Prediction of successful application for disability benefits for people with arthritis using the Health Assessment Questionnaire

D. S. Memel, J. R. Kirwan1,, C. Langley, S. Hewlett1 and M. Hehir1

Air Balloon Surgery, Bristol and
1 University of Bristol Academic Rheumatology, Bristol, UK


    Abstract
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 Abstract
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 Method
 Results
 Discussion
 References
 
Background. Many eligible people with arthritis do not receive disability benefits. Application forms are lengthy and complex, and doctors and nurses are often unsure which patients would qualify.

Aim. To investigate how severe disability on the Health Assessment Questionnaire (HAQ) relates to successful application for disability benefits by people with osteoarthritis (OA) and rheumatoid arthritis (RA).

Method. RA patients attending a hospital out-patient rheumatology clinic and patients with OA or RA in two general practices completed an HAQ and were asked about receipt of disability benefits. Those scoring 2 or more on the HAQ (severe disability) and not in receipt of benefits were offered professional help to complete applications for Disability Living Allowance (DLA) or Attendance Allowance (AA).

Results. Eighty per cent of patients with an HAQ score of 2 or more were already in receipt of benefits. Seventy-nine per cent of the new applicants applied successfully, the average benefit being in excess of £2580 per annum.

Conclusion. This initial study suggests that people who score 2 or more on the HAQ should be encouraged to apply for disability benefits. A test of the generalizability of these findings and the success rate associated with lower HAQ scores should be undertaken.

KEY WORDS: Arthritis, Health Assessment Questionnaire, Disability benefits, Welfare benefits.


    Introduction
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It is common that the needs of people with chronic arthritis are not met through clinical treatment alone. For disabled people, especially those with the most severe impairments, maximizing health potential and maintaining quality of life involves extra costs [1]. Financial help can be accessed through the welfare benefits system but doctors and nurses in both primary and secondary care are rarely confident of the criteria used, are aware that the corresponding forms are long and complex and are, therefore, unclear as to whether or not they should advise their patients to apply for benefits.

Disability Living Allowance (DLA) and Attendance Allowance (AA) are non-means-tested benefits which aim to help meet some of the extra costs incurred by disabled people [2]. DLA awards are for people under 65 yr and currently range between £14.05 and £89.95 and AA is awarded to those who are 65 yr and older and is £35.40 or £52.95 per week. Thus, a disabled person of pensionable age can benefit by at least £1783.60 per annum; in addition, receipt of DLA or AA can lead to other benefits. In 1998 only 45.8% of initial claims for DLA were successful and the figure for AA was 73.7% [3]. Although the value of benefits can be significant, many people do not apply. One national report suggested that only 40–60% of those eligible are actually in receipt of benefits [4] and similar lack of take-up has been found in our two recent studies of arthritis in primary care [5, 6]. There may be a number of reasons for this, but people may be more comfortable applying if the likelihood of their eligibility is brought to their attention and they are assisted in completing the lengthy application form by someone, such as a welfare benefits advice worker, who is knowledgeable about the adjudication criteria [7]. Welfare benefits advice is available in various settings, including a few general practice surgeries and hospitals [8], but it is important to target advice to those most likely to benefit.

The Health Assessment Questionnaire (HAQ) is commonly used by rheumatologists to assess functional disability reliably in arthritis [9] and its use has been advocated in primary care [10]. It is easily self-completed within 4–5 min and takes 1 min or less to score. It gives a score of between 0 and 3 in steps of 0.125, where 3 means complete dependency in many activities of daily living. The HAQ is therefore much more accessible than the DLA and AA forms, which often take up to 2 h to complete. However, it was designed to assess functional status rather than the care and mobility needs that are addressed during assessment for provision of DLA and AA.

From our previous studies, we were interested to find that only 53% of people severely disabled by arthritis (HAQ score 2 or more) were receiving DLA or AA, only 6% having applied and been turned down [5, 6]. In this initial study we aimed to determine the likelihood that an HAQ score of 2 or more in patients with rheumatoid arthritis (RA) or osteoarthritis (OA) would be sufficient in itself to provide a useful indicator of successful application for DLA or AA. If so, there would be a strong argument for testing the wider use of the HAQ in this way and of exploring success in applications by those with lower scores.


    Method
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Patients with OA or RA were identified in two settings. The hospital sample was made up of follow-up RA patients attending a rheumatology out-patient clinic at a teaching hospital. The general practice sample was taken from a database of patients who had been involved in recent studies in two general practices in central Bristol [5, 6]. It included all those with a confirmed diagnosis of OA or RA and who had scored 1.75 or more on the HAQ but were not receiving DLA or AA at that time.

Consenting patients in both samples completed an HAQ and those scoring 2 or more but not receiving benefits were invited to apply with the help of an advice worker. Patients were offered appointments at the hospital out-patient clinic or at the general practice with trained welfare benefits advice workers from a local advice centre or the Citizens Advice Bureau (CAB). The advice workers discussed and explained the application form, clarified the meaning and implications of some of the questions and helped patients to complete the form. Three months after submission of the DLA/AA forms, patients were contacted again to enquire about the outcome of their application.


    Results
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Hospital out-patient sample
Over the period of the study (8 months) 109 eligible patients had a score of 2 or more on the HAQ and 91 of these were already receiving disability benefits. Of the remaining 18, 12 people accepted an appointment to see a CAB advice worker at the hospital, who helped them to complete the relevant forms and also advised them concerning other benefits to which they might be entitled. Nine were successful in their applications for disability benefits. The results are detailed in Table 1Go.


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TABLE 1. Outcomes of applications for disability benefits

 

General practice sample
Twenty-three people were identified from the database set up during previous studies. They were contacted with a view to obtaining an up-to-date HAQ score. Two of these declined and five others did not reply or were ineligible, leaving usable replies from 16 people, 13 of whom had OA and three had RA. Nine of these reported successful application for DLA or AA since the previous assessment (maximum 2 yr). The remaining seven patients, all of whom had OA, were offered an appointment and all accepted. A welfare benefits advice worker saw them at one of the practices and the appropriate form was completed. Six were successful and the other case has gone for review/appeal. The total amount awarded is shown in Table 1Go.

None of the eligible patients in either the general practice or hospital samples had made a previous application for DLA or AA.


    Discussion
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This study has indicated that patients scoring 2 or more on the HAQ have a high rate of success when applying for disability benefits. In this sample, 80% were already receiving or had applied for and were awarded DLA or AA, and 79% of new applicants were successful. Awards for the new claims ranged between £730.60 and £5220, with a mean of £2581 annually.

Although this finding was true for both hospital and general practice patients, taking samples from both illustrated an interesting difference. Hospital rheumatology out-patient clinics involve higher numbers of patients who are severely disabled and score 2 or more on the HAQ, but in this study these patients were more likely to be in receipt of DLA/AA than those with similar levels of functional disability seen in general practice [5, 6]. In the event, the two methods of recruitment produced similar numbers of patients who could apply for benefits.

Bearing in mind the reported low take-up figures for disability benefits, a surprisingly large proportion of the patients were already in receipt of benefits. This could be a feature of the populations from which the samples were drawn as they may have been sensitized through previous research or influenced by health-care professionals to apply.

Overall, this initial study has shown that, for people with arthritis, a score of 2 or more on the HAQ is a very strong indicator of successful application for DLA or AA. If confirmed, this simple questionnaire could be used by doctors and nurses working in primary and secondary care to advise their patients to apply for benefits. Because the HAQ is self-completed quickly and easily by patients it does not involve staff in much extra work, and functional assessment can improve other aspects of patient care, such as referrals to occupational therapists and physiotherapists [11]. Furthermore, there is the potential for direct dissemination to people with arthritis, through organizations such as Arthritis Care, of the HAQ and scoring system (which are in the public domain) and advice about applying for benefits.

It is now necessary to test the generalizability of this finding in a wider range of hospital and general practice settings and to determine the success rate associated with lower scores on the HAQ. Such a study has now been funded, and it will recruit patients with a score of 1.5 or more. However, whereas a high HAQ score appears to have a high positive predictive value, a low HAQ score alone cannot be expected to have a high negative predictive value, as there are other factors involved in successful application for these disability benefits. Some people with low HAQ scores will be eligible for reasons other than arthritis disability, such as comorbidity or specific care needs.

This approach of linking functional health scales to disability benefit application could be extended to other chronic diseases, such as chronic respiratory and neurological disease using appropriate scales.


    Acknowledgments
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The authors thank Caroline Coleman and volunteers from Bristol Citizens’ Advice Bureau and Debbie Gubbay of Barton Hill Advice Centre Outreach Project for providing advice and assistance in making claims, and all patients who participated. Air Balloon Surgery is funded for research through the national R&D Support for NHS Providers scheme.


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Correspondence to: J. Kirwan, University of Bristol Academic Rheumatology, United Bristol Healthcare NHS Trust, Marlborough Street, Bristol BS2 8HW, UK Back


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Submitted 23 February 2001; Accepted 20 July 2001