[Show abstract][Hide abstract] ABSTRACT: Objective:
The purpose of this study is to examine the perceptions of primary care physicians (PCPs) regarding indications, contraindications, risks and benefits of total joint arthroplasty (TJA) and their confidence in selecting patients for referral for TJA.
PCPs recruited from among those providing care to participants in an established community cohort with hip or knee osteoarthritis (OA). Self-completed questionnaires were used to collect demographic and practice characteristics and perceptions about TJA. Confidence in referring appropriate patients for TJA was measured on a scale from 1-10; respondents scoring in the lowest tertile were considered to have 'low confidence'. Descriptive analyses were conducted and multiple logistic regression was used to determine key predictors of low confidence.
212 PCPs participated (58% response rate) (65% aged 50+ years, 45% female, 77% > 15 years of practice). Perceptions about TJA were highly variable but on average, PCPs perceived that a typical surgical candidate would have moderate pain and disability, identified few absolute contraindications to TJA, and overestimated both the effectiveness and risks of TJA. On average, PCPs indicated moderate confidence in deciding who to refer. Independent predictors of low confidence were female physicians (OR = 2.18, 95%CI: 1.06-4.46) and reporting a 'lack of clarity about surgical indications' (OR = 3.54, 95%CI: 1.87-6.66).
Variability in perceptions and lack of clarity about surgical indications underscore the need for decision support tools to inform PCP - patient decision making regarding referral for TJA.
Osteoarthritis and Cartilage 10/2015; DOI:10.1016/j.joca.2015.09.017 · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective:
Pain is not always correlated with radiographic osteoarthritis (OA) severity possibly because people modify activities to manage symptoms. Measures of symptoms that consider pain in the context of activity level may therefore provide greater discrimination than pain alone. Our objective was to compare discrimination of a measure of pain alone with combined measures of pain relative to physical activity across radiographic OA levels.
This is a cross-sectional study of the Osteoarthritis Initiative accelerometer substudy, including those with and without knee OA. Two composite pain and activity knee symptom (PAKS) scores were calculated as Western Ontario and McMaster (WOMAC) Universities Osteoarthritis Pain Scale plus one divided by physical activity measures (step and activity counts). Symptom score discrimination across Kellgren and Lawrence (KL) grades were evaluated using histograms and quantile regression.
1806 participants, mean age 65.1 (9.1) years, mean BMI 28.4 (4.8) kg/m(2) , and 55.6% female, were included. WOMAC, but not PAKS scores, exhibited a floor effect. Adjusted median WOMAC by KL grades 0 - 4 were 0, 0, 1, 1, and 3 respectively. Median PAKS1 and PAKS2 were 24.9, 26.0, 32.4, 46.1, 97.9, and 7.2, 7.2, 9.2, 12.9, 23.8, respectively. PAKS scores had more statistically significant comparisons between KL grades compared with WOMAC.
Symptom assessments incorporating pain and physical activity did not exhibit a floor effect and were better able to discriminate radiographic severity than pain alone, particularly in milder disease. Pain in the context of physical activity level should be used to assess knee OA symptoms. This article is protected by copyright. All rights reserved.
Arthritis and Rheumatology 09/2015; DOI:10.1002/art.39271
[Show abstract][Hide abstract] ABSTRACT: Objective:
Systematic reviews often struggle with how to combine information when more than 1 instrument is used across studies being synthesized. Different techniques have been suggested based on frequency of use in the literature, or on consensus. We explore an approach blending 2 initiatives: OMERACT (Outcome Measurement in Rheumatology) and COSMIN (Consensus On Selection of Measurement Instruments), and investigate the effects of an evidence-based measurement approach on selection of outcomes.
Readings were circulated to attendees registered for a preconference workshop on pain measurement. Three instruments were considered and exercises conducted to engage people in the content and measurement performance of these tools. Consensus was sought that an evidence-based approach could be created for selection of instruments for summary of findings (SoF) tables.
The blending of COSMIN and OMERACT approaches led to an evidence-based approach that depended both on a clear definition of target concept and a review of measurement performance of the instrument. Participants emphasized that conceptual clarity and practical considerations should come before measurement property results.
Evidence-based approaches can be adopted for selection of instruments for SoF tables. A research agenda was formulated.
The Journal of Rheumatology 09/2015; 42(10). DOI:10.3899/jrheum.141446 · 3.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rationale, aims and objectives:
As total joint arthroplasty (TJA) rates rise, there is need to ensure appropriate use. Our objective was to elucidate surgeons' perspectives on appropriateness for TJA.
Semi-structured telephone interviews were conducted in a sample of orthopaedic surgeons that perform TJA in three Canadian Provinces. Surgeons were asked to discuss their criteria for TJA appropriateness for osteoarthritis; potential value of a decision-support tool to select appropriate candidates; and the role of other stakeholders in assessing appropriateness.
Of 17 surgeons approached for participation, 14 completed interviews (12 males; 7 aged <50 years; 5 academic; 8 in urban practices). Surgeons agreed that pain and pain impact on patients' quality of life and function were the key criteria to assess appropriateness for TJA, but that these concepts were difficult to assess and not always congruent with structural changes on joint radiography. Some used a wider range of criteria, including their assessments of patient expectations, ability to cope and readiness for surgery. While patient age was not identified as a criterion itself, surgeons did acknowledge that appropriateness criteria may differ for younger versus older patients. Most agreed that a decision-support tool would help ensure that all elements of appropriateness are assessed in a standardized manner, albeit the ultimate decision to offer surgery must be left to the discretion of surgeons, within the context of the doctor-patient relationship.
Surgeons recognized the need for a tool to support decision making for TJA, particularly in the context of increasing surgical demand in younger patients with less severe arthritis. The work to develop and test such a decision-support tool is underway.
Journal of Evaluation in Clinical Practice 09/2015; DOI:10.1111/jep.12449 · 1.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background:
There is a perception that the impacts of arthritis are greatest among older adults. However, the effect of age on health-related outcomes in individuals with arthritis has not been explicitly studied. This study examined whether the physical and mental health impacts of arthritis are greater in older (75+ years) versus younger (20-44, 45-64 and 65-74 years) Canadian adults.
Data were from the arthritis component of the 2009 Survey on Living with Chronic Diseases in Canada. The responses were weighted to be representative of Canadians (≥20 years) with arthritis. Associations between age and the prevalence of severe/frequent joint pain, severe/frequent fatigue, sleep limitations, instrumental activities of daily living (IADLs) limitations, high levels of stress, suboptimal general and suboptimal mental health, were examined descriptively prior to conducting multivariate log-binomial regression analyses.
A total of 4565 respondents completed the survey (78 % response rate). Individuals with arthritis were mostly female (63 %), of working age (57 %) and overweight or obese (67 %). Upon adjusting for covariates, younger (20-44 years) and/or middle aged (45-64 years) adults were more likely than those older (75+ years) to report severe/frequent joint pain, sleep limitations, high levels of stress and suboptimal mental health. After adjusting for covariates, age was not associated with IADL limitations, severe/frequent fatigue or suboptimal general health.
Contrary to the belief that older adults with arthritis experience more severe physical and mental health outcomes, we found that older adults were less likely to report worse outcomes than younger adults. In light of these findings, public health messaging should stress that arthritis does not just affect the elderly and emphasize the importance of timely diagnosis and management at all ages in order to prevent or, minimize arthritis-related impairment.
[Show abstract][Hide abstract] ABSTRACT: Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited.
We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained?
We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whether differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors.
There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,165-14,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,736-25,041), respectively. Variation cannot be explained by differences in hospital structure. Median (interquartile range) episode payments were greater for hospitals in the Northeast (USD 26,291 [22,377-30,323]) compared with the Midwest, South, and West (USD 20,614, [USD 18,592-22.968]; USD 21,584, [USD 19,663-23,941]; USD 22,421, [USD 20,317-25,860]; p < 0.001) and for teaching compared with nonteaching hospitals (USD 23,152 [USD 20,426-27,127] versus USD 21,336 [USD 19,352-23,846]; p < 0.001). Patient characteristics explained approximately 15% of the variance in hospital payments, hospital characteristics (teaching status, geographic region) explained 30% of variance, and approximately 55% of variance was not explained by either factor.
There is much unexplained variation in episode-of-care payments at the hospital-level, suggesting opportunities for enhanced efficiency. Further research is needed to ensure an appropriate balance between such efficiencies and access to care.
Level II, economic analysis.
Clinical Orthopaedics and Related Research 08/2015; 473(11). DOI:10.1007/s11999-015-4445-0 · 2.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: During OMERACT 12, a workshop was held with the aim to endorse a core set of domains for 3 settings: clinical trials of symptom and structure modification and observational studies. Additional goals were to endorse a core set of contextual factors for these settings, and to define preliminary instruments for each core domain. Finally, an agenda for future research in hand osteoarthritis (OA) was to be proposed.
Literature reviews of preliminary instruments for each core domain of the proposed core set for hand OA in the settings described above. Literature review of radiographic scoring methods and modern imaging in hand OA were also performed. Proposed contextual factors for a core set were identified through 2 Delphi exercises with participation of hand OA experts, patient partners, and OMERACT participants.
Results from Delphi exercises and systematic literature reviews were presented and discussed. It was agreed that a preliminary core domain set for the setting clinical trials of symptom modification should contain at least "pain, physical function, patient global assessment, joint activity and hand strength." The settings clinical trial of structure modification and observational studies would in addition include structural damage. Preliminary instruments for the proposed domains were agreed on. A list of prioritized contextual factors was defined and endorsed for further research. A research agenda was proposed for domain instrument validation according to the OMERACT Filter 2.0.
Preliminary core sets for clinical trials of symptom and structure modification and observational studies in hand osteoarthritis, including preliminary instruments and contextual factors, were agreed upon during OMERACT 12.
The Journal of Rheumatology 07/2015; DOI:10.3899/jrheum.141017 · 3.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined fracture patients' understanding of "high" fracture risk after they were screened through a post-fracture secondary prevention program and educated about their risk verbally, numerically, and graphically. Our findings suggest that messages about fracture risk are confusing to patients and need to be modified to better suit patients' needs.
The aim of this study was to examine fracture patients' understanding of high risk for future fracture.
We conducted an in-depth qualitative study in patients who were high risk for future fracture. Patients were screened through the Osteoporosis Exemplary Care Program where they were educated about fracture risk: verbally told they were "high risk" for future fracture, given a numerical prompt that they had a >20 % chance of future fracture over the next 10 years, and given a visual graph highlighting the "high risk" segment. This information about fracture risk was also relayed to patients' primary care physicians (PCPs) and specialists. Participants were interviewed at baseline (within six months of fracture) and follow-up (after visit with a PCP and/or specialist) and asked to recall their understanding of risk and whether it applied to them.
We recruited 27 patients (20 females, 7 males) aged 51-87 years old. Fractures were sustained at the wrist (n = 7), hip (n = 7), vertebrae (n = 2), and multiple or other locations (n = 11). While most participants recalled they had been labeled as "high risk" (verbal cue), most were unable to correctly recall the other elements of risk (numerical, graphical). Further, approximately half of the patients who recalled they were high risk did not believe that high risk applied, or had meaning, to them. Participants also had difficulty explaining what they were at risk for.
Our results suggest that health care providers' messages about fracture risk are confusing to patients and that these messages need to be modified to better suit patients' needs.
Osteoporosis International 06/2015; DOI:10.1007/s00198-015-3214-y · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: RATIONALE: The cost of continuous positive airway pressure (CPAP) treatment and socioeconomic status (SES) have been reported as barriers to its acceptance. Ontario has a universal, single-payer health system that covers diagnostic services for obstructive sleep apnea (OSA) and 75% of the CPAP cost. This offers a unique environment to evaluate the effect of SES as the range of income does not affect the coverage. Using a large historical cohort of patients with OSA, we evaluated the association between patient income status and purchase of CPAP device as determined by provincial health administrative data, controlling for confounders.
METHODS: All adults who underwent a first diagnostic sleep study at St Michael’s Hospital (Toronto, Ontario, Canada) between 2004 and 2010 and were diagnosed with OSA (apnea-hypopnea index [AHI] ≥5 events/hour), were included.
Patient data were linked to Ontario health administrative data from 1991 to 2011 to determine who purchased CPAP equipment through the Assistive Devices Program, neighbourhood income status, comorbidities at baseline and a number of primary care visits over 3 years before baseline.
OSA was classified as mild (AHI of 5 to 14.9), moderate (AHI of 15 to 30) or severe (AHI>30). Our main analysis was based on patients with severe OSA and extensive daytime sleepiness (DS) as measured by the Epworth Sleepiness Scale (ESS) (ESS≥10) following our assumption that most of them would have been prescribed CPAP. Patients with moderate multivariable logistic and Cox regressions. The characteristics that distinguished those who did versus did not purchase CPAP were determined using classification and regression trees.
RESULTS: Of the 4,291 patients with AHI≥5 events/hour, 656 (15%) participants had AHI>30 and the ESS≥10 and 383 of 656 (58%) purchased a CPAP devise.
Controlling for age, sex, body mass index, smoking status, comorbidities, severity of disease and primary care exposure, there was no significant relationship found between income level and CPAP purchase, irrespective of the modeling approach (Table 1).
CONCLUSIONS: In a large cohort, we found that the probability of purchasing a CPAP machine among patients with moderate to severe OSA and extensive DS did not vary with the income status, suggesting that in the province of Ontario, financial concerns may be not an obstacle to CPAP treatment for this patient population. Despite this, even among this group of patients the CPAP acceptance rate was low.
American Thoracic Society International Conference 2015; 05/2015
[Show abstract][Hide abstract] ABSTRACT: Rigorous implementation research is important for testing strategies to improve the delivery of effective osteoarthritis (OA) interventions. The objective of this manuscript is to describe principles of implementation research, including conceptual frameworks, study designs and methodology, with specific recommendations for randomized clinical trials of OA treatment and management. This manuscript includes a comprehensive review of prior research and recommendations for implementation trials. The review of literature included identification of seminal articles on implementation research methods, as well as examples of previous exemplar studies using these methods. In addition to a comprehensive summary of this literature, this manuscript provides key recommendations for OA implementation trials. This review concluded that to date there have been relatively few implementation trials of OA interventions, but this is an emerging area of research. Future OA clinical trials should routinely consider incorporation of implementation aims to enhance translation of findings.
Published by Elsevier Ltd.
Osteoarthritis and Cartilage 05/2015; 23(5):826-838. DOI:10.1016/j.joca.2015.02.772 · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To develop a plan for harmonizing outcomes for people undergoing total joint replacement (TJR), to achieve consensus regarding TJR outcome research.
The TJR working group met during the 2014 Outcome Measures in Rheumatology (OMERACT) 12 meeting in Budapest, Hungary. Multiple conference calls preceded the face-to-face meeting. Brief presentations were made during a 1.5-h meeting, which included an overview of published systematic reviews of TJR trials and the results of a recent systematic review of TJR clinical trial outcome domains and measures. This was followed by discussion of potential core set areas/domains for TJR clinical trials (as per OMERACT Filter 2.0) as well as the challenges associated with the measurement of these domains.
Working group participants discussed which TJR clinical trial outcome domains/areas map to the inner versus outer core for core domain set. Several challenges were identified with TJR outcomes including how to best measure function after TJR, elucidating the source of the pre- and post-TJR joint pain being measured, joint-specific versus generic quality of life instruments and the importance of patient satisfaction and revision surgery as outcomes. A preliminary core domain set for TJR clinical trials was proposed and included pain, function, patient satisfaction, revision, adverse events, and death. This core domain set will be further vetted with a broader audience.
An international effort with active collaboration with the orthopedic community to standardize key outcome domains and measures is under way with the TJR working group. This effort will be further developed with new collaborations.
The Journal of Rheumatology 04/2015; DOI:10.3899/jrheum.141201 · 3.19 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The incidence of chronic diseases, including diabetes mellitus (DM), heart failure (HF) and chronic obstructive pulmonary disease (COPD) is on the rise. The existing health care system must evolve to meet the growing needs of patients with these chronic diseases and reduce the strain on both acute care and hospital-based health care resources. Paramedics are an allied health care resource consisting of highly-trained practitioners who are comfortable working independently and in collaboration with other resources in the out-of-hospital setting. Expanding the paramedic’s scope of practice to include community-based care may decrease the utilization of acute care and hospital-based health care resources by patients with chronic disease.
This will be a pragmatic, randomized controlled trial comparing a community paramedic intervention to standard of care for patients with one of three chronic diseases. The objective of the trial is to determine whether community paramedics conducting regular home visits, including health assessments and evidence-based treatments, in partnership with primary care physicians and other community based resources, will decrease the rate of hospitalization and emergency department use for patients with DM, HF and COPD. The primary outcome measure will be the rate of hospitalization at one year. Secondary outcomes will include measures of health system utilization, overall health status, and cost-effectiveness of the intervention over the same time period. Outcome measures will be assessed using both Poisson regression and negative binomial regression analyses to assess the primary outcome.
The results of this study will be used to inform decisions around the implementation of community paramedic programs. If successful in preventing hospitalizations, it has the ability to be scaled up to other regions, both nationally and internationally. The methods described in this paper will serve as a basis for future work related to this study.
ClinicalTrials.gov: NCT02034045. Date: 9 January 2014.
[Show abstract][Hide abstract] ABSTRACT: Rheumatoid arthritis (RA) is a systemic inflammatory disease that targets synovial joints and can lead to joint destruction. While most total knee and total hip arthroplasty procedures are performed in patients with osteoarthritis (OA), they are also effective in treating advanced joint destruction of the knee and hip in patients with RA, although differences have been reported between these groups. Patterns of use, complications and outcomes may differ for patients with RA compared with patients with OA. This review will address the change in utilization of arthroplasty in RA, differences in comorbidities and adverse events in patients with RA compared with OA, and the similarities and differences in pain and function outcomes after total knee arthroplasty and total hip arthroplasty.