Expectation and outlook: the impact of patient preference on arthritis care among African Americans

We investigated beliefs of blacks with osteoarthritis (OA) regarding total knee replacement (TKR) surgery. These beliefs potentially related to the known racial disparity in the use of TKR. Ninety-four community-dwelling blacks aged 50 to 89 with knee OA in Harlem, NY, were assessed for arthritis knowledge, expectations, quality of life (QoL), and disability. Subjects have had OA for a median of 6 years and the disability was severe. Only 36% believed that TKR was likely to improve knee pain; 45% stated that TKR would not improve their current health. Mean QoL was 7.6 +/- 1.7 (max 10). Despite debilitating OA, African American patients perceive a high QoL, yet have low expectations from TKR and are therefore less likely to consider TKR as a treatment for OA.     

The effect of patient characteristics on variability in pain and function over two years in early knee osteoarthritis

Background  

Large variations in pain and function are seen over time in subjects at risk for and with radiographic knee osteoarthritis (OA). We hypothesized that this variation may be related not only to knee OA but also to patient characteristics. The objective of this study was to investigate the influence of age, gender, and body mass index (BMI) on clinically relevant change in pain and function over two years in subjects at high risk for or with knee OA.     

Analysing uncertainty around costs of innovative medical technologies: the case of fibrin sealant (QUIXIL) for total knee replacement

This paper presents a relatively simple cost model comparing the costs of using a commercial fibrin sealant (QUIXIL) in addition to conventional haemostatic treatment vs. conventional treatment alone in total knee replacement (TKR) surgery, and demonstrates and discusses how one- and two-way sensitivity analyses can inform decisions regarding an innovative medical technology, for which there is limited evidence on economic parameters. The model synthesises data from various sources and assesses the proportion of individuals likely to need blood transfusion, the resource use after TKR and transfusion-related adverse events. Whether using fibrin sealant is cost saving strongly depends on the amount used, the achieved reduction in hospital length of stay (LOS) and price of QUIXIL. If a 10-ml dose of fibrin sealant is required to achieve the effects as described in the published trials, its use adds cost, but if 25% or more of patients are treated with a 5-ml dose, its use becomes cost saving for the NHS. The sensitivity analyses provide clear guidance regarding parameters for additional data collection; design of future trials; and product pricing in relation to its effectiveness, and are likely to be preferred over more sophisticated approaches to inform medical device decision-making, particularly at the local level.     

Trends in total knee replacement surgeries and implications for public health, 1990-2000

OBJECTIVES: Total joint replacements are important surgical interventions for treating severe arthritis of weight-bearing joints. The most common indication for total knee replacement (TKR) is osteoarthritis of the knee joint. The goals of this study were to assess the trend in rate of TKR in Wisconsin and to describe the economic impact of these surgical procedures on the health care system. METHOD: A population-based cross-sectional study of TKR surgeries was conducted among Wisconsin residents aged > or = 45 years. The Wisconsin inpatient hospital discharge data from 1990 through 2000 were used. Rates were age-adjusted to the 2000 U.S. population, and charges for TKR were adjusted for inflation. RESULTS: From 1990 through 2000, the age-adjusted rate for TKR increased by 81.5% (from 162 to 294 per 100,000; p<0.001). The rate increased the most among the youngest age group (45-49 years), rate ratio 5.1 for men, 4.2 for women. The total charges for TKR increased from 69.4 million dollars to 148 million dollars (109.2% inflation-adjusted increase). Medicare received the highest proportion of charges for TKR procedures, but throughout the study period, the proportion of charges covered by private insurance increased by 39%. CONCLUSIONS: The rate and costs of TKR procedures among Wisconsin residents increased substantially from 1990 through 2000, especially among younger age groups. Changes in medical practices probably accounted for some of this increase, but these trends also may reflect an increased prevalence of osteoarthritis, which in turn may be related to dramatic increases in the number of individuals who are overweight.     

Decision-making regarding total knee replacement surgery: A qualitative meta-synthesis

Background  

Knee osteoarthritis is a highly prevalent condition that can result in disability and reduced quality of life. The evidence suggests that total knee replacement surgery (TKR) is an effective intervention for patients with severe knee problems, but there is also an unmet need for this treatment in the UK. To help understand the reason for this unmet need, the aim of this study was to explore the factors that influence the decision-making process of TKR surgery by synthesising the available evidence from qualitative research on this topic.     

The role of orthoses in knee osteoarthritis

Objectives: Taking into account that the role of orthoses in patients with knee osteoarthritis (OA) is unclear and controversial, the purpose of this article is to review recent literature with the aim of answering the following question: What is the current role of orthoses in the treatment of knee OA?

Methods: A Cochrane Library and PubMed (MEDLINE) search related to the role of orthoses in knee OA was performed.

Results: Unloader braces decrease the adduction moment of the knee. In patients with varus medial compartment knee OA bracing is beneficial for pain, stiffness, function and quality of life (low grade of evidence). Lateral wedge arch support insoles seem not to decrease knee load. Lateral wedge insoles appear inefficacious at attenuating structural changes in patients with medial knee OA.

Conclusions: The ideal option for an orthosis in patients with knee OA keeps on indeterminate, and long-run inferences are lacking.     

BLISS index for analyzing knee osteoarthritis trials data

OBJECTIVES: Different pain thresholds were investigated, using the WOMAC Pain Scale (WOMAC-P) to determine if they could differentiate between treatment groups (hylan G-F 20 vs. appropriate care) at low and very low levels of state attainment in patients with knee osteoarthritis (OA). A method, termed the BLISS (Bellamy et al. Low Intensity Symptom State-attainment) Index, for analyzing OA knee clinical trials data, was proposed. STUDY DESIGN AND SETTING: Five analyses were performed: time to first BLISS day, BLISS days over 12 months, patients with a BLISS response at month 12, patients with a BLISS response at any time, and number of BLISS periods over 12 months. For each analysis, five levels of WOMAC-P were examined: 相似文献   

Knee Osteoarthritis Treatment Costs in the Medicare Patient Population

BackgroundSeveral nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care.ObjectivesTo analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA–related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty.MethodsWe identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged <65 years, had incomplete claim history, did not reside in any of the 50 states, had claim history <12 months before knee OA diagnosis, or did not enroll in Medicare Part A and Part B. The study analyzed knee OA–related costs from a payer perspective in terms of reimbursements provided by Medicare, as well as the time from the diagnosis of knee OA to knee arthroplasty for patients who had knee arthroplasty, and the time from the first hyaluronic acid injection to knee arthroplasty for those who received the injection. We compared patients who received hyaluronic acid and those who did not receive hyaluronic acid injections. Patients who received hyaluronic acid injection who subsequently had knee arthroplasty were also compared with those who did not have subsequent knee arthroplasty.ResultsOf the 275,256 patients with knee OA, 45,801 (16.6%) received a hyaluronic acid injection and 35,465 (12.9%) had knee arthroplasty during the study period. The median time to knee arthroplasty was 16.4 months for patients who received hyaluronic acid versus 5.7 months for those who did not receive hyaluronic acid. Non–arthroplasty-related therapies and knee arthroplasty accounted for similar proportions of knee OA–related costs, with hyaluronic acid injection comprising 5.6% of the total knee OA–related costs. For patients who received hyaluronic acid injections and subsequently had knee arthroplasty, hyaluronic acid injection contributed 1.8% of the knee OA–related costs versus 76.6% of the cost from knee arthroplasty. Patients who received hyaluronic acid injections and did not have knee arthroplasty incurred less than 10% of the knee OA–related costs that patients who had surgery incurred.ConclusionAlthough limiting hyaluronic acid use may reduce the knee OA–related costs, in this study hyaluronic acid injection only comprised a small fraction of the overall costs related to knee OA. Among patients who had knee arthroplasty, those who received treatment with hyaluronic acid had surgery delayed by a median of 10.7 months and associated costs for a significant period. The ability to delay or avoid knee arthroplasty altogether can have a substantial impact on healthcare costs.     

Willingness to go through surgery again validated the WOMAC clinically important difference from THR/TKR surgery

OBJECTIVE: The objective was to determine the clinically important difference (CID) from primary total hip replacement (THR) and total knee replacement (TKR) surgeries using the Western Ontario McMaster University (WOMAC) osteoarthritis index. STUDY DESIGN AND SETTING: WOMAC scores were collected at decision for and 1 year after surgery (n=2,709). Transition ratings (15-point scale) were obtained at 1 year for pain and function, as well as a global assessment of willingness to go through surgery again. A "good deal better" defined the positive CID. WOMAC change scores for transition ratings and willingness to go through surgery again were evaluated using receiver operating characteristic curves. Patient characteristics within transition rating categories were examined. RESULTS: For THR, the positive CIDs were 41 of 100 for pain and 34 of 100 for function. The negative CIDs were 35 and 33, respectively. For TKR, the positive CIDs were 36 for pain and 33 for function. The negative CIDs were 30 and 25, respectively. Change scores for willingness to go through surgery again validated CID values. Postoperative complications decreased the likelihood of a positive CID. CONCLUSION: Improvement that is "a good deal better" is an appropriate threshold for the THR/TKR positive CID. Attaining a positive CID is negatively related to postoperative complications.     

Racial/ethnic differences in preferences for total knee replacement surgery

OBJECTIVES: To determine whether there are ethnic differences in preferences for surgery vs. medical treatment of knee osteoarthritis (OA). STUDY DESIGN AND SETTING: Cross-sectional in-person interviews using conjoint analysis methodology, a technique often used in marketing, involved individuals making choices between alternative hypothetical scenarios for medical or surgical treatment of knee OA. One hundred ninety-three individuals over the age of 20 were recruited through random digit dialing in Harris County, TX, and 198 individuals with knee OA were recruited from a large outpatient health care provider in Houston, TX. RESULTS: African Americans were significantly less likely to chose surgery than whites (odds ratio 0.63 [0.42, 0.93]). Women and older individuals were also less likely to choose surgery (0.69 [0.51, 0.94], 0.98 [0.97, 0.99]). Larger reductions in negative symptoms with surgery significantly increased the likelihood of choosing surgery. There was no difference between the public and patients, and no effect of income level. CONCLUSIONS: Disparities in knee replacement rates among ethnic groups may be partly due to differences in preferences for surgery. Conjoint analysis was shown to be a feasible methodology for collecting preferences in health research. This methodology has great promise in contributing to our knowledge of drivers of health care decision making in individuals.     

Women's Perceptions of Influences on Their Mood

Aims: Knowledge of prevailing community ideas about mood determination can guide research about variability in mood. A random sample of urban Canadian women, aged 18–40 years (n = 507), was asked to compare the relative importance of three specified domains (physical health, social support, stress) as influences on their mood and then to list additional life experiences they considered important. They also rated the frequency and recurrence patterns (cyclicity) of their daily positive and negative moods.

Results: More women reported a positive overall mood than negative mood. Of three domains studied, social support was listed as the greatest influence on positive mood and stress on negative mood in the bivariate tests. More frequent moods (both positive and negative) were more likely to be viewed as recurrent or cyclical. Patterns of influence for positive mood differed from those for negative mood.

Multivariate modeling found that women reporting frequent positive mood were more often North American and employed full-time and likely to consider stress or lack of stress was unimportant as an influence on positive mood. The only factors in the model associated with frequent negative mood were the perception of physical health and stress as important influences on negative mood. Less than 5% cited menstrual cycle phase as an influence.

Conclusions: These subjective data suggest that women perceived a wide range of external, usually interpersonal, influences as relevant to their mood, however menstrual cycle was rarely mentioned. Perceptions of influences on mood are statistically related to frequency of moods. In addition, ethnicity and paid employment are independently associated with positive mood.     

Relevance between arthroscopic pathology and clinical characteristics in knee osteoarthritis

Arthroscopy can be used to identify accurately cartilage and synovial changes in knee osteoarthritis (OA). The objective of this study was to find the correlation between arthroscopically established knee chondropathy and synovitis and the corresponding algofunctional characteristics in OA. METHODS: 41 patients with OA in only one knee joint were investigated. The diagnosis of knee OA fulfilled the clinical, laboratory and radiological ARA criteria. Low pressure arthroscopy of the affected knee was performed under local anaesthesia. Chondropathy was evaluated according to the method of R E Outerbridge. Synovial inflammation was assessed by the scoring system of S. Lindblad and E. Hedfors. RESULTS: We found statistically significant correlation (Spearman's rho test) between chondropathy of the knee and the following clinical indices: pain at night, pain after standing 30 minutes, pain on walking, pain on getting up from a chair without help of arms, maximum walking distance. We failed to demonstrate statistical significant correlation between chondropathy and morning stiffness and activities of daily living. There was also no statistical correlation between knee synovitis and any of the Lequesne's clinical indices. CONCLUSION: The arthroscopically established scores of the cartilage pathology were consistent with most of the clinical algofunctional symptoms. The degree of synovitis in our study was not correlated with clinical activity symptoms of OA, according to Leguesne. Five positive algofunctional Lequesne's scores corresponded to heavy breakdown of knee cartilage in OA.     

Secondary loss and pain-associated disability: theoretical overview and treatment implications

In the area of occupational pain disability, a major barrier to effective rehabilitation of patients may be the extensive personal losses that can arise as secondary features of chronic pain disability. In this review, we discuss the concept of secondary loss and how it can have a profound impact on patients with occupational pain disability. Such secondary loss issues are extremely important to consider in any rehabilitation program in order to ensure the most comprehensive and compassionate treatment of these patients. We discuss the types of intervention that may be employed within the context of interdisciplinary rehabilitation programs.     

Charcot's Legacy: Opening New Frontiers of the Psyche

ABSTRACT

Introduction: Knee osteoarthritis (OA) is one of the preeminent musculoskeletal illnesses in the adult population.

Aim: To investigate the role of intra-articular injections of joint fat-derived mesenchymal stem cells (MSCs) in knee OA.

Methods: A Cochrane Library and PubMed (MEDLINE) search related to the role of intra-articular injections of joint fat-derived MSCs in knee OA was analyzed.

Results: Experimental and clinical studies on intra-articular injections of joint fat-derived MSCs have provided satisfactory results (pain relief) in the short term. However, the results of a systematic review are controversial (more consistent trials are required for conclusive analysis).

Conclusions: The insufficient information found on the role of intra-articular injections of fat-derived MSCs in knee OA leads me to conclude that the technique is not appropriate for the management of OA. Raising false expectations and hopes to patients with knee OA should be eluded.     

The Impact of Regression to the Mean on Economic Evaluation in Quasi‐Experimental Pre–Post Studies: The Example of Total Knee Replacement Using Data from the Osteoarthritis Initiative

Many treatments are evaluated using quasi‐experimental pre–post studies susceptible to regression to the mean (RTM). Ignoring RTM could bias the economic evaluation. We investigated this issue using the contemporary example of total knee replacement (TKR), a common treatment for end‐stage osteoarthritis of the knee. Data (n = 4796) were obtained from the Osteoarthritis Initiative database, a longitudinal observational study of osteoarthritis. TKR patients (n = 184) were matched to non‐TKR patients, using propensity score matching on the predicted hazard of TKR and exact matching on osteoarthritis severity and health‐related quality of life (HrQoL). The economic evaluation using the matched control group was compared to the standard method of using the pre‐surgery score as the control. Matched controls were identified for 56% of the primary TKRs. The matched control HrQoL trajectory showed evidence of RTM accounting for a third of the estimated QALY gains from surgery using the pre‐surgery HrQoL as the control. Incorporating RTM into the economic evaluation significantly reduced the estimated cost effectiveness of TKR and increased the uncertainty. A generalized ICER bias correction factor was derived to account for RTM in cost‐effectiveness analysis. RTM should be considered in economic evaluations based on quasi‐experimental pre–post studies. Copyright © 2017 John Wiley & Sons, Ltd.     

Improving functional status in arthritis: the effect of social support

We present data from a longitudinal study of patients with symptomatic osteoarthritis (OA) of the knee and/or hip. One component of this study involved interviewers telephoning patients bi-weekly for 6 months to inquire about stressors which they have experienced and to obtain self-assessment of their health. We hypothesized that telephone interviewers (TI) may provide OA patients with social support, and thus improve their functional status. Patients' functional status (physical disability, psychological disability, and pain) improved significantly after 6 months of receiving bi-weekly telephone calls. Since our outcome variables have been shown to be reliable measures of disability over time, and because OA is a progressively degenerative process, one would expect deterioration rather than improvement. Furthermore, since patients reported more social support at 6 months than at baseline, we attributed the improvement in health status to the TIs being viewed as a source of social support to elderly persons who may have support deficits. We suggest that future studies redefine TIs' roles from an unbiased data collector to a provider of social support. TIs should follow their own panel of patients so that continuity can be established. Furthermore, TIs should undergo training about OA, its treatment, common medications and their side effects, and other pertinent information. In this manner, social support may be further enhanced and provide the greatest potential to improve patients' health status.     

Age differences in the pain-depression link for women with osteoarthritis. Functional impairment and personal control as mediators.

PURPOSE: This study examines functional impairment and personal control as mediators between pain and depressive symptoms in middle-aged and older women with osteoarthritis (OA). METHOD: Ninety-nine middle-aged and older women with OA completed face-to-face interviews to assess pain, functional impairment, personal control, depressive symptoms, and self-rated health. RESULTS: Controlling for self-rated health, functional impairment mediated the relationship between pain and depressive symptoms for middle-age women but not for older women. Alternately, personal control was a mediator for older women but not for middle-aged women. CONCLUSIONS: Functional limitations at least partially explain the relationship between pain and depression for middle-aged women who are juggling many roles and do not expect trouble with daily activities. For older women, functional limitations are expected, but personal control becomes more important. Implications for intervention are discussed.     

Importance of patient satisfaction with care in predicting osteoarthritis-specific health-related quality of life one year after total joint arthroplasty

Purpose  

After previous results observed with a generic health-related quality of life (HRQoL) instrument, we aimed to confirm that immediate postoperative patient satisfaction with care predicts self-perceived health 1 year after total hip replacement/total knee replacement (THR/TKR), using an osteoarthritis (OA)-specific HRQoL questionnaire.     

Musculoskeletal disorders in farmers and farm workers

Farming is a physically arduous occupation and this places farm workers at potential risk of musculoskeletal disorders such as osteoarthritis (OA) of the hip and knee, low back pain (LBP), neck and upper limb complaints, and hand-arm vibration syndrome (HAVS). This review considers the epidemiological evidence concerning such risks. The strongest evidence relates to OA of the hip, for which the public health impact is likely to be considerable. There is also weaker, but suggestive evidence that farmers more often have knee OA and LBP than workers in occupations with fewer physical demands. Tractor drivers, in particular, seem to have more LBP. Relatively little information exists on the risks of soft tissue rheumatism in the limbs and neck. For some outcomes, the link with occupational risk factors (such as heavy loading of joints and whole-body vibration) is sufficient to suggest the course that future prevention should take, but for several outcomes more research is first needed.     

Anterior knee pain associated with sports and work

Anterior knee pain is not a disease, but a syndrome with numerous causes. This paper describes its appearance in the patellofemoral joint in sportsmen and in untrained people. Chondromalacia patellae is a condition of the cartilage, not a disease, that is, it is never diagnosed alone. Relative muscular insufficiency, especially of the knee extensors, may occur in children and adolescents, as they grow rapidly. The consequence is a unbalance of active stabilizers and the disturbance of the slippery trail of patella, particularly in the presence of dysplasia of patellofemoral joint. The impingement syndrome pain occurs in sportsmen and people overloading the patellofemoral joint. Other causes of anterior knee pain should be excluded in clinical examination and slippery trail of patella, its position, and signs of instability should be determined. This paper gives an overview of patellar chondromalacia, lateral pressure syndrome, patellar subluxation, patellar acute and recurrent luxation, and idiopathic anterior knee pain. The treatment is basically conservative. Stretching exercises and the strengthening of certain groups of femoral muscles serves to regain the balance, thus normalising the slippery trail and taking off the burden from the patellofemoral joint. If conservative treatment fails, surgery is the alternative.