CLINICAL RESEARCH e-ISSN 1643-3750 © Med Sci Monit, 2016; 22: 2768-2774 DOI: 10.12659/MSM.900367

Effect of Chronic Medical Conditions in Veterans with Multiple Sclerosis on Long-Term Disability

Received: 2016.07.01 Accepted: 2016.07.20 Published: 2016.08.05

Authors’ Contribution: Study Design  A Data Collection  B Statistical Analysis  C Data Interpretation  D Manuscript Preparation  E Literature Search  F Funds Collection  G

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Meheroz H. Rabadi Christopher E. Aston

1 Department of Neurology, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, U.S.A. 2 Department of Neurology, Oklahoma University Health Sciences Center, Oklahoma City, OK, U.S.A. 3 Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, OK, U.S.A.

Meheroz H. Rabadi, e-mail: [email protected] Dr. Christopher Aston was funded by NIH 1 U54GM104938

The goal of this observational study was to examine the effect of common chronic medical conditions (CMCs) on long-term disability (activity limitation) in veterans already diagnosed with multiple sclerosis (MS). We retrospectively reviewed the electronic charts of 124 veterans with MS who have been regularly followed in our MS clinic for 10 or more years. General linear model analysis examined whether MS-related severity as measured by the Expanded Disability Status Scale (EDSS) and the presence of CMCs affected long-term disability as measured by the total score on the Functional Independence Measure (TFIM). Commonly encountered CMCs were increased BMI (61%), hyperlipidemia (78%), hypertension (65%), current smokers (47%), and arthritis/arthralgia (24%). Results suggest that the number of CMCs was not predictive of final TFIM scores; of the variables examined, only initial EDSS score was predictive of final TFIM scores. The presence of CMCs did not affect the long-term disability in veterans diagnosed with MS, this was due mainly to CMCs being closely monitored and co-treated with other medical specialties. Comorbidity • Disabled Persons • Multiple Sclerosis

Abbreviations: BMI – Body Mass Index; CIS – Clinical Isolated syndrome; CMCs – Chronic Medical Conditions; EDSS – Expanded Disability Status Scale; MS – Multiple Sclerosis; NARCOMS – North American Research Committee on Multiple Sclerosis; PPMS – primary-progressive MS; RRMS – relapsing-remitting MS; SPMS – secondary-progressive MS; TFIM – Total Functional Independence Measure Full-text PDF:

http://www.medscimonit.com/abstract/index/idArt/900367

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Rabadi M.H. et al.: Effect of chronic medical conditions in veterans with multiple sclerosis… © Med Sci Monit, 2016; 22: 2768-2774

CLINICAL RESEARCH

Background Multiple sclerosis (MS) is a chronic progressive disease and a leading cause of disability (defined by the WHO as activity limitation) especially in young adults [1]. More and more patients with MS are living longer as treatments are being instituted at an early stage with the aim to reduce relapses, slow disease progression, and minimize MS-related complications. Chronic medical conditions (CMCs) such as obesity, hypertension, and arthritis are common in the general population [2] and are responsible for functional limitations [3], increased hospitalization, and increased mortality [4]. Presence of 1 or more CMCs in people with an index disease is referred to as co-morbidity [5]. The number of CMCs afflicting an individual increases with age [6]. In the Framingham Heart Study, presence of vascular risk factors, a common CMC, caused systemic inflammation as evidenced by an increase in blood cytokine levels resulting in greater brain atrophy than expected for age; therefore, CMCs are likely to further worsen disability in MS patients with increase brain plaque load [7]. Finlayson et al. showed that MS-related fatigue was affected by the presence of diabetes mellitus and arthritis [8]. Presence of CMCs has been found to delay MS diagnosis and increase MS-related disability at diagnosis, negating efforts to initialize treatment at earlier stages [9]. Both of these studies [8,9] were based on data from the North American Research Committee on Multiple Sclerosis (NARCOMS) registry. Although this is a large data base comprising 18 000 patients with MS, the cohort is primarily white and based on self-reporting. This limits generalizability of its conclusions to other patient groups and presents a potential bias. The presence of CMCs complicates the treatment of MS. Franklin et al. [10], in their study of 136 542 discharges with a diagnosis of MS, found that 9.2% (n=12 504) had a comorbid cardiac condition that contraindicated the prescription of fingolimod. Subsequently, these patients had a significantly higher hospitalization cost compared to those patients with no cardiac condition ($17 623 vs. $11 663). Finally, just as the presence of CMCs affects immuno-modulatory treatment choices [11], the response, compliance, and administration of MS treatments can worsen the CMCs. A veteran is a person who served in active military service and is now discharged or released from service. As long as the conditions of discharge or release were other than dishonorable, they qualify for Veterans Affairs (VA) health care benefits. VA operates the nation’s largest integrated health care system providing basic to advanced and specialized medical care to 9 million veterans at 1400 sites, including university-affiliated teaching hospitals, community clinics, veteran’s centers (nursing homes), and counseling centers.

This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)

Given that the risk of MS and the presence of CMCs increases with age, we wanted to study the impact of the presence of commonly encountered CMCs on long-term disability (activity limitation) in veterans already diagnosed with multiple sclerosis (MS). Compared to NARCOMS, the veteran population differs in being mainly white men, older, and with confirmed MS diagnosis. The CMCs selected for study was based on those chronic conditions that cause the most disability and death in the veteran population and account for a disproportionate health care utilization and rising health care cost [12]. These CMCs also are the most common cause of disability and death in the United States [13]. A rising prevalence of similar vascular risk factors have been found in MS patients in a recent Canadian study [14], and was associated with a more rapid progression of gait dysfunction than in MS patients without these co-morbidities [15]. The findings of the present study may help institute changes in the VA MS program to decrease the additive effect of CMCs-related disability on the overall MS-related disability.

Material and Methods Participants and procedures This retrospective study included eligible veterans already diagnosed with MS (using the McDonald criteria) [16] and followed every 4 months for 10 or more years (from 2000 to 2012). A minimum of 10 years of follow-up was selected to ensure a sufficient period for the presence of these commonly encountered CMCs to have an effect upon disability. There were no exclusion criteria. Data were obtained via chart review (Veterans Administration [VA] electronic record or paper chart from non-VA facilities of veterans who transferred their care to our facility). This study was approved by the Institutional Review Board for Human Subjects Research and the local VA Research and Development Committee. Data recorded were basic demographics (age, sex, and ethnicity), and relevant clinical variables such as age at onset of MS, duration of the disease, clinical MS subtype: relapsing-remitting MS (RRMS), secondary-progressive MS (SPMS), primary-progressive MS (PPMS), and clinical isolated syndrome (CIS) [17]. Patients, who on direct questioning complained of depression and fatigue on their initial or follow-up evaluations, completed the Beck depression inventory, fatigue severity scale, and modified fatigue impact scale to confirm and quantify their depression or fatigue. Preexisting and new-onset commonly encountered CMCs selected for documentation were hypertension, diabetes mellitus, hyperlipidemia, elevated body mass index (BMI) (overweight: BMI ≥25 and

Effect of Chronic Medical Conditions in Veterans with Multiple Sclerosis on Long-Term Disability.

BACKGROUND The goal of this observational study was to examine the effect of common chronic medical conditions (CMCs) on long-term disability (activit...
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