This grant is requested to develop three areas of special interest. The first is applied research in which we aim to: 1) develop a necessary and sufficient data base for the rational planning of health services to arthritics, and 2) develop and evaluate model components of cost-effective health care delivery for arthritis patients. Thus under Community Component, we propose to develop and critically evaluate: a seven-day rehabilitation work schedule; a model health care system for arthritis disability; stepped-up rehabilitation services to homebound patients; a system of followup of rheumatic disease patients discharged from a tertiary care facility; a patient-oriented strategy to improve clinical outcomes; and an educational strategy for the primary prevention of low back injuries in the work place. As one of the 4 major joint replacement centers in the world, we propose to evaluate the cost-effectiveness of joint replacement by a multi-dimensional outcome assessment. We seek to document the economic burden to arthritics and shortfalls in the present health care reimbursement scheme. We propose to evaluate the means by which interventions can be evaluated by comparing the relative merits of existing health status functional instruments. The second priority is the development of a Core Unit for quantitative research methods, Clinical Epidemiology and Evaluation Research, which would overlap with many activities of the Center and would aid investigators in training and establishing investigators. The Unit would support at least 10 projects from the day-to-day management of special disease registries to clinical studies directed at improving clinical strategies and decision making in rheumatology, and applications of basic research. Finally, we propose pilot studies in a neglected area of research, the management of severe rheumatoid arthritis patients who have failed all conventional therapy: thus, the protocols addressing the critical evaluation of total nodal irradiation therapy and leukapheresis therapy of refectory rheumatoid arthritis.
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