Edward Yelin

The purpose of this study was to estimate the increment in medical care expenditures and wage losses associated with disability in the adult population after taking into account other characteristics of adults with disabilities. The authors used the 1997 Medical Expenditures Panel Survey Household Component (MEPS), a national probability sample of the noninstitutionalized population, to tabulate all medical care expenditures of the adult MEPS respondents, stratified by disability status. They then used regression techniques to estimate the increment of health care expenditures attributable to disability. They used the same methods to estimate the magnitude of the earnings losses sustained by persons with disabilities. Adults with disabilities incurred mean total medical care expenditures of $8,035, for a total of $182.6 billion. The mean increment in medical care expenditures specifically attributable to disability among those 18 and older was $2,953, for a total of about $65.9 billion. Persons with disabilities ages 18 through 64 earned $10,191 less, on average, than other persons these ages, for a total of $115.3 billion. The average increment in earnings losses attributable to disability was $13,160, for a total of $148.9 billion. A large proportion of the total medical care expenditures of adults with disabilities would occur in the absence of the disability, but persons with disability actually earned more than would be expected on the basis of their other characteristics.

Objective To compare the use of biologic agents among persons with rheumatoid arthritis (RA) in managed care and fee‐for‐service settings. Methods The present study uses data from the University of California, San Francisco RA Panel Study in which 529 patients with RA from a random sample of northern California rheumatologists were interviewed annually between 1999 and 2002 using a structured survey instrument. Linear and logistic regression were used to compare current utilization, initiation, and cessation of biologic agents and other treatments among patients with RA in managed care and fee‐for‐service settings, with and without adjustment for differences in demographic and health characteristics. Results After adjustment, patients with RA in health maintenance organizations (HMOs) were significantly less likely to use biologic agents than those in other managed care settings (difference of −6.6%; 95% confidence interval [95% CI] −11.4%, −1.7%) or than those in fee‐for‐service settings (difference of −12.5%; 95% CI −19.0%, −5.9%); patients in other managed care settings and fee‐for‐service did not differ significantly in their use of biologic agents. Patients with RA in HMOs were significantly less likely than those in other managed care settings to initiate the use of biologic agents (difference of −7.3%; 95% CI −11.5%, −3.1%); there were no other differences between patients in HMOs and those in other managed care and fee‐for‐service settings in rates of initiation or cessation of these agents. Patients with RA in HMOs were less likely to use methotrexate, cyclooxygenase 2 (COX‐2) inhibitors, and corticosteroids than those in other managed care settings; they were also less likely to use COX‐2 inhibitors than those in fee‐for‐service settings. Conclusion Patients with RA in HMOs were significantly less likely to use biologic agents than those in other managed care and fee‐for‐service settings, primarily due to lower rates of initiation.

Background: Exposure to environmental tobacco smoke (ETS), which contains potent respiratory irritants, may lead to chronic airway inflammation and obstruction. Although ETS exposure appears to cause asthma in children and adults, its role in causing COPD has received limited attention in epidemiologic studies.Methods: Using data from a population-based sample of 2,113 U.S. adults aged 55 to 75 years, we examined the association between lifetime ETS exposure and the risk of developing COPD.Participants were recruited from all 48 contiguous U.S. states by random digit dialing. Lifetime ETS exposure was ascertained by structured telephone interview. We used a standard epidemiologic approach to define COPD based on a self-reported physician diagnosis of chronic bronchitis, emphysema, or COPD.Results: Higher cumulative lifetime home and work exposure were associated with a greater risk of COPD. The highest quartile of lifetime home ETS exposure was associated with a greater risk of COPD, controlling for age, sex, race, personal smoking history, educational attainment, marital status, and occupational exposure to vapors, gas, dusts, or fumes during the longest held job (OR 1.55; 95% CI 1.09 to 2.21). The highest quartile of lifetime workplace ETS exposure was also related to a greater risk of COPD (OR 1.36; 95% CI 1.002 to 1.84). The population attributable fraction was 11% for the highest quartile of home ETS exposure and 7% for work exposure.Conclusion: ETS exposure may be an important cause of COPD. Consequently, public policies aimed at preventing public smoking may reduce the burden of COPD-related death and disability, both by reducing direct smoking and ETS exposure.

Historically, the largest components of costs associated with rheumatoid arthritis (RA), the most common inflammatory rheumatic disease, were hospitalizations, principally for joint replacement surgery, and work loss. Thus, for expensive interventions such as biological agents to be "worthwhile," they must reduce the prevalence of joint replacement and assist persons with RA in maintaining employment. However, joint replacement surgery and work losses tend to occur at least several years after onset of disease, even in severe cases. Assessing the cost-effectiveness of expenditures becomes computationally and politically difficult when the expenditure and the outcome are separated in time. The computational issue concerns the translation of future benefits--surgeries avoided and jobs held onto years from now--into present monetary values. The computational issue may be even more complex when the benefits are less tangible than surgery and wages; for example, when measured by quality-adjusted life-years. The political issue concerns the disjuncture between the agents making the expenditures--provincial health insurance in Canada or an employer's health plan in the US--and the agents reaping the benefits, a private disability insurance company or provincial or state workers' compensation fund. In addition, there is an ethical dilemma. In the US, many of the advances in the care for RA such as the biological agents derive, at least in part, from federal research expenditures. Such expenditures are financed by increasingly regressive taxes. Yet the individuals bearing an increasing share of the tax burden find themselves relegated to more restrictive health insurance plans less likely to provide access to those agents. Thus, whether expenditures for early interventions are worthwhile may turn on such issues as how long the expenditure and the benefits are separated in time, how well the interests of the agent making the expenditure and the agent reaping the rewards are aligned, and how equitable the financing of the benefit and the access to it.

Objective: To provide estimates of the total medical care expenditures and earnings losses associated with arthritis and other rheumatic conditions (AORC), as well as the increment in such costs specifically attributable to these conditions, in the US in 1997.Methods: The estimates were derived from the 1997 Medical Expenditures Panel Survey (MEPS), a national probability sample of 14,147 households including 34,551 persons, of whom 4,776 self‐reported arthritis. After weighting, those who self‐reported AORC represent 38.4 million persons. We tabulated all medical care expenditures of the adult MEPS respondents, stratified by arthritis and comorbidity status, and then used regression techniques to estimate the increment in health care expenditures attributable to AORC, after taking comorbidity, demographic characteristics, and insurance status into account. Using the same methods, we also estimated the magnitude of the earnings losses sustained by persons of working ages (18–64 years) who had AORC.Results: Persons with AORC incurred mean total medical care expenditures of $4,865 (total $186.9 billion). The largest components of these expenditures were inpatient care (39%), ambulatory care (29%), and prescriptions (14%). The mean increment in medical care expenditures specifically attributable to AORC among those ages 18 years and older was $1,391 (total ∼$51.1 billion). Persons with AORC ages 18–64 years earned $3,812 less on average than did other persons of these ages (total $82.4 billion). Of this average, $1,579 was attributable to the AORC (total $35.1 billion).Conclusion: In 1997, persons with AORC incurred direct and indirect costs of $269.3 billion, of which $86.2 billion was attributable to these conditions.

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee‐for‐service settings. Design. Cross‐sectional structured telephone survey of Norther...

Persons with all forms of musculoskeletal conditions incur total medical care expenditures of about US$240 billion, or about 2.9% of GDP. Of this total, approximately US$77 billion, or about 0.9% of GDP, would not have occurred in the absence of the musculoskeletal conditions. Such persons had lower labor force participation rates, resulting in indirect costs of about US$98 billion; of this amount, almost all (over US$90 billion) remained after taking into account characteristics other than the presence of a musculoskeletal condition that might result in lower earnings. Thus, the majority of direct costs incurred by persons with musculoskeletal conditions would occur in the absence of the conditions, but the wage losses would not occur were the conditions to be eradicated. The importance of indirect costs in the economics of musculoskeletal conditions is underscored by the studies of the costs of specific diseases. In all but OA, indirect costs are at least as large as, if not larger than, direct costs. Reducing the economic impact of RA, SLE, AS, and low back pain requires treatments that reduce work disability associated with each of these conditions. Some promising results from short term studies have been reported, but it would appear to be an appropriate time to inaugurate trials focused on longterm work outcomes.

Objective: To assess the association between use of etanercept and employment outcomes among patients with rheumatoid arthritis (RA).Methods: In 1999, 497 RA patients of working ages (18–64 years) reported their employment status in the year of diagnosis and as of the study year, in structured telephone interviews. Of these, 238 had been in clinical trials of etanercept and were currently taking that medication, while 259 were members of an observational study and were not taking etanercept. We used regression techniques to estimate whether employment outcomes in 1999 (employed versus not and, among the employed, hours of work per week, weeks of work per year, and hours of work per year) among the 379 of the 497 patients who were employed at the time of diagnosis were associated with etanercept use, with and without adjustment for demographic characteristics, RA status, overall health status, and the nature of the job held at the time of diagnosis.Results: At the time of diagnosis, 75% of RA patients from the observational study who did not take etanercept and 77% of those who did take the medication were employed. By 1999, among those employed at diagnosis, 55% of the former group and 71% of the latter were employed (difference 16 percentage points). After adjustment for demographics, overall health status, duration of RA, RA status, and occupation and industry, the difference widened to 20 percentage points. Among all who were employed at the time of diagnosis, those from the etanercept clinical trials worked an average of 5.4 more hours per week in 1999; after adjustment, the etanercept group worked 7.4 more hours per week.Conclusion: Among all persons who were employed at the time of RA diagnosis, having been in the etanercept clinical trials was associated with higher employment rates in 1999 and a greater number of hours per week of work in that year, suggesting that a randomized trial to establish the relationship between treatment and employment outcomes is now warranted.