Carol A. Mancuso MD is a general internist and clinical epidemiologist with joint appointments at the New York Presbyterian Hospital and the Hospital for Special Surgery. As a clinical researcher, she works closely with clinicians and researchers at both institutions. Her areas of particular interest are expectations of elective orthopedic surgery, adverse lifestyle outcomes caused by rheumatoid arthritis and systemic lupus erythematosus, and self-management and quality of life in asthma patients. 

Patients’ Expectations and Satisfaction with Outcomes of Orthopedic Surgery

Dr. Mancuso conducted a series of studies to ascertain patients’ expectations and satisfaction with hip, knee, and shoulder surgery. She found that in addition to improvement in pain and function, major expectations included regaining independence and restoring psychological well-being. These studies resulted in the development and validation of patient-derived surveys that have become gold standards for measuring expectations in clinical practice and research. Dr. Mancuso used these surveys in a study supported by the Arthritis Foundation to assess fulfillment of expectations of total hip arthroplasty, and in two randomized controlled trials supported by the National Institute on Aging to test the effectiveness of educational interventions to modify expectations of total hip and total knee arthroplasty. Future work will include development of expectations surveys for patients undergoing spine surgery, and assessment of change in expectations during staged bilateral arthroplasty and revision arthroplasty.

Adverse Psychosocial Outcomes in Patients with Connective Tissue Diseases 

Most studies of employment in patients with rheumatoid arthritis (RA) focus on job loss; less is known about workplace experiences in patients who continue to work. To study these experiences, Dr. Mancuso conducted a longitudinal study comparing the incidence of negative workplace events between employed patients with RA and healthy controls. Compared to controls, negative events were associated primarily with more fatigue and more social stress in RA patients. In addition, RA patients were more likely not to meet national goals for daily physical activity and to become progressively more inactive over time. In a parallel study supported by the Mary Kirkland Center for Lupus Research, patients with systemic lupus erythematosus (SLE) also were more likely not to meet national activity goals. Future work will include measurement of exercise capacity and development of an intervention to increase lifestyle physical activity in SLE patients. 

Improving Quality of Life and Clinical Outcomes in Primary Care and Emergency Department Patients with Asthma

As a Robert Wood Johnson Generalist Physician Faculty Scholar, Dr. Mancuso conducted a longitudinal study to identify patient-centered predictors of functional decline and resource utilization in asthma patients. The results showed that more depressive symptoms, less self-efficacy and unrealistic expectations predicted worse outcomes. This work became the foundation for the development of a patient self-management program aimed at increasing asthma knowledge, self-efficacy, and asthma-related social support. The program was tested with primary care patients in a randomized controlled trial supported by a K-23 award from the National Heart Lung and Blood Institute, and determined that the intervention was particularly affective in patients with more depressive symptoms. 

During these studies, Dr. Mancuso found that many asthma patients limit physical activity and avoid exercise because they are concerned about exacerbating their respiratory symptoms. Lack of exercise, however, predisposes not only to direct adverse cardiovascular events, but also to obesity, depressive symptoms, and decreased pulmonary reserve, all of which can lead to adverse asthma outcomes. In order to increase physical activity, Dr. Mancuso conducted a randomized controlled trial to study the effectiveness of a novel psychosocial intervention to foster healthy lifestyle activities in primary care asthma patients. Supported by the National Heart Lung and Blood Institute, the trial resulted in clinically important increases in weekly physical activity, and was particularly effective in patients with more depressive symptoms. 

Patients who present to urban emergency departments (ED) for asthma often do not have good self-management skills and do not have established sources of primary care. To address the educational needs of asthma ED patients, Dr. Mancuso conducted a randomized controlled trial supported by the National Heart Lung and Blood Institute aimed at fostering self-management in patients presenting for asthma to the ED at two inner city hospitals. Patients received interventions that addressed asthma knowledge, self-efficacy, and social support, and provided feedback regarding respiratory function. Quality of life and repeat ED visits improved in both groups, with particular benefit in younger patients. 

A recurring theme throughout this trajectory of work has been the impact of depressive symptoms on asthma outcomes. This covariate will be assessed in detail in future work supported by the National Heart Lung and Blood Institute which will characterize the spectrum and manifestations of depressive symptoms in asthma patients.