NR 503 Evaluation of an Epidemiological Disease or Problem

NR 503 Evaluation of an Epidemiological Disease or Problem

NR 503 Evaluation of an Epidemiological Disease or Problem

For most people, arthritis is a health condition associated with people over the age of 65. The stiff, inflamed joints and nagging aches and pains are just seen as side effects of aging and years of wear and tear on the body. While arthritis is a health condition that results from inflammation of the joints and causes chronic pain, it is not just a health condition that affects elderly people. Arthritis can develop in children, teenagers, even adults in their twenties and thirties. As a long-term care nurse for over 15 years, my familiarity with the effects of arthritis in patients living in long-term care (LTC) facilities settings is considerable. Residents suffering from chronic arthritis find it extremely difficult to lift items, open doors, walk long distances, and perform activities of daily living (ADL): bathing, getting dressed, using the toilet, eating, transferring oneself to or from the bed or chair, or generally participating in activities that require strength and flexibility. Millions of people suffering from arthritis do not live in LTC facilities, so they do not have nursing assistance to help them with their ADLs or instrumental activities of daily living (IADLs): housework, grocery shopping, driving, caring for pets, etc.  On the other hand, millions of arthritis sufferers are forced to give up their independence every year and move into long-term care facilities as they find they are no longer able to perform normal daily functions due to the pain and discomfort caused by their arthritis.

The Georgia Department of Public Health (GDPH) reports that arthritis is the predominant reason for disability in the United States and Georgia, affecting over 53 million people across the nation (Bayakly, 2015). In 2013, one in four adults in Georgia, ranging in ages from 18 to 85, were reported to have been diagnosed with arthritis by their primary care physicians (Bayakly, 2015). With the average age of onset arthritis reported to be 47 years old, cost-effective evidence-based strategies are needed to treat LTC patients suffering with arthritis (Tavakoli, Akwara, Kish, 2018). This paper will examine the prevalence of osteoarthritis (OA) and rheumatoid arthritis (RA) and describe their backgrounds. The paper will also discuss surveillance methods, provide an epidemiology analysis of OA and RA, and explain how they are diagnosed. Lastly, this paper will reflect on what actions can be taken to address OA and RA as a family nurse practitioner.

Background of arthritis

Arthritis is a degenerative joint disease that causes swelling, tenderness, and pain of the joints. Arthritis may affect one joint and cause occasional discomfort, but it often times affects multiple joints in the body and decreases mobility. People of all ages can develop arthritis; however, their chances increase as they grow older. The Centers for Disease Control and Prevention (2018) report there are over 100 types of arthritis. The most prevalent cases of arthritis are osteoarthritis and rheumatoid arthritis (CDC: Arthritis basics, 2018). Other commonly diagnosed forms of arthritis include juvenile rheumatoid arthritis, knee osteoarthritis, degenerative joint disease, fibromyalgia, and gout (CDC: Arthritis basics, 2018). OA occurs in the joints when cartilage begins to break down; this may be the result of injury, aging, or overuse of the joints (CDC: Arthritis basics, 2018). Osteoarthritis is the most common type of arthritis and affects 30 million people or 60 percent of all diagnosed cases within the U.S. (CDC: Arthritis basics, 2018) and for 70.9 percent of all cases in Georgia (Martyn, Bayakly, & Bagchi, 2013). Furthermore, OA is the reason for 79 percent of hospitalizations among Georgia patients 65 years and older (Martyn, Bayakly, & Bagchi, 2013). OA targets the neck, lower back, hands, hips, and knees and worsens over time, resulting in permanent disability (PubMed Health, 2018).

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Rheumatoid arthritis is an autoimmune disorder that occurs when the immune system attacks the healthy cells in the connective tissue lining of the joints, causing damage and inflammation to joints throughout the body (CDC: Arthritis basics, 2018). Rheumatoid arthritis mainly attacks the synovial membrane soft tissue that lines the joints and leads to bone damage (CDC: Arthritis basics, 2018). RA causes chronic pain in the joint tissues of the hands, wrists, and knees; as a result, the person may develop a lack of balance or a deformity of the hands. Advanced RA may affect other tissues and cause health issues in organs such as the lungs and heart (CDC: Arthritis basics, 2018). RA is the most diagnosed autoimmune inflammatory arthritis in adults, affecting about 1 percent of U.S. general population and accounting for 0.7 percent of hospitalizations among Georgia patients ages 35 – 65 and over (Martyn, Bayakly, & Bagchi, 2013). RA is often misdiagnosed or mistaken for other disorders (Martyn, Bayakly, & Bagchi, 2013). The burden that OA, RA and other forms of arthritis places on arthritis sufferers is significant as it leads to a lower quality of life. Due to physical limitations and difficulty of staying healthy, arthritis sufferers find it increasingly difficult to work or participate in social or familial activities.

Signs and symptoms

The overall symptoms of OA are aching pain, stiffness in affected areas, decreased range of motion, and joint swelling. The general symptoms of RA include pain, stiffness, weakness, tenderness, and swelling of the joints. Accompanying systemic symptoms for RA are weight loss, fever, fatigue, eye inflammation, anemia, pleurisy, and subcutaneous nodules (PubMed Health, 2018). When RA symptoms worsen, they are called flare-ups; when symptoms do not appear, they are said to be in remission (CDC: Arthritis basics, 2018). Risk factors associated with osteoarthritis and rheumatoid arthritis are multifactorial and include familial, individual, or behavioral causes (Martyn, Bayakly, & Bagchi, 2013). Hereditary risk factors are genetic mutations that increase the risk of RA or OA; individual risk factors include aging, being female, and being White; behavioral risk factors are joint injuries sustained during an activity, repetitive motion characteristic of certain jobs, long-term infections, and obesity (Martyn, Bayakly, & Bagchi, 2013). In terms of the effect of RA and OA on patients in long-term care, the ability of these arthritic conditions to debilitate the body has adverse mental effects. Affected residents often experience feelings of fear, helplessness and anxiety, which lead to depression and increased stress levels. Many patients with RA suffer from comorbidity

Incidence/Prevalence statistics

Of the 1.7 million adult Georgians who report having been diagnosed with arthritis, 76,000 report they are disabled

NR 503 Evaluation of an Epidemiological Disease or Problem
NR 503 Evaluation of an Epidemiological Disease or Problem

(Martyn, Bayakly, & Bagchi, 2013). Among racial and ethnic groups diagnosed with arthritis, the most affected group is White non-Hispanic at 69 percent (Ibid.). RA and OA are most prevalent among women at 59 percent (Ibid.). Women are 30 percent more likely to report symptoms of arthritis than men at 22 percent (Ibid.). Among racial and ethnic groups, White non-Hispanic females are most likely to report arthritis symptoms at 32 percent, followed by White non-Hispanic males at 25 percent, Black non-Hispanic females at a 26 percent, and Black non-Hispanic males at 20 percent (Ibid.). Georgians 65 years and older report arthritis symptoms at 57 percent while Georgians ages 18 to 24 years old only report at 4 percent (Ibid.). Among Georgia adults diagnosed with arthritis, 58 percent were still employed, 10 percent had retired, and 18 percent were totally disabled and unable to work (Ibid.).

On average, 24,360 Georgia residents are hospitalized every year due to arthritis complications (Martyn, Bayakly, & Bagchi, 2013). Of the Georgia adults who have health insurance, 28 seek medical attention for arthritis; 18 percent of Georgia adults without health insurance seek medical attention for arthritis symptoms (Martyn, Bayakly, & Bagchi, 2013).  The rate of hospitalizations was highest among women at 58 percent , Whites  at 77 percent, and patients 55 years and older at 77 percent (Ibid.). Per year, an average of 2,084 Georgians dies from arthritis or health issues linked to arthritis (Ibid.). Of these deaths, 66 percent occurred among females, 66 percent occurred among Whites, and 61 percent among people age 65 years or older (Ibid.).  The prevalence of arthritis is drastically lower in metro-Atlanta county health districts: the lowest numbers reveal Clayton County at 16.7 percent, DeKalb County at 17.6 percent, and Fulton County at 20 percent (Ibid.). The prevalence of arthritis is higher outside of metro-Atlanta counties: the cities with the highest incidences are Dublin at 32.8 percent, Albany at 31.2 percent, Augusta at 31.2 percent, Waycross at 31.1 percent, and North Georgia health districts at 31.1 percent (Ibid.).

 

Figure 2: Georgia public health district arthritis comparison.

Prevalence of Doctor-Diagnosed Arthritis

Top 5 Georgia Public Health District

Waycross 36.5 %
Rome 32.6 %
Albany 32 %
Dublin 30.8 %
Valdosta 30.6 %

 

On a national scale 22.7 percent (54.4 million people) of the population has been diagnosed with arthritis, and 21 million of these sufferers complain they are disabled due to their arthritis (CDC: Arthritis related statistics, 2018). 7.1 percent of people between the ages of 18 to 44 report they have been diagnosed with arthritis; 29.3 percent of people between the ages of 45 to 64 report arthritis; 49.6 percent of people age 65 and older have reported doctor-diagnosed arthritis (Ibid.). 26 percent of the women and 19.1 percent of men in the U.S. report doctor-diagnosed arthritis (Ibid.). Out of the 54.4 million people to be diagnosed with arthritis, 4.4 million are Hispanics, 41.3 million are non-Hispanic Whites, 6.1 are non-Hispanic Blacks, and 1.5 are non-Hispanic Asians (Ibid.). By 2040, 78 million or 26 percent of the adult U.S. population is projected to be diagnosed with some form of arthritis (Ibid.).

Current surveillance methods

The CDC (2018) suggests the Behavioral Risk Factor Surveillance System (BRFSS) is the most reliable resource for accessing state-specific arthritis prevalence statistics. The BRFSS survey system is based in every state, the District of Columbia, and three U.S. territories (CDC: State statistics, 2018). The system randomly dials individuals aged 18 years or older who have a registered phone number (CDC: State statistics, 2018).  The BRFSS system has been collecting arthritis data from since 1996 (Ibid). The Morbidity and Mortality Weekly Report (MMWR) provides an arthritis surveillance summary that explains the differences between each type of arthritis and the impact arthritis has at the state and local levels (Ibid.). The CDC (2018) also recommends self-reporting methods to estimate the prevalence of doctor-diagnosed arthritis. Researchers should consider individuals to have self-reported, if they ever responded “yes” to the following question found in the National Health Interview Survey (NHIS) and the state-based Behavioral Risk Factor Surveillance System (BRFSS): “Have you been informed by a physician or other healthcare professional that you have some form of arthritis?” (Ibid.). For public health surveillance, the CDC has coordinated with the National Arthritis Data Workgroup to administer the National Health Interview Survey (NHIS) to identify people in every U.S. state and territory with at least one of the 100 diseases that fall under arthritis conditions (Ibid.). The Georgia Department of Public Health relies on the information collected by the CDC, BRFSS, and minimum data set (MDS) nurses in public and private healthcare facilities to compile its state numbers on arthritis (Martyn, Bayakly, & Bagchi, 2013).

Epidemiology analysis

Nationwide, approximately 54 million people report having been diagnosed with arthritis.. Risk factors are multifactorial, with old age, being White and female as the main factors. OA affects over 30 million adults; research suggests wear and tear plays a large role in its diagnosis. RA affects a little over one percent of the national population; research suggests that behavioral and genetic factors play a role in its diagnosis. Women develop arthritis more than men, especially after age 50 with a significantly higher age-adjusted prevalence in women at 23.5 percent than in men at 18.1 percent. Inactive adults have a higher prevalence of arthritis conditions at 23.6 percent than adults who report they are active at 18.1 percent.  In Georgia, 26 percent of the population suffers from some form of arthritis. White non-Hispanics report doctor-diagnosed arthritis at 29 percent, which is more than any other racial/ethnic group in the state. Georgians 65 years are more prone to doctor-diagnosed arthritis. Cobb-Douglas County has reported to date the lowest prevalence of arthritis at 18.4 percent. The population most affected is White women over the age of 65.

Incidence of RA in women is lower among women who take oral contraceptives compared with women who have never taken oral contraceptives or those who have stopped taking oral contraceptives (Tavakoli, Akwara, & Kish, 2018). Research shows that female subfertility increases RA in women (Tavakoli, Akwara, & Kish, 2018). Women who breastfeed and women who go through a postpartum period after a first pregnancy are at greater risk of RA (Ibid.). Environmental factors such as viral and bacterial infections increase the chance of RA in men and women (Ibid.). Men and women who smoke cigarettes increase their risk of RA (Ibid.). Over 15 percent of female in-home nursing assistance insurance claims are due to arthritis (Ibid.). The numbers show that 10 percent of nursing home residents receiving benefits for arthritis or arthritis related conditions are women over age 50 diagnosed with arthritis (Ibid.).

In 2013, the national arthritis medical care costs and earnings losses totaled $303.5 billion; attributable lost wages amounted to $164 billion (CDC: Cost statistics, 2018). The direct total cost per adult in national arthritis medical amounted to $2,117 (CDC: Cost statistics, 2018). OA is the second most costly hospitalized health conditions among U.S. residents, accounting for $16.5 billion of the combined costs for hospitalizations and $6.2 billion in hospital costs for privately insured patients (CDC: Cost statistics, 2018). Adults with arthritis bring home $4,040 less pay compared to adults without arthritis due to taking days off to recuperate from symptoms (CDC: Cost statistics, 2018).  The State of Georgia estimates it loses over $2.4 billion in direct costs and $1.5 billion in indirect costs treating patients with arthritis conditions (Martyn, Bayakly, & Bagchi, 2013).

Diagnosis and Screening and Prevention

To diagnose arthritis, a doctor will ask about symptoms then perform a physical examination to detect swollen joints or loss of range of motion (Martyn, Bayakly, & Bagchi, 2013). To distinguish the type of arthritis the doctor will order blood tests and X-rays (Ibid.). Doctors’ evaluations may include questions about symptoms, current and past health issues, health habits, and family medical history (Martyn, Bayakly, & Bagchi, 2013). Doctors will conduct a hands-on joint evaluation; depending on the findings, the doctor may order lab or imaging tests (CDC: Arthritis basics, 2018). The primary care doctor may refer the patient to a rheumatologist for a more comprehensive assessment (CDC: Arthritis basics, 2018). If necessary, the rheumatologist may make a referral for an orthopaedist who will determine if surgery is needed (CDC: Arthritis basics, 2018). To date there are no specific screening tests for arthritis (Ibid.). Early diagnosis has been determined to be the best screening method to detect arthritis (Ibid.).  The National Arthritis Action Plan is a public health strategy headed by the CDC and the Arthritis Foundation to combine efforts with other health organization to educate the public about arthritis and self-management goals (Ibid.).

Since there is a lack of data about the sensitivity, specificity, and costs factor of tests used to diagnose arthritis, more specifically rheumatoid arthritis, a five-year study was conducted to compare the following tests: B-cell gene expression, MRI, IL-6 serum level, and genetic assay (Busiman et al., 2016). The results of the study revealed, the B-cell exam was the overall best test when doctors used it as an additional test to confirm early diagnosis and as an overall diagnostic replacement in at-risk patients (Busiman et al., 2016). The following numbers show the B-cell test has better health outcomes, one of the lowest cost values, and high prevention value: B-cell gene expression test sensitivity reads 0.60, specificity reads 0.90, costs on average is $170—which means the test is not that sensitive to false positive results, it’s about 90 percent accurate, and is affordable without insurance (Busiman et al., 2016).

Nurse practitioner implementation plan and conclusion

Arthritis is the leading cause of disability in the U.S. and Georgia. There are 100 different types of arthritis that affect people of all ages and backgrounds. OA and RA are the most common types of arthritis, and women are affected more than men. After I graduate, I will use my knowledge of arthritis and its management to develop a fall prevention strategy for LTC patients. My program will involve a risk assessment for patients who walk with gaits or who have been noted to have balance difficulties or a history of falling. The assessment will involve muscle evaluation for weakness, an orthostatic hypotension check, a full examination of the feet, and a replacement of inefficient and unsafe footwear. The assessment will evaluate the patient’s ADL capabilities and use of mobility aids. I will also give patients a questionnaire about fears, falling, exercise, medication, and health goals. This information will make a difference in how interventions and treatment plans are executed.

Since arthritis is characterized by pain, stiffness and inflammation in affected joints, nurse practitioners play a pivotal role in both the early detection of arthritis symptoms in at risk patients and the pain management of patients with chronic arthritis. The first action I will take is getting involved in arthritis community programs that educate the general public about non-pharmaceutical pain management methods. Addiction to pain medication has become a national concern, and arthritis patients who become addicted to pain medications will only make their health conditions worse. Next, I will address the physical, psychological and social needs of the patient by asking questions during patient check-ups about each of these areas then by providing resources to help resolve any concerns.  My goal is to improve the patient’s quality of life, so I will focus on a holistic approach to alleviating arthritis symptoms that involves a manageable diet and exercise regimen, participation in a social or spiritual activity, and shared decision making about treatment options.

References

Bayakly, A. R. (2015). Burden of Chronic Disease in Georgia. Retrieved from Georgia Department of Public Health website: https://dph.georgia.gov/sites/dph.georgia.gov/files/Chronic%20Disease%20Burden_Rana_8.13.15.pdf

Buisman, L. R., Luime, J. J., Oppe, M., Hazes, J. M. W., & Rutten-van Mölken, M. P. M. H.

(2016). A five-year model to assess the early cost-effectiveness of new diagnostic tests in the early diagnosis of rheumatoid arthritis. Arthritis Research & Therapy18, 135. http://doi.org/10.1186/s13075-016-1020-3

Centers for Disease Control and Prevention (CDC). (2018, February 21). Arthritis basics. Retrieved from https://www.cdc.gov/arthritis/basics/index.html

Centers for Disease Control and Prevention (CDC). (2018, August 1). Arthritis-related statistics. Retrieved from https://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm

Centers for Disease Control and Prevention (CDC). (2018, July 18). Arthritis: State statistics. Retrieved from https://www.cdc.gov/arthritis/data_statistics/state-data-current.htm

Centers for Disease Control and Prevention (CDC). (2018, July 18). State statistics. Retrieved from https://www.cdc.gov/arthritis/data_statistics/state-data-current.htm

Martyn, A., Bayakly, A. R., & Bagchi, S. (2013). Georgia Arthritis Burden Report. Retrieved from Georgia Department of Public Health (Epidemiology Program) website: https://dph.georgia.gov/sites/dph.georgia.gov/files/related_files/site_page/Arthritis%20Burden%20Report_2013.pdf

PubMed Health. (2018). Arthritis. Retrieved from NIH – National Institute of Arthritis and Musculoskeletal and Skin Diseases website: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0024677/

Tavakoli, N., Akwara, C., & Kish, P. (2018). Considerations in the management of rheumatoid arthritis among older adults in long-term care. Annals of Long Term Care26(4), 18-23. Retrieved from DOI: 10.25270/altc.2018.08.00035