D J Watson

Merck, Whitehouse Station, New Jersey, United States

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Publications (14)62.75 Total impact

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    ABSTRACT: Most nonsteroidal anti-inflammatory drugs (NSAIDs) are non-selective cyclooxygenase-1 (COX-1) and COX-2 inhibitors and are associated with upper gastrointestinal (GI) dyspeptic symptoms often resulting in GI co-medication usage or treatment discontinuation. To compare the rates of new use of gastroprotective agents and discontinuations due to dyspepsia with the COX-2 selective inhibitor etoricoxib compared with non-selective NSAIDs. This pre-specified combined analysis used data from nine randomized, double-blind, controlled, clinical trials with etoricoxib in patients with osteoarthritis, rheumatoid arthritis, chronic low back pain, or ankylosing spondylitis. The cumulative incidences of (1) new use (new prescription or increased dose) of gastroprotective agents (GPA) and (2) discontinuation due to dyspeptic symptoms were compared among patients treated with etoricoxib (60 mg, 90 mg, or 120 mg daily) vs. non-selective NSAIDs (diclofenac 50 mg. t.i.d. or naproxen 500 mg. b.i.d.). The overall rates/100 patient-years for new use of GPAs were 9.1 and 13.0 for etoricoxib and NSAIDs, respectively (RR = 0.75; 95% confidence interval [CI] 0.64, 0.89; p < 0.001). A benefit with etoricoxib was seen in the first 6 months when most new GPA usage occurred; after 6 months new use of GPAs was similar between etoricoxib and NSAIDs. The rates/100 patient-years of treatment discontinuation due to dyspeptic symptoms with etoricoxib and NSAIDs were 1.5 and 2.7, respectively (RR = 0.60; 95% CI 0.41, 0.87; p = 0.007). Analyses of placebo-controlled treatment periods showed significantly more new GPA use and more discontinuations due to dyspeptic symptoms with NSAIDs vs. placebo, but not with etoricoxib vs. placebo. In this combined analysis of clinical trials of patients with OA, RA, chronic low back pain, or AS, new use of gastroprotective agents was significantly lower with etoricoxib than with the comparator non-selective NSAIDs during the initial 6 months of treatment and similar thereafter. There were significantly fewer discontinuations for dyspeptic symptoms with etoricoxib than with NSAIDs over the entire follow-up period.
    Current Medical Research and Opinion 12/2004; 20(12):1899-908. · 2.37 Impact Factor
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    ABSTRACT: The comparative effects of cyclooxygenase-2- (COX-2) selective inhibitors and nonselective, nonsteroidal anti-inflammatory drugs (NSAIDs) on blood pressure are debated. Clinicians have been concerned about the need for antihypertensive treatment following therapy with these agents. To compare initiation of antihypertensive treatment among new users of the COX-2-selective inhibitor rofecoxib and of nonselective NSAIDs in clinical practice. Retrospective cohort study using the MediPlus (UK) database that covers 1.8 million patients throughout the UK. Patients included were at least 50 years of age, had at least 1 prescription for either diclofenac, ibuprofen, naproxen or rofecoxib (drugs of interest, DOIs), and had no prescription for any NSAID, COX-2 inhibitor, or antihypertensive treatment during the 6 months prior to their first/index prescription date. A subset of patients, classified as chronic and persistent new users, had at least 3 prescriptions of the index prescription DOI and did not switch to another DOI during the 6-month follow-up period. Logistic regression analysis, adjusted for potential predictors, was used to assess initiation of new antihypertensive treatment. 18,737 suitable patients were identified (diclofenac 7,861, ibuprofen 8,423, naproxen 1,556 and rofecoxib 897). Those using rofecoxib were older and more likely to be female than those using NSAIDs. During the 6 months following the index prescription, 7.0% of all new users and 11.5% of chronic and persistent new users initiated antihypertensive treatment. After adjusting for potential predictors there were no statistically significant differences in the risk of initiating antihypertensive treatment between new or chronic and persistent new users of rofecoxib, diclofenac, ibuprofen and naproxen (p > 0.05). The results of this study did not indicate any significant differences in the initiation of antihypertensive therapy among patients who were prescribed rofecoxib and NSAIDs, even after multiple prescriptions.
    International journal of clinical pharmacology and therapeutics 05/2004; 42(5):260-6. · 1.20 Impact Factor
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    ABSTRACT: Previous studies have shown that 20% to 40% of patients requiring nonsteroidal anti-inflammatory drugs (NSAIDs) are concomitantly prescribed gastroprotective agents (GPAs) such as proton pump inhibitors (PPIs) and H2-receptor antagonists. The purpose of this study was to examine NSAID prescription patterns and the concurrent use of GPAs in a large national sample of patients who were prescribed NSAIDs for the first time. Patterns of NSAID use, particularly chronic NSAID use, and of concomitant use of GPAs were examined using a large US-based prescription database. Patients with at least 1 NSAID prescription dispensed between May 1 and August 31, 1998, were identified. Persons with any NSAID prescription within 4 months prior to the first (index) prescription were excluded. The remaining patients were defined as new NSAID users and then classified as chronic users (> or = 30 days of supply of NSAIDs during the 120 days of follow-up after the first NSAID prescription) or acute users (<30 days of NSAID supply during the 120 days of follow-up). Concomitant GPA use was defined as receipt of any GPA prescription between the fill date of NSAID prescription and 125% of days of supply. NSAIDs included diclofenac/misoprostol (in a fixed combination), diclofenac, naproxen, nabumetone, ibuprofen, and "other" (comprising several less frequently prescribed agents). Patients were classified as users of a particular NSAID based on the first NSAID prescription they received. GPAs included PPIs, H2-receptor antagonists, and misoprostol. A total of 3,028,808 new NSAID users were identified. Chronic NSAID users (47.8% of the sample) were older than acute users. The percentage of new chronic users aged > or = 65 years for each of the NSAIDs was 41.2% for diclofenac/ misoprostol, 33.0% for nabumetone, 30.8% for diclofenac, 20.4% for naproxen, and 20.3% for ibuprofen. The percentage of women was higher among patients treated with diclofenac/misoprostol than among patients treated with all other NSAIDs (P < 0.001). During the 120 days of follow-up, the percentages of NSAID users with concomitant GPA use were 22.7% for diclofenac/misoprostol, 16.3% for diclofenac, 11.5% for naproxen, 18.0% for nabumetone, 12.3% for ibuprofen, and 14.8% for other NSAIDs. Based on days of supply, the rates of concomitant GPA use were 31.1%, 23.6%, 17.6%, 27.3%, 18.8%, and 22.5% for diclofenac/misoprostol, diclofenac, naproxen, nabumetone, ibuprofen, and other NSAID users, respectively. Among those who were taking GPAs before the NSAID index prescription date, -89% continued GPA therapy. Approximately 22% of the days of NSAID supply were covered by GPAs. Prior GPA use was the strongest predictor of subsequent concomitant GPA/ NSAID use. Differences in GPA use were observed among patients using different NSAIDs.
    Clinical Therapeutics 12/2001; 23(12):1984-98. · 2.23 Impact Factor
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    ABSTRACT: Patients treated with nonselective cyclooxygenase inhibitors (nonsteroidal anti-inflammatory drugs [NSAIDs]) often experience dyspepsia and upper gastrointestinal (GI) adverse effects, and frequently require GI comedications and diagnostic procedures. This study combined existing data to test the hypothesis that GI comedications and GI diagnostic procedures occur less frequently in osteoarthritis (OA) patients treated with rofecoxib compared with nonselective NSAIDs. Combined analysis of 8 randomized controlled clinical trials. Rheumatology and general practice clinics. Men and women aged 40 years and older with OA. Random assignment to placebo (n = 514), rofecoxib (n = 3357; 12.5, 25, or 50 mg daily combined; average 24.7 mg), or NSAIDs (n = 1564; ibuprofen 800 mg thrice daily, diclofenac 50 mg thrice daily, or nabumetone 1500 mg daily, combined). The cumulative incidence of patients using GI comedications (antacids, antispasmodics, antiflatulents, antiregurgitants, H2 antagonists, proton pump inhibitors, sucralfate, prostaglandins, other antiulcer therapy) and needing GI procedures (upper GI barium studies, upper or lower GI endoscopies) over 12 months. Compared with those treated with NSAIDs, patients treated with rofecoxib had a significantly lower incidence of GI comedication use (17.5% vs 27.0%, P <.001) and GI procedures (3.3% vs 5.3%, P =.02) over 12 months. Similar results were seen in analyses of protocols with placebo; in these studies, rates of GI comedications and procedures were highest with NSAIDs, while those with rofecoxib and placebo were similar to each other. OA patients treated with rofecoxib for up to 12 months required significantly less GI comedication and significantly fewer GI procedures than those treated with NSAIDs.
    MedGenMed: Medscape general medicine 11/2001; 3(4):6.
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    ABSTRACT: It is well established that nonsteroidal anti-inflammatory drugs (NSAIDs) have gastrointestinal (GI) side-effects. However, the cost of health care resources spent on preventing and managing these side-effects is not clear. The objective of this study was to estimate the direct cost of NSAID-related GI events in an elderly population. From the Régie de l'assurance-maladie du Québec (RAMQ) database, we obtained medical, pharmaceutical and demographic records of a 10% random sample (n = 49 033) of seniors who, between January 1, 1993 and December 31, 1997, had a dispensed prescription of a NSAID. Patients who did not have any GI events during the year prior to their first dispensed prescription were included in the cohort. All patients were followed-up for 2 years. The daily direct Canadian dollar costs of GI events that were incurred by these patients while they were on NSAID therapy were compared with those of GI events that were incurred by these same patients while they were not on NSAID therapy. The difference in these daily costs was attributed to NSAIDs. A total of 12 082 new NSAID users were included in the study. Two hundred and seventeen (1.8%) were hospitalized for GI-related problems; of these, 130 (60%) had their GI hospitalization as their first GI event; 3257 (27.0%) used gastroprotective agents (GPAs), and 857 (26.3%) took GPAs without any apparent prior GI symptoms; 801 (6.6%) had GI diagnostic tests; and 661 (5.5%) died. The average direct costs of GI side-effects per patient-day on NSAIDs were 3.5 times higher than those of a patient-day not on NSAIDs. The direct cost of GI side-effects per patient-day on NSAIDs was $1.34, of which more than 70% ($0.94) was attributed to GI events resulting from NSAID treatment. Approximately one Canadian dollar was added to patient costs for every day he/she was on NSAID therapy. Safer therapies and appropriate patient risk management may potentially reduce NSAID-related health care resource use.
    British Journal of Clinical Pharmacology 09/2001; 52(2):185-92. · 3.58 Impact Factor
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    ABSTRACT: Results of phase III clinical trials of rofecoxib, a selective inhibitor of cyclooxygenase 2, have shown that osteoarthritis patients treated with rofecoxib had significantly fewer clinically significant gastrointestinal (GI) adverse events than those who received nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This paper explores the potential economic implications of the use of rofecoxib versus nonselective NSAIDs for the treatment of osteoarthritis via a decision analytic model based on rofecoxib clinical data and the published literature. Base-case 1-year analyses were done with data on GI adverse events, specifically perforations, ulcers, and bleeds (PUBs), obtained from a prespecified pooled analysis of the rofecoxib clinical trials. Analyses were also performed using pooled results of two 12-week endoscopic surveillance trials, with adjustments for silent ulcers of 40% and 85%. Under base-case conditions, the expected cost savings in GI problems and comedications averted with rofecoxib versus NSAIDs was 0.81 dollars per day, representing an 85% offset of the difference in drug price. For rofecoxib versus NSAIDs, the expected cost per PUB avoided with rofecoxib was 4738 dollars, and expected cost per year of life saved was 18,614 dollars. In analyses based on endoscopic data, therapy with rofecoxib was less expensive than therapy with NSAIDs, regardless of silent ulcer adjustment. Results were most sensitive to prophylactic GI comedication rates, and were robust over a range of model assumptions and costs. In this analysis based on differences in clinically significant GI events for osteoarthritis patients, cost differences between rofecoxib and NSAIDs were markedly offset by expected cost savings in GI problems and comedications averted with rofecoxib. Costs per year of life saved with rofecoxib versus NSAIDs were well within accepted benchmarks for cost-effectiveness. When endoscopic data alone were considered, rofecoxib was cost saving across all assumptions about silent ulcer rates.
    Clinical Therapeutics 08/2001; 23(7):1061-79. · 2.23 Impact Factor
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    ABSTRACT: Bodily pain and physical disability can negatively impact health-related quality of life (HRQL) in patients with osteoarthritis (OA). To assess the effects of treatment with a new agent, rofecoxib, on HRQL in patients with OA. Randomized, double-blind, 6-week clinical trial comparing treatment with rofecoxib, 5 to 50 mg, with placebo in 672 patients with OA of the hip or knee. Patient HRQL was assessed at baseline and at the end of treatment using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). At 6 weeks, mean change from baseline in all SF-36 mental and physical health domain scores demonstrated significant improvement with rofecoxib use (P < .05 for all doses for all SF-36 domains), with evidence of a dose-response relation. Improvements in mental and physical HRQL domains with rofecoxib treatment were significantly greater than those with placebo treatment (P < .05 for each dose of rofecoxib vs placebo for all domains except general health) and highly correlated with improvements observed using disease-specific OA outcome measures such as the Western Ontario and McMaster Universities Osteoarthritis Index-visual Analog 3.0 OA index pain and physical function subscales. The effect of rofecoxib vs placebo treatment on mental health largely disappeared after adjustment for improvement in OA disease-specific measures. Rofecoxib treatment increased physical and mental HRQL domain scores on the SF-36. Improvements in mental health with rofecoxib use primarily resulted from effective treatment of OA (i.e., reduction in pain and improvement in physical function).
    The American journal of managed care 07/2001; 7(6):609-16. · 2.12 Impact Factor
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    ABSTRACT: To compare gastrointestinal (GI) healthcare resource use (HCRU) and associated costs in patients taking a fixed combination of diclofenac and misoprostol versus other nonsteroidal anti-inflammatory drugs (NSAIDs). We analysed a sample (49,033 patients) of the Government of Quebec Health Insurance Agency database. Patients were included in the study if they did not have GI events during the year preceding the date of their first NSAID prescription dispensing (the index date). Patients were followed up for 2 years. A 3-stage model was used to determine the factors that influenced the direct medical costs of GI HCRU: (i) a logistic regression model (model 1) to estimate the risk of GI HCRU; (ii) a linear regression model (model 2) to estimate the direct costs of GI HCRU for those who had such events; (iii) multiplying the estimated risks from model 1 by the estimated costs from model 2 gave the estimated direct costs of GI HCRU for all patients. Provincial government of Quebec, Canada. 1,533 patients were prescribed diclofenac/misoprostol at the index date and 10,540 another NSAID. Comorbidity markers were not significantly different between the 2 groups. Of the diclofenac/misoprostol patients, 23 (1.5%) were hospitalised for GI problems compared with 194 (1.8%) of the NSAID group; 403 (26.3%) of diclofenac/misoprostol patients used gastroprotective agents compared with 2,849 (27.0%) of the NSAID patients; 118 (7.7%) of diclofenac/misoprostol patients had GI diagnostic tests compared with 682 (6.5%) of the NSAID patients. The average direct medical cost of GI HCRU was 310.52 Canadian dollars ($Can)/patient (1997 values) in the diclofenac/misoprostol group compared with $Can231.19/patient (1997 values) in the NSAID group. When adjusted for baseline factors, the ratio of the total direct medical cost of GI HCRU in the diclofenac/misoprostol group to that of the NSAID group was 1.15 (95% confidence interval: 0.89, 1.48). Our data showed no significant differences in GI HCRU among patients taking diclofenac/misoprostol compared with those taking NSAIDs.
    PharmacoEconomics 02/2001; 19(5 Pt 2):577-88. · 2.86 Impact Factor
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    ABSTRACT: To determine the minimal perceptible clinical improvement (MPCI) in patients with osteoarthritis (OA) with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, and patient and investigator global assessment of disease status in randomized clinical trials for treatment of OA. Subjects with OA of the knee or hip were randomized to receive either rofecoxib 12.5 or 25 mg once daily, ibuprofen 800 mg 3 times daily, or placebo for 6 weeks. The WOMAC and global assessments were completed at baseline and Weeks 2, 4, and 6. A patient global assessment of response to therapy (0 to 4 scale) was used to "anchor" the WOMAC scores. MPCI was defined as the difference in mean change from baseline in WOMAC (100 mm normalized visual analog scale, VAS) between patients with 0 = "None" global response to therapy and patients with 1 = "Poor" global response to therapy. MPCI was determined to be 9.7, 9.3, and 10.0 mm for the WOMAC pain, physical function and stiffness subscales, respectively, and 11.1 mm for WOMAC question 1: Pain walking on a flat surface. The MPCI for the investigator was 0.4 with investigator assessment of disease status reported on a 0 to 4 Likert scale. Of note, the estimated MPCI for the WOMAC and investigator globals were similar irrespective of treatment, sex, age, or geographic region. In this analysis, mean changes of roughly 9 to 12 mm (100 mm normalized VAS) on WOMAC scales were perceptible changes to patients with hip and knee OA. A mean decrease of 0.4 in global disease status (0 to 4 Likert scale) as assessed by the investigator corresponded to the patients' MPCI. Understanding the minimal perceptible differences may permit a better assessment of the clinical relevance of therapeutic interventions in OA.
    The Journal of Rheumatology 12/2000; 27(11):2635-41. · 3.26 Impact Factor
  • F Wolfe, S X Kong, D J Watson
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    ABSTRACT: To evaluate the relationship between gastrointestinal (GI) symptoms and health related quality of life (QOL) in patients with osteoarthritis (OA) and rheumatoid arthritis (RA). A total of 1773 patients with arthritis participating in a longterm outcome study (OA of the hip or knee = 648, RA = 1125) completed mailed surveys that included assessments of GI symptoms and overall GI symptom severity, Short Form-36, the visual analog scale (VAS) for the EuroQol (Health QOL), a VAS global disease severity scale, and measures of disease and psychological status. The overall response rate exceeded 85%. Dyspepsia (heartburn, bloating, or belching) and upper abdominal/epigastric pain were identified as the most important GI contributors to reduction in QOL, and the simultaneous presence of both these symptoms was associated with lower QOL (54.5) compared to those without symptoms (70.9) on the 0-100 Health QOL scale. Similarly, those in the upper tertile of the global GI severity scale had Health QOL scores of 55.7 compared to 76.4 for those in the lower tertile. These differences in GI symptoms and GI severity, however, were reduced substantially when the effects of functional disability, pain, and depression were adjusted for: 62.3 to 68.6 (p = 0.003) and 63.7 to 70.3 (p<0.001) for the GI symptoms and GI severity scales, respectively. QOL is significantly impaired among unselected arthritis patients with GI symptoms compared to those without these symptoms. Dyspepsia and upper abdominal/epigastric pain are more strongly related to QOL measures than other GI symptoms, and are common among arthritis patients. It is possible to construct a simple scale of these 2 symptoms or to use the VAS GI severity scale and get a clinically useful idea of the current level of GI distress and alteration of QOL by GI problems. Two components of impairment can be identified, one that is smaller and unrelated to disease or psychological factors, and a second that is larger and includes these factors. Because GI symptoms can alter function, pain, and psychological status, it is likely that the true effect of GI symptoms on QOL is somewhere between the unadjusted and adjusted values cited above.
    The Journal of Rheumatology 06/2000; 27(6):1373-8. · 3.26 Impact Factor
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    ABSTRACT: To estimate gastrointestinal (GI) health care resource use and direct costs associated with prescription nonsteroidal antiinflammatory drugs (NSAIDs) in an elderly population. Using the Government of Quebec's health insurance database, we obtained the medical, pharmaceutical, and demographic records of 73,850 senior citizens who, between 1993 and 1997, had either an NSAID or an acetaminophen prescription dispensed. The date of their first dispensed prescription for an NSAID or acetaminophen was termed their index date. Patients who were not taking oral corticosteroids or anticoagulants at their index date, were not diagnosed with cancer at their index date, and were not hospitalized and did not have any GI events during the year prior to their index date were included in the study. Patients who had a dispensed NSAID prescription at their index date formed the NSAID cohort; the others formed the acetaminophen cohort. All patients were followed up for 2 years. The daily direct costs of GI events incurred during NSAID therapy by the NSAID cohort were compared with those incurred during a similar followup period by the acetaminophen cohort. The difference in these average daily costs was attributed to NSAID use. The NSAID cohort included 5,268 senior citizens and the acetaminophen cohort 2,245. More GI adverse events were observed in the NSAID cohort (odds ratio 2.48, 95% confidence interval 2.06, 3.00). The average daily direct cost of GI events for a day of NSAID therapy attributed to the NSAIDs was $0.84 (Canadian). On average, for each Canadian dollar spent on NSAIDs, an additional $0.66 was spent on their side effects. Safer alternatives to NSAIDs would significantly reduce medical care costs for patients in need of NSAID therapy.
    Arthritis & Rheumatology 05/2000; 43(4):917-24. · 7.48 Impact Factor
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    ABSTRACT: Nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal (GI) toxic effects, such as upper GI tract perforations, symptomatic gastroduodenal ulcers, and upper GI tract bleeding (PUBs), are thought to be attributable to cyclooxygenase 1 (COX-1) inhibition. Rofecoxib specifically inhibits COX-2 and has demonstrated a low potential for causing upper GI injury. To compare the incidence of PUBs in patients with osteoarthritis treated with rofecoxib vs NSAIDs. Prespecified analysis of all 8 double-blind, randomized phase 2b/3 rofecoxib osteoarthritis trials conducted from December 1996 through March 1998, including one 6-week dose-ranging study, two 6-week efficacy studies vs ibuprofen and placebo, two 1-year efficacy studies vs diclofenac, two 6-month endoscopy studies vs ibuprofen and placebo, and one 6-week efficacy study vs nabumetone and placebo. Multinational sites. Participants Osteoarthritis patients (N = 5435; mean age, 63 years [range, 38-94 years]; 72.9% women). Rofecoxib, 12.5, 25, or 50 mg/d (n = 1209, 1603, and 545, respectively, combined) vs ibuprofen, 800 mg 3 times per day (n = 847), diclofenac, 50 mg 3 times per day (n = 590); or nabumetone, 1500 mg/d (n = 127) (combined). Cumulative incidence of PUBs for rofecoxib vs NSAIDs, based on survival analysis of time to first PUB diagnosis, using PUBs that met pre-specified criteria judged by a blinded, external adjudication committee. The incidence of PUBs over 12 months was significantly lower with rofecoxib vs NSAIDs (12-month cumulative incidence, 1.3% vs 1.8%; P = .046; rate per 100 patient-years, 1.33 vs 2.60; relative risk, 0.51; 95% confidence interval, 0.26-1.00). The cumulative incidence of dyspeptic GI adverse experiences was also lower with rofecoxib vs NSAIDS over 6 months (23.5% vs 25.5%; P = .02), after which the incidence rates converged. In a combined analysis of 8 trials of patients with osteoarthritis, treatment with rofecoxib was associated with a significantly lower incidence of PUBs than treatment with NSAIDs.
    JAMA The Journal of the American Medical Association 12/1999; 282(20):1929-33. · 29.98 Impact Factor
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    G M Davies, D J Watson, N Bellamy
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    ABSTRACT: This study compares the responsiveness and relative effect sizes of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) with the Medical Outcomes Study Short Form Health Survey (SF-36) in a randomized clinical trial for treatment of osteoarthritis (OA). Patients with OA of the knee or hip were randomized to receive either placebo or 2,400 mg/day of ibuprofen for 28 days. Patients completed the WOMAC and SF-36 at baseline and days 7, 14, and 28 of the trial. Patients receiving ibuprofen showed significant improvement in WOMAC pain, physical functioning, and the total score, while improvement was detected only for bodily pain on the SF-36. The WOMAC detected significant differences between ibuprofen and placebo for pain and physical functioning, whereas the SF-36 detected differences for the bodily pain subscale. These results suggest the WOMAC has greater power to detect treatment differences than the SF-36, with respect to pain and physical functioning, in OA clinical trials.
    Arthritis care and research: the official journal of the Arthritis Health Professions Association 07/1999; 12(3):172-9.
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    Value in Health 01/1999; 2(1):29-29. · 2.19 Impact Factor

Publication Stats

846 Citations
62.75 Total Impact Points

Institutions

  • 2001–2004
    • Merck
      Whitehouse Station, New Jersey, United States
    • Northwestern University
      • Feinberg School of Medicine
      Evanston, Illinois, United States
    • McGill University
      Montréal, Quebec, Canada
  • 2000
    • Centre hospitalier de l'Université de Montréal (CHUM)
      Montréal, Quebec, Canada