a serious problem with the impact of arthritis on quality of life. Adults with arthritis are more likely than those without to be in poor health, have activity limitations, become injured during a fall, and have other chronic diseases or modifiable risk factors. These findings stress the importance of providing appropriate treatment and management education to adults with this condition. The lack of access to medical care reported by some adults with arthritis or joint symptoms also raises concerns about barriers to providing these individuals with adequate treatment and education. Furthermore, for those with access to care, physicians and health care providers could use more opportunities to recommend physical activity and weight control to those who could benefit from them. In addition to the physical burden, arthritis accounted for over $680 million in hospital charges in Georgia in 2004. The purpose of this report is to present the prevalence and impact of arthritis in Georgia to increase awareness of its burden among Georgians. Future surveillance activities will include monitoring trends in arthritis burden and identifying "high risk" populations that should be targeted for interventions. These data will also be used to support the development and implementation of evidence-based interventions to better prevent, treat, and manage arthritis in Georgia. An Arthritis Foundation Exercise Program instructor training in Waycross, GA. 14 APPENDICES Appendix A: Definitions Arthritis and Related Conditions Some/Hardly Anything Based on responses to: Respondents who answered "I can do some things I 1) The next questions refer to the joints in your body. Please would like to do" or "I can hardly do anything I would do not include the back or neck. During the past 30 days, like to do" when asked, "Thinking about your arthritis have you had any symptoms of pain, aching, or stiffness or joint symptoms, which of the following best describes in or around a joint? you today?" 2) Did your joint symptoms first begin more than 3 months ago? Activity Limitations 3) Have you ever been told by a doctor or other health Respondents who answered "yes" when asked, "Are you professional that you have some form of arthritis, now limited in any way in any of your usual activities rheumatoid arthritis, gout, lupus, or fibromyalgia? because of arthritis or joint symptoms?" Respondents were categorized as having doctor-diagnosed arthritis if they responded "yes" to question three or having Work Limitations chronic joint symptoms if they responded "yes" to both Respondents who answered "yes" when asked, questions one and two and "no" to question three. Everyone "Referring to work for pay, do arthritis or joint else was categorized as having neither doctor-diagnosed symptoms now affect whether you work, the type of arthritis nor chronic joint symptoms. work you do or the amount of work you do?" Fair/Poor Health Inactivity Respondents who answered "fair" or "poor" when asked, Respondents who were categorized as "No physical "Would you say that in general your health is excellent, very activity" by their self reported physical activity level good, good, fair, or poor?" instead of "Insufficient physical activity" or "Meet physical activity recommendations." Reported Days of Poor Physical Health Respondents who answered anywhere between 1-30 days Obesity when asked, "Now thinking about your physical health, which Respondents having a body mass index (BMI) greater includes physical illness and injury, for how many days during than or equal to 30 where body mass index is defined the past 30 days was your physical health not good?" as weight in kilograms divided by height in meters squared (weight/height2). Reported Days of Poor Mental Health Respondents who answered anywhere between 1-30 days Losing weight when asked, "Now thinking about your mental health, which Respondents who answered "yes" when asked, "Has a includes stress, depression, and problems with emotions, for doctor or other health professional ever suggested losing how many days during the past 30 days was your mental weight to help your arthritis or joint symptoms?" health not good?" Exercise Reported Days when Poor Health Kept from Doing Usual Respondents who answered "yes" when asked, "Has Activities a doctor or other health professional ever suggested Respondents who answered anywhere between 1-30 days physical activity or exercise to help your arthritis or when asked, "During the past 30 days, for about how joint symptoms?" many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or Not Seen a Doctor for Joint Symptoms recreation?" Respondents who answered "no" when asked, "Have you ever seen a doctor or other health professional for Every/Most Things these joint symptoms?" Respondents who answered "I can do everything I would like to do" or "I can do most things I would like to do" when asked, "Thinking about your arthritis or joint symptoms, which of the following best describes you today?" 15 Needed to See a Doctor in the Past 12 Months but Could Not because of Cost Respondents who answered "yes" when asked, "Was there a time in the past 12 months when you needed to see a doctor but could not because of the cost?" Fall in Past 3 Months Respondents who answered "yes" when asked, "In the past 3 months, have you had a fall?" Injured Due to Fall Respondents who answered "yes" to the previous question and when asked, "Were you injured?" Disability Respondents who answered "yes" when asked, "Are you limited in any way in any activities because of physical, mental, or emotional problems?" and/or "Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?" Dr. Jean Gearing (center) holds an open discussion with seniors on what they can do about arthritis. 16 Appendix B: Technical Notes Behavioral Risk Factor Surveillance System (BRFSS) The BRFSS is a population-based, random-digit-dialed telephone survey of the U.S. civilian, non-institutionalized population aged >18 years in 50 states, the District of Columbia, and certain U.S. territories (Guam, Puerto Rico, and the U.S. Virgin Islands). Hospitalizations with a primary diagnosis of arthritis or other related conditions were identified using ICD9-CM codes. Hospital charges are the hospital's full, established rates. They do not include physician's fees or medications and therefore may underestimate true costs. Arthritis-related questions were included on the Georgia BRFSS annually from 1998 to 2000 and every other year since 2001. In 2005, 6,064 adult Georgians participated in this survey. Their responses were used to estimate the statewide prevalence of arthritis and other data presented in this report (Appendix C, Tables 1-4). In 2002, the BRFSS case definition for arthritis was changed. Specifically, a case of doctor-diagnosed arthritis is now defined as a positive response to the question: "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?" Respondents who answer "no" to this question but report joint symptoms during the past 30 days that first began more than 3 months ago are considered to have possible arthritis, or chronic joint symptoms only. Fewer than 50 Respondents Small sample sizes may produce unstable estimates. The BRFSS follows a rule of not reporting or interpreting percentages based upon a denominator of fewer than 50 respondents (unweighted sample). Hospital Discharge Data Information on arthritis-related hospitalizations and their associated medical charges is from hospital discharge data for 2004 from non-federal acute care hospitals in Georgia (Appendix C, Tables 5-6). These data are provided by the Georgia Hospital Association to the Division of Public Health's Office of Health Information and Policy on an annual basis. Prevalence The percentage of a population that has a disease or risk factor at a specific time. Age-adjusted Prevalence Prevalence calculated in a manner that allows for the comparison of prevalence derived from populations with different age distributions. When comparing adults by arthritis status, prevalence estimates are adjusted for age because adults with doctor-diagnosed arthritis are generally older than the remaining population. Race/Sex Groups Sex-specific prevalence by race is presented only for whites and blacks. Sample size was not large enough to provide reliable estimates in other race/ethnicity groups. Statistical Significance The data provide sufficient statistical evidence to conclude that the observed results differ due to true differences as opposed to random error. In this report, a p-value <.05 was considered statistically significant. 17 Appendix C: Data Tables Table 1. Prevalence of Doctor-diagnosed Arthritis and Chronic Joint Symptoms Among Adults, Georgia, 2005 Total Sex Male Female Race/Ethnicity White Black Hispanic Other Race/Sex White Male Black Male White Female Black Female Age 18-24 25-34 35-44 45-54 55-64 65+ Education Did not graduate high school Graduated high school Some college or technical school Graduated college Income Less than $15,000 $15,000 - $24,999 $25,000 - $34,999 $35,000 - $49,999 $50,000 - $74,999 $75,000 or more Health Insurance Status Health Insurance No Health Insurance Total n 5,982 2,025 3,957 4,191 1,417 135 197 1,474 407 2,717 1,010 345 816 1,024 1,233 1,043 1,480 894 1,871 1,469 1,736 771 973 657 794 819 1,118 5,151 819 Doctor-diagnosed Arthritis % 95% CI Chronic Joint Symptoms % 95% CI 25.8 24.3 - 27.2 13.7 12.5 - 15.0 22.3 20.0 - 24.7 13.7 11.8 - 15.8 29.1 27.3 - 30.9 13.7 12.2 - 15.3 27.4 25.8 - 29.2 15.1 13.6 - 16.7 25.3 22.2 - 28.6 11.7 9.5 - 14.2 11.3 6.9 - 18.1 12.8 7.0 - 22.4 18.4 12.7 - 25.9 7.7 4.5 - 12.9 22.6 20.1 - 25.3 16.9 14.4 - 19.6 25.4 20.2 - 31.4 9.6 6.5 - 13.8 31.9 29.7 - 34.1 13.5 11.7 - 15.4 25.2 21.9 - 28.8 13.5 10.8 - 16.7 3.8 2.0 - 7.1 13.3 9.5 - 18.3 7.1 5.3 - 9.5 13.9 11.1 - 17.3 21.4 17.9 - 25.4 14.8 12.4 - 17.6 32.5 29.3 - 35.8 15.8 13.3 - 18.7 45.6 41.7 - 49.6 13.8 11.0 - 17.3 56.5 53.1 - 59.9 8.8 7.1 - 10.9 39.7 34.7 - 44.9 15.4 11.9 - 19.7 24.0 21.6 - 26.6 13.5 11.4 - 15.9 28.2 25.2 - 31.4 12.5 10.4 - 14.9 20.0 17.7 - 22.4 14.2 12.1 - 16.5 45.6 40.3 - 51.0 15.5 12.1 - 19.6 30.2 25.9 - 34.8 16.6 13.3 - 20.6 26.3 22.0 - 31.0 11.1 7.9 - 15.3 23.5 20.1 - 27.4 15.2 12.0 - 19.1 22.0 18.8 - 25.5 11.6 9.1 - 14.7 17.7 15.2 - 20.5 13.8 11.4 - 16.7 27.1 25.6 - 28.8 19.0 15.7 - 22.7 12.5 19.2 11.3 - 13.9 15.6 - 23.4 Source: GA BRFSS 18 Table 2. Prevalence of Doctor-diagnosed Arthritis Among Adults by Health District, Georgia, 2003 & 2005 Total n % 95% CI Georgia 13550 26.2 25.3-27.2 1-1 Rome 613 28.2 24.1-32.7 1-2 Dalton 520 26.9 22.5-31.8 2-0 Gainesville 1205 28.8 25.9-31.9 3-1 Cobb 520 20.7 17.0-25.1 3-2 Fulton 502 19.3 15.0-24.6 3-3 Clayton 442 18.5 14.4-23.4 3-4 Lawrenceville 547 22.9 19.1-27.1 3-5 Dekalb 475 16.7 13.3-20.7 4-0 Lagrange 510 27.0 22.7-31.8 5-1 Dublin 1122 32.6 28.9-36.6 5-2 Macon 518 28.9 24.6-33.6 6-0 Augusta 1135 29.1 26.2-32.2 7-0 Columbus 596 26.7 22.6-31.2 8-1 Valdosta 531 26.7 22.5-31.4 8-2 Albany 1120 29.6 26.3-33.3 9-1 Savannah/Brunswick 1087 24.6 21.5-27.9 9-2 Waycross 1075 29.2 25.9-32.7 10-0 Athens 1032 25.3 22.3-28.6 * Estimates are not reported if n < 50 (fewer than 50 respondents) Sex Male Female % 95% CI % 95% CI 22.7 21.2-24.3 29.6 28.3-30.8 21.6 15.9-28.7 34.5 29.3-40.1 22.1 15.6-30.3 31.7 26.3-37.5 26.0 21.7-30.8 31.6 27.8-35.6 18.0 12.7-24.9 23.4 18.5-29.2 20.7 13.6-30.2 18.0 13.6-23.4 10.9 6.2-18.2 25.5 20.0-31.9 17.8 12.9-24.0 28.0 22.8-34.0 13.4 8.5-20.3 19.8 15.5-24.8 25.3 18.4-33.7 28.6 23.5-34.2 27.4 21.9-33.6 37.8 33.5-42.4 25.6 19.0-33.6 31.9 26.7-37.6 26.6 22.1-31.6 31.4 27.7-35.3 24.1 17.8-31.7 29.1 24.3-34.5 19.8 13.8-27.5 33.4 28.1-39.2 27.7 22.0-34.2 31.4 27.8-35.3 22.6 17.9-28.2 26.4 22.8-30.4 25.5 20.9-30.7 32.9 28.6-37.6 22.4 17.7-27.9 28.0 24.3-31.9 Race White Black % 95% CI % 95% CI 28.6 27.4-29.8 23.5 21.5-25.6 30.2 25.8-35.0 15.0 6.7-30.3 29.0 24.3-34.2 ---* 29.9 26.8-33.2 ---* 23.4 18.8-28.7 11.8 6.2-21.1 16.5 11.9-22.4 24.1 16.5-33.9 27.5 19.4-37.5 14.8 10.7-20.1 26.3 21.6-31.5 18.4 10.5-30.1 21.7 16.2-28.5 15.2 10.7-21.1 26.0 21.0-31.7 29.7 20.5-40.9 34.3 30.3-38.5 32.8 26.3-40.1 33.3 27.4-39.8 22.9 16.9-30.3 32.6 28.8-36.7 23.3 18.9-28.4 28.2 22.4-34.8 28.2 21.9-35.6 28.9 23.6-34.9 24.5 17.4-33.2 29.5 25.6-33.7 29.8 23.6-36.9 26.0 22.5-29.9 25.7 18.9-34.0 29.7 26.2-33.4 28.6 19.6-39.7 24.8 21.5-28.5 28.4 20.7-37.5 18-44 % 95% CI 11.8 10.7-13.1 13.9 9.5-20.0 14.2 9.1-21.4 12.3 9.4-16.1 9.6 5.9-15.4 13.3 8.0-21.4 10.0 6.2-15.7 13.1 9.1-18.6 8.4 5.1-13.4 13.4 8.5-20.5 15.3 11.5-20.3 13.4 8.5-20.4 12.6 9.7-16.4 11.2 7.0-17.4 14.6 9.8-21.3 15.5 11.1-21.3 14.0 10.4-18.7 13.2 9.4-18.3 13.0 9.6-17.5 Age 45-64 % 95% CI 38.6 36.9-40.4 42.3 35.2-49.8 41.6 34.3-49.3 44.7 39.4-50.1 34.9 27.6-42.9 25.6 18.9-33.8 36.3 27.5-46.0 35.0 27.9-42.8 29.1 21.9-37.6 41.0 33.1-49.4 46.3 40.1-52.6 40.6 33.1-48.5 43.4 38.2-48.7 43.1 35.5-51.1 38.7 31.0-47.0 42.1 36.3-48.2 36.6 31.1-42.5 45.2 39.7-50.8 38.2 32.8-43.8 65+ % 95% CI 58.2 55.7-60.6 58.2 48.5-67.2 52.2 41.1-63.2 60.8 54.7-66.6 56.8 44.6-68.3 43.3 31.4-55.9 34.7 21.6-50.7 64.0 51.3-74.9 43.0 29.6-57.5 55.2 43.5-66.4 67.4 60.4-73.7 64.3 54.4-73.1 68.7 61.7-74.9 62.7 52.3-72.0 57.0 47.4-66.1 58.6 51.0-65.7 50.0 41.7-58.3 65.4 58.3-71.9 59.6 50.5-68.2 Source: GA BRFSS 19 Table 3. Age-adjusted Prevalence of Selected Health Indicators Among Adults by Arthritis Status, Georgia, 2005 20 Doctor-diagnosed Arthritis n %* 95% CI Health-related Quality of Life Fair/Poor Health Reported Days of Poor Physical Health Reported Days of Poor Mental Health Reported Days when Poor Health Kept from Doing Usual Activities 2,127 29.8 2,047 55.6 2,078 42.7 1,310 51.1 25.7 - 34.3 50.7 - 60.4 37.3 - 48.3 46.4 - 55.8 Impact of Arthritis or Joint Symptoms Every/Most Things Some/Hardly Anything 2,043 69.5 2,043 30.5 64.0 - 74.4 25.6 - 36.0 Limitations Due to Joint Symptoms Daily Activity Limitations Work-related Activity Limitations^ 2,121 41.6 1,618 40.7 36.3 - 47.2 35.6 - 46.0 Behavioral Risk Factors Inactivity Obesity 2,010 21.8 2,047 34.6 18.4 - 25.6 30.1 - 39.3 Doctor Recommendations to Manage Arthritis or Joint Symptoms For obese, Losing weight Losing weight + exercise For normal weight, Exercise 704 64.9 59.9 - 69.6 695 54.7 49.6 - 59.7 566 49.1 43.0 - 55.2 Not Seen a Doctor for Joint Symptoms 1,563 12.5 7.4 - 20.3 Needed to See a Doctor in the Past 12 Months But Could Not Due to Cost 2,135 24.1 19.3 - 29.6 Falls and Disability Fall in Past 3 Months^ Injured Due to Fall^ 2,073 377 Disability 2,134 * Age-adjusted to U.S. 2000 population Questions were not asked to 'Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms' Adults aged 18-64 years ^ Based on 2003 Georgia BRFSS Adults aged 45+ years Question was asked to those who reported a fall in the past 3 months 17.0 44.0 46.7 15.0 - 19.2 37.6 - 50.5 41.2 - 52.4 Chronic Joint Symptoms n %* 95% CI Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms n %* 95% CI 773 24.6 20.5 - 29.1 3,017 9.6 8.3 - 11.1 762 44.9 40.3 - 49.6 2,990 25.1 23.1 - 27.3 761 42.5 38.2 - 46.9 2,986 26.5 24.5 - 28.5 458 38.2 32.6 - 44.2 1,296 31.4 28.2 - 34.8 752 84.0 80.2 - 87.2 --- 752 16.0 12.8 - 19.8 --- 771 21.6 17.9 - 25.9 --- 1,097 14.9 12.4 - 17.8 --- 734 19.4 15.8 - 23.7 2,861 13.7 12.2 - 15.4 741 27.7 23.6 - 32.1 2,915 21.6 19.6 - 23.7 217 51.3 42.1 - 60.5 --- 212 40.6 31.5 - 50.4 --- 248 26.0 18.5 - 35.1 --- 775 47.7 43.0 - 52.4 --- 773 26.2 22.3 - 30.5 3,020 11.0 9.7 - 12.5 622 13.8 10.0 - 18.8 1,517 7.4 5.7 - 9.4 81 31.1 19.6 - 45.5 112 20.9 13.7 - 30.5 771 26.5 22.5 - 31.0 3,022 9.5 8.2 - 11.0 Source: GA BRFSS Table 4. Adjusted Prevalence of Selected Health Conditions Among Adults by Arthritis Status, Georgia, 2005 Doctor-diagnosed Arthritis n %* 95% CI High Cholesterol 1,845 35.4 31.9 - 39.0 High Blood Pressure 2,004 34.7 31.3 - 38.2 Smoking 2,036 32.3 28.4 - 36.5 Asthma 2,032 12.2 9.3 - 15.7 Diabetes 2,047 11.9 10.2 - 13.8 Stroke 2,026 6.2 4.2 - 9.0 Heart Attack 2,027 5.5 4.4 - 6.8 Angina/CHD 2,004 5.2 4.3 - 6.3 Any Chronic Disease 2,047 75.9 71.6 - 79.7 * Adjusted by age, sex, and BMI to 2000 national BRFSS data Chronic Joint Symptoms Neither Doctor-diagnosed Arthritis nor Chronic Joint Symptoms n %* 95% CI n %* 95% CI 582 33.6 29.6 - 38.0 2,285 24.7 22.6 - 26.9 734 28.6 25.1 - 32.5 2,872 23.7 22.0 - 25.6 738 28.4 24.6 - 32.5 2,898 18.9 17.2 - 20.8 739 6.0 4.2 - 8.6 2,906 5.1 4.2 - 6.3 741 7.1 5.3 - 9.3 2,915 6.4 5.3 - 7.6 741 3.9 2.5 - 6.1 2,913 1.9 1.4 - 2.7 739 3.5 2.2 - 5.5 2,911 3.5 2.7 - 4.5 740 3.4 2.3 - 5.1 2,903 3.1 2.4 - 4.2 741 66.4 62.0 - 70.5 2,915 52.1 49.9 - 54.4 Source: GA BRFSS Table 5. Hospitalizations and Charges for Primary Diagnoses of Arthritis Among Adults, Georgia, 2004 Hospitalizations % of Total Total Sex Male Female Race White Black Age 18-24 25-34 35-44 45-54 55-64 65+ 22,451 8,711 13,740 16,919 5,179 251 651 1,569 3,690 5,695 10,595 100.0 38.8 61.2 75.4 23.1 1.1 2.9 7.0 16.4 25.4 47.2 Charges ($) 680,549,918 % of Total Charges 100.0 265,371,113 39.0 415,178,805 61.0 513,862,790 75.5 153,050,592 22.5 6,574,584 1.0 19,283,555 2.8 45,434,921 6.7 117,204,245 17.2 181,151,596 26.6 310,901,017 45.7 Source: Georgia Hospital Association 21 Table 6. Hospitalizations Due to Five Most Common Types of Arthritis Among Adults by Age, Georgia, 2004 Total Arthritis Hospitalizations Osteoarthritis (ICD-9 code 715.xx) Number of % Total Arthritis Hospitalizations Hospitalizations* Rheumatoid Arthritis (ICD-9 code 714.xx) Number of % Total Arthritis Hospitalizations Hospitalizations* Gout (ICD-9 code 274.xx) Number of % Total Arthritis Hospitalizations Hospitalizations* Systemic Lupus Erythematosus (ICD-9 code 710.0) Number of % Total Arthritis Hospitalizations Hospitalizations* Fibromyalgia (ICD-9 code 729.1) Number of % Total Arthritis Hospitalizations Hospitalizations* Total 22,451 13,984 62.3 439 2.0 388 1.7 Age 18-24 251 14 5.6 10 4.0 --- 25-34 651 55 8.4 19 2.9 --- 35-44 1,569 428 27.3 30 1.9 37 2.4 45-54 3,690 1,827 49.5 88 2.4 62 1.7 55-64 5,695 3,853 67.7 114 2.0 92 1.6 65+ 10,595 7,807 73.7 178 1.7 186 1.8 * % Total Arthritis Hospitalizations = (Number of Hospitalizations for type, by total or age / Total Arthritis Hospitalizations, by total or age)*100 (Sample Calculation: % Total Arthritis Hospitalizations for Gout, by ages 65+ = (186 / 10,595)*100 = 1.8) Small cell counts are not reported 456 2.0 116 0.5 73 29.1 --- 134 20.6 --- 105 6.7 23 1.5 94 2.5 29 0.8 36 0.6 18 0.3 14 0.1 28 0.3 Source: Georgia Hospital Association 22 23 DHR GEORGIA DEPARTMENT OF HUMAN RESOURCES 24