Rationale for Including the Optional BRFSS Arthritis Management Module
In Odd Years (2007, 2009, 2011, etc.)

**[Background]{.underline}**

Arthritis questions first appeared as an optional module in BRFSS in
1996 (six states used it). By 2000, the module was used by 39 states. In
2001 and 2003 arthritis questions became part of the core BRFSS
questionnaire and are slated to reappear in the core in odd years 2005,
2007, 2009 (see Table 1 for core questions on arthritis). A four
question optional module (Arthritis Management -- see Table 1) became
available in 2003 for concurrent use with the core arthritis questions
to efficiently maximize data available on arthritis and concurrently
appearing items of programmatic relevance, e.g., physical activity,
health-related quality of life, etc. This optional module was used by
states in 2003 and 2005. About 43% of respondents are eligible for this
optional module based on prior experience.

**[Rationale]{.underline}**

Arthritis affects 21% of adults and is the leading cause of disability
in the U.S. CDC currently funds states to conduct arthritis programs.
The main goal of these programs is to improve the quality of life of
persons affected by arthritis. One objective these programs share to
achieve this goal is to promote educational courses on self management
of arthritis. These courses have been shown to reduce arthritis-related
pain by 20% and overall health care costs by 40% by reducing physician
visits (*Lorig K, et al. Evidence suggesting that health education for
self-management in patients with chronic arthritis has sustained health
benefits while reducing health care costs. Arthritis Rheum
1993;36:439-46*). Question 4 in the optional (management) module
measures how well arthritis programs are achieving this objective among
persons with arthritis. Question 4 is used by Healthy People 2010 in the
National Health Interview Survey to track progress for objective 2-8.

Question 1 measures societal arthritis burden and, over time, how well
the combined effects of all interventions (including public health
efforts) are impacting upon activity limitation from arthritis. For
example, public health efforts encouraging people with symptoms to seek
medical evaluation, and promoting reductions in obesity, increases in
physical activity levels, and taking self management education courses
would all decrease limitation severity from arthritis.

Counseling from health care professionals is important in spurring those
with arthritis to modify behaviors to prevent disability. As state
programs direct more resources to professional education efforts and
health care system policy changes, questions 2 and 3 help monitor if
providers are urging persons with arthritis to lose weight (if
overweight/obese) and to increase physical activity (if inactive). These
questions provide valuable baseline data for evaluating the professional
education and system change efforts and also assist in monitoring state
progress towards HP 20120 objectives. Questions 2 and 3 are used by
HP2010 in the National Health Interview Survey to track progress for
objectives 2-4a and 2-4b.

*[Benefit to States]{.underline}*

State-specific data allow state arthritis programs to determine the need
for further interventions or actions to achieve the objectives of 1)
motivating providers to urge persons with arthritis to lose weight (if
overweight) and to increase physical activity (if less than optimally
active); 2) promoting educational courses on self management of
arthritis among person with arthritis; and 3) lessening the activity
limitation level among persons with arthritis.

*[Suitability to telephone interviewing]{.underline}*

The optional module has been used for years and works well. The wording
is straightforward; three questions are yes/no format. One question uses
a form of scaled response. No complex responses are required.

*[Pertinence to Year 2010 Objectives]{.underline}*

Healthy People 2010 contains a number of objectives for arthritis.
Specific objectives that relate to the optional module are:

-   2-2. Reduce the proportion of adults with doctor-diagnosed arthritis
    who experience a limitation in activity due to arthritis or joint
    symptoms.

-   2-4. Increase the proportion of adults with doctor-diagnosed
    arthritis who receive health care provider counseling.

2-4a. For weight reduction among overweight and obese persons.

2-4b. For physical activity or exercise.

-   2-8. Increase the proportion of persons with doctor-diagnosed
    arthritis who have had effective, evidence-based arthritis education
    as an integral part of the management of their condition.

The optional (management) module questions directly measure achievement
of these objectives.

*[Measurement over time]{.underline}*

As these questions have been used in 2003 and 2005, many states have
baseline data for tracking. Moreover, the National Health Interview
Survey has used questions 2- 4 since 2002, thus providing ongoing
national estimates. These BRFSS data are important to gather in future
years to monitor the changing activity limitation profile of arthritis
[at the state level]{.underline} and [impacts of state program
interventions]{.underline}. Pooling data over years allows subgroup and
smaller geographic unit analysis of these important state programmatic
and *HP2010* objectives.

*[Alternate data sources]{.underline}*

Questions 2 - 4 have appeared on the NHIS questionnaire since 2002 and
beyond and allow for estimation of national prevalence over time.
However, sample size constraints do not allow for state level estimates
from these data. Currently there is no other national or state level
data source that gathers these data routinely. Clinical data (e.g.,
physician or clinic encounter-based data) are of limited value in that
they do not contain this programmatic information.

*[Adequacy for planned analysis]{.underline}*

Given a typical state sample size of 4,000, we expect that 800 (20%) of
adults would report doctor diagnosed arthritis and be asked the optional
module questions. This sample size should prove sufficient to generate
state level estimates with adequate precision. Precision for prevalence
estimates for demographic subgroups (age, race, sex) or areas smaller
than the entire state (counties or cities) will be an issue. If the
optional module questions are included every other year, it would be
possible for states to combine data over two cycles and do more detailed
analysis of subgroups with more statistical stability.

*[Relationship to other topics]{.underline}*

Demographic core questions are necessary to consider subgroup
prevalence. Other questions that are used in analysis of arthritis
optional module data include health status, obesity, physical activity,
sedentary lifestyle, quality of life, and health care access.

*[Validity]{.underline}*

Question 1 is taken verbatim from a widely used, well validated
instrument used to assess persons with arthritis - the Multidimensional
Health Assessment Questionnaire (*Pincus T, Swearingen C, Wolfe F.
Toward a multidimensional health assessment questionnaire. Assessment of
advanced activities of daily living and psychological status in the
patient-friendly health assessment questionnaire format. Arthritis &
Rheumatism 1999;42:2220-2230*). The two questions ascertaining being
advised by a health care provider to lose weight or increase physical
activity have face validity. While a survey of providers might show that
many claim to so counsel patients, asking patients tests not only
whether the physician delivered the message, but also (and more
importantly) whether it was heard and remembered by the patient. The
question on taking an educational course has similar face validity.

*[Effect on length]{.underline}*

Assuming 5 seconds per question for questions 2 - 4 and 15 seconds for
question 1, this module would add \~30 seconds to the survey.
Approximately, 43% of respondents would be asked the questions, i.e.,
only those targeted from responses to the core questions on arthritis.

**[Analytic plan]{.underline}**

Anticipated analyses for the optional module are:

  ---------------- ----------------- ------------- ----------------- ------------- ----------------- ------------
                   Among persons                                                                     
                   with arthritis,                                                                   
                   the percent                                                                       
                   with...                                                                           

                   Doctor/health                   Doctor/health                   Took class/course 
                   professional                    professional                    on                
                   suggested losing                suggested                       arthritis/joint   
                   weight to help                  physical activity               symptoms          
                   arthritis/joint                 to help                                           
                   symptoms                        arthritis/joint                                   
                                                   symptoms                                          

  Sex\...                                                                                            

  Age group\...                                                                                      

  Race group\...                                                                                     

  Educational                                                                                        
  level\...                                                                                          

  Income group\...                                                                                   

  Body mass                                                                                          
  index\...                                                                                          

  Physical                                                                                           
  activity                                                                                           
  level\...                                                                                          

  Health care                                                                                        
  access\...                                                                                         

  Health                                                                                             
  status\...                                                                                         

  All with                                                                                           
  arthritis                                                                                          

                   Among persons                                                                     
                   with arthritis,                                                                   
                   the limitation                                                                    
                   status (row                                                                       
                   percentages)                                                                      

                   Can do everything Can do most                     Can do some,                    Can do
                   wants to          things wants                    but not all,                    hardly
                                     to do, but                      things wants                    anything
                                     some                            to do, has                      wants to do
                                     limitations                     many                            
                                                                     limitations                     

  Sex\...                                                                                            

  Age group\...                                                                                      

  Race group\...                                                                                     

  Educational                                                                                        
  level\...                                                                                          

  Income group\...                                                                                   

  Body mass                                                                                          
  index\...                                                                                          

  Physical                                                                                           
  activity                                                                                           
  level\...                                                                                          

  Health care                                                                                        
  access\...                                                                                         

  Health                                                                                             
  status\...                                                                                         

  All with                                                                                           
  arthritis                                                                                          
  ---------------- ----------------- ------------- ----------------- ------------- ----------------- ------------

**Table 1. BRFSS Core Questions on Arthritis (Arthritis Burden)**

1\. The next questions refer to your joints. Please do **NOT** include
the back or neck. **DURING THE PAST 30 DAYS**, have you had any symptoms
of pain, aching, or stiffness in or around a joint?

1 Yes

2 No **Go to Q4**

7 Don\'t Know/Not Sure **Go to Q4**

9 Refused **Go to Q4**

2\. Did your joint symptoms **FIRST** begin more than 3 months ago?

1 Yes 2 No

7 Don\'t Know/Not Sure 9 Refused

3\. Have you **EVER** seen a doctor or other health professional for
these joint symptoms?

1 Yes 2 No

7 Don\'t Know/Not Sure 9 Refused

4\. Have you **EVER** been told by a doctor or other health professional
that you have some form of arthritis, rheumatoid arthritis, gout, lupus,
or fibromyalgia?

1 Yes 2 No

7 Don\'t Know/Not Sure 9 Refused

**IF EITHER Q1 = 1 OR Q4 = 1 THEN CONTINUE. OTHERWISE, GO TO NEXT
SECTION.**

5\. Are you now limited in any way in any of your usual activities
because of arthritis or joint symptoms?

1 Yes 2 No

7 Don\'t Know/Not Sure 9 Refuse

**IF EITHER CORE Q1 = 1 OR Q4 = 1 THEN ELIGIBLE FOR OPTIONAL MODULE**

**[Optional Module (Arthritis Management Module)]{.underline}**

1\. Thinking about your arthritis or joint symptoms, which of the
following best describes you **TODAY**? (Read responses 1- 4)

> 1 I can do everything I want to do;
>
> 2 I can do most of the things I want to do, but I have some
> limitations;
>
> 3 I can do some, but not all, of the things I want to do and I have
> many limitations;
>
> 4 I can do hardly any of the things I want to do.

7 Don\'t Know/Not Sure

9 Refused

2\. Has a doctor or other health professional **EVER** suggested losing
weight to help your arthritis or joint symptoms?

1 Yes 2 No

7 Don\'t Know/Not Sure 9 Refused

3\. Has a doctor or other health professional **EVER** suggested
physical activity or exercise to help your arthritis or joint symptoms?

1 Yes 2 No

7 Don\'t Know/Not Sure 9 Refused

4\. Have you **EVER** taken an educational course or class to teach you
how to manage problems related to your arthritis or joint symptoms?

1 Yes 2 No

7 Don\'t Know/Not Sure 9 Refuse