Is a “false‐positive” clinical diagnosis of knee osteoarthritis just the early diagnosis of pre–radiographic disease?

Objective

In routine practice, diagnosis of knee osteoarthritis (OA) currently relies on the combination of conventional risk factors and the presence of cardinal signs and symptoms. However, their role in early diagnosis has received little attention compared with biomarker research.

Methods

Using data from 122 adults ages ≥50 years with knee pain but no definite radiographic OA, we tested whether the clinical diagnostic probability of OA, based on risk factors, signs, and symptoms, was associated with subsequent incidence of radiographic OA 3 years later.

Results

Clinical diagnostic probability performed only modestly in discriminating incident radiographic knee OA (area under the receiver operating characteristic curve = 0.59, 95% confidence interval 0.49–0.70).

Conclusion

Improving the measurement of conventional markers and using study designs that test the ability of new biomarkers to add to or replace conventional markers are priorities for research in the early diagnosis of OA.     

Demographic and Clinical Factors Associated With Nonsurgical Osteoarthritis Treatment Among Patients in Outpatient Clinics

Objective

To identify patient demographic and clinical characteristics associated with osteoarthritis (OA) treatment use.

Methods

This was a secondary data analysis of 3 clinical trials among patients with hip or knee OA conducted in Duke Primary Care practices, the Durham Veterans Affairs (VA) Health Care System, and the University of North Carolina–Chapel Hill (UNC). At baseline, participants reported sociodemographic characteristics, OA‐related pain and function, and OA treatment use, including oral analgesics, topical creams, joint injections, and physical therapy. Separate, multivariable logistic models (adjusted for clustering of clinics and providers for the Duke and VA cohorts) were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for the associations between participant characteristics and each type of OA treatment.

Results

Oral analgesic use was reported by 70–82% of participants across the 3 cohorts. Physical therapy, knee injections, and topical creams were used by 39–52%, 55–60%, and 25–39% of Duke, VA, and UNC participants, respectively. In multivariable models, worse pain, stiffness, and function, per 5‐unit increase, were associated with greater odds of using any oral analgesic for the cohorts from Duke (OR 1.18 [95% CI 1.08–1.28]) and UNC (OR 1.14 [95% CI 1.05–1.24]), but not for the VA cohort (OR 1.04 [95% CI 0.95–1.14]). For all 3 cohorts, nonwhites had higher odds of using topical creams compared to whites.

Conclusion

Results suggest potential underutilization of therapies other than oral analgesics. Patient characteristics may affect OA treatment use, and understanding the relationship between these factors and OA treatment preferences may improve adherence to OA treatment guidelines.     

Trends in physician‐diagnosed osteoarthritis incidence in an administrative database in British Columbia,Canada, 1996–1997 through 2003–2004

Objective

Prevalence of osteoarthritis (OA) is expected to increase due to population aging. However, there is little information on the trends in the incidence of OA over time. The purpose of this study was to describe changes in physician‐diagnosed OA incidence rates between 1996–1997 and 2003–2004 in British Columbia (BC), Canada.

Methods

We used data on all visits to health professionals and hospital admissions covered by the Medical Services Plan of BC (population ～4 million) for the fiscal years 1991–1992 through 2003–2004. Rates were standardized to the BC population in 2000. We used 2 definitions of OA: 1) at least 1 visit or hospitalization with a diagnostic code for OA, and 2) at least 2 visits or 1 hospitalization with a code for OA. Incidence rates were calculated with a 5‐year run‐in period to exclude prevalent cases.

Results

Between 1996–1997 and 2003–2004, crude incidence rates of OA based on definition 1 increased from 10.5 to 12.2 per 1,000 in men and from 13.9 to 17.4 per 1,000 in women. The age‐standardized rates did not change in men and increased from 14.7 to 16.7 per 1,000 in women. Incidence rates based on definition 2 were almost 50% lower, but the trends were similar.

Conclusion

We observed an increase in the incidence of OA in both men and women due to population aging and an additional increase in women beyond the effect of aging. These trends have important implications for public health and provision of health services to this very large group of patients.     

Do radiographic disease and pain account for why people with or at high risk of knee osteoarthritis do not meet physical activity guidelines?

Objective

Knee osteoarthritis (OA) and pain are assumed to be barriers to meeting physical activity guidelines, but this has not been formally evaluated. The purpose of this study was to determine the proportions of people with and those without knee OA and knee pain who meet recommended physical activity levels through walking.

Methods

We performed a cross‐sectional analysis of community‐dwelling adults from the Multicenter Osteoarthritis Study who had or who were at high risk of knee OA. Participants wore a StepWatch activity monitor to record steps per day for 7 days. The proportion of participants who met the recommended physical activity levels was defined as those accumulating ≥150 minutes per week at ≥100 steps per minute in bouts lasting ≥10 minutes. These proportions were also determined for those with and those without knee OA, as classified by radiography and by severity of knee pain.

Results

Of the 1,788 study participants (mean ± SD age 67.2 ± 7.7 years, mean ± SD body mass index 30.7 ± 6.0 kg/m², 60% women), lower overall percentages of participants with radiographic knee OA and knee pain met recommended physical activity levels. However, these differences were not statistically significant between those with and those without knee OA; 7.3% and 10.1% of men (P = 0.34) and 6.3% and 7.8% of women (P = 0.51), respectively, met recommended physical activity levels. Similarly, for those with moderate/severe knee pain and those with no knee pain, 12.9% and 10.9% of men (P = 0.74) and 6.7% and 11.0% of women (P = 0.40), respectively, met recommended physical activity levels.

Conclusion

Disease and pain have little impact on achieving recommended physical activity levels among people with or at high risk of knee OA.

     

Variability in knee radiographing: implication for definition of radiological progression in medial knee osteoarthritis

OBJECTIVES—(1) To assess reproducibility of medial knee joint space width (JSW) measurement in healthy subjects and osteoarthritic (OA) patients. (2) To define minimal relevant radiological change in knee JSW based on the reproducibility of its measurement.
PATIENTS AND METHODS—(1) Healthy volunteers: in the first part of the study, 20 knees of healthy adult volunteers were radiographed in the weightbearing, anteroposterior extended view, twice, two weeks apart, using three different radiographic procedures: (a) without guidelines, (b) with guidelines and without fluoroscopy, (c) with guidelines and fluroroscopy. (2) Knee OA patients: in the second part of the study, 36 knees of OA patients were radiographed twice with guidelines and without fluoroscopy. JSW was measured blindly using a graduated magnifying glass. Based on the Bland and Altman graphic approach, cut off points defining minimal relevant radiological change are proposed.
RESULTS—Standard deviation (SD) of differences in JSW measurement between two sets of knee radiographs in healthy subjects were 0.66 mm for radiography performed without guidelines, 0.37 mm for radiography performed with guidelines and without fluoroscopy, and 0.31 mm for radiography with guidelines and fluoroscopy. SD of differences in JSW measurement in OA patients were 0.32 mm for radiography performed with guidelines and without fluoroscopy. A minimal relevant change in JSW between two radiographs performed in healthy subjects can be defined by a change of at least 1.29 or 0.59 mm when radiographs are taken without guidelines, and with guidelines and fluoroscopy, respectively. When radiographs are taken with guidelines and without fluoroscopy, the change must be at least 0.73 mm. A similar figure, 0.64 mm was observed in knee OA patients.
CONCLUSION—Definition of radiological progression varies greatly according to the radiographic procedure chosen. Use of guidelines reduces the threshold of progression required to consider that change between two measures is relevant.

Keywords: radiography; knee; osteoarthritis     

Global Burden of Disease Study 2019: an opportunity to understand the growing prevalence and impact of hip,knee, hand and other osteoarthritis in Australia

Background

Understanding population-level trends in osteoarthritis (OA) is critical for planning health services and disease prevention initiatives.

Aim

To examine trends in the burden of hip, knee, hand and other OA related conditions in Australia from 1990 to 2019 and consider the OA burden in the context of other common conditions associated with older age.

Methods

Global Burden of Disease Study 2019 data for Australia on OA prevalence, OA-related years lived with disability (YLDs) and OA-related YLDs attributable to high body mass index (BMI) were sourced for 1990–2019. Age-standardised YLD data for ischaemic heart disease, stroke, dementia, type 2 diabetes and chronic obstructive pulmonary disease were obtained for comparison.

Results

Overall, 3.20 million Australians were estimated to have OA in 2019, with substantial growth in the prevalence of hip (+171%), knee (+126%), hand (+110%) and other types of OA (+130%) from 1990 to 2019. Age-standardised prevalence rates reflect the contribution of population ageing. Concomitant growth in OA-related YLDs was also evident; knee OA and hand OA demonstrated the highest disease burden in 2019 (59 684 and 41 893 YLDs respectively). The proportion of knee OA burden attributable to high BMI was 36% in 2019. In 2019, age-standardised YLD rates were higher for OA (313 per 100 000 population) than other common conditions (range: 47 per 100 000 (ischaemic heart disease) to 284 per 100 000 (type 2 diabetes)).

Conclusions

OA is an increasingly prevalent, impactful condition with a high non-fatal disease burden relative to other health conditions. Growth in OA populations and OA-related disability underscore the need for enhanced investment in prevention and management.     

Objective physical activity measurement in the osteoarthritis initiative: Are guidelines being met?

Objective

Osteoarthritis (OA) clinical practice guidelines identify a substantial therapeutic role for physical activity, but objective information about the physical activity of this population is lacking. The aim of this study was to objectively measure levels of physical activity in adults with knee OA and report the prevalence of meeting public health physical activity guidelines.

Methods

Cross‐sectional accelerometry data from 1,111 adults with radiographic knee OA (49–84 years old) participating in the Osteoarthritis Initiative accelerometry monitoring ancillary study were assessed for meeting the aerobic component of the 2008 Physical Activity Guidelines for Americans (≥150 minutes/week moderate‐to‐vigorous–intensity activity lasting ≥10 minutes). Quantile regression was used to test median sex differences in physical activity levels.

Results

Aerobic physical activity guidelines were met by 12.9% of men and 7.7% of women with knee OA. A substantial proportion of men and women (40.1% and 56.5%, respectively) were inactive, having done no moderate‐to‐vigorous activity that lasted 10 minutes or more during the 7 days. Although men engaged in significantly more moderate‐to‐vigorous activity (average daily minutes 20.7 versus 12.3), they also spent more time in no or very‐low‐intensity activity than women (average daily minutes 608.2 versus 585.8).

Conclusion

Despite substantial health benefits from physical activity, adults with knee OA were particularly inactive based on objective accelerometry monitoring. The proportions of men and women who met public health physical activity guidelines were substantially less than those previously reported based on self‐reported activity in arthritis populations. These findings support intensified public health efforts to increase physical activity levels among people with knee OA.

     

Variation in route to diagnosis of heart failure in primary care in England: analysis of a retrospective cohort between 2010 and 2013

Background

Heart failure is common (affecting at least 550?000 people in the UK) and costly, with frequent admission to hospital and high mortality. Diagnosis remains difficult in primary care. We have demonstrated previously that few patients follow a route to diagnosis aligned with National Institute for Health and Care Excellence (NICE) guidelines, suggesting lack of implementation of evidence-based guidelines and variability in provision of care. Therefore, we explored variation in the route to diagnosis of heart failure in primary care by key patient factors and general practice.

Lifetime Risk and Age at Diagnosis of Symptomatic Knee Osteoarthritis in the US

Objective

To estimate the incidence and lifetime risk of diagnosed symptomatic knee osteoarthritis (OA) and the age at diagnosis of knee OA based on self‐reports in the US population.

Methods

We estimated the incidence of diagnosed symptomatic knee OA in the US by combining data on age‐, sex‐, and obesity‐specific prevalence from the 2007–2008 National Health Interview Survey, with disease duration estimates derived from the Osteoarthritis Policy (OAPol) Model, a validated computer simulation model of knee OA. We used the OAPol Model to estimate the mean and median ages at diagnosis and lifetime risk.

Results

The estimated incidence of diagnosed symptomatic knee OA was highest among adults ages 55–64 years, ranging from 0.37% per year for nonobese men to 1.02% per year for obese women. The estimated median age at knee OA diagnosis was 55 years. The estimated lifetime risk was 13.83%, ranging from 9.60% for nonobese men to 23.87% in obese women. Approximately 9.29% of the US population is diagnosed with symptomatic knee OA by age 60 years.

Conclusion

The diagnosis of symptomatic knee OA occurs relatively early in life, suggesting that prevention programs should be offered relatively early in the life course. Further research is needed to understand the future burden of health care utilization resulting from earlier diagnosis of knee OA.     

Findings from the first national clinical audit of treatment for people with HIV

Objectives

We reviewed the impact of and assessed adherence to British HIV Association (BHIVA) guidelines in routine clinical practice. Feedback has been provided to clinical centres to facilitate any necessary change.

Methods

We used a questionnaire to gauge clinicians' views on the guidelines and availability of antiretroviral therapy (ART) drugs and specialized tests. A case note review of 2044 patients was conducted to assess adherence to guideline recommendations plus patterns of use of HIV resistance testing.

Results

Most clinicians (74.1%) report that BHIVA guidelines have influenced care at their centres. A significant minority report problems with access to specialized tests. Most patients who started ART did so at CD4 counts lower than guidelines recommend but in most cases this reflected the CD4 count at diagnosis of HIV. Of patients on ART, an overwhelming majority (97.6%) were receiving three or more drugs. Of those on three or more drugs, 58.9% had latest viral load (VL) below 50 HIV‐1 RNA copies/mL and a further 18.1% below 500 copies/mL. Only 19.3% of patients had been tested for HIV resistance, of whom more than half showed resistance to more than one class of drugs.

Conclusions

This clinical audit provides encouraging evidence of the quality of care offered to people with diagnosed HIV in the UK. However late diagnosis means most people start ART at a more advanced stage than guidelines recommend.

     

Role of the Nav1.7 R1150W amino acid change in susceptibility to symptomatic knee osteoarthritis and multiple regional pain

Objective

To assess the genetic association of pain in patients with knee osteoarthritis (OA) and those with multiple regional pain with the R1150W variant in the α‐subunit of the voltage‐gated sodium channel Na_V1.7.

Methods

Knee OA patients from 2 UK cohorts (1,411 from the Genetics of Osteoarthritis and Lifestyle study and 267 from the Hertfordshire Cohort Study; 74% with symptomatic OA) with Western Ontario and McMaster Universities OA Index (WOMAC) pain scores were genotyped for rs6746030 (encoding the R1150W change). One hundred seventy‐six knee OA patients (53% symptomatic) from the Clearwater Osteoarthritis Study were also tested. A total of 4,295 samples (both affected and unaffected OA) from all 3 studies with data on multiple regional pain were tested. Fixed‐effects meta‐analyses were carried out with the WOMAC, symptomatic OA (adjusting for radiographic severity), and multiple regional pain as outcomes.

Results

No association with the WOMAC was seen in the UK cohorts. Overall, the meta‐analysis of WOMAC yielded a summary statistic of β = 0.47 (95% confidence interval [95% CI] 0.04, 0.89; P = 0.030) for the variant allele. The meta‐analysis of symptomatic versus asymptomatic OA did not demonstrate an association with rs6746030 (odds ratio [OR] 0.90 [95% CI 0.71, 1.15], P = 0.38). The meta‐analysis of multiple regional pain resulted in a significant OR of 1.40 (95% CI 1.08, 1.80; P = 0.0085). No interstudy heterogeneity was seen for any of the analyses.

Conclusion

We find evidence that the R1150W amino acid change in the Na_V1.7 α‐chain is associated with multiple regional pain. This variant is confirmed to be involved in genetic susceptibility to pain, but it does not appear to have a major role in OA‐specific pain.     

Disparities in Total Knee Replacement: Population Losses in Quality‐Adjusted Life‐Years Due to Differential Offer,Acceptance, and Complication Rates for African Americans

Objective

Total knee replacement (TKR) is an effective treatment for end‐stage knee osteoarthritis (OA). American racial minorities undergo fewer TKRs than whites. We estimated quality‐adjusted life‐years (QALYs) lost for African American knee OA patients due to differences in TKR offer, acceptance, and complication rates.

Methods

We used the Osteoarthritis Policy Model, a computer simulation of knee OA, to predict QALY outcomes for African American and white knee OA patients with and without TKR. We estimated per‐person QALYs gained from TKR as the difference between QALYs with current TKR use and QALYs when no TKR was performed. We estimated average, per‐person QALY losses in African Americans as the difference between QALYs gained with white rates of TKR and QALYs gained with African American rates of TKR. We calculated population‐level QALY losses by multiplying per‐person QALY losses by the number of persons with advanced knee OA. Finally, we estimated QALYs lost specifically due to lower TKR offer and acceptance rates and higher rates of complications among African American knee OA patients.

Results

African American men and women gain 64,100 QALYs from current TKR use. With white offer and complications rates, they would gain an additional 72,000 QALYs. Because these additional gains are unrealized, we call this a loss of 72,000 QALYs. African Americans lose 67,500 QALYs because of lower offer rates, 15,800 QALYs because of lower acceptance rates, and 2,600 QALYs because of higher complication rates.

Conclusion

African Americans lose 72,000 QALYs due to disparities in TKR offer and complication rates. Programs to decrease disparities in TKR use are urgently needed.

     

UK‐based physical therapists' attitudes and beliefs regarding exercise and knee osteoarthritis: Findings from a mixed‐methods study

Objective

Within the UK, differences exist between physical therapists' use of exercise for patients with knee osteoarthritis (OA) and recent exercise recommendations. This may be explained by their underlying attitudes and beliefs. We aimed to describe UK physical therapists' attitudes and beliefs regarding exercise and knee OA, and understand and explain them.

Methods

A survey was mailed to 2,000 UK‐based chartered physical therapists that included 23 attitude statements derived from recently published recommendations. Semistructured telephone interviews were conducted with a purposeful sample of questionnaire respondents (n = 24), and were recorded and analyzed thematically.

Results

The questionnaire response rate was 58% (n = 1,152); 538 respondents reported treating a patient with knee OA in the last 6 months. The survey highlighted uncertainty about potential benefits of exercise for knee OA: only 56% largely/totally agreed that knee problems are improved by local exercise. Although exercise adherence was deemed important, it was seen as the patient's, not the therapist's, responsibility. Interviews revealed an underlying biomedical model of care of knee pain, with knee OA viewed as a progressive degenerative condition. A paternalistic treatment approach was evident. Health care systems presented a number of barriers to best practice, including limited opportunity to provide followup.

Conclusion

Although the attitudes and beliefs of physical therapists may help to explain differences between current practice and recent exercise recommendations, the wider health care system also plays a part. Further research is needed to support meaningful shifts in physical therapy care in line with the best practice recommendations.     

A national review of assessment and monitoring of HIV-infected patients

Objectives

The British HIV Association (BHIVA) audit subcommittee aimed to survey UK clinic policy and practice regarding baseline assessment and immunization of newly diagnosed HIV‐positive patients, and frequency of follow‐up and testing in established patients in the UK.

Methods

UK centres providing HIV care were requested to complete an online survey between October 2006 and March 2007.

Results

111 centres participated in the survey. 89.2% of centres routinely performed baseline HIV resistance testing. 99% of centres had a policy of routine screening for hepatitis B. Only 91% of centres were routinely offering a sexual health screen at diagnosis. Frequency of routine follow‐up for patients not requiring antiretroviral therapy (ART) and stable on ART varied between three and six months.

Discussion

This review showed variations in practice regarding the post diagnosis assessment and routine monitoring of HIV patients. It is of concern that not all centres perform baseline HIV resistance testing. It has also been noted that hepatitis B vaccination is not being offered to non‐immune patients at diagnosis. Less frequent follw‐up of stable patients (both on and off ART) should allow resources to be focussed on those with specific clinical needs.     

Trends in Hospital Readmission of Medicare-Covered Patients With Heart Failure

Background

The Medicare Hospital Readmissions Reduction Program has led to fewer readmissions following hospitalizations with a principal diagnosis of heart failure (HF). Patients with HF are frequently hospitalized for other causes.

Predictors and variation of routine home discharge in critically ill adults with cystic fibrosis

Background

The short-term outcomes of patients with cystic fibrosis (CF) surviving critical illness were not examined systematically.

Longitudinal performance evaluation and validation of fixed‐flexion radiography of the knee for detection of joint space loss

Objective

The ability of nonfluoroscopically guided radiography of the knee to assess joint space loss is an important issue in studies of progression and treatment of knee osteoarthritis (OA), given the practical limitations of protocols involving fluoroscopically guided radiography of the knee. We evaluated the ability of the nonfluoroscopically guided fixed‐flexion radiography protocol to detect knee joint space loss over 3 years.

Methods

We assessed the same‐day test–retest precision for measuring minimum joint space width (JSW), the sensitivity for detection of joint space loss using serial films obtained a median of 37 months (range 23–47 months) apart, and the relationship of joint space loss to radiographic and magnetic resonance imaging (MRI) measures of knee OA. Participants were men and women (ages 70–79 years) with knee pain who were participating in the Health, Aging, and Body Composition Study. We assessed baseline radiographic OA and measured JSW using a computerized algorithm. Serial knee MRIs obtained over the same interval were evaluated for cartilage lesions.

Results

A total of 153 knees were studied, 35% of which had radiographic OA at baseline. The mean ± SD joint space loss for all knees over 3 years was 0.24 ± 0.59 mm (P < 0.001 for change). In knees with OA at baseline, the mean ± SD joint space loss over 3 years was 0.43 ± 0.66 mm (P < 0.001), and in knees with joint space narrowing at baseline, joint space loss was 0.50 ± 0.67 mm (P < 0.001). Joint space loss and its standardized response mean increased with the severity of baseline joint space narrowing and with the presence of cartilage lesions at baseline and worsening during followup.

Conclusion

Radiography of the knee in the fixed‐flexion view provides a sensitive and valid measure of joint space loss in multiyear longitudinal studies of knee OA, without the use of fluoroscopy to aid knee positioning.

     

Incidence of systemic lupus erythematosus in the United Kingdom, 1990–1999

Objective

To estimate the annual incidence of systemic lupus erythematosus (SLE) over a 10‐year period in the UK, and to examine age‐, sex‐, and region‐specific rates.

Methods

The study was based on the UK General Practice Research Database (GPRD), which covers ～5% of the UK population. We estimated SLE incidence rates, during the period 1990–1999, among persons registered with practices contributing to the GPRD, representing >33 million person‐years of observation.

Results

A total of 1,638 patients with incident SLE (1,374 females, 264 males) were identified. The age‐standardized SLE incidence in the UK during the 1990s was 7.89 per 100,000 (95% confidence interval [95% CI] 7.46, 8.31) for females and 1.53 per 100,000 (95% CI 1.34, 1.71) for males (overall female‐to‐male ratio 5.2:1). Peak incidence occurred at age 50–54 years for females and 70–74 years for males. There was a small but insignificant increase of SLE incidence over the 10 years among females but not males. No clear association between latitude and SLE incidence was found, but regional variations existed, with age‐standardized rates ranging from 3.56 per 100,000 (95% CI 3.00, 4.13) for the West Midlands to 7.62 per 100,000 (95% CI 5.59, 9.65) for Northern Ireland.

Conclusion

This study provides updated estimates of SLE incidence in the UK. Standard methodology throughout the study period and target population allowed for comparison of rates over time and across regions.     

The incidence of primary hip osteoarthritis in active duty US military servicemembers

Objective

Although multiple studies have reported the prevalence of primary hip osteoarthritis (OA), little has been reported on incidence rates of hip OA. We sought to determine the incidence rate and demographic risk factors of hip OA in an ethnically diverse and physically active population of US military servicemembers.

Methods

A query was performed using the US Defense Medical Epidemiology Database for the International Classification of Diseases, Ninth Revision, Clinical Modification code for hip OA (715.95). Multivariate Poisson regression analysis was used to estimate the rate of hip OA per 100,000 person‐years, controlling for sex, race, age, rank, and service.

Results

The overall unadjusted incidence rate of hip OA was 35 per 100,000 person‐years. Women, compared with men, had a significantly increased adjusted incidence rate ratio for hip OA of 1.87 (95% confidence interval [95% CI] 1.73–2.01). The adjusted incidence rate ratio for black servicemembers when compared with white servicemembers was 1.32 (95% CI 1.23–1.41). The adjusted incidence rate ratio for the ≥40‐year‐old age group compared with the 20‐year‐old group was 22.21 (95% CI 17.54–28.14). With junior officers as the referent category, junior enlisted, senior enlisted, and senior officers rank groups had a significantly increased adjusted incidence rate ratio for hip OA. With the Air Force as the referent category, each service had a significantly increased adjusted incidence rate ratio for hip OA.

Conclusion

Female sex; black race; age ≥40 years; junior enlisted, senior enlisted, and senior officer rank groups; and military service in the Navy, Army, or Marines were all risk factors for hip OA.     

Missed Opportunities for Depression Screening in Patients with Arthritis in the United States

BACKGROUND

Arthritis affects 20 % of the adult US population and is associated with comorbid depression. Depression screening guidelines have been endorsed for high-risk groups, including persons with arthritis, in the hopes that screening will increase recognition and use of appropriate interventions.

OBJECTIVE

To examine national rates of depression and depression screening for patients with arthritis between 2006 and 2010.

PARTICIPANTS AND DESIGN

We used nationally representative cross-sections of ambulatory visits in the United States from the National Ambulatory Medical Care Survey from 2006 to 2010, which included 18,507 visits with a diagnosis of arthritis. When weighted to the US population, this total represents approximately 644 million visits.

MEASUREMENTS

Visits where arthritis was listed among diagnoses. Outcomes were survey-weighted estimates of depression and prevalence of depression screening among patients with arthritis across patient and physician characteristics.

KEY RESULTS

Of the 644,419,374 visits with arthritis listed, 83,574,127 (13 %) were associated with a comorbid diagnosis of depression. The odds ratio for comorbid depression with arthritis was 1.42 (95 % CI 1.3, 1.5). Depression screening occurred at 3,835,000 (1 %) visits associated with arthritis. When examining the rates of depression screening between ambulatory visits with and without arthritis listed, there was no difference in depression screening rates; both were approximately 1 %. There was no difference in screening rates by provider type. Compared to visits with other common, chronic conditions, the prevalence of depression at arthritis visits was high (13 per 100 visits), although the prevalence of depression screening at arthritis visits was low (0.68 per 100 visits).

CONCLUSIONS

Despite the high prevalence of depression with arthritis, screening for depression was performed at few arthritis visits, representing missed opportunities to detect a common, serious comorbidity. Improved depression screening by providers would identify affected patients, and may lead to appropriate interventions such as mental health referrals and/or treatment with anti-depressants.