Arthritis-specific policies also exist, including some substan- tial Federal-level arthritis policies. The National Arthritis Act of 1974 (NAA) was the first of five major national efforts that can be identified as policy initiatives to address arthritis.
Establishment of a separate arthritis institute (now know as the National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS]) at the National Institutes of Health (NIH) [21] was the second, and the third national effort to address arthritis was the addition of arthritis-specific and arthritis-related objectives to Healthy People 2010 [22, 23].
Fourth, the National Arthritis Action Plan: A Public Health Strategy (NAAP) [7] was written in the late 1990s, and, fifth, the CDC received its first congressional direction and fund- ing to address arthritis.
National Arthritis Act of 1974; National Arthritis Plan of 1976
Congress unanimously approved the National Arthritis Act of 1974 in December of that year, responding to the magnitude of the burden of arthritis in the USA [24]. Purposes of the NAA included establishing a temporary National Commission on Arthritis and formulating a long-range Arthritis Plan;
making grants to carry out arthritis screening, detection,
prevention, and referral demonstration projects; developing comprehensive arthritis centers (i.e., multipurpose arthritis centers); and establishing an arthritis data bank (i.e., the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) [25]). Goals of the long-range Arthritis Plan were largely centered around physician and public edu- cation, with a lesser emphasis on improving treatment through greater access to arthritis centers and advances in biomedical research and intervention development [24].
National Institute of Arthritis
and Musculoskeletal and Skin Diseases
NIH is the principal biomedical research agency of the fed- eral government in the USA, sponsoring scientific programs carried out through its individual institutes. These institutes reflect public priorities in health and demonstrate financial commitment to pursuing each institute’s mission, making them overt manifestations of health policy. In 1986, all arthri- tis-related precursors were superseded by the establishment of NIAMS, solidifying its arthritis-specific identity. One of 19 current institutes, NIAMS focuses primarily on the train- ing of basic and clinical scientists to perform biomedical research on the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; awarding grants to meet these goals; and disseminating research findings. Other NIH institutes also provide important information and fund- ing for arthritis research. For example, the National Institute on Aging (NIA) has a significant interest in improving the understanding, prevention, and treatment of age-related mus- culoskeletal diseases including osteoarthritis.
Healthy People 2010
The third in a series of 10-year plans detailing health objec- tives for the USA, Healthy People 2010 (HP2010) was the first to include arthritis-specific objectives (Table 11.1).
These national health objectives set priorities for improving the health of all Americans. People with arthritis were explicitly highlighted in eight arthritis-specific objectives and are also a targeted subgroup of related physical activity and nutrition objectives. The arthritis-specific objectives address important goals such as reducing pain and arthritis- attributable personal care and work limitations among peo- ple with arthritis, and increasing the proportion who receive health-care provider counseling for weight reduction and exercise. Making arthritis objectives a part of our nation’s health goals is a policy approach that raises the visibility of arthritis burden and draws attention to public health efforts and accomplishments related to arthritis. Healthy People 2020
(HP2020) will be released near the end of 2010; it is anticipated that all but one of the HP2010 objectives will be continued, and two new arthritis-specific objectives will be added (Table 11.1).
The National Arthritis Action Plan: A Public Health Strategy (1998)
The NAAP is organized around three major focus areas (surveillance, epidemiology, and prevention research; com- munication and education; and programs, policies, and sys- tems), which are designed to establish and enhance a coordinated national effort for reducing arthritis and its accompanying disability [7]. The NAAP and HP2010 com- plement each other in that HP2010 objectives set public health goals for the future, and the NAAP outlines a public health strategy for meeting those goals and reducing the population impact of arthritis.
Table 11.1 Healthy people 2010 and 2020 arthritis objectives 2–1 Reduce the mean level of joint pain among adults
with doctor-diagnosed arthritis
2–2 Reduce the proportion of adults with doctor-diagnosed arthritis who experience a limitation in activity due to arthritis or joint symptoms
2–3 Reduce the proportion of adults with doctor-diagnosed arthritis who have difficulty in performing two or more personal care activities, thereby preserving independence 2–4 Increase the proportion of adults with doctor-diagnosed
arthritis who receive health- care provider counseling (a) For weight reduction among overweight and obese
persons
(b) For physical activity or exercise
2–5 Reduce the impact of doctor-diagnosed arthritis on employ- ment in the working-aged population
(a) Reduction in the unemployment rate among adults with doctor-diagnosed arthritis
(b) Reduction in the proportion of adults with doctor-diag- nosed arthritis who are limited in their ability to work for pay due to arthritis
2–6 Eliminate racial disparities in the rate of total knee replace- ments among persons aged 65 years and older eliminated in HP2020
2–7 Increase the proportion of adults with chronic joint symp- toms who have seen a health-care provider for their symptoms
2–8 Increase the proportion of adults with doctor-diagnosed arthritis who have had effective, evidence-based arthritis education as an integral part of the management of their condition
Proposed objectives likely to be added to HP2020
Reduce the proportion of adults with doctor-diagnosed arthritis who find it “very difficult” to perform specific joint-related activities
Reduce the proportion of adults with doctor-diagnosed arthritis who report serious psychological distress
97 11 Health Policy, Public Health, and Arthritis Among Older Adults
Health policy interventions play an important role in achieving the NAAP vision, and these include educating policy makers on the burden and impact of arthritis; ensuring arthritis is represented in federal health and disabilities poli- cies; developing indicators of success regarding prevention strategies to guide policy and other decision makers; and drafting a policy requiring managed care organizations to cover any arthritis treatment or prevention intervention that is proven to be cost effective [7]. As part of its plan to imple- ment these and other useful strategies, NAAP called for fed- eral staff dedicated to arthritis at NIH, the CDC, and other agencies.
CDC Arthritis Program
Due in part to strategies outlined in the NAAP, CDC received its first congressional appropriation in 1999 to initiate a pub- lic health response to arthritis. The CDC Arthritis Program is structured to help achieve the arthritis-specific HP2010 objectives and focuses its efforts on three key areas: strength- ening the public health science base, fostering the develop- ment of state arthritis programs, and developing interventions, including policy initiatives, to reduce the impact of arthritis.
CDC Arthritis Program Activities
The CDC Arthritis Program is embedded in CDC’s National Center for Chronic Disease Prevention and Health Promotion, a center with a rich tradition of using policy change to improve the health of the American public. During the 1980s, CDC’s responsibilities expanded from an infectious disease focus to address noncommunicable diseases – principally those with a major impact on the nation’s health, such as cancer, heart disease, diabetes, and other leading causes of death. In 1988, the agency’s expanding role in tobacco and other chronic disease risk factors led to the establishment of the National Center for Chronic Disease Prevention and Health Promotion. Because of its focus on high-prevalence, high-impact chronic diseases, the center helped spearhead the development of NAAP and the inclusion of arthritis-spe- cific objectives in HP2010.
Within the National Center for Chronic Disease Prevention and Health Promotion, the Arthritis Program is positioned to mobilize the public health system to complement efforts of the health-care delivery system to meet the needs of people with arthritis. CDC’s Arthritis Program focuses on three key intervention areas: (1) self-management education, (2) phys- ical activity, and (3) weight control. State health department arthritis programs are essential partners of CDC’s Arthritis Program to expand the availability and reach of evidence-
based arthritis self-management education and physical activity interventions (Table 11.2).
Arthritis Public Health Activities Intersect with Clinical Care
The three intervention areas that make up the cornerstone of CDC’s public health approach to arthritis are also explicitly endorsed in clinical treatment guidelines of the American College of Rheumatology (ACR). ACR guidelines stress the importance of patient education, involvement, and self-man- agement in coping with rheumatologic disease. Exercise pro- grams are considered “first-line,” nonpharmacologic treatments for osteoarthritis (OA) and rheumatoid arthritis (RA) patients, and weight management – specifically losing weight among those who are overweight or obese – has long been recom- mended by the ACR for overweight patients with hip or knee OA [26, 27].
As this overlap demonstrates, public health’s population goals often intersect with the clinical care approach at the individual level, particularly with regard to self-management (Fig. 11.2). This relationship is innately symbiotic and can increase success in attaining both patient-outcome and pub- lic health goals. For example, research has demonstrated that establishing a connection between physician counseling for physical activity (individual) and community-based physical activity programs (population) may enhance the effective- ness of physician counseling [28]. Moreover, professional advice to lose weight is a strong predictor of weight-loss attempts; in one study, obese arthritis patients who were advised by a health-care professional to lose weight were three times more likely to attempt weight loss than those who did not receive counseling [29]. In another striking example, patients who were advised by a health-care pro- vider to take a self-management education course were greater than 18 times more likely to have done so [30].
Public health interventions and health policies can also enhance specific medical efforts for disease management. For instance, many features of the chronic care model (e.g., evi- dence-based support tools, clinical information systems, mul- tidisciplinary health-care teams, and patient self-management support) can be facilitated through policy interventions at multiple action levels [31, 32]. Given the widely recognized importance of self-management among people with arthritis and other chronic conditions in the control of their disease, policy interventions designed to improve the ability of patients to manage their conditions clearly complement the one-on- one efforts of the physician–patient relationship. The public health system, therefore, is working to establish and expand the intervention delivery infrastructure to which health-care providers can refer their patients.