close

Вход

Забыли?

вход по аккаунту

?

Social and economic impacts of four musculoskeletal conditions.

код для вставкиСкачать
90 1
SOCIAL AND ECONOMIC IMPACTS OF FOUR
MUSCULOSKELETAL CONDITIONS
A Study Using National Community-Based Data
JANE S. KRAMER, EDWARD H. YELIN, and WALLACE V . EPSTEIN
The present study uses data from a national,
community-based survey to compare the social impact
of and medical care use due to 4 musculoskeletal conditions: rheumatoid arthritis, osteoarthritis, lower back
pain, and tendinitis. The study also compares the impacts experienced by persons with these conditions with
those experienced by a sample of persons having a
broader range of musculoskeletal conditions, and by an
age-adjusted sample representing the entire U.S. population. Rheumatoid arthritis leads to the most frequent
use of physician services; lower back pain results in the
most hospitalizations and surgery. Rheumatoid arthritis
also causes the most restriction in activity. We found
that as a broad group, persons with musculoskeletal
disease experience about the same amount of restriction
in activity and use about the same amount of medical
care as U.S. citizens as a whole. This study demonstrates
that health planning on the basis of specific musculoskeletal conditions is necessary to serve the disparate needs
of persons with particular, discrete conditions.
The impacts of musculoskeletal disease as a
whole have been well documented. We know, for
example, that musculoskeletal conditions rank second
to circulatory diseases in restricting activities ( l ) ,
From the Social Science Research Component, Multipurpose Arthritis Center, the Robert Wood Johnson Clinical Scholars
Program, and the Institute for Health Policy Studies, University of
California, San Francisco.
Supported in part by Grant No. AM-20684 from the National Institutes of Arthritis, Diabetes, and Digestive and Kidney
Diseases, and by the Robert Wood Johnson Foundation, Princeton,
New Jersey.
Address reprint requests to Jane Kramer, MSc, 350 Parnassus Avenue, Suite 407, San Francisco, CA 941 17.
Submitted for publication August 9, 1982: accepted in
revised form March 1, 1983.
Arthritis and Rheumatism, Vol. 26, No. 7 (July 1983)
make up 41% of the persons referred to vocational
rehabilitation (2), and are the second most frequent
cause of work disability, accounting for 15% of all
those claiming to be work disabled (1). Musculoskeletal conditions also account for 20% of Medicare hospital costs (3), and are the second most frequent cause of
outpatient physician visits among all chronic conditions (4). Kelsey et a1 point out that musculoskeletal
conditions rank highly on all measures of disease
impact, except mortality ( 5 ) . The impacts of musculoskeletal conditions as a group have been relatively well
identified, as have some of the impacts of particular
conditions in clinical samples, such as hospital or
academic medical settings (6-8). The impacts of particular musculoskeletal conditions in the community at
large, however, have not been well documented.
The purpose of this paper is threefold: we first
describe some of the social and medical characteristics
of persons with one of 4 common musculoskeletal
conditions: rheumatoid arthritis (RA), osteoarthritis
(OA), lower back pain (LBP), and tendinitis (TEN).
We then describe the impacts of these conditions and
compare them with the impacts experienced by a
sample of persons having a broad range of musculoskeletal diseases. In doing this we are able to determine whether the impacts of musculoskeletal disease
broadly defined are significantly different from the
impacts of these 4 discrete musculoskeletal conditions. Finally, we compare the impacts of the 4 distinct
musculoskeletal conditions with those experienced by
an age-adjusted sample which represents the entire
United States population regardless of health status.
The purpose of this is to understand the extent to
which persons with these discrete musculoskeletal
conditions, and with those more broadly defined, are
KRAMER ET A L
different from similarly aged U.S. citizens in ability to
perform work and other daily activities and in use of
medical care.
METHODS
The data for this paper are derived from the 1976
National Health Interview Survey (NHIS) (9),administered
by the National Center for Health Statistics. The NHIS is an
annual survey of the civilian, noninstitutionalized population
of the continental U.S., and includes approximately 115,000
persons in 42,000households. The interviews for the NHIS,
which are conducted in person, collect information on social
and demographic characteristics of respondents, injuries and
illnesses they experience, their functional capacity, and the
medical care they use.
A specific diagnosis is recorded in the NHIS only if
the respondent’s physician has provided one to the patient or
if the symptoms reported by the respondent lead to an
unambiguous diagnosis. For example, if a respondent reports a type of arthritis that has not been diagnosed by a
physician and the symptoms do not clearly imply a discrete
entity, the condition would be classified as “arthritis unspecified.”
We selected all persons from the NHIS with an
International Classification of Diseases (ICDA) (10) code for
each of the 4 specific conditions in the study, eliminating
persons with musculoskeletal comorbidities. In total there
were 238 persons with R A (ICDA codes 7122-7125), 152
persons with OA (ICDA codes 7130-7139), 1,452with LBP
(ICDA codes 7250-7259), and 2,284with TEN (ICDA codes
7310-7319). These numbers may not reflect the true prevalence of these conditions since persons with mild conditions
may not have received a discrete diagnosis. Accordingly,
studies of the NHIS indicate that respondent reports of
diagnoses are generally specific, though not highly sensitive
(1 1).
We compared the relative impacts of each of the 4
discrete conditions among themselves, and with a sample of
300 persons drawn randomly from among all 18,690persons
in the NHIS who had any musculoskeletal condition, regardless of discrete diagnosis. We also drew a random sample of
296 persons from among all 113,OOO respondents to the
NHIS, to represent the entire U.S. population. This was ageadjusted to the sample of persons with any musculoskeletal
condition.
Most studies of persons with musculoskeletal diseases draw samples from clinical settings such as university
medical centers or private practices. These studies provide
valuable detail that is often unattainable in community-based
surveys, particularly data on the severity of a condition.
However, they generally obtain a relatively homogeneous
sample group in terms of diagnosis, severity of illness, and
demographic characteristics. One important attribute of the
NHIS is that it generates respondents from the community.
For this particular study, the community-based samples
provide a more reliable estimate of the range of impacts of
these 4 musculoskeletal conditions, among persons who are
aware of their condition, both in terms of restriction of
activities and medical care utilization.
The NHIS reports the mean number of physician
visits and hospitalizations and the extent of restricted activity for persons in each sample, stratified by demographic
characteristics. When the measures of impact were continuous (number of physician visits, hospitalizations, and restricted activity days), we used an analysis of variance to
determine if utilization or restriction of activities differed by
sample and demographic (sex, race, age, and marital) characteristics. When the measures were categorical (kinds of
activity limitations), we used chi-square tests for the same
purpose. All reported comparisons among the particular
samples in each analysis were significant ( P < 0.05) by the Ftest and chi-square. The statistical tests used assume inde-
Table 1. Characteristics of persons in each sample studied
Characteristics
Fernalehale
Whitelnonwhite
Age (mean 2 SD)
Marital status
Married
Widowed, separated, divorced
Never married
Usual activity
Working
Retiredlhealth
Retiredlot her
Housework
Student
Miscellaneous
Rheumatoid
arthritis
(n = 238)
Osteoarthritis
(n = 152)
Lower back
pain
(n = 1.452)
Tendinitis
(n = 2.284)
All
musculoskeletal
conditions
(n = 300)
65/35*
9317
54 2 16
68/32
9713
57 2 14
44/56
9317
48 2 14
58/42
9515
47 t 15
62/38
90110
54 2 17
60140
9218
54 t 19
69
23
6
62
33
5
74
19
71
19
7
7
64
24
9
66
21
13
29
12
4
43
3
9
26
13
6
48
0
7
53
6
4
28
8
4
44
5
6
39
3
2
39
5
1
53
3
5
32
3
* All numbers shown, except age, are percents.
Sample of all
U.S. citizens
(n = 296)
8
36
7
4
903
IMPACT OF MUSCULOSKELETAL CONDITIONS
pendence of the samples, because of the very slight representation of the discrete illnesses in the 2 control samples.
Medical symptoms due to each condition, %
Table 2.
Rheumatoid
arthritis
Osteoarthritis
Lower
back
pain
Tendinitis
Frequency of symptoms
due to this condition
Always
Infrequently or never
54
28
44
37
25
55
11
77
Extent of symptoms
due to this condition
Great deal
Little or none
64
7
50
I5
47
14
36
22
RESULTS
Table 1 provides a broad outline of the social
and demographic characteristics of the persons in each
of the 6 samples in our study. The sex differential in
the RA and OA groups reflects epidemiologic findings
that women are more likely to have rheumatoid arthritis and osteoarthritis than men. The tendinitis and
lower back pain samples also reflect epidemiologic
reports on the sex distribution of these illnesses (12).
The epidemiology literature reports that the prevalence rates of OA are similar among blacks and whites,
but that blacks have much higher rates of RA than
whites (13). In our study samples, however, there are
fewer minorities reporting these conditions than would
be expected. Nonwhites may be less likely to receive a
specific diagnosis from a physician, and therefore less
likely to be included in the disease-specific samples
under review.
Several studies have found that there is a higher
probability of marital dissolution among the chronically ill than in the general population, and that this is
independent of age (14, IS). Unfortunately the NHIS
did not ask respondents to relate divorce or separation
to illness, and it is therefore impossible to infer such
relationships from this survey. We can only hypothesize that both age and illness are linked with the
variation in marital status in the 6 samples in the study.
Table 1 also shows the percentage of persons in
each category who were working, doing housework,
retired due to health reasons, or retired for other
reasons. The TEN and LBP samples had the highest
proportions of persons who were working (53%), while
RA and OA had the lowest (29% and 26%, respectively). A large percentage of persons with RA and OA
were doing housework (43% and 48%). These findings
probably reflect the age and sex distribution of the
diseases. However, they also reflect the impact of RA
and OA in comparison with TEN and LBP.
Table 2 reports the frequency and extent of
symptoms experienced by persons with each of the 4
conditions under study. A much higher percentage of
persons with RA (54%) claimed that their condition
was always symptomatic than did those with the other
3 conditions; only about one-fourth of persons with
RA stated that the symptoms never or only infrequently bothered them. The symptoms of tendinitis were the
most episodic among the 4 conditions, with only 11%
of those afflicted by the condition claiming that the
condition always bothered them. Persons with RA
were also more likely to report more extensive symptoms: 64% of those with RA stated that their illness
Table 3. Utilization of physician and hospital services, by sample population
Utilization
Due to condition studied
Physician visits in past year
(mean rt SD)
Interval since last visit
(mean)
% ever hospitalized
% ever with surgery
For all conditions
Physician visits in past
year (mean ? SD)
Physician visits in past
2 weeks (mean 2 SD)
Hospitalizations in past year
(mean 2 SD)
Rheumatoid
arthritis
Osteoarthritis
Lower
back
pain
Tendinitis
7.1 t 12.5
3.5 -+ 5.5
2.8 t 6.9
1.5 t 3.7
6-12 months
6-12 months
1 year
I year
36
14
32
17
50
22
6
4
All musculoskeletal
conditions
Sample of
all U . S .
citizens
6.0 2 9.3
6.5 t 30.4
15.5
10.9 f 18.0
8.3
f
24.1
0.42 2 0.78
0.47 t 0.84
0.35
?
0.87
0.3s -C 0.83
0.27
0.64
0.22 t 0.53
0.33
0.28
0.35
f
0.70
0.21
0.24 2 0.54
0.20 t 0.55
11.5
f
?
0.61
f
0.60
6.5
_t
-C
13.0
0.57
-t
KRAMER ET AL
Table 4.
Social and work limitations, by sample population
Limitations
Can't do usual activity (%)
Limited in arnount/kind
of major activity (%)
Limited in activities
outside major one (%)
Not limited (%)
This condition is primary
cause of activity
limitation (%)
Persons wirh history of labor
force participation, reporting work disability (%)
Activity limitations in past
2 weeks 'due to this
condition (mean)
Restricted activity days
Bed days
Work loss days
Activity limitations in past
year due to this condition
(mean)
Bed days
Work loss days
Restriction of activities in past
2 weeks from all conditions
(mean)
Restricted activity days
Bed days
Work loss days
Tendinitis
All musculoskeletal conditions
Sample of all
U.S. citizens
13
7
9
8
39
36
19
31
14
12
24
14
30
13
8
66
12
38
49
8
70
52
51
41
3
24
29
6
2
10
6
2.2
0.3
1.7
0.8
0.3
1.2
0.4
0.3
0.3
0.1
0.0
22.9
7.4
14.2
5.2
8.3
8.0
1.1
3.4
1.6
0.2
2.2
I .o
0.3
2.3
0.8
0.5
I .7
0.5
0.2
1.1
0.4
0.1
Rheumatoid
arthritis
Osteoarthritis
Lower back
pain
22
18
43
1 .o
bothered them a great deal, while only 7% reported
little or no symptoms due to the condition. Again,
tendinitis seemed to be the least symptomatic, with
only 36% of these respondents claiming that this
condition bothered them a great deal.
Table 3 presents data on the differences in
utilization of physician and hospital services for persons with RA, OA, 'TEN, LBP, any musculoskeletal
condition, and for the age-adjusted sample of all U.S.
citizens. Persons with RA clearly utilized outpatient
physician services for their condition most frequently,
while persons with LBP were hospitalized and had
surgery for their condition most often. The mean
number of visits in 1 year attributable to RA was 7.1 ;
the corresponding figures were 3.5 for OA, 2.8 for
LBP, and 1.5 for TEN.
Considering that persons with LBP utilized
outpatient physician services for their condition so
infrequently and on average had not visited a physician for 1 year for their condition, it is surprising that
these persons had such a high surgery and hospitalization rate. This is even more striking considering that
over half the persons with LBP reported experiencing
1.2
1.5
0.5
0.2
their symptoms infrequently (Table 2). Nevertheless,
50% of the persons interviewed claimed that they had
been hospitalized at some time for their condition,
compared with 36%, 32%, and 6% for RA, OA, and
TEN, respectively. Additionally, 22% of persons with
LBP in the survey had had surgery for their condition,
compared with 14%, 17%, and 4% for RA, OA, and
TEN, respectively.
The mean number of physician visits in a year
for all reasons ranged from 6.5 for persons with TEN
to 11.5 for those with RA, Among persons with any
musculoskeletal condition, the average number of
physician visits in a year was 6.0. The corresponding
figure in the age-adjusted sample of the U.S. population as a whole was 6.5, indicating that overall utilization of physician visits among all persons with musculoskeletal disease is similar to that of persons in the
same age range who do not necessarily have musculoskeletal disease.
The difference between the mean numbers of
visits attributed to the specific condition and to all
conditions provides a rough indication of the comorbid
utilization of persons with each of the 4 conditions
905
IMPACT OF MUSCULOSKELETAL CONDITIONS
under study. The typical person with RA visited the
physician almost 4% times a year for reasons other
than the RA (11.5-7.1 visits); the corresponding figures for persons with OA, LBP, and TEN were 7%
~ Y z and
,
5 , respectively. Thus, persons with these
conditions make almost as many visits to the physician
for reasons other than their musculoskeletal condition
as a similarly aged U.S. citizen makes for all reasons,
another indication that persons with these specific
conditions use a large quantity of medical services. In
fact, persons with each of the 4 conditions under study
reported having an average of 1 other medical condition (data not reported).
Table 4 reports on activity limitations experienced by the persons in each sample. From the data it
is apparent that rheumatoid arthritis caused more
severe restrictions in activities than the other illnesses.
Twenty-two percent of the persons in the RA sample
reported that they were unable to perform their usual
activity, while only 24% were not limited in activities
in any way. These figures compare most strikingly
with those for persons with TEN, only 7% of whom
reported that they were unable to perform their usual
major activity, and 66% of whom were not limited in
any way by their illness. Osteoarthritis and lower back
pain followed RA in terms of effect on activity limitation. About half of all persons with any musculoskeletal condition reported being limited by their illnesses
to some extent. In contrast, only 30% of the ageadjusted sample of all U.S. citizens claimed to be
limited in activities. At least 40% of all persons with a
musculoskeletal condition experienced some limitation in their major activity, a percentage about twice as
high as that for the age-adjusted sample of all U.S.
citizens.
Musculoskeletal disability was the primary
cause of limitation for the majority of persons with RA
and OA who experienced limitations. In comparison,
only 3% of the persons with tendinitis who experi-
Table 5.
enced limitations reported that this illness was the
primary cause of their limitation. One particularly
striking finding was that at least one-foutth of persons
with RA or OA who had held jobs at some time in the
past reported that they were retired due to health
reasons. In contrast, only 6% of those with LBP
reported work disability. Moreover, 10% of the persons in the all musculoskeletal disease sample with a
work history reported work disability. The age-adjusted U.S. sample experienced significantly less work
disability (6%).
RA generated the most severe impacts as reflected in the number of restricted activity and bed
days attributable to the condition. For example, the
mean number of bed days due to the condition in the
past year was 22.9 for RA, 14.2 for OA, 8.3 for LBP,
and 1.1 for TEN.
DISCUSSION
Previous studies (1-8) have indicated that musculoskeletal conditions are among the leading diseases
associated with social and economic costs to individuals and society. In fact, they show that musculoskeletal diseases surpass almost all other disease groups in
measures of disability, restriction of activity, use of
vocational rehabilitation, and medical costs. The only
area in which they do not have a comparatively high
impact rate is as a cause of death. However, these
findings are derived from clinical samples or from
aggregate-level data.
The use of a community-based sample of individuals has enabled us to obtain a more accurate
estimate of the impacts of 4 musculoskeletal conditions-rheumatoid arthritis, osteoarthritis, tendinitis,
and lower back pain-than is possible from a clinical
study or from aggregate data. We found that persons
with RA utilize significantly more physician services
than persons with any of the other musculoskeletal
National impact of rheumatoid arthritis (RA) and osteoarthritis (OA)*
Illness and
estimated
prevalence
(reference)
Physician visits due
to this condition in
1 year (millions)
All physician visits
for persons with
this condition in I
year (millions)
Hospitalizations of
persons with this
condition in 1 year
(millions)
Bed days due to
this condition in 1
year (millions)
Work loss days due
to this condition in
I year (millions)
RA
0.2% (13)
2. I
3.5
0.1
6.9
2.2
45.1
142.2
3.7
185.3
67.9
OA
8.7% (18)
~
*
Based on U.S. population of 150 million adults aged 18-79 in 1980, and published prevalence rates of RA and OA.
906
conditions under study. Persons with rheumatoid arthritis also experience the most extensive limitation in
activities, although the impact of osteoarthritis on
functional ability is also severe. Persons with lower
back pain use more hospital services and receive more
surgery than persons with any of the other conditions
under study. Tendinitis is, as expected, the least
severe of the 4 musculoskeletal conditions as assessed
by utilization and restriction of activity measures.
It is valuable to consider all musculoskeletal
conditions together when comparing them with, for
example, respiratory diseases. The value of grouping
all musculoskeletal conditions together, however, is
limited when one wants to deal with a particular one.
There are a number of reasons it is important to study
musculoskeletal conditions individually. First, the
needs of persons with particular conditions are different depending upon the type and seventy of the
condition. Second, the National Institutes of Health
allocates funds on the basis of the demonstrated
importance of illnesses, using as criteria the number of
persons affected, extent and severity of impact, and
direct and indirect costs (16). Third, Health Systems
Agencies, the federally funded, local health planning
agencies, use data on impacts of specific diseases for
resource allocation purposes (17).
The wide variation in impact of disease and
utilization of medical services among the 4 musculoskeletal conditions demonstrates the importance of
considering each one separately, for health planning
purposes. This becomes even clearer when we compare the sample representing persons with all musculoskeletal conditions with the age-adjusted sample of
persons in the United States. The similarity between
these 2 groups in terms of health care used reveals that
in regard to medical care used, most persons with
musculoskeletal diseases broadly defined are not significantly different from similarly aged persons who do
not have musculoskeletal disease. Health planning and
resource allocation based on the premise that most
persons with musculoskeletal conditions are similar to
the age-adjusted U.S. sample would inadequately reflect the resource requirements €or specific types of
musculoskeletal illnesses. It would lead to an underallocation of resources for the more severe illnesses
such as RA and OA, and an overallocation for others
such as TEN.
When allocating resources, health planners can
use information from studies such as this one to take
into account the special medical and social service
needs of persons with specific conditions. Table 5
KRAMER E T AL
provides an example of how health planners might use
such information for RA and OA. The table shows
estimates of several dimensions of the national impact
of RA and OA, using conservative estimates of the
prevalence of these 2 illnesses among adults in the
United States and estimates of disease impact from
Tables 3 and 4. Using only the strictest definitions of
these conditions and the most conservative estimates
of prevalence, RA and OA are responsible for 2 and 46
million physician visits per year, respectively, and
result in 2 and 68 million work loss days, respectively.
The aggregate impacts of these 2 conditions will increase significantly because the prevalence of each
and incidence of OA increase with age.
The present study demonstrates the wide range
in disability, restriction of activity, and medical care
utilization among 4 musculoskeletal conditions: rheumatoid arthritis, osteoarthritis, tendinitis, and lower
back pain. Our study also reveals significant differences in utilization and impacts between the individual
musculoskeletal conditions and a sample representing
all musculoskeletal conditions. Moreover, the present
study demonstrates that persons with a broad range of
musculoskeletal conditions are similar to persons of
similar age in terms of medical care use, although they
experience higher rates of disability. We conclude that
planning on the basis of musculoskeletal diseases as a
whole would not serve the specific and different needs
of those with these 4 discrete conditions.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the wise counsel
of Michael Nevitt and Curtis Henke, and the assistance of
Roy Kriedeman.
REFERENCES
Acute Conditions: Incidence and Associated Disability,
US, 1974-1975. Vital and Health Statistics Series 10,
Number 114. USDHEW Publication no. (HRA)77-1541,
1977
Lehman JF: Patient care needs as a basis for development of objectives of physical medicine and rehabilitation teaching in undergraduate medical schools. J
Chronic Dis 21:3-12, 1968
Inpatient Utilization of Short-Stay Hospitals, by Diagnosis, US, 1971. Vital and Health Statistics Series 13,
Number 16. USDHEW Publication no. (HRA)75-1767,
1975
Physician Visits: Volume and Interval Since Last Visit,
US, 1971. Vital and Health Statistics Series 10, Number
97. USDHEW Publication no. (HRA)75-1524, 1975
IMPACT OF MUSCULOSKELETAL CONDITIONS
5 . Kelsey J, Pastides H , Bisbee G. Musculo-Skeletal Disorders: Their Frequency of Occurrence and Their Impact on the Population of the United States. New York,
Prodist, 1978
6. Yelin E, Meenan R, Nevitt M, Epstein W: Work disability in rheumatoid arthritis: effects of disease, social, and
work factors. Ann Intern Med 9331-556, 1980
7. Meenan RF, Yelin EH, Nevitt M, Epstein WV: The
impact of chronic disease: a sociomedical profile of
rheumatoid arthritis. Arthritis Rheum 24544-549, 1981
8. Lubeck DP, Spitz PW, Fries JF: The Health Assessment
Questionnaire (HAQ): assessment of personal economic
costs (abstract). Arthritis Rheum (suppl) 25:S149, 1982
9. Current Estimates from the Health Interview Survey,
United States, 1976. Vital and Health Statistics Series
10, Number 119. USD-HEW Publication No. (PHS) 781547, 1977
10. Eighth Revision International Classification of Diseases.
USD-HEW Publication No. (PHS) 1693, 1977
11. Health Interview Responses Compared with Medical
12.
13.
14.
15.
16.
17.
18.
907
Records. Vital and Health Statistics Series 2, Number 7.
USDHEW Publication no. (PHS) IOOO, 1965
Cobb S: The Frequency of the Rheumatic Diseases.
Cambridge, Harvard University Press, 1971
Rheumatoid Arthritis in Adults, US, 1960-1962. Vital
and Health Statistics Series 11, Number 17. Public
Health Service Publication no. 1000, 1966
Medsger A , Robinson H: Comparative study of divorce
in rheumatoid arthritics and other rheumatic diseases. J
Chronic Dis 25:269-275, 1972
Franklin P: Impact of disability on the family structure.
SOCSecur Bull 5:3-18. 1977
Strickland S: Research and the Health of Americans.
Lexington, Massachusetts, Lexington Press, 1978
Knox E, Acheson R, Anderson D, Bice T, White K:
Epidemiology in Health Care Planning. Oxford, England, Oxford University Press, 1979
Prevalence of Osteoarthritis in Adults by Age, Sex,
Race, and Geographic Area, United States, 1960-1962.
Vital and Health Statistics Series 11, Number 15. USDHEW Publication no. (PHS)1000, 1966
Curriculum in Rheumatology for Office Nurses
August 7-10, 1983, Westowner in Madison, Wisconsin, sponsored by the Multipurpose Arthritis Center at the
Dartmouth-Hitchcock Medical Center, with faculty from both Dartmouth College and from the Jackson Clinic in
Madison. Topics to be covered include communications, biology and pathophysiology of the joint, joint
examination, musculoskeletal symptoms and treatment of rheumatic diseases, and strategies of patient
education. Application will be made to the New Hampshire Nurses Association for appropriate CEUs. For further
information, contact Martha Doolittle, Dartmouth-Hitchcock Arthritis Center, Hanover, NH 03756.
Документ
Категория
Без категории
Просмотров
4
Размер файла
588 Кб
Теги
social, four, economic, conditions, impact, musculoskeletal
1/--страниц
Пожаловаться на содержимое документа