Virginia Arthritis Action Plan 2008-2012 - Augusta … · The Virginia Arthritis Action Plan for 2008 ... Ed Ansello, PhD – Virginia Center on Aging; Kirk Ballin, MDiv – AgrAbility

Virginia Arthritis Action Plan 2008-2012

Virginia Arthritis State Plan 2008-2012

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Virginia Arthritis State Plan

Planning Actions to Address the Burden of Arthritis in Virginia

2008- 2012

The Virginia Arthritis Action Coalition (VAAC)

The VAAC was established in 2000 as a collaborative effort to increase awareness of, and promote meaningful responses to, issues surrounding arthritis in Virginia. VAAC members

include not-for-profit organizations, academic institutions, public health agencies, local government offices, community based organizations, individuals, private businesses, and

health care organizations. The mission of the Virginia Arthritis Action Coalition is to reduce the burden of arthritis in Virginia by being a forum for communication and

collaboration. Visit http://www.vahealth.org/cdpc/arthritis for more information about arthritis in Virginia This publication was supported by Grant Number U58/CCU322781 from the Centers for Disease Control and Prevention (CDC). Its contents are the responsibility of the authors and do not necessarily represent the official views of the CDC.


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Table of Contents Preface………………………..………………………………………………………………………. 4 Acknowledgements ………………………………………………………………………………....5 Executive Summary ……………..……………………………………………………………………6 Introduction ……..…………………………………………………………………………………….8 Adults Children, Teens and Young Adults Risk Factors for Arthritis ………….…………………………………………………………………11 Gender Age Co-Morbidity Obesity Evidence-based Interventions………..…….…………………………………………………………13 Benefits of Exercise Treatment and Prevention Community Arthritis Management Programs Burden of Arthritis in Virginia…………….…………………………………………………………17 Geography Population Access to Health Care Prevalence Costs Associated with Arthritis………………………………………………………………………22 Health Care Social and Behavior Activity and Work Limitations Comparative Data Highlights.………………………….…………………………………………….28 Arthritis Data and Statistics Characteristics of Adults with Arthritis Physical Activity, Body Weight and Health Status Arthritis and other Chronic Conditions Self Management, Related Limitations and Factors Goals and Strategies…………………………………………………………………………………..33 Communication and Marketing Programs and Education Surveillance and Epidemiology Health Systems and Policy Appendix A: Virginia Arthritis Action Coalition Member Organizations …...……..……………….43 Appendix B: U.S. Healthy People 2010 Arthritis Related Objectives ..……………………….…….44 Resources ...………………………………………………………………………………………..46 References …..……………………………………………………………………………………….51 Virginia Arthritis Plan Feedback Form..….………………………………………………………….54


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Preface From the Virginia Arthritis Action Coalition -- VAAC Arthritis affects individuals physically, economically, psychologically, and socially. Arthritis-related efforts in Virginia focus on prevention, self-management, education, and proper medical care when needed, in order to maintain quality of life, sustain the productivity of its citizens, and assure physical and mental well-being. In an effort to address the issues surrounding arthritis in Virginia, concerned individuals and organizations established the Virginia Arthritis Action Coalition in 2000; membership represents a wide range of partners from across the state, including not-for-profit organizations, academic institutions, public health agencies, local government offices, community-based organizations, individuals, private business, and health care organizations. The mission of the Virginia Arthritis Action Coalition is to provide a forum for communication and collaboration with the intent to reduce the burden of arthritis in Virginia. The aim is to strengthen alliances and provide education and outreach activities among arthritis stakeholders across the Commonwealth. A current list of members can be found in Appendix A. Members of the Virginia Arthritis Action Coalition are proud to present the Virginia State Arthritis Plan. The plan is a result of the collaborative efforts of many individuals and agencies that have contributed their time and expertise. The plan provides a framework that includes key goals and strategies. It is intended to provide guidance for the design, implementation and evaluation of arthritis-related activities for the general public, people with arthritis and their families, and health care systems. The Virginia Arthritis Action Plan for 2008 - 2012 is meant to be a comprehensive framework to support and direct the efforts of partners and communities in a coordinated approach to reduce disability and improve the quality of life for Virginia residents with arthritis and related conditions. The purpose of the plan is to:

q Describe arthritis and related conditions and how they affect Virginians. q Identify opportunities for reducing arthritis related disabilities and improving the quality of life for

Virginians with arthritis. q Offer information about arthritis disease management strategies that can be implemented to

address the burden of arthritis in Virginia. q Begin establishing a statewide arthritis network system with regional presence and community-

based partners. q Encourage all Virginians to commit to implement the goals and strategies outlined in the plan and

lessen the burden of arthritis in Virginia. The Virginia Arthritis Action Coalition is committed to coordinating efforts that will produce the most effective, efficient, and comprehensive benefits for all. We appreciate everyone who has contributed to the development of this plan. Every citizen of Virginia is invited to join in the implementation and evaluation of this plan. Sincere thanks, Chairs & Co-chairs of the Virginia Arthritis Action Coalition


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Acknowledgements The Virginia Arthritis Project was a federally-supported initiative of the Virginia Department of Health. The project, now concluded, was managed by B.A. Caro-Justin of the Division of Chronic Disease Prevention & Control, Virginia Department of Health. The Virginia Arthritis Project was instrumental in establishing the Virginia Arthritis Action Coalition which continues its work. This Coalition meets regularly to draw upon the diverse expertise of its members in an on-going effort to improve the quality of life of Virginians with arthritis and related conditions. The Virginia Arthritis Action Coalition would like to acknowledge and thank those who shared their time and expertise to create this plan. The plan is a result of the coordinated efforts of many individuals, agencies, and organizations from across the Commonwealth. It is only with the continued commitment of the individuals and organizations of the Virginia Arthritis Action Coalition that the goals outlined in the Virginia Arthritis Action Plan 2008-2012 will be realized. A special thank you is extended to the following individuals and organizations for helping to develop a new vision for Virginia’s future effort in arthritis initiatives. Judy Altman Yoder, MA– Virginia Arthritis Foundation; Ed Ansello, PhD – Virginia Center on Aging; Kirk Ballin, MDiv – AgrAbility Virginia; Deborah Batakis, RN – Virginia Beach Health District; Katie Benghauser, MS – SeniorNavigator; Frank Brown, MD – Anthem Blue Cross – Blue Shield; Laverne Morrow Carter, PhD – Carter Research Group Inc; Mary Casebolt – Mary Washington Hospital Nursing Center of Excellence; Alison Clarke, CTRS. – Sheltering Arms; Pat Davidson, BS – Virginia Beach Health District; Joanne Hammer, RN – Augusta Medical Center; Eletta Hansen, RN, MPH – Mary Washington Hospital Nursing Center of Excellence; Deborah Harris, MPH – Women and Infants Health Care, Virginia Department of Health; Mary Jo Ivan, RN – Fairfax County Department of Health; Linda Gail Johnson, RN, MPH – Augusta Medical Center; Susan Johnson, MA – Virginia Area Agency on Aging; Pam Lane, MPH – Three Rivers Health District; Charlene Learner, RN, BSN – Virginia Beach Health District; Donna Mahan – Big Stone Gap Parks and Recreation Department; Marilyn Pace Maxwell, MSW – Mountain Empire Older Citizens, Inc; Terri Morris, RN, BSN-Fairfax County Health Department; Beth O’Connor, MEd – Virginia Rural Health Resource Center; Mildred Roberson, PhD – Professor of Nursing (retired); Susan Kennedy Spain, MS - Office of Family Health Services, Virginia Department of Health; Jean Skinner – Fairfax County Parks Authority; Elaine Smith, MS, RD – Virginia Department for the Aging; Nancy Smith, BS – Mountain Empire Older Citizens; Alice Steele,CPRN – Certified Registered Nurse Anesthetist, Retired; Theresa Teekah, RN, MA, – Virginia Cancer Control Project, Virginia Department of Health; Debra Waln, VP – Medicaid for Southern Health Services, Inc; Sheila Ward, PhD – Norfolk State University; Kristy Zafar, MES. – American Family Fitness Center and May Therapy. A special thank you is extended to the following individuals and organizations for helping to develop a new vision for Virginia’s arthritis initiatives. David Suttle, MD, Director of the Office of Family Services, Ramona Schaeffer, MSEd, CHES, Director of the Division of Chronic Disease Prevention and Control, Myra Shook, MPH, Chronic Disease Program Supervisor, for their continued support and leadership; Sharon K. Dwyer, MS - Institute for Community Health at Virginia Tech, for writing and coordinating the plan; Gail Jennings, PhD – Epidemiologist, Division of Chronic Disease - Virginia Department of Health, for providing all the arthritis data and maps. B.A. Caro-Justin, Project Manager The Virginia Arthritis Project


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Executive Summary Arthritis and related conditions affect almost 50 million Americans: one in five adults report having doctor-diagnosed arthritis. Arthritis is a costly health problem and the leading cause of disability in the U.S. Arthritis is one of Virginia’s most common chronic health problems, affecting almost one in three (28%) residents 18 years of age or older and costs the Commonwealth over $3 billion dollars yearly in direct health costs and lost productivity. Arthritis affects all race and ethnic groups. While adults reporting doctor-diagnosed arthritis are predominately age 65 and over (59 %), almost 40 percent of those with arthritis are 45 to 64 years of age and those 18 to 44 years of age make up an additional 12 percent. The incidence of doctor-diagnosed arthritis in women is almost 10 percent higher than in men, with almost one out of three women in Virginia having a diagnosis. Approximately 1,539,000 adults or 28 percent of Virginia’s adult population report that they have doctor-diagnosed arthritis, while over 37 percent of Virginia residents with arthritis have some limitations in their daily activities. Of Virginians age 65 years and older, over 59 percent have arthritis and, among those ages 45 to 64, the percentage is over 37 percent. One in three women and one in four men in Virginia report having arthritis. Although the actual numbers of adults with arthritis vary widely by race and ethnicity, the percentages of the respective population groups diagnosed vary by only three percent or less, with 28 percent of non-Hispanic white adults, 27 percent of Hispanic adults, and 25 percent of black adults reporting doctor-diagnosed arthritis. Awareness and knowledge surrounding arthritis and the effective approaches for controlling and managing the disease continue to grow. The efforts of those involved in preventing and managing arthritis will make significant contributions and positively affect the lives of Virginians affected by this disease. Goals for the Virginia Arthritis Plan include: § Increase the awareness among people with or without arthritis of available resources, so that they

are prepared to seek early diagnosis and/or develop or improve self-management skills. § Increase the public awareness of the many forms of arthritis, the signs and symptoms of arthritis,

and the importance of early diagnosis and self-management. § Increase awareness among healthcare providers of the need for early detection and management of

arthritis, as well as available arthritis resources. § Increase the availability of arthritis prevention programs in Virginia. § Increase knowledge and awareness of arthritis and related conditions and the benefits of evidence-

based interventions and programs that support Virginia residents who suffer the effects of these conditions.

§ Increase the availability, accessibility, and participation in effective evidence-based physical activity, weight control, and self management programs for Virginia residents with arthritis and related conditions.

§ Develop support systems in Virginia for persons with arthritis. § Increase knowledge of Virginia health care professionals concerning arthritis prevention, diagnosis

and treatment, and the programs available for their patients/clients. § Increase effective arthritis prevention awareness strategies for at-risk populations. § Improve surveillance of arthritis in general and of specific types of arthritis. § Examine state level mechanisms for reporting, collecting, and analyzing prevalence data for

selected chronic diseases, including arthritis.


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§ Support data systems to track the occurrence and impact of arthritis. § Disseminate Virginia arthritis data in a variety of forms and formats. § Identify groups and individuals who affect policy related to arthritis and related conditions. § Identify federal and state statutes, regulations and budget provisions affecting consumers,

providers and payers of arthritis and arthritis-related services. § Identify best practices in the public and private sectors for the treatment and management of

arthritis and arthritis related conditions. § Examine comprehensive arthritis policy agendas from other states and develop a Virginia agenda. § Explore the development of a statewide system of resources that will address arthritis and other

related or co-morbid conditions.

This plan provides a framework to guide arthritis efforts and a blueprint for achieving goals by public and non-government agencies, health systems, community organizations, and others. The plan is a living document with a few actions suggested for each goal in order to initiate and promote new ideas. It is intended to unify efforts and prompt actions of individuals and organizations involved in arthritis-related care, education, research, surveillance, and outreach.


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Introduction Arthritis is the term used to describe more than 100 different conditions that affect joints, as well as other parts of the body. For this document the word arthritis is used as an umbrella term for all of these conditions. Nationally, arthritis affects nearly 50 million Americans or one out of five people, including adults and children, making it one of the most common diseases in the U.S. As the nation’s population continues to age, by the year 2020 arthritis is expected to affect an estimated 60 million Americans or almost 20 percent of the population, and almost 65 million by 2030 (Friedman et. al., 2007). Arthritis is a serious and costly public health problem. Among all adults with disabilities, almost 20 percent reported that the main health condition associated with their disability was arthritis or rheumatism, making it the number one cause of disability in the United States. People with arthritis often are being affected by other chronic diseases or illnesses. Over 30 percent of those with doctor diagnosed arthritis report having one or more other chronic conditions such as heart disease or diabetes. Arthritis costs the U.S. economy $86.2 billion dollars annually and is the third leading cause of work limitation (Yelin, 2003).

Six Most Common Forms of Arthritis

Osteoarthritis is the most common type of arthritis, affecting over 20 million people in the U.S. It occurs when the cartilage covering the end of the bones gradually wears away. Without the protection of the cartilage, the bones begin to rub against each other and the resulting friction leads to pain and swelling. Osteoarthritis can occur in any joint, but most often affects the hands and weight-bearing joints such as the knee, hip and facet joints (in the spine). Osteoarthritis often occurs as the cartilage breaks down, or degenerates, with age and is sometimes called degenerative joint disease.

Rheumatoid arthritis is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as other organs in the body. While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. Typically, however, rheumatoid arthritis is a progressive illness that has the potential to cause joint destruction and functional disability.

Fibromyalgia is a condition characterized by aching and pain in muscles, tendons, and joints all over the body, but especially along the spine. The body also is tender to touch in specific areas, called tender or trigger points. The primary symptom is pain, and stress can make fibromyalgia symptoms worse. Common symptoms include widespread pain throughout the muscles of the body, fatigue, sleep disorders, headaches, and irritable bowel syndrome.

Gout is one of the few types of arthritis where the cause is known. It results from deposits of needle-like crystals of uric acid in the connective tissue, joint spaces, or both. Uric acid is a byproduct of the breakdown of purines or waste products in the body. Normally, uric acid breaks down in the blood and is eliminated in urine. When the body increases its production of uric acid or if the kidneys do not eliminate enough uric acid from the body, levels build up.

Lupus is a disorder of the immune system known as an autoimmune disease. In autoimmune diseases, the body harms its own healthy cells and tissues. This leads to inflammation and damage to various body tissues and organs. Lupus can affect many parts of the body, including the joints, skin, kidneys, heart, lungs, blood vessels, and brain. It is characterized by periods of illness, called flares, and periods of wellness, or remission. Symptoms include extreme fatigue, painful or swollen joints (arthritis), unexplained fever, skin rashes, and kidney problems. There is no cure for lupus.

Juvenile Rheumatoid Arthritis (JRA) is the most common form of arthritis in children. It may be a mild condition that causes few problems over time, but it can be much more persistent and cause joint and tissue damage in other children. JRA can produce serious complications in more severe cases. The most common features of JRA are joint inflammation, joint contracture (stiff, bent joint), joint damage and/or alteration or change in growth. Other symptoms include joint stiffness following rest or decreased activity level (also referred to as morning stiffness), and weakness in muscles and other soft tissues surrounding the involved joints. JRA affects each child differently, a child may not experience all of these changes and may vary in the degree to which they are affected by any particular symptom.


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Adults Defining arthritis in adults has evolved over time. Currently, the Centers for Disease Control and Prevention (CDC) defines arthritis as those individuals reporting doctor-diagnosed arthritis and/or chronic joint symptoms. Possible arthritis is characterized by having had pain, aching or stiffness in or around a joint within the past 30 days that was present for three or more months. Using this definition, a 2005 state health behavior survey found that 27.6 percent of Virginians or 1.54 million adults reported arthritis that has been diagnosed by a healthcare provider, that is, doctor diagnosed arthritis (Behavioral Risk Factor Surveillance System, 2005). Arthritis affects every segment of the population, but most commonly affects individuals 65-74 years of age (59%), women (32%), people with incomes below $20,000 (46%), and people with less than a high school education (44%). More than one fourth of those reporting arthritis had not been doctor-diagnosed, indicating that more effort is needed to increase awareness of the importance of early diagnosis and treatment. Adults with arthritis are three times more likely than other adults to report that their health status is either fair or poor. Twenty-eight percent of adults with arthritis say that they can do hardly anything or only some things. One-third (33%) of adults with arthritis were told by their physician to lose weight and 59.7 percent were advised to exercise more. Arthritis is more prevalent among adults with other chronic diseases and health conditions (BRFSS, 2005). Diagnosed arthritis is reported by 55.5 percent of adults with diabetes (excluding gestational and pre-diabetes), by 58.3 percent of adults with cardiovascular disease (defined as having had either a heart attack or angina), by 48.9 percent of adults with high blood pressure, and by 41.4 percent of adults with high cholesterol. Children, Teens and Young Adults While arthritis increases with age and is usually associated with adults, children can be affected by any of the 100 types of arthritis. The Arthritis Foundation reports that over 300,000 children under the age of 18 in the U.S. suffer from some form of juvenile rheumatoid arthritis. Definitive numbers are unavailable but a recent study estimates that 7,200 (95% CI: 4,600 – 9,800) juveniles in Virginia have significant pediatric arthritis and other rheumatologic conditions (SPARC, Sacks et al., 2007). Juvenile rheumatoid arthritis (JRA) is the most common type of arthritis in children. JRA is a chronic condition causing joint inflammation and stiffness for at least six weeks in a child 16 years or younger. The term “juvenile rheumatoid arthritis” is generally seen as an umbrella term for a group of conditions. The conditions can vary widely and are classified according to the number of joints affected, the signs and symptoms, and the results of blood tests. Inflammation causes redness, swelling, warmth, and soreness in the joints, although many children with JRA do not complain of joint pain. Any joint can be affected and inflammation may limit the mobility of affected joints. One type of JRA can also affect the internal organs. Doctors classify JRA into three types by the number of joints involved, the symptoms, and the presence or absence of certain antibodies found by a blood test. (Antibodies are special proteins made by the immune system.) These classifications help the doctor determine how the disease will progress and whether the internal organs or skin is affected. Family members play a critical role in helping young people cope with juvenile arthritis. Arthritis has the potential to impact school performance, social life, family relationships, dating, sports, and almost every other aspect of a young person's life and thus raises special concerns and needs. Specific coping skills may be needed to deal with the everyday challenges of arthritis. For teens and young adults who are entering the workforce, there may be additional issues to face. Arthritis can dramatically affect the quality of life for all children and young people affected. Proper management of the disease is key, with and can


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have profound benefits in terms of their productivity, psychosocial benefits, and long-term health outcomes.

Three Categories of Juvenile Rheumatoid Arthritis

• Pauciarticular -- Pauciarticular is the most common form of JRA; about half of all children with JRA have this type. Pauciarticular means that four or fewer joints are affected. Pauciarticular disease typically affects large joints, such as the knees. Girls under age 8 are most likely to develop this type of JRA. Some children with pauciarticular disease outgrow arthritis by adulthood, although eye problems can continue and joint symptoms may recur in some people.

• Polyarticular-- About 30 percent of all children with JRA have polyarticular disease. In polyarticular disease, five or more joints are affected. The small joints, such as those in the hands and feet, are most commonly involved, but the disease may also affect large joints. Polyarticular JRA often is symmetrical; that is, it affects the same joint on both sides of the body. Some children with polyarticular disease have a more severe form of the disease, which doctors consider to be similar in many ways to adult rheumatoid arthritis.

• Systemic--Besides joint swelling, the systemic form of JRA is characterized by fever and a light skin rash, and may also affect internal organs such as the heart, liver, spleen, and lymph nodes. Doctors sometimes call it Still's disease. The systemic form affects 20 percent of all children with JRA. A small percentage of these children develop arthritis in many joints and can have severe arthritis that continues into adulthood.


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Risk Factors for Arthritis Gender Gender is a significant risk factor for arthritis, but not one that can be modified. It is, however, an important factor to note for those targeting prevention and early diagnosis educational information. Arthritis is far more prevalent among women than among men consistently across all age groups. Women make up about 60 percent of arthritis cases. Before age 45, osteoarthritis occurs more frequently in males. However, after age 55, it occurs more frequently in females. The tendency of males to develop arthritis before age 45 is influenced by sports participation and work-related joint injuries. After age 55, women are affected because of weight increases and changes in hormonal levels and bone health. Osteoarthritis, the most common form, affects twice as many women as men. Rheumatoid arthritis, one of the most severe and crippling forms, affects up to 2.5 times as many women as men. (Theis, 2007). Age Arthritis does not affect only older individuals and is not a normal part of aging. There are 8.4 million adults nationwide and almost 350,000 in Virginia (BRFSS, 2005) between the ages of 18-44 who have arthritis and many others at risk for developing it. Arthritis affects individuals of all ages, races, and socio-economic classes, although the prevalence of arthritis does increase with age. This pattern suggests that, while treatment services should be targeted to older individuals, prevention efforts must be directed to the general population. Among adults over 65, the prevalence is almost 50 percent, meaning that nearly half of the elderly population will have some form of arthritis. Risk increases with age as does the presence of other complicating chronic conditions. Co-Morbidity Many people with diabetes and cardiovascular disease also have arthritis, thereby complicating the management of all these health conditions. In Virginia, 55.5 percent of adults with diabetes also have arthritis and 58.3 percent of adults with cardiovascular disease have arthritis. The presence of arthritis in people with diabetes, heart disease, asthma, and other chronic conditions may create barriers to adopting a healthier lifestyle. The symptoms of arthritis which include loss of flexibility, decreased mobility, pain, and fatigue, can make physical activity difficult for many individuals. People with diabetes or heart disease who also have arthritis may be reluctant to increase their physical activity for fear of increasing joint damage or increasing pain. This decreased activity can make the management of arthritis and co-existing chronic conditions challenging or place people with arthritis at greater risk of developing other chronic conditions such as diabetes, high blood pressure, obesity, cardiovascular disease, and depression (Virginia Department of Health, Division of Chronic Disease Prevention and Control, 2006). Obesity Being overweight and obese increases the risk of an individual developing arthritis. The most effective strategy for controlling weight is combining dietary changes and exercise. One-third (33.5%) of adults with arthritis were told by their physician to lose weight and 59.7 percent were told to exercise more (BRFSS, 2005). Because diet and exercise are important prevention and treatment strategies for arthritis, interventions are needed that focus on these areas. At the same time, the presence of arthritis can make weight management more challenging, as individuals with arthritis are less able to maintain the level, variety, and regularity of physical activity as the rest of the population.


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Obesity is associated with osteoarthritis in adults and associated with gout in men. Obesity can be a contributing factor causing osteoarthritis by increasing the mechanical stress on the cartilage. Next to aging, obesity is the most powerful risk factor for osteoarthritis of the knees. Obesity can also make regular exercise and daily physical activity challenging.

Weight and Physical Activity in Virginia 1996 - 2006

A confidence rate of 95 percent in the data reported. Source: Virginia Behavioral Risk Factor Surveillance System, 1996-2006. Percentages are population-weighted. As illustrated in the figure above, the percentage of adults who are obese has increased from 15.9 percent in 1996 to 25.1 percent in 2006, almost a 10 percentage point increase in the rate of obesity in 10 years. Those adults identified as overweight increased from 33.4 percent in 1996 to 36.7 percent in 2006. During the same time period, adults who said that they did not participate in physical activity during their leisure time dropped dramatically from 29.2 percent in 1996 to 21.7 percent in 2006.


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Evidence-based Interventions Benefits of Exercise An exercise program that includes a balance of exercises, range of motion, balance, strengthening, and endurance, can relieve the symptoms of arthritis and protect joints from further damage.

• Range of motion exercises are intended to improve flexibility and help prevent further joint damage. Flexibility exercises help the body to stay limber by stretching the muscles and tissues that hold the body’s structure in place. Range of motion exercises include general stretching exercises, which will move joints through their entire range of mobility. Stretching exercises, in turn, include calf stretches, quadriceps (thigh) stretch, and hamstring (tendons in the back of the knee) stretch. Joint-specific exercises target a particular joint such as the knee in order to improve motion in that joint and prevent further damage. An example of this is a quadriceps (thigh) stretch to keep the knees flexible.

• Balance exercises help to prevent falls, a common problem in older adults. Falling is a major cause of broken hips and other injuries that can often lead to disability and loss of independence. Some balance exercises build up leg muscles; others may be as simple as briefly standing on one leg.

• Strength exercises build muscle. Even very small increases in muscle can make a big difference in the ability to do things on one’s own. Strength exercises also increase the metabolism, helping to keep weight and blood sugar under control and may also help prevent osteoporosis. They can improve, maintain, and prevent loss of strength in the muscles. Strength exercises include: Simple, safe, and effective exercises such as abdominal crunches, push-aways, wall squats and other exercises that improve abdominal, neck, arm, shoulder, and leg strength. Many exercise books and videotapes show how to do these exercises properly.

• Endurance or aerobic exercise can strengthen the heart and lungs and increase endurance. They improve the health of the heart, lungs, and circulatory system. Having more endurance not only helps keep one healthier; it can also improve stamina for daily tasks such as climbing stairs, shopping, and socializing. Endurance exercises also may delay or prevent many diseases associated with aging. Aerobic exercises include walking, which can be done outdoors, through the neighborhood or along city paths, or indoors on a treadmill. If walking is uncomfortable, it can be done in water up to the waist or chest. The water helps take the weight off painful joints, and also provides some resistance. Many locations offer classes specifically for people with arthritis. Swimming is an excellent choice for people with hip or knee osteoarthritis, because water takes weight off the joints while also providing some resistance (Wilcox, 2006; Brady, 2003; Der Ananian et.al., 2006).

Exercise can also:

• Help maintain normal joint movement.

• Increase muscle flexibility and strength.

• Help maintain weight to reduce pressure on joints.

• Help keep bone and cartilage tissue strong and healthy.

• Improve endurance and cardiovascular fitness.


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Treatment and Prevention The goal of treatment is to provide pain relief and increase joint mobility and strength. Treatment options include medication, exercise, hot/cold compresses, use of joint protection, and surgery. An individual treatment plan may involve several or all of these options. With early diagnosis, most types of arthritis can be managed, with the pain and disability minimized. In addition, early diagnosis and treatment may be able to prevent tissue damage caused by arthritis. Early, aggressive treatment is particularly important for rheumatoid arthritis in order to help prevent further damage and disability down the road.

Although it may not be possible to prevent arthritis, there are steps to take to reduce the risk of developing the disease and to slow or prevent permanent joint damage. These include:

• Eating a healthy, well balanced, nutritious diet to help strengthen the bones and muscles

• Performing consistent and appropriate exercises to keep muscles strong to protect and support the joints

• Using joint-protection devices and techniques. Proper lifting and posture can help to protect the muscles and joints.

Recommendations for Arthritis Prevention for Virginians At-Risk for Arthritis National data reflect that arthritis affects all age groups and both genders. The highest risk populations for arthritis are women, older persons, persons with genetic predisposition, obese persons, and persons who have sustained occupational or sports related joint injuries. Below are a few primary prevention strategies that are considered effective for arthritis. These include:

• Weight control. Maintaining an appropriate weight or reducing weight to a recommended level lowers a person’s risk for certain forms of arthritis. Obesity is a risk factor for osteoarthritis of the knee and gout in men.

• Occupational injury prevention. Taking precautions to avoid repetitive joint use and resulting joint injury in the occupational setting can help to prevent arthritis.

• Sports injury prevention. Using recommended injury prevention strategies (e.g., warm-ups, strengthening exercises, and appropriate equipment) helps to avoid joint injuries and damage to ligaments and cartilage, all of which can increase the risk of osteoarthritis.

Joint Injuries Recreational activities, sports, occupational and repetitive motion joint injuries increase the risk of arthritis. Occupations such as farming, heavy industry, and those involving repetitive motion are associated with arthritis. Studies have found that self-reported, physician-attended, hand and wrist arthritis was common among employed persons. The highest prevalence was among technicians, machine operators, assemblers, and farmers, and in the mining, agriculture, and construction industries. Compared to other occupations, injuries and occupational illnesses were more common among farmers and farm workers. Work that required repetitive hand bending and twisting was associated with hand-wrist arthritis. Among workers with hand arthritis, almost 20 percent had to make a change in their job or work, 7.4 percent had made major changes in their work, 7.6 percent missed work, and 4.5 percent stopped working or changed jobs because of the problem (Dillon et al., 2002; Grisso et al., 2007).


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Evidence-based Interventions

The CDC Arthritis Program recommends evidence-based interventions that have demonstrated effectiveness to improve the quality of life for people with arthritis. Expanding the reach (the number of people attending) and availability (access to programs) of evidence-based interventions for arthritis is desirable to promote self-management, increase mobility and lead to a positive mental and emotional outlook. These approaches include physical activity programs such as the Arthritis Foundation Exercise Program (AFEP) and the Arthritis Foundation Aquatics Program (AFAP) and self-management education programs like the Arthritis Foundation Self-Help Program (AFSH) and Chronic Disease Self-Management Program (CDSMP), both of which are delivered by trained instructors in community settings.

Chronic diseases, such as programs on diabetes, cardiovascular disease, and arthritis, target many of the same people and have common goals such as increasing physical activity and/or reaching and maintaining a normal weight. Cross cutting evidence-based self-management education and physical activity programs have demonstrated improved health outcomes for people with all three of these conditions and can increase their reach and impact by working together.

Self-management education programs like AFSH, CDSMP, and Active Living Every Day (ALED) teach people how to manage arthritis on a day-to-day basis. Research has shown that appropriate physical activity offers substantial benefits to people with arthritis and can decrease arthritis pain and disability. Preliminary studies have shown AFEP (formerly People with Arthritis Can Exercise or PACE) and the AFAP to be both safe and effective for people with arthritis.

Arthritis and chronic disease self-management programs vary by format and duration. These interventions can potentially decrease the impact of arthritis by reducing pain and the need for health-care. They can improve both the physical and mental health of individuals with arthritis by increasing their self-confidence and improving their ability to function in their daily life and activities. See the following Table for specific details about each evidence-based program (Brady, 2003; Der Ananian et al., 2006; Wilcox, 2006).


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Community Arthritis Management Programs

Program Characteristics Benefits Active Living Every Day (ALED)

• Focus is on behavior change to address physical inactivity and unbalanced eating

• Lifestyle management skills and paced change for long lasting change

• Flexible delivery options (in groups, online, face to face)

• Classes are conducted by trained instructor

• Ongoing support provided

• Addresses both physical activity and quality nutrition

• Addresses the underlying causes of poor health habits

• Approaches allow people to tailor program based on stage of readiness, lifestyle and personal preferences.

Arthritis Foundation Aquatic Program (AFAP)

• Classes are conducted by trained instructor

• Includes range of motion, stretching, breathing, and light aerobic activities

• Meets 2-3 hours a week

• Improve joint range of motion, strength, physical functioning, and health status

• Decrease in pain Arthritis Foundation Exercise Program (AFEP) (formerly known as PACE)

• Community based, recreational exercise program

• Taught by trained instructors • Includes range of motion, endurance

activities, relaxation, and health education

• Meets 2-3 hours a week

• Includes activities to improve physical endurance and joint mobility

• Group exercise encourages peer interaction and socialization

• Program accommodates for individual limitations

• Includes basic principles of arthritis exercise, body mechanics, and joint protection

Arthritis Foundation Self-Help Program (formerly known as AFSH)

• Guided by trained instructors, at least one of whom has arthritis

• Participants have arthritis • Designed to improve self-efficacy • Techniques to manage arthritis,

identifying exercise, use of medications, communicating effectively, nutrition, and action plan and problem solving

• Specific attention to managing pain

• Increase quality of life, knowledge, and recommended health behaviors

• Decrease pain and use of medical services

Chronic Disease Self-Management Program (CDSMP)

• Facilitated by two trained leaders • Participants have at least one chronic

disease • Designed to improve self-efficacy • Includes managing chronic disease,

identifying appropriate exercise, use of medications, communicating effectively, nutrition, developing an action plan and problem solving

• Improve exercise, communication with physicians, self-reported general health

• Decrease health distress, fatigue, disability, and social & role activities limitations


17

The Burden of Arthritis in Virginia Geography The Commonwealth of Virginia encompasses 42,767 square miles, making it the 35th largest state geographically. Local jurisdictions are comprised of 97 counties and 37 independent cities totaling 134 localities. The Virginia Department of Health (VDH) has grouped these localities into 35 health districts and five health planning regions. Virginia has both rich agricultural history and widely diverse geographical regions with six distinct climatic zones, and five general agricultural production areas. Farm lands (approximately 8.7 million acres) support Virginia livestock and agricultural products. Forest lands (15.2 million acres) support important wood-based industries, as well as hunting, fishing and other forest recreation. Wetlands comprise approximately 350 thousand acres and are impacted directly by agricultural and forest activities. Geographically, Virginia is divided into regions stretching from the Eastern Shore and the Atlantic Ocean through the Shenandoah Valley to the Piedmont and the Blue Ridge Mountains of Appalachia in the west. Virginia's unusual length running east to west means that metropolitan northern Virginia lies as close to New York City and New England as to its own rural western panhandle. Conversely, Lee County, at the tip of the southwest panhandle, is closer to eight other state capitals than it is to Richmond, Virginia's own capital (Economic Research Service; VAES). Population Virginia is the 12th most populated state in the U.S. with 7,567,465 residents (U.S. Census, 2005), an increase of almost half a million residents or seven percent from 2000 and a 14.4 percent increase since 1990, according to the U.S. Census Bureau. A significant part of this growth in population has occurred in the northern part of the state. Concentration of population varies widely between Virginia’s urban and rural areas. Twenty-five localities have densities of less than 50 persons per square mile. Half of the Virginia localities have total populations under 30,000 persons, with 24 of those having less than 10,000 persons. Fifty-two counties and cities are considered to be rural (non-metropolitan) areas, however, more than three-fourths of the state’s population lives within metropolitan areas, according to the Census Bureau. The population of Virginia is 51 percent female and 49 percent male. Women aged 15 years and older account for 60 percent of arthritis cases nationwide. A large portion of Virginia’s population is at risk of developing some form of arthritis due to being female. People are moving away from the state's central cities and counties to the surrounding suburbs and exurbs. As a result, the number of metropolitan areas is expected to increase and the boundaries of existing metro areas are expected to expand. Rural counties that are next to metro areas are likely to experience significant population growth as space and affordable housing become harder to obtain in the urban core areas. Counties with significant quality of life advantages, those with access to urban amenities (either their own or nearby), and those with a diversified, service-based economy are particularly prone to rapid growth. The average age of the population will increase as the baby boom generation enters retirement age. By 2030, nearly one in five Virginians is projected to be 65 years or older. This population will be predominantly female, as women have a longer life expectancy than men.


18

Again, age and gender increase the risk for arthritis. As the baby boomers age, the percentage of older workers will increase, as will the average age of the labor force. By 2030, the number of Virginia adults with diagnosed arthritis is projected to be 2.3 million people – an increase of 50 percent from the number in 2005 – which places Virginia 13th among all 50 states in terms of the percentage change (Spar, 2006).

Population Estimates by Demographic Group, Virginia, 2005

2005 2000 Demographic Subgroup Count Percent* Count Percent*

TOTAL 7,567,465 100.0 7,078,515 100.0

Male 3,723,365 49.2 3,471,895 49.1 Sex Female 3,844,100 50.8 3,606,620 51.0 < 18 1,824,568 24.1 1,738,262 24.6 18-64 4,877,794 64.5 4,547,920 64.3 Age 65 and older 865,103 11.4 792,333 11.2 White 5,625,586 74.3 5,324,398 75.2 Black 1,541,683 20.4 1,438,727 20.3 Asian or Pacific Islander 373,773 4.9 289,647 4.1 Race

American Indian or Alaska Nativeç 26,423 0.35 25,743 0.36

Ethnicity** Hispanic 452,511 6.0 329,540 4.7 Source: Virginia Division of Health Statistics. Figures obtained from the U.S. Census Bureau. * Percentages may not add up to 100 percent due to rounding. ** Ethnicity is not mutually exclusive of race. ç According to 2000 U.S. Census data, there were approximately 2,500 people who identified themselves as belonging to any of eight native tribes—Chickahominy, Eastern Chickahominy, Mattaponi, Upper Mattaponi, Pamunkey, Monacan, Nansemond, and Rappahannock-- recognized by the Commonwealth of Virginia.

Access to Health Care Socio-economic status, education, language, race, ethnicity and disability can be predictors of who has access to adequate health care. According to the 2005 American Community Survey, an estimated 684,000 Virginians or 9.2 percent of the population had annual household incomes below the poverty level and were considered “poor, and 15.9 percent had annual incomes between 100 percent and 199 percent of the federal poverty level and were considered to be “near poor” (American Community Survey, 2005). Based on a two-year average (2004-2005), 13.9 percent of Virginians had no health insurance. According to a report by the Urban Institute and the Kaiser Commission on Medicaid and the Uninsured, 13 percent of Virginians were uninsured, 61 percent were insured through their employer, four percent paid for their own insurance, eight percent received Medicaid, 11 percent received Medicare and five percent were on other public assistance. As of January 2008, approximately 25 counties were federally designated health professional shortage areas (HPSAs) lacking access to primary care providers. About 14 percent of Virginians, or over 972,000 people, lived in geographic areas (e.g. counties, census tracts) designated as a primary care HPSA.


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The state is culturally and ethnically diverse, particularly in the north where it is urban and more densely populated. The countries of origin for some of these residents include Korea, Vietnam, China, India, Philippines, Western Europe (e.g., Germany), Mexico, El Salvador, and Bolivia. An estimated 9.9 percent or 723,000 Virginians are foreign born, including 309,000 naturalized U.S. citizens and 414,000 non-citizens. Virginia ranks 17th in the percentage of the population who are foreign born and fifth in the percentage of foreign born from Asia (40.6%). Almost 13 percent of Virginia residents speak a language other than English at home; among these groups, 43 percent speak English “less than very well”. The most common second language is Spanish or Spanish Creole (45%). The foreign-born are more likely to speak a language other than English, as well as to have less than a high school education. Non-U.S. citizen foreign born individuals are more likely to live below the poverty level. Developing culturally sensitive prevention programs, literature, and activities can make an impact on the prevalence of arthritis and related conditions and help increase quality of life for Virginians who may develop these conditions (American Community Survey, 2006). Such culturally sensitive programs must also include what prevention and therapeutic programs are necessarily unique to rural communities, particularly to those involved in agriculture.


20

Prevalence Approximately, 1,539,000 adults, or 29 percent of Virginia’s adult population, reported that they had doctor-diagnosed arthritis while over 37 percent of Virginia residents with arthritis have limitations in their daily activities. Of Virginians age 65 years and older, over 57 percent have arthritis and for those ages 45 to 64 the percentage is over 40 percent. One in three adult women and one in four men in Virginia reported having arthritis (BRFSS, 2003-2005). Although the actual numbers of adults with arthritis vary widely by race and ethnicity, the percentages of the respective population groups diagnosed were quite close and varied by only three percent or less, with 28 percent of non-Hispanic white adults, 27 percent of Hispanic adults and 25 percent of black adults reporting doctor-diagnosed arthritis. Education level was inversely correlated with the number of individuals reporting doctor-diagnosed arthritis. Those with less than a high school education had a prevalence rate at 42 percent; those with a high school education at 30 percent; and those with more than a high school degree at 24 percent. In this case, education level may be a proxy for vocation and involve issues related to joint stress and injury.

Prevalence of Doctor-Diagnosed Arthritis, Adults 18 and Older, 2005

2430

4259

3712

272528

3223

2827

0 20 40 60 80

> High school degreeHigh school degree

Less than high school65 and older

45-6418-44

HispanicBlackWhite

FemaleMale

VA AdultsUS Adults

Prevalence (%)


21

As the map below demonstrates, the areas of the state that have the highest percentage of the population with doctor-diagnosed arthritis tend to be in the more rural regions of the state. In a recent survey, Virginia farmers responded that about 30 percent had been diagnosed with arthritis. Of those affected, about half of them said that the condition interferes with their daily activities, even though only 42 percent of them are currently receiving treatment for their arthritis. The inflammation in joints and the accompanying pain that can limit mobility have important economic and social implications, for disabling agricultural workers and for farmers without proper care. (Mariger, et al, 2007).

Doctor-Diagnosed Arthritis, Adults 18 Years and Older Virginia, 2003-2005


22

Costs Associated with Arthritis Health Care Costs Direct (medical) and indirect (lost earnings) costs attributable to arthritis and other rheumatic conditions in the U.S. during 2003 topped $128 billion. In 1997 nearly 37 million people in the U.S. had arthritis, with the number increasing to 46 million in 2003. The rise in arthritis medical costs includes more than a doubling of prescription drug costs, from about $33 billion in 1997 to almost $75 billion in 2003. The average arthritis prescription costs per person were $141 in 1997 and over twice that, $338, in 2003. Inpatient treatment costs dropped during the same period. In 1997, average inpatient costs per arthritis patient totaled $508, dropping to $352 per person in 2003 (Yelin, Murphy, Cisternas et al., 2007).

Every year in the U.S., arthritis produces 750,000 hospitalizations, 36 million ambulatory care visits, and 44 million physician visits. Women account for 63 percent of these visits and individuals under 65 years account for almost 70 percent of these visits. The estimated total cost of arthritis was over $50 billion dollars in healthcare expenditures and an additional $35 billion in lost productivity.

Arthritis is costly in terms of both medical care (direct costs) and lost productivity earnings (indirect costs). Based on analysis of 2003 Medical Expenditure Panel Survey (MEPS) data, the estimated direct costs in Virginia were $2.12 billion (affecting 1.48 million people) and the estimated indirect costs were $1.35 billion (affecting 1.1 million people), for a total of $3.47 billion in costs associated with arthritis (Yelin, Cisternas, Foreman, et al., 2007).


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In 2004, there were 22,077 hospitalizations (stays) with a primary diagnosis of arthritis or other allied condition in Virginia.1 The total charges for these hospital stays was over $616 million, with an average of $27,911 spent per stay. Patients spent a total of over 90,000 days in the hospital for arthritis-related conditions, for an average of 4.1 days per stay.

Percent of Total Arthritis Hospitalizations, by Diagnosis, Virginia, 2004

66.4

2.0

0.6

0.4

7.5

3.8

10.5

2.0

1.7 5.2Osteoarthritis

Rheumatoid arthritis

Myalgia/myositis

Carpal tunnel syndrome

Soft tissue disorder

Joint pain/effusion

Spondylosis/spondylitis

Diffuse connective tissuediseaseGout/crystal arthropathies

Other rheumatic conditions

Source: Virginia Health Information.

• Osteoarthritis represented the majority (n=14,652; or 66%) of the hospital stays and total hospital

charges spent (n=$450 million; 73%). • Women had more arthritis-related hospitalizations (61%) than men (39%). • Women had a higher age-adjusted rate (332.4 per 100,000) of hospitalization for arthritis than men

(258.4).2 • Blacks had a higher age-adjusted rate (312.6 per 100,000), compared to whites (288.0), Hispanics

(91.8) or people of other races (109.0). • The eastern region of the state had more hospitalizations (5,887, or 27%) than other regions (Chronic Disease in Virginia, 2006).

1 Includes osteoarthritis; rheumatoid arthritis; myalgia or myositis; carpal tunnel syndrome; soft tissue disorder; joint pain, effusion, or unspecified joint disorder; spondylosis or spondylitis; diffuse connective tissue disease; gout and crystal arthropathies; and other specified rheumatic conditions. See the diagnostic categories developed by the National Arthritis Data Workgroup (NADW). 2 Rates are age-adjusted to the 2000 U.S. standard population.


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Social and Behavioral Costs

Although the increasing frequency of individuals with arthritis and the accompanying fiscal costs is startling, the costs associated with arthritis are not only monetary. Individuals and families coping with arthritis experience physical, mental, and social costs as well. Twenty eight percent of adults in Virginia with doctor-diagnosed arthritis reported that their general health was fair or poor, compared to 7.6 percent of adults without arthritis (BRFSS, 2005). Adults with arthritis had, on average, 6.5 days in the past month when their physical health was not good, compared to 2.1 days for people without arthritis, and 4.2 days in the past month when their mental or emotional health was not good, compared to 2.8 days for people without arthritis.

Individuals coping with arthritis may experience low self-esteem, depression, feelings of helplessness, and anxiety. In addition, those dealing with arthritis and other joint related health concerns report a higher level of mental distress than the general population. People with arthritis were 60 percent more at risk than people without arthritis for experiencing “frequent mental distress” defined as having 14 or more mentally unhealthy days in a 30 day period. Other costs associated with the presence of arthritis may include: reduction in work hours, or the loss of job, loss of time with family and friends, and decreased ability for engagement with family and community activities.


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Arthritis-Attributable Activity Limitation Cost Arthritis is the leading cause of disability in the United States, affecting 18.9 million adults. Over half a million (577,000) adults in Virginia reported that they have activity limitations that they attribute to their arthritis (BRFSS, 2005). This represents 10 percent of the adult population and over a third (38%) of adults with arthritis. More adults who reported having arthritis-attributable activity limitations tended to be obese and/or physically inactive.

Doctor-Diagnosed Arthritis Prevalence of Diagnosed Arthritis with Activity Limitation1 2005 Data Count

(in thousands) Pct. Rate (95% CI)

Count (in thousands)

Pct. Rate (95% CI)

Female 917 32.0 (29.9-34.2) 346 38.3 (34.4-42.2) Sex Male 622 23.0 (20.7-25.2) 231 37.5 (32.6-42.4) 18-44 348 12.2 (10.4-14.0) 117 34.7 (27.4-42.0) 45-64 690 37.3 (34.4-40.2) 260 37.9 (33.5-42.2)

Age

65+ 497 58.9 (55.1-62.7) 197 40.2 (35.3-45.0) White, non-Hispanic

1,184 28.0 (26.2-29.8) 432 36.8 (33.4-40.1)

Black, non-Hispanic

178 24.6 (20.7-28.6) 82 46.5 (37.9-55.1)

Hispanic 42 26.9 (14.1-39.6) NC NC

Race/-Ethnicity

Other 85 24.8 (17.7-31.9) 35 43.4 (28.3-58.4) < HS 201 41.8 (36.3-47.2) 90 45.9 (38.5-53.4) HS or GED 477 30.1 (27.1-33.2) 179 38.4 (33.0-43.8)

Education

> HS 856 24.5 (22.5-26.5) 307 36.0 (32.0-40.1) Obese 496 36.4 (33.2-39.7) 235 47.6 (42.5-52.8) Overweight 537 27.5 (24.9-30.3) 193 36.2 (31.3-41.5)

Weight

Neither 456 21.9 (19.5-24.5) 133 29.9 (24.8-35.5) Inactive 206 41.0 (35.7-46.4) 105 52.8 (45.5-60.1) Insufficient 595 28.9 (26.3-31.6) 223 37.9 (33.1-43.0)

Physical Activity (PA) Recom-

mended 613 23.1 (20.9-25.4) 200 32.8 (28.3-37.6)

Total 1,539 27.6 (26.0-29.2) 577 38.0 (35.0-41.0) 1 Denominator is the total population of adults in Virginia. NC = Not calculated. Source: Virginia Behavioral Risk Factor Surveillance System. Percentages and counts are population-weighted.


26

Prevalence of Doctor-Diagnosed Arthritis and Arthritis Attributable Activity Limitation, Virginia 2005 Although the number of people who suffer with arthritis has been growing over the years, the prevalence rate has remained steady between 2002 (26.2%) and 2005 (27.6%). Between 2002 and 2005, there has been a significant increase in the rate of adults with activity limitations associated with arthritis.

Doctor-Diagnosed Arthritis and Arthritis-Related Activity Limitation, Virginia: 2002 to 2005

Activity Limitation Due to Arthritis, Adults Ages 18 and Older

Virginia, 2003-2005


27

Arthritis Limits Work in Virginia In all states, working-age (18-64 years) adults face limitations on their ability to work that they attribute to arthritis. These first state-specific estimates show that the prevalence of work limitations due to arthritis varied by state but was generally high, ranging from 3.4 percent to 15 percent of all working-age adults. The proportion of working-age adults with arthritis who reported that the disease was severe enough to limit their ability to work ranged from 25.1 percent in Nevada to 51.3 percent in Kentucky. These variations may be related to different levels of arthritis in states or to the predominance of certain occupations, such as mining, manufacturing, service, or agricultural jobs, in a particular state. The data provide an important illustration of arthritis’ impact on working-age adults in all states, and also demonstrate the need for increased interventions (Yelin, E. et al, 2007).

Arthritis can affect work productivity. Examining the impact of work is important, especially as arthritis is projected to increase with the aging of the population, and Americans are staying in the workforce longer. The increased use of effective and available interventions among those with arthritis should help reduce the high impact that arthritis has on work. According to findings from the 2003 Behavioral Risk Factor Surveillance System (BRFSS), one third (33.7%; 95% CI: 30.1 – 37.4%) of all working-age adults with arthritis in Virginia report that their condition affected their ability to work, which is similar to the national median (Theis et al., 2007). This figure represents 349,000 adults or 7.6 percent of all working adults in Virginia. This rate is the 16th highest rate among all states and the District of Columbia. Older employed adults were affected more than younger adults.

State vocational rehabilitation agencies are charged with assisting people with disabilities to become employed. A recent longitudinal study looked at consumers participating in vocational rehabilitation agency services to determine whether secondary conditions, such as chronic pain, fatigue, depression, and arthritis, could help predict future employment outcomes. Arthritis was ranked seventh in a list of 29 secondary conditions, with 56 percent of respondents indicating that arthritis limited their work participation. However, when asked how much each condition limited them on a scale of 0 (never limits) to 3 (significant limitation of more than 11 hours per week), arthritis was second only to chronic pain in severity (Ipsen, 2007).


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Comparative Data Highlights for Arthritis in Virginia, 2003 – 2005 Arthritis Data and Statistics Coordinated and supported by the CDC, the Behavioral Risk Factor Surveillance System (BRFSS) is conducted by the 50 state health departments, and provides state-specific information about issues such as diabetes, health care access, hypertension, obesity, cancer screening, nutrition and physical activity and more. Federal, state, and local health officials and researchers use this information to track health risks, identify emerging problems, monitor health risk behaviors, chronic diseases and disabilities, prevent disease, and improve treatment. The BRFSS is used by Virginia and other states to collect information on health indicators for arthritis among the state’s adult population. It is the primary tool for collecting data on arthritis in Virginia. The BRFSS is an ongoing, state-based, random digit-dialed telephone survey of the citizen, non-institutionalized population age 18 years and older. Arthritis data has been collected as part of the BRFSS since the 1990s. Defining Arthritis In 2002 the definition used for arthritis changed. Before 2000, 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 efforts. Those persons with chronic joint symptoms are counted as possible arthritis cases. Focusing surveillance on persons with doctor-diagnosed arthritis allows programs to target those for whom it is more certain that they have arthritis or other rheumatic conditions. The new surveillance definition means that the definition that is used is more comparable to the case definitions used for other chronic diseases such as diabetes and heart disease. This change in case definitions and the change in wording of some questions, however, means that direct comparison of data from all previous years is not always possible. The following table is based upon the BRFSS collected for Virginia during the years 2003 to 2005 when there were sections and questions that allow for direct comparison of the data.


29

Demographic Characteristics of Adults with Arthritis Arthritis affects all races and ethnic groups. Approximately 1,539,000 adults or almost 29 percent of Virginia’s adult population report that they have doctor-diagnosed arthritis. While adults reporting doctor-diagnosed arthritis are predominately age 65 and over (59 percent), almost 40 percent of those with arthritis are from 45 to 64 years of age and 12 percent are 18 to 44 years of age. The percentage of women with doctor-diagnosed arthritis is 10 percent higher than men, with almost one out every three women in Virginia having a diagnosis. Although the actual numbers of adults with arthritis vary widely by race and ethnicity, the percentages of the respective population groups diagnosed are quite close, varying only three percent or less; that is, 28 percent of non-Hispanic white adults, 27 percent of Hispanic adults, and 25 of black adults reporting doctor diagnosed arthritis (BRFSS 2003-2005). Education level is inversely correlated with the number of individuals reporting doctor-diagnosed arthritis: 42 percent among those with less than a high school education, 30 percent among those with a high school education, and 24 percent among those with more than a high school degree. In this case, education level may be a proxy for vocation and involve issues related to joint stress and injury. Demographics, age, education, race and ethnicity in Virginia 2003 2004 2005

Adults who have doctor diagnosed arthritis 1,469,000 (27%)

1,501,000 (29%)

1,539,000 (28%)

Adult women who have doctor diagnosed arthritis 841,000 (30%)

899,000 (33%)

917,000 (32%)

Adult men who have doctor diagnosed arthritis 628,000 (24%)

603,000 (24%)

622,000 (23%)

Adults age 18-44 years who have doctor diagnosed arthritis

374,000 (14%)

364,000 (13%)

348,000 (12%)

Adults age 45-64 years who have doctor diagnosed arthritis

654,000 (37%)

689,000 (41%)

690,000 (37%)

Adults age 65+ years who have doctor diagnosed arthritis

396,000 (52%)

444,000 (57%)

497,000 (59%)

Non-Hispanic white adults who have doctor diagnosed arthritis

1,108,000 (29%)

1,138,000 (30%)

1,184,000 (28%)

Non-Hispanic black adults who have doctor diagnosed arthritis

208,000 (26%)

166,000 (26%)

178,000 (25%)

Hispanic adults who have doctor diagnosed arthritis

20,000 (13%)

48,000 (17%)

42,000 (27%)

Adults with less than a high school education who have doctor diagnosed arthritis

253,000 (44%)

201,000 (36%)

201,000 (42%)

Adults with a high school education who have doctor diagnosed arthritis

447,000 (29%)

415,000 (30%)

477,000 (30%)

Adults with more than a high school education who have doctor diagnosed arthritis

766,000 (24%)

883,000 (27%)

856,000 (24%)


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Arthritis and Physical Activity, Body Weight and Health Status Physical activity in the form of regular moderate exercise maintains joint health, relieves pain, and improves function. Physical activity can reduce the risk of functional decline by 38 to 41 percent and incident disability by 47 percent among adults with arthritis. However, arthritis is a more frequent cause of activity limitation than heart disease, cancer or diabetes. Individuals with arthritis need specific guidance on types, duration, and frequency of physical activity that is appropriate for arthritis. Reducing body weight can reduce the risk of incident knee osteoarthritis and limit the progress of disease. Losing as little as 10 pounds can reduce the risk of incident knee osteoarthritis by half. Weight loss programs incorporating both exercise and diet restrictions are the most effective and result in significant improvements in pain and function.

Activity Limitations, Body Weight, and Health Status in Virginia 2003 2004 2005

Adults with activity limitations due to arthritis or joint symptoms

544,000 (10%)

557,000 (10%)

577,000 (10%)

Adults with arthritis who have activity limitations due to arthritis or joint symptoms 37% 37% 38%

Adult men who have activity limitations 232,000 218,000 231,000

Adult men with arthritis who have activity limitations due to arthritis 37% 36% 38%

Adult women who have activity limitations 312,000 339,000 346,000 (12%)

Adult women with arthritis who have activity limited due to arthritis 38% 38% 38%

Percentage of obese adults who have doctor diagnosed arthritis 38% 40% 37%

Adults who are physically inactive and have doctor diagnosed arthritis

Not Available

Not Available

206,000 (41%)

Adults with arthritis… …who report they are physically inactive

NA NA 15%

…who are overweight 36% 36% 36%

…who are obese 30% 32% 33%

…with poor or fair health 27% 25% 28%


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Arthritis and Other Chronic Conditions Chronic diseases affect well over one hundred million Americans. Chronic diseases pose a significant threat to the health, economic status and quality of life for individuals, families, and communities, with the greatest burden concentrated in the 65 and older age group. With the aging of the baby boomers, demographic trends indicate increases in the frequency of chronic diseases in the next 20 to 30 years. The presence of arthritis can complicate the symptoms and management of other chronic conditions by potentially presenting an additional barrier to healthier lifestyles, such as increased pain during physical activity. There are a growing number of people with multiple chronic conditions who need help finding ways to maintain their health, manage multiple chronic conditions and improve the quality of their lives. Diagnosed arthritis was reported by 55.5 percent of adults with diabetes (excluding gestational diabetes and pre-diabetes), by 58.3 percent of adults with cardiovascular disease (defined as having had either heart attack or angina), by 48.9 percent of adults with high blood pressure and by 41.4 percent of adults with high cholesterol. The major barrier to physical activity among people with arthritis is pain. Individuals with diabetes or cardiovascular disease who also have arthritis may be reluctant to increase their physical activity for fear of increasing joint damage or pain. The co-existence of multiple chronic diseases may make a healthy diet and exercise program more challenging and require more creative options and health plans that are individualized and developed in partnership with health care professionals.

Adults with a Chronic Disease who also have Arthritis in Virginia

2003

2004

2005

Adults with diabetes who also have arthritis

209,000 (53%)

215,000 (58%)

213,000 (56%)

Adults with heart disease who also have arthritis

185,000 (58%)

179,000 (66%)

211,000 (58%)

Adults with high blood pressure who also have arthritis

655,000 (49%)

678,000 (49%)

730,000 (49%)

Adults with high cholesterol who also have arthritis

623,000 (44%)

684,000 (47%)

677,000 (41%)

Adults who are overweight who also have arthritis

512,000 (27%)

520,000 (28%)

534,000 (27%)

Adults who are obese who also have arthritis

427,000 (38%)

453,000 (40%)

490,000 (37%)

Adults who are inactive who also have arthritis Not Available Not Available 206,000

(41%)


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Arthritis Self Management, Related Limitations and Factors Chronic diseases are the dominant health care problem today and effective self-management is an essential part of the solution. There is growing enthusiasm for evidence based self management programs, as either stand alone programs or as part of broader chronic care models, to control or prevent chronic disease complications. There is not unanimous agreement on the individual elements that should be included in all self management programs. However, a broad definition of “chronic disease self-management” would include a systematic intervention that is targeted toward patients with chronic disease to help them to participate in either or both of the following:

• Self-Monitoring of symptoms or physiological processes and/or • Decision-Making about managing the disease or its impact based on self-monitoring.

Self-management education programs emphasize the role of patient education in preventive and therapeutic health care activities and consist of organized learning experiences designed to assist with adopting health-promoting behaviors. Self-management programs can have many benefits beyond pain reduction, including mood improvement, enhanced self-efficacy, and reduced need for medical services. The percentage of individuals with arthritis who have ever taken a class for arthritis continues to be low (10 %) and holds great potential for outreach and education.

Self-Management of Arthritis Related Limitations 2003 2004 2005

Adults with Arthritis….

who report they can do all or most things they want

985,000 (70%)

1,079,000 (72%)

1,067,000 (72%)

who report they can do some things or hardly anything

421,000 (30%)

416,000 (28%)

409,000 (28%)

who were told by their doctor to lose weight

300,000 (21%)

472,000 (32%)

497,000 (34%)

who were told by their doctor to exercise

710,000 (50%)

830,000 (56%)

886,000 (60%)

who have ever taken a class to manage their arthritis

164,000 (12%)

156,000 (10%)

145,000 (10%)


33

Goals and Strategies The following goals and objectives were developed by the four work groups of the Virginia Arthritis Action Coalition (VAAC) and will be used during the next several years to implement and evaluate the progress of the Arthritis Plan in addressing the burden of arthritis in Virginia. The four VAAC work groups are: Communication and Marketing; Programs and Education; Surveillance and Epidemiology; and Health Systems and Policy. Their reports follow. Communication and Marketing Introduction and Statement of Problem The development of communication strategies will aim at increasing awareness of arthritis, its impact, management, and available services and resources among the general public and especially among high risk populations. Increasing awareness of the prevalence, severity, and disability associated with arthritis and related conditions can help promote early diagnosis and appropriate management and prevention or reduction of severe disability and pain. Communication is key to raising awareness of the prevalence of arthritis. Public awareness and education are necessary to dispel misunderstanding about arthritis and link individuals to accurate and useful information. Collective strategies that are presented with consistent messages can reach entire populations. Many people with arthritis believe that there is little they can do to affect their disease. Others lack knowledge about their disease or effective means to prevent future disability. They need information about programs and resources available and how to access these services. Health care professionals are a credible source of health-related information. Advice and referral from a health care professional is a powerful tool. Increasing awareness and knowledge among health care professionals and providers of 1) the appropriate clinical guidelines and standards of care, 2) the importance of early diagnosis in minimizing the extent of disability, 3) appropriate management of pain, and 4) the resources and services available for people with arthritis will better equip them to impact the quality of life of people with arthritis.

Communication and Marketing Work Group Members Deborah Batakis, RN, Chairperson Virginia Beach Health District Katie Benghauser, MS Gerontology SeniorNavigator Pat Davidson, BS, CHES Virginia Beach Health District Linda Gail Johnson, RN, BSN, MPH Augusta Medical Center Susan E. Johnson, MA Virginia Area Agency on Aging Shirley Miller, BS Lenowisco Health District


34

Nancy Smith, BS Mountain Empire Older Citizens, Inc Theresa Teekah, MA, RN, CHES Division of Chronic Disease Prevention & Control, Virginia Department of Health Elaine Smith, MS, RD Virginia Department for the Aging Communication and Marketing Goals and Strategies Goal #1: Increase the awareness and availability of arthritis prevention and control resources to assist Virginians who seek early diagnosis or to develop/improve self-management skills. Strategies:

A. Develop and implement a public awareness campaign that promotes the importance of early diagnosis for arthritis, using multiple media outlets (i.e., tool kits, websites, television, radio, newspapers, billboards, pharmacy and grocery bags, newsletters, etc.).

B. Develop tailored messages and identify and use appropriate media to meet the needs and concerns of target audiences.

C. Publicize available arthritis resources through a catalogue of statewide arthritis resources, tool kits, radio messages, newspaper ads, articles, flyers, exhibit boards, church bulletins, community calendars, health club newsletters, websites, etc.

D. Support marketing the statewide resource system including regional based centers and community programs.

Goal # 2: Increase the public awareness of the many forms of arthritis, the signs and symptoms of arthritis, and the importance of prevention, early diagnosis, and self-management. Strategies:

A. Develop and implement a public awareness campaign utilizing a variety of media outlets, both published and electronic, to reach a large cross section of the population.

B. Provide workshops, meetings and speakers for the general public to access up to date information about arthritis and resources.

C. Provide materials that are appropriate for a variety of public audiences. D. Identify and promote information about the availability and benefits of arthritis early

detection and self-management programs.

Communication and Marketing to Healthcare Providers Goal # 3: Increase awareness among healthcare providers of the need for the early detection and management of arthritis, as well as available arthritis resources. Strategies:

A. Promote education programs for healthcare providers to increase their awareness of the need for early diagnosis and treatment, and the availability of resources.

B. Provide workshops and meetings for continuing education opportunities for health care professionals.

C. Assist in the distribution and use of educational materials for health care providers and their clients.


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Programs & Education Introduction and Statement of Problem Educational programs can both ensure quality health care and services to people with arthritis and alleviate the financial, emotional, and physical burden of arthritis. Tailoring educational programs to diverse audiences (such as minorities, low income and older adults) will increase awareness of prevention, early diagnosis, self-management, and treatment of arthritis. These programs will facilitate change in knowledge, attitudes, beliefs, and behaviors that promote health and alleviate arthritis. Such efforts will lead to both a higher quality of life and a more productive work life. Effective interventions that lead to a continuum of care, supportive of primary, secondary, and tertiary prevention, will provide the framework for programs geared at the community and health system needs of people with arthritis. Such initiatives will incorporate strategies that reduce risk factors, provide for early diagnosis, adapt personal environments, and promote self-management. In addition, this strategy will also address the prevalence of arthritis co-morbidities, such as, diabetes, heart disease, stroke, and obesity, and stress the importance of understanding such conditions to secure quality treatment, improve disease management, and provide for appropriate pharmaceutical care. Virginia health care professionals need the most current standards of care regarding arthritis prevention, diagnosis, and treatment, along with information about community resources that address arthritis interventions for their patients. VAAC will partner with other professional organizations to provide workshops, conference sessions, and onsite trainings related to current arthritis information for health care professionals. People with arthritis and their families need to have access to community based programs supportive of their physical, mental, social and economic well-being. Education programs that include the benefits of physical activity, weight control, nutrition, and the importance of early diagnosis and treatment need to be encouraged within the community. Interventions at work sites, sport/fitness facilities, health departments, health systems, and other community organizations such as churches, senior centers, and parks and recreation facilities need to be supported.

Programs & Education Work Group Members Charlene Learner, RN, BSN, Former Chairperson Virginia Beach Health District Mary Casebolt Mary Washington Hospital, Nursing Center of Excellence Alison Clarke, CTRS. Sheltering Arms Rehabilitation Center Jo Anne Hammer, RN Augusta Medical Center Jean Skinner Fairfax County Parks Authority Alice G. Steele, CPRN Retired Nurse Anesthetist Debra Waln, Vice-President Medicaid for Southern Health Services, Inc. Kristy Zafar, Maitrise es Lettres (France), MES May Therapy and American Family Fitness Centers


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Programs and Education Goals and Strategies Goal 1: Increase the availability of arthritis prevention programs in Virginia. Strategies:

A. Assess existing programs and partner with rehabilitative organizations to identify and target under-served and high risk populations.

B. Maintain and develop skilled staff to oversee arthritis programs. C. Partner with Virginia workplaces in both the public and private sectors to develop and institute

targeted, on-site arthritis education and occupation injury prevention programs. D. Partner with sport and fitness trainers, athletic associations, and schools to develop and

implement education programs to prevent overuse joint injuries. E. Partner with Cooperative Extension and AgrAbility to develop and conduct arthritis education

and prevention programs targeted to agriculture workers. F. Partner with other chronic disease prevention programs to provide cross-cutting prevention

programs and education. Goal 2: Increase knowledge and awareness of arthritis and related conditions and the benefits of evidence-based interventions and programs that support Virginia residents who suffer the effects of these conditions. Strategies:

A. Expand participation in evidence-based physical activity, nutrition, and weight control programs to help people with arthritis.

B. Support the development of evidence-based physical activity, nutrition, and weight control programs where they do not exist.

C. Increase the proportion of adults with doctor-diagnosed arthritis who receive health care provider counseling for physical activity or exercise.

D. Partner with state and community organizations to promote self-management of arthritis through the completion of approved evidence-based programs in multiple community settings.

E. Increase the proportion of persons with doctor-diagnosed arthritis who have had effective, evidence based arthritis education as an integral part of their disease management.

Goal 3: Increase the availability, accessibility, and participation in effective evidence-based physical activity, weight control, and self-management programs for Virginia residents with arthritis and related conditions. Strategies:

A. Conduct an assessment of the availability of evidence-based physical activity, weight control, and self-management programs in Virginia.

B. Encourage and assist with the development of local arthritis coalitions in Virginia health districts targeting those who have limited availability for persons with arthritis.

C. Encourage local coalitions to work within their communities to increase availability of programs that benefits persons with arthritis.

D. Partner with other organizations to fund and provide Instructor Trainer courses for chronic disease self-management programs and arthritis physical activity programs.

E. Provide statewide listing of programs on Virginia arthritis related websites.


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Goal 4: Develop support systems in Virginia for persons with arthritis. Strategies:

A. Support educational and program efforts of the statewide resource system, regional centers, and community programs.

B. Partner with other organizations to establish local support groups for persons with arthritis, their families, and caregivers.

C. Develop and distribute information or resources for persons with arthritis on adapting their personal environment and about devices available to assist them with activities of daily living.

D. Place information about adaptive environments and devices available on various arthritis related Virginia-based websites.

E. Partner with appropriate organizations to distribute arthritis education materials. Goal 5: Increase knowledge of Virginia health care professionals about arthritis prevention, diagnosis, and treatment and the programs available for their patients/clients. Strategies:

A. Assess the need of health care professionals and their clients for information about arthritis prevention, treatments, and programs.

B. Partner with other organizations to provide workshops, conference sessions, and onsite trainings related to current arthritis information for health care professionals.

C. Provide a list of available community self-management, physical activity, weight control, and arthritis education programs to Virginia health care professionals so they can refer patients.

D. Increase the proportion of adults with doctor-diagnosed arthritis that receive health care provider counseling for weight reduction.

Goal 6: Increase effective arthritis prevention awareness for at-risk populations. Strategies:

A. Identify at risk populations and groups in Virginia. B. Develop an arthritis prevention brochure and target distribution to at-risk individuals and groups. C. Identify and partner with appropriate organizations to promote the development and distribution of

an arthritis prevention video targeted to at-risk populations. D. Support the implementation of occupational, agricultural, and worksite injury prevention programs

specifically targeted to at-risk workers. E. Partner with Virginia organizations such as Cooperative Extension Service, and AgrAbility to

disseminate information about the importance of prevention, early diagnosis, and adaptive strategies to support agriculture and farm workers with or at-risk for arthritis.


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Surveillance and Epidemiology Introduction and Statement of Problem Surveillance is the ongoing, systematic collection, analysis, and interpretation of data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control. Quality data collection and ongoing surveillance are at the center of informed decision-making and programmatic planning. Surveillance data can be used to:

• Raise the visibility of arthritis among the public by documenting the magnitude of the statewide arthritis problem.

• Develop state and regional arthritis databases. • Monitor the arthritis burden and track trends within various subgroups. • Allow a more accurate comparison of arthritis relative to other health conditions. • Allow for comparison of arthritis among regions and communities. • Guide program efforts by identifying “high risk” population groups. • Identify disparities in occurrence and impact of arthritis. • Track the progress toward meeting program objectives. • Provide information to people interested in arthritis.

Surveillance and Epidemiology Work Group Members

Pam Lane, MPH, Chairperson Three Rivers Health District Ed Ansello, PhD Virginia Commonwealth University Center on Aging Deborah Harris, MPH, RD, CED Women and Infants Health Care, Virginia Department of Health Gail Jennings, PhD Division of Chronic Disease, Virginia Department of Health Beth O’Connor, MEd. Virginia Rural Health Resource Center Millie Roberson, RN, PhD Professor of Nursing (Retired) Sheila Ward, PhD Norfolk State University


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Surveillance and Epidemiology Goals and Strategies Goal 1: Improve surveillance of arthritis in general and of specific types of arthritis in Virginia. Strategies:

A. Collect and analyze BRFSS arthritis prevalence, arthritis management, and quality of life data every other year (or as funding permits) to gather insights into the burden of arthritis.

B. Identify surveillance gaps, including lack of data on children with arthritis. C. Identify the existence and causes of disparities in arthritis prevalence in different populations. D. Analyze data on inpatient hospital discharges with a primary diagnosis of arthritis for the

general population. E. Monitor state and national arthritis surveillance through the National Health Interview Survey

(NHIS) and other national data sources. F. Determine which agencies have jurisdiction over reporting prevalence and find out the

feasibility of amending the reporting to include chronic diseases. Goal 2: Support data systems to track the occurrence and impact of arthritis. Strategies:

A. Assess Medicaid and Medicare Services (CMS) aggregate data on outpatient physician visits, pharmacy charges, and inpatient hospitalizations related to arthritis for the population served by the two state-managed care programs.

B. Analyze aggregate data from managed care organizations (MCOs) on physician visits and hospital discharges related to arthritis

C. Coordinate, to the extent possible, Virginia arthritis initiatives and evaluation with national and regional arthritis research and evaluation efforts.

D. Encourage the Joint Commission on Health Care to examine and the Joint Legislative Audit and Review Commission to study the burden of arthritis in Virginia regarding prevalence, incidence, costs, impact on quality of life, plus resource accessibility and utilization.

E. Partner with AARP and Area Agencies on Aging to conduct a targeted survey on awareness of arthritis prevention and management, as well as the personal effects of arthritis.

F. Explore alternative data sources to identify information on arthritis resources and utilization trends.

Goal 3: Disseminate Virginia arthritis data in a variety of forms and formats. Strategies:

A. Support statewide and regional arthritis data, where appropriate. B. Distribute resources of relevant and current data. C. Assess the arthritis data needs for a variety of audiences in the state. D. Monitor and report impact and outcomes of regional efforts. E. Support a variety of data delivery methods. F. Identify the need for culturally appropriate delivery of arthritis data. G. Support the delivery of arthritis data and supporting information in culturally appropriate formats

and languages. H. Update the VAAC with arthritis data on an annual basis.


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Health Systems and Policy Introduction and Statement of the Problem Virginians, like most Americans, are affected by health and health care policies through our access to medical care, how to pay for health services, and the quality of the care received. Most Virginians enjoy the best health care in the world, but many are uninsured and unable to afford needed care and prescription drugs that reduce the morbidity of diseases and prolong life. Policies and legislation are critical in determining when, where, and how citizens, particularly those who are vulnerable and live in underserved areas, receive medical care. Proactive policies that are diffused across the state can greatly enhance the chances of success in preventing arthritis and improving the quality of life of those affected by this condition. Providers, consumers, and policy makers have no access to a single source of information on policies, legislation, and regulations in Virginia that benefit individuals with arthritis and related conditions. There is a need for a cohesive statewide network that can bring regionally coordinated, community based resources together to meet the needs of persons who have been diagnosed with arthritis and other chronic diseases. Additionally, information on practices and policies within health care systems, managed care organizations, and employer groups may prove useful in determining what works best in the prevention and control of arthritis. In some states, such as Missouri, the development of Regional Arthritis Centers has helped to fill this gap. The Virginia Arthritis Action Coalition (VAAC) Polices and Systems Work Group proposes that the state plan continue to be revisited and updated periodically to include recommendations that address policy issues related to arthritis.

Health Systems and Policy Workgroup Members

Kirk Ballin, M. Div, Co-Chairperson AgrAbility Virginia Mary Jo Ivan, RN, Co-Chairperson Fairfax County Department of Health Judy Altman Yoder, MA Arthritis Foundation, Virginia Chapter Laverne Morrow Carter, PhD (Former Chair) Carter Research Group, Inc. Jamie Farmer, MPH, CHES Arthritis Foundation, Metropolitan Washington Chapter Eletta Hansen, RN, MPH Mary Washington Hospital, MediCorp Health System Marilyn Pace Maxwell, MSW, ACSW Mountain Empire Older Citizens, Inc, Terri Morris, RN, BSN Fairfax County Department of Health Leonard Recupero, M.Ed Division of Injury and Violence Prevention, Virginia Department of Health


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Health Systems & Policy Goals and Strategies Goal 1: Identify groups and individuals who affect policy related to arthritis and related conditions. Strategies:

A. Identify policymakers in Virginia, including legislators, state agency leaders, health educators, and members of the Joint Commission on Health Care who can inform VAAC of current legislative activities related to arthritis.

B. Participate in networking activities to establish VAAC initiatives as a part of the legislative platform of other associated groups.

C. Inform VAAC members of relevant legislative issues on a regular basis. D. Determine the current regulations and policies related to the reporting of chronic diseases. E. Identify partners from other chronic disease programs and explore possible collaborative

efforts. Goal 2: Identify federal and state statutes, regulations, and budget provisions affecting consumers, providers, and payers of arthritis and arthritis-related services. Strategies:

A. Partner with an academic public policy program to explore strategies that provide information about regulations, statutes, and policies.

B. Establish a database of relevant policies and statues. C. Provide an easy to use summary of relevant regulations.

Goal 3: Examine state level mechanisms for reporting, collection, and analysis of prevalence data for selected chronic diseases, including arthritis. Strategies:

A. Determine what the current regulations and policies are related to the reporting of chronic diseases.

B. Determine which agencies have jurisdiction over reporting prevalence and ascertain from the staff of that agency the feasibility of amending the reporting mechanisms to include chronic diseases–including arthritis.

C. Identify partners from other chronic disease programs. D. When appropriate, propose to state policymakers and lawmakers, a recommendation to

amend state disease reporting regulations to include arthritis.

Goal 4: Identify best practices in the public and private sectors for the treatment and management of arthritis and arthritis related conditions, using the best partners and information sources. Strategies:

A. Collect information on agencies and organizations involved in arthritis diagnosis, treatment, and management in the Commonwealth of Virginia.

B. Place the names, contact information, and services of each agency in a database. C. Mail surveys to the organizations to ascertain the practices and services they are providing. D. Develop a set of criteria for best practices. E. Review survey results and establish a compendium of “best practice” programs in the state. F. Disseminate the findings to appropriate agencies and stakeholders through a publication.


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Goal 5: Examine comprehensive arthritis policy agendas from other states and develop a Virginia agenda. Strategies:

A. Request support for a study about the affect and cost of arthritis on the Commonwealth by the Joint Commission on Health Care or similar organizations (e.g., Disability Commission).

B. Convene a working retreat of the Work Group and stakeholders to develop an arthritis state policy agenda for Virginia.

C. Present the agenda to the Virginia Health Commissioner for consideration and action. When appropriate, propose to state policymakers and lawmakers a recommendation to amend state disease reporting regulations to include arthritis.

Goal 6: Explore the development of a statewide system of resources that will address arthritis and other related or co-morbid conditions. Strategies:

A. Partner with existing health care service providers and centers to increase the availability of arthritis resources and information.

B. Develop a list of center standards with the Arthritis Foundation – Virginia and Metropolitan Chapters, Virginia Arthritis Project, Virginia Arthritis Action Coalition, and other key stakeholders.

C. Establish an evaluation tool for partner sites based on established standards. D. Partner with existing health care service providers and centers to increase the availability of

arthritis resources and information. E. Identify stakeholders to participate in statewide resource system. F. Convene a meeting of advisory group and key stakeholders.


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Appendix A: Virginia Arthritis Action Coalition Member Organizations AgrAbility - Easter Seals Virginia American Family Fitness Center Anthem Blue Cross-Blue Shield Arthritis Foundation – DC/Metropolitan Chapter, Arthritis Foundation - Virginia Chapter, Richmond Augusta Medical Center, Community Wellness Big Stone Gap Parks and Recreation Bon Secours Parish Nurse Network CareNet of Southern Health Services Inc. Carter Research Group, Inc. Division of Chronic Disease Prevention and Control at Virginia Department of Health Division of Injury and Violence Prevention, Virginia Department of Health Division of Women’s and Infant’s Health, Virginia Department of Health Fairfax County Health Department Fairfax County Parks and Recreation Interfaith Council of Greater Richmond Lenowisco Health District McGuire Hospital Mary Washington Hospital Nursing Center of Excellence May Therapy MediCorp Health Systems Mountain Empire Older Citizens, Inc Norfolk State University Portsmouth Health District Prospect Empowering Center SeniorNavigator Sheltering Arms Physical Rehabilitation Centers Stone Mountain Health Services Three Rivers Health District Veterans Administration Virginia Association of Area Agencies of Aging Virginia Beach Health District Virginia Center on Aging at Virginia Commonwealth University Virginia Department for the Aging Virginia Department of Health Virginia Rural Health Resource Center Virginia Tech - Institute for Community Health Women’s Health Virginia


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Appendix B: U.S. Healthy People 2010 Arthritis Related Objectives Arthritis, Osteoporosis, and Chronic Back Pain Conditions

Ø Increase mean days without severe pain for U. S. adults with arthritis to more than 20 days

of the last 30 days.

Ø Reduce to no more than 15 percent the proportion of people with arthritis who experience a

limitation in activity due to arthritis.

Ø Reduce the proportion of all people with arthritis who have difficulty in performing two or

more personal care activities, thereby preserving independence.

Ø Increase the proportion of people with arthritis ages 18 and older who seek help in coping

with personal and emotional problems.

Ø Increase the proportion of the working-age population with arthritis who desire to work (i.e.,

both those who are employed and those who are unemployed but looking for work, called the

labor force participation rate) to 60 percent.

Ø Reduce racial differences in the rate of total knee replacements for severe pain and

disability.

Ø Decrease to five percent the proportion of individuals who report they have arthritis but

have not seen a doctor for it.

Ø Increase the early diagnosis and appropriate treatment of individuals with systemic

rheumatic diseases.

Ø Increase the proportion of people with arthritis who have had effective, evidence-based

arthritis education (including information about community and self-help resources) as an

integral part of the management of their condition.

Ø Increase the proportion of hospitals, managed care organizations, and large group practices

that provide effective, evidence-based arthritis education (including information about

community and self-help resources) as an integral part of the management of their condition.

Ø Increase the proportion of overweight people with arthritis who have adopted some dietary

practices combined with regular physical activity to attain an appropriate body weight.

Physical Activity and Fitness

Ø Increase to 85 percent the proportion of people ages 18 and older who engage in any leisure

time physical activity.

Ø Increase to at least 30 percent the proportion of people ages 18 and older who engage

regularly, preferably daily, in sustained physical activity for at least 30 minutes per day.


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Ø Increase to at least 25 percent the proportion of people ages 18 and older who engage in

vigorous physical activity that promotes the development and maintenance of cardio-

respiratory fitness three or more days per week for 20 minutes or more per occasion.

Nutrition

Ø Increase to at least 60 percent the prevalence of healthy weight (defined as a BMI equal to or

greater than 19.0 and less than 25.0) among all people ages 20 and older.

Ø Reduce to less than 15 percent the prevalence of BMI at or above 30 among people ages 20

and older.


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Resources Active Living Every Day Human Kinetics/Active Living Partners 1607 North Market St. P.O. Box 5076 Champaign, Illinois 61825-5076 800-747-4457 (phone) 217-351-2674 (fax) Internet: www.activeliving.info Active Living Every Day helps individuals become and stay physically active. Participants learn how to set realistic goals, avoid pitfalls, and find support for being active. For a complete description see the website. AgrAbility 201 East Main Street Salem, Virginia 24153 540-777-7325 (phone) 540-777-2194 (fax) Internet: www.agrability.ext.vt.edu/ Assisting farmers and their families who have disabilites, assessing needs, and finding solutions. American Academy of Orthopedic Surgeons 6300 North River Road Rosemont, IL 60018-4262 Phone: 1-800-824-BONES Internet: www.aaos.org Ask for free publications about how to exercise safely.

American College of Sports Medicine P.O. Box 1440 Indianapolis, IN 46206-1440 Internet: www.acsm.org

American Diabetes Association 1701 North Beauregard Street Alexandria, VA 22311 Phone: 1-800-342-2383 Internet: www.diabetes.org Offers free pamphlets about exercise for people of all ages who have diabetes, including "Exercise and Diabetes," "Starting to Exercise," and "20 Steps to Safe Exercise."

American Family Fitness Clubs 4435 Waterfront Drive, Suite 304 Glen Allen, VA 23060 Phone: 804-965-5300 Fax: 804-217-7871 Internet: www.amfamfit.com Each day our employees strive to improve the physical and mental well-being of our members.


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American Heart Association 7272 Greenville Ave. Dallas, TX 75231-4596 Phone: 1-800-242-8721 Internet: www.americanheart.org Offers free pamphlets about exercise for people of all ages. American Physical Therapy Association 1111 North Fairfax St. Alexandria, VA 22314-1488 Phone: 1-800-999-2782 Internet: www.apta.org Request "For the Young at Heart" (free exercise brochure). Arthritis Foundation P.O. Box 7669 Atlanta, GA 30357-0669 Phone: 1-800-568-4045 Internet: www.arthritis.org Free pamphlet provides guidelines on how to protect joints during exercise; includes range-of-motion exercises for joint mobility, and others. Information about the Arthritis Foundation aquatic, self-help and exercise program (formerly known as Pace) can be found on the website. Augusta Health Care Community Health Foundation P.O. Box 1000 Fisherville, Virginia 22939 540-932-4191 540-932-4215 Internet: www.augustamed.com The foundation is a non- profit organization that supports the community health and safety projects and agencies that primarily serve the citizens of the service area of Augusta Medical Center. Augusta Medical Center (AMC) Community Wellness P.O. Box 1000 Fishersville, Virginia 22939 540-932-4190 540-932-4215 Internet: www.augustamed.com AMC Community Wellness, a department of Augusta Medical Center, serves the community with health promotion information and education, with the specific goal of reducing the risk of chronic diseases in and around Augusta County. Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30333 Phone: 1-800-311-3435 Internet: www.cdc.gov Part of US Department of Health and Human Services. Offers physical activity tips and the Surgeon General's Report: "Physical Activity and Health."


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Centers for Independent Living Various sites across Virginia Internet: http://www.vadrs.org/cbs/cilslisting.htm The Department of Rehabilitative Services administers these programs which offer a broad range of services to individuals with disabilities to enhance opportunities for independent living.There are 16 sites and four satellite locations across Virginia. Chronic Disease Self-Management Program Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto, California 94304 650-723-7935 650-725-9422 (fax) Internet: [email protected] Chronic Disease Self-Management is designed for individuals with different chronic health problems, including arthritis. It can be used successfully by individuals with more than one chronic condition as it teaches the skills to coordinate things needed to manage their health, as well as to help them keep active in their lives. Fairfax County Park Authority 12055 Government Center Parkway, Suite 927 Fairfax, virginia 22035 703-324-8565 Internet: www.fairfaxcounty.gov/parks A deverse variety of county facilities meeting the needs of the citizens of Fairfax County Foundation for Rehabilitation Equipment and Endowment (FREE) P.O. Box 8873 Roanoke, VA 24014 540-777-4929 540-777-1030 (fax) Internet: www.free-foundation.org Offers and accepts special equipment for people after a serious illness or injury to help them regain their fullest potential. Jewish Community Centers (also appears as Young Men's Hebrew Association or Young Women's Hebrew Association.) Check phone book for local listing, or call national headquarters at the phone number below. 212-532-4949 Internet: www.jcca.org Most locations offer a variety of exercise and physical activity programs for older adults. All denominations welcome. Mary Washington Hospital 1001 Sam Perry Blvd. Fredericksburg, VA 22401 540-741-1100. Opened its doors in 1899 debt-free, made possible by the generous donations of community members. Mary Washington Hospital and its affiliates continue that tradition and are proud to support the health care needs of the citizens of Fredericksburg and its surrounding communities.


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May Physical Therapy 9101 Midlothian Turnpike Suite 200 Richmond, VA 23235 804-272-9192 May Physical Therapy Services combines specialized attention and compassionate care in one-on-one physical therapy. National Association for Health and Fitness c/o Be Active New York State 65 Niagara Square, Room 607 Buffalo, NY 14202 716-583-0521 Internet: www.physicalfitness.org Sponsors physical-fitness events for older adults. Ask for address and phone number of your State's association. National Heart, Lung and Blood Institute NHLBI Information Center P.O. Box 30105 Bethesda, MD 20824-0105 301-592-8573 Internet: www.nhlbi.nih.gov Part of the National Institutes of Health. Offers free publications on exercise, diet, and cholesterol. National Institute of Arthritis and Musculoskeletal and Skin Diseases National Arthritis and Musculoskeletal and Skin Disease Information Clearinghouse 1 AMS Circle Bethesda, MD 20892-3675 1-877-22-NIAMS Internet: www.niams.nih.gov Part of the National Institutes of Health. Provides free information about exercise and arthritis; large-print copies available upon request. National Institute on Aging, National Institute of Health Bldg. 31 Rm. 5C27 31 Center Drive, MSC 2292 Bethesda, MD 20892-2292 1-800-222-2225 TTY: 1-800-222-4225 Internet: www.nia.nih.gov Free publications about health and fitness for older adults. National Osteoporosis Foundation 1232 22nd Street NW Washington, DC 20037-1292 202-223-2226 Internet: www.nof.org Call to request free copy of "The Role of Exercise in the Prevention and Treatment of Osteoporosis," "Guidelines for Safe Movement," and "Fall Prevention."


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National Senior Games Association P.O. Box 82059 Baton Rouge, LA 70884-2059 225-766-6800 Internet: www.nationalseniorgames.org Conducts summer and winter National Senior Games - The Senior Olympics. President's Council on Physical Fitness and Sports Department W 200 Independence Avenue SW, Room 738 H Washington, DC 20201 202-690-9000 Internet: www.fitness.gov Provides "Pep Up Your Life," a free exercise booklet for older adults, in partnership with AARP SeniorNavigator 7501 Boulders View Drive, Suite 201 Richmond, Virginia 23225 804-525-7740 866-393-0957 (toll free) Internet: www.seniornavigator.org A statewide non-profit website that provides information on over 21,000 programs and services available to seniors, caregivers, and adults with disabilities. Sheltering Arms Physical Rehabiliation Centers 8254 Atlee Rd. Mechanicsville, Virginia 23116 877-567-3422 (toll free) Internet: www.shelteringarms.com The mission of Sheltering Arms Physical Rehabilitation Hospital is to provide comprehensive physical rehabilitation of the highest caliber with compassion and respect, to enhance the quality of life to those persons experiencing disabilities, and to offer financial assistance to those in need. Southern Health Services, Inc. 9881 Mayland Dr. Richmond, Virginia 23233 804-747-3700 Internet: www.southernhealth.com Southern Health, in partnership with our network of health care professionals and the groups we serve, is dedicated to improving the health of our members and our community. Virginia Center on Aging Virginia Commonwealth University P.O. Box 980229 Richmond, Virginia 23298-0229 804-828-1525 804-829-7905 (fax) Internet: www.vcu.edu/vcoa VCoA maintains four primary operating objectives: 1) Training, education, and lifelong learning; 2) Alzheimer's research and education; 3) Expanding the community's capacity to provide caregiving; and 4)


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Serving as a statewide resource center. Target audiences include older Virginians, their families, and those who work with them. Virginia Rural Health Association 2265 Kraft Drive Blacksburg, Virginia 24060 540-231-792 540-231-5338 Internet: www.vrha.org This is a not for profit organization comprised of a diverse group of individuals from communities spread across Virginia who care about improving the health of Virginia's rural residents. Women's Health Virginia 1924 Arlington Blvd., Suite 203 Charlottesville, Virginia, 22903 434-220-4500 434-220-4545 Internet: www.womenshealthvirginia.org Education, research and providing information to health professionals and consumers; raising awareness of issues that affect women and girls' wllness; increasing communication and collaboration among public, business and non-profit organizations that share our goal of improving women and girls' wellness. YMCA and YWCA Check phone book for local listings. Services vary from location to location: many offer exercise programs for older adults, including endurance exercises, strength exercises, water exercises, and walking.

References American Community Survey (2005). US Census Bureau. U.S. Department of Commerce: Economics and Statistics Administration. www.usgov.census/acs/ Arthritis: Findings from Virginia’s Behavioral Risk Factor Surveillance Survey—2001-2003. (Unpublished report, June 2004). Brady, T.J., J. Kruger, C.G. Helmick, L.F. Callahan, M.L. Boutaugh. (2003). Intervention programs for arthritis and other rheumatic diseases. Health Education Behavior, 30: 44-63. CDC. (2007).Centers for Disease Control and Prevention. National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions – United States, 2003. MMWR, 56: (01): 4-7. CDC. (2005). Centers for Disease Control and Prevention. Monitoring progress in arthritis management –United States and 25 states, 2003. MMWR, 54: 484-8.


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CDC. (2003, 2004, 2005). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention.

Chronic Disease in Virginia: A Comprehensive Data Report. 2006 Edition. Division of Chronic Disease Prevention and Control. Virginia Department of Health. Last Accessed April 2008 at www.vahealth.org/cdpc/documents/2007/2006%20Chronic%20Disease%20Data%20Report_040607.pdf Der Ananian C, Wilcox S, Saunders R, Watkins K, Evans A. (2006). Factors that influence exercise among adults with arthritis in three activity levels. Preventing Chronic Disease, 3: 1-15. http://www.cdc.gov/ped/issues/2006/jul/05_0220.htm. Dillon, C., Peterson, M., and Tanaka, S. (2002). Self-reported hand and wrist arthritis and occupation: Data from the U.S. national health interview survey-occupational health supplement. American Journal of Industrial Medicine, 42(4), 318-327. Dunlop, DD; Manheim, LM; Yelin, EH; Song, J; Chang, RW. (2003). The cost of arthritis. Arthritis and Rheumatism, 15: 101-3.

Economic Research Service, USDA, Washington, DC: The Economics of Food, Farming, Natural Resources and Rural America. State Fact Sheets: Virginia. Accessed February 2008 at http://www.ers.usda.gov/State Facts/VA.htm.

Friedman, M., Hootman, J.M., and Helmick, M.D. (2007). Projected state-specific increases in self-reported doctor-diagnosed arthritis and arthritis-attributable activity limitation—United States, 2005-2030. MMWR, 56(17), 423-425. Grisso, R.D., J.V. Perumpral, S.C. Mariger, D.E. Suttle, K. Funkenbush, K. Ballin. (2007) Arthritis and Farming. Virginia Cooperative Extension, Publication 442-083, Virginia Tech. Blacksburg, VA Healthy People 2010, Chapter 2: Arthritis, Osteoporosis, and Chronic Back Conditions,” Centers for Disease Control and Prevention & National Institutes for Health. Hootman, J.M., Helmick, C.G. (2006). Projections of U.S. prevalence of arthritis and associated activity limitations. Arthritis and Rheumatism; 54: 226-229. Ipsen, C. (2007). Building the Case: Health Promotion for Vocational Rehabilitation Consumers. Rural Disability and Rehabilitation Research Progress Report #38. Missoula: The University of Montana Rural Institute. Mariger, S.C., R.D. Grisso, J.V. Perumpral, A.W. Sorenson, N.K.Christensen and R.L. Miller. 2007. Virginia agricultural safety and health survey. ASABE Paper and Presentation No. 075109. St. Joseph, MI:ASABE (Presentation: http://filebox.vt.edu/users/rgrisso/Pres/075109_Pres.pdf, Paper: http://filebox.vt.edu/users/rgrisso/Papers/075109.pdf) National Arthritis Action Plan: A Public Health Strategy. (1999). Arthritis Foundation, Association of State and Territorial Health Officials, Centers for Disease Control and Prevention. Office of Minority Health and Public Health Policy, Virginia Department of Health, Virginia Primary Care Health Professional Shortage Areas (HPSA). Data reported as of January, 2008, using 2005 population estimates used.


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Physical Activity and Health: A Report of the Surgeon General. (1996). US Department of Health and Human Services, Centers for Disease Control and Prevention and the Presidents Council on Physical Fitness and Sports. Russo, C.A. and Andrews, R.M. The National Hospital Bill: The Most Expensive Conditions, by Payer, 2004. HCUP Statistical Brief #13. September 2006. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb13.pdf Sacks, J.J., Helmick, C.G., Luo, Y., Ilowite, N.T., and Bowyer, S. (2007). Prevalence of and annual ambulatory health care visits for pediatric arthritis and other rheumatologic conditions, United States, 2001-2004. Arthritis Care and Research, 57(8), 1439-1445. Spar, M.A. and Cai, Q. (May, 2006). Virginia Population Estimates. Weldon Cooper Center for Public Service. University of Virginia. Theis, K.A., Helmick, C.G. and J. M. Hootman. Arthritis burden and impact are greater among U.S. women than men: Intervention opportunities. Journal of Women’s Health, 16 (4), 2007. Theis, K.A., Hootman, J.M., Helmick, C.G., Murphy, L., Bolen, J., Langmaid, G., and Jones, G.C. (2007). State-specific prevalence of arthritis-attributable work limitation—United States, 2003. MMWR, 56(40), 1045-1049. U.S. Census Bureau, Current Population Survey, 2004 to 2006 Annual Social and Economic (ASEC) Supplements. Revised CPS ASEC Health Insurance Public Use Data. Last accessed April 2008 at http://www.census.gov/hhes/www/hlthins/usernote/usernote3-21rev.html VAES. Virginia Agricultural Experiment Station. Virginia Geography. Accessed February 2008 at http://www.vaes.vt.edu/about/geography.html Virginia Division of Health Statistics, 2005 state population estimates. Wilcox S, Der Ananian C, Abbott J, Vrazel J, Ramsey C, Sharpe P, Brady T. (2006). Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: Results from a qualitative study. Arthritis Care and Research, 55: 616-27. Yelin, E., Cisternas, M., Foreman, A., Pasta, D., and Helmick, C.G. (2007). National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions—United States, 2003. MMWR, 56 (01), 4-7. Yelin E, Murphy L, Cisternas M, Foreman A, Pasta D, Helmick C. (2007). Medical Care Expenditures and Earnings Losses Among Persons with Arthritis and Other Rheumatic Conditions in 2003, and Comparisons to 1997. Arthritis and Rheumatism; 56 (5):1397-1407.


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Virginia Arthritis Action Coalition at VDH 1 804 864-7880 OR go to www.vahealth.org/cdpc/arthritis and complete the form online

Virginia Arthritis Plan Feedback Did you find the content of this report useful? If yes, what did you find most useful? If no, what changes would make it more useful for you? Were the materials in the plan easy to understand? If no, what changes would make it easier to understand? What additional information would be helpful to you? What other changes or suggestions do you have to improve the plan? Will you be able to use the information in the plan for your work? How? Would you like more information about the Virginia Arthritis Action Coalition? Visit www.vahealth.org/cdpc/arthritis for more information about arthritis in Virginia

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Virginia Arthritis Action Plan 2008-2012 - Augusta … · The Virginia Arthritis Action Plan for 2008 ... Ed Ansello, PhD – Virginia Center on Aging; Kirk Ballin, MDiv – AgrAbility

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