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ABSTRACT: We examined patients' self-management of bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. Awareness of fracture risk was accompanied by positive lifestyle changes in participants' lives such as being careful. Future research should evaluate how lifestyle changes mitigate fracture risk. INTRODUCTION: We examined patients' understanding of bone health and self-management decisions regarding bone health and fracture risk, particularly behaviors other than medication use and seeking diagnostic testing. METHODS: A phenomenological (qualitative) study was conducted. English-speaking patients, 65+ years old, who were "high risk" for future fracture and prescribed pharmacotherapy after being screened through a post-fracture osteoporosis initiative were eligible. Patients were interviewed for 1-2 h and were asked to discuss perceptions of bone health status (bone densitometry results and perceived fracture risk), recommendations received for bone health, and lifestyle changes since their most recent fracture. We analyzed the data guided by Giorgi's methodology. RESULTS: We interviewed 21 fracture patients (6 males and 15 females), aged 65 to 88 years old. With the exception of one participant, all participants appeared to understand that they had low bone mass and were at risk of sustaining another fracture. Most participants (n = 20) were predominantly concerned about being careful, and they focused their responses on personal and environmental factors that they perceived to be modifiable. Participants also spoke about strategies to manage their bone health such as exercise, having a healthy diet and taking supplements, and using aids and devices. Non-pharmacological strategies used by patients appeared to be independent of current use of pharmacotherapy. CONCLUSIONS: Awareness of fracture risk was accompanied by a number of positive lifestyle changes in participants' lives such as being careful and engaging in exercise. Future research needs to evaluate how lifestyle changes such as being careful mitigate fracture risk.
Osteoporosis International 06/2013; · 4.58 Impact Factor
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ABSTRACT: As fracture risk assessment is a basis for treatment decisions, accurate risk assessments on bone mineral density (BMD) reports are important. Over 50 % of sampled BMD reports for Ontarians with fracture histories underestimated fracture risk by a single category. Risk assessments in Ontario may not accurately inform treatment recommendations. INTRODUCTION: The shifting emphasis on fracture risk assessment as a basis for treatment recommendations highlights the importance of ensuring that accurate fracture risk assessments are present on reading specialists' BMD reports. This study seeks to determine the accuracy of fracture risk assessments on a sample of BMD reports from 2008 for individuals with a history of fracture and produced by a broad cross section of Ontario's imaging laboratories. METHODS: Forty-eight BMD reports for individuals with documented history of fragility fracture were collected as part of a cluster randomized trial. To compute fracture risk, risk factors, and BMD T-scores from reports were abstracted using a standardized template and compared to the assessments on the reports. Cohen's kappa was used to score agreement between the research team and the reading specialists. RESULTS: The weighted kappa was 0.21, indicating agreement to be at the margin of "poor to fair." More than 50 % of the time, reported fracture risks did not reflect fracture history and were therefore underestimated by a single category. Over 30 % of the reports containing a "low" fracture risk assessment were assessed as "moderate" fracture risk by the research team, given fracture history. Over 20 % of the reports with a "moderate" fracture risk were assessed as "high" by the research team, given fracture history. CONCLUSIONS: This study highlights the high prevalence of fracture risk assessments that are underestimated. This has implications in terms of fracture risk categorization that can negatively affect subsequent follow-up care and treatment recommendations.
Osteoporosis International 08/2012; · 4.58 Impact Factor
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A. Papaioannou,
C. C. Kennedy,
A. Cranney, G. Hawker,
J. P. Brown,
S. M. Kaiser,
W. D. Leslie,
C. J. M. O’Brien,
A. M. Sawka,
A. Khan,
K. Siminoski,
G. Tarulli,
D. Webster,
J. McGowan,
J. D. Adachi
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ABSTRACT: SummaryIn this systematic review, we summarize risk factors for low bone mineral density and bone loss in healthy men age 50years
or older. Consistent risk factors were: age, smoking, low weight, physical/functional limitations, and previous fracture.
Data specific to men has clinical and policy implications.
IntroductionOsteoporosis is a significant health care problem in men as well as women, yet the majority of evidence on diagnosis and management
of osteoporosis is focused on postmenopausal women. The objective of this systematic review is to examine risk factors for
low bone mineral density (BMD) and bone loss in healthy men age 50years or older.
Materials and methodsA systematic search for observational studies was conducted in MEDLINE, Cochrane Database of Systematic Reviews, DARE, CENTRAL,
CINAHL and Embase, Health STAR. The three main search concepts were bone density, densitometry, and risk factors. Trained
reviewers assessed articles using a priori criteria.
ResultsOf 642 screened abstracts, 299 articles required a full review, and 25 remained in the final assessment. Consistent risk factors
for low BMD/bone loss were: advancing age, smoking, and low weight/weight loss. Although less evidence was available, physical/functional
limitations and prevalent fracture (after age 50) were also associated with low BMD/bone loss. The evidence was inconsistent
or weak for physical activity, alcohol consumption, calcium intake, muscle strength, family history of fracture/osteoporosis,
and height/height loss.
ConclusionIn this systematic review, we identified several risk factors for low BMD/bone loss in men that are measurable in primary
practice.
Osteoporosis International 04/2012; 20(4):507-518. · 4.58 Impact Factor
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ABSTRACT: We examined patients' communication about fragility fractures to gain insight into why patients do not connect fractures to bone health. The term "fragility" fracture was a misnomer to patients who perceived the event as physically and emotionally traumatic. Improved communication about such fractures could facilitate awareness of bone health. INTRODUCTION: We examined patients' communication about fragility fractures to gain insight into why patients do not perceive the connection between their fracture and low bone mass. METHODS: A descriptive phenomenological (qualitative) study was conducted. During face-to-face interviews, the participants described the experience of their fracture in detail and the circumstances surrounding the fracture. Data analysis was guided by Giorgi's methodology. English-speaking male and female patients aged 65+ years and "high" risk for future fracture were eligible and screened for osteoporosis through an established screening program at an urban teaching hospital. RESULTS: We recruited 30 participants (9 males, 21 females), aged 65-88, who presented with a hip (n = 11), wrist (n = 11), shoulder (n = 6), or other (n = 2) fracture. Ten of the 30 fractures occurred inside the home and the remaining fractures occurred outside the home. Sustaining a fragility fracture was perceived as a traumatic event, both physically and emotionally. In general, participants used forceful, action-oriented words and referred to hard surfaces to describe the experience. Explanations for the fracture, other than bone quality, were often reported, especially that falls were "freak" or "fluke" events. Patients who sustained a fracture under more mundane circumstances seemed more likely to perceive a connection between the fracture and their bone health. CONCLUSIONS: The term fragility fracture was a misnomer for many older adults. By reexamining how this term is communicated to fracture patients, health care providers may better facilitate patients' awareness of bone health.
Osteoporosis International 02/2012; · 4.58 Impact Factor
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ABSTRACT: The rates of bone mineral density testing for osteoporosis among healthy mid-life women are high, although their osteoporosis or fracture risk is low. To reduce unnecessary testing, we created and evaluated a tool to guide bone density testing based on the woman's age, weight, fracture history, and menopausal status.
This study aims to improve case finding of mid-life women with low bone mass on bone mineral density (BMD) assessment.
Among healthy women aged 40-60 years having their first BMD test, osteoporosis risk factors were assessed by questionnaire and BMD by dual-energy X-ray absorptiometry. The combination of risk factors that best discriminated women with/without low bone mass (T-score ≤ -2.0) was determined from the logistic regression model area under the curve (AUC) and internally validated using bootstrapping. Using the model odds ratios, a clinical prediction rule was created and its discriminative properties assessed and compared with that of the osteoporosis self-assessment tool (OST). Sensitivity analyses examined results for pre-/peri- and post-menopausal women, separately.
Of 1,664 women referred for baseline BMD testing, 433 with conditions known to be associated with bone loss were excluded. Of 1,231 eligible women, 944 (77%) participated and 87 (9.2%) had low bone mass (35 pre-/peri- and 52 post-menopausal). Four risk factors for low bone mass were identified and incorporated into a clinical prediction rule. Selecting women for BMD testing with weight of ≤70 kg or any two of age >51, years' post-menopause of ≥1, and history of fragility fracture after age 40 was associated with 93% sensitivity to identify women with low bone mass, compared with 47% sensitivity for an OST score of ≤1 (AUC 0.75 versus OST AUC 0.69, p = 0.04). Results restricted to post-menopausal women were similar.
Among healthy mid-life women receiving a baseline BMD test, few had low bone mass, supporting the need for guidance about testing. A prediction rule with four risk factors had improved sensitivity over the OST. Further validation is warranted.
Osteoporosis International 12/2011; 23(7):1931-8. · 4.58 Impact Factor
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S B Jaglal,
O S Donescu,
V Bansod,
J Laprade,
K Thorpe, G Hawker,
S R Majumdar,
L Meadows,
S M Cadarette,
A Papaioannou,
M Kloseck,
D Beaton,
E Bogoch,
M Zwarenstein
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ABSTRACT: We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management.
To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control).
A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was 'appropriate' management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications.
Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3-4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0-7.0).
A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.
Osteoporosis International 07/2011; 23(1):87-95. · 4.58 Impact Factor
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ABSTRACT: In the last decade, there have been a number of action plans published to highlight the importance of preventing osteoporosis and related fractures. In the province of Ontario Canada, the Ministry of Health provided funding for the Ontario Osteoporosis Strategy. The goal is to reduce morbidity, mortality, and costs from osteoporosis and related fractures through an integrated and comprehensive approach aimed at health promotion and disease management. This paper describes the components of the Ontario Osteoporosis Strategy and progress on implementation efforts as of March 2009. There are five main components: health promotion; bone mineral density testing, access, and quality; postfracture care; professional education; and research and evaluation. Responsibility for implementation of the initiatives within the components is shared across a number of professional and patient organizations and academic teaching hospitals with osteoporosis researchers. The lessons learned from each phase of the development, implementation, and evaluation of the Ontario Osteoporosis Strategy provides a tremendous opportunity to inform other jurisdictions embarking on implementing similar large-scale bone health initiatives.
Osteoporosis International 03/2010; 21(6):903-8. · 4.58 Impact Factor
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S B Jaglal, G Hawker,
V Bansod,
N M Salbach,
M Zwarenstein,
J Carroll,
D Brooks,
C Cameron,
E Bogoch,
L Jaakkimainen,
H Kreder
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ABSTRACT: This study evaluated a multi-component intervention (educational materials and outreach visits) to increase knowledge and improve post-fracture care management in five rural communities in Canada. One hundred and twenty-five patients pre- intervention and 149 post-intervention were compared. No significant improvement in post-fracture care was documented suggesting that a more targeted intervention is needed.
Currently, the majority of patients with a low trauma fracture are under-investigated and under-treated for osteoporosis. We set out to evaluate an educational intervention on increasing knowledge of post-fracture care among health care professionals (HCPs) and fracture patients and on improving post-fracture management.
We studied five rural communities in Ontario, Canada, using a multi-component intervention ("Behind the Break"), including educational material for HCPs and patients and educational outreach visits to physicians. The study had a historical control, non-equivalent pre/post design. Telephone surveys were carried out with individuals > or =40 years of age who had a low trauma fracture in 2003 (n = 125) or in 2005 (n = 149). Family physicians and emergency department staff were also surveyed.
A total of 4,207 educational packages were distributed. Seventy-three percent of family physicians had an outreach visit. Two-thirds indicated that they received enough information about post-fracture follow-up to incorporate it into their practice. Despite this, no significant improvement in post-fracture care was documented (32% in the "pre" group had a bone mineral density test and 25% in the "post" group). Of those diagnosed with osteoporosis, the majority were prescribed a bone-sparing medication (63% "pre" and 80% "post").
A more targeted intervention linking fracture patients to their physician needs to be evaluated in rural communities.
Osteoporosis International 02/2009; 20(2):265-74. · 4.58 Impact Factor
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A Papaioannou,
C C Kennedy,
A Cranney, G Hawker,
J P Brown,
S M Kaiser,
W D Leslie,
C J M O'Brien,
A M Sawka,
A Khan,
K Siminoski,
G Tarulli,
D Webster,
J McGowan,
J D Adachi
[show abstract]
[hide abstract]
ABSTRACT: In this systematic review, we summarize risk factors for low bone mineral density and bone loss in healthy men age 50 years or older. Consistent risk factors were: age, smoking, low weight, physical/functional limitations, and previous fracture. Data specific to men has clinical and policy implications.
Osteoporosis is a significant health care problem in men as well as women, yet the majority of evidence on diagnosis and management of osteoporosis is focused on postmenopausal women. The objective of this systematic review is to examine risk factors for low bone mineral density (BMD) and bone loss in healthy men age 50 years or older.
A systematic search for observational studies was conducted in MEDLINE, Cochrane Database of Systematic Reviews, DARE, CENTRAL, CINAHL and Embase, Health STAR. The three main search concepts were bone density, densitometry, and risk factors. Trained reviewers assessed articles using a priori criteria.
Of 642 screened abstracts, 299 articles required a full review, and 25 remained in the final assessment. Consistent risk factors for low BMD/bone loss were: advancing age, smoking, and low weight/weight loss. Although less evidence was available, physical/functional limitations and prevalent fracture (after age 50) were also associated with low BMD/bone loss. The evidence was inconsistent or weak for physical activity, alcohol consumption, calcium intake, muscle strength, family history of fracture/osteoporosis, and height/height loss.
In this systematic review, we identified several risk factors for low BMD/bone loss in men that are measurable in primary practice.
Osteoporosis International 09/2008; 20(4):507-18. · 4.58 Impact Factor
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ABSTRACT: The objective of this work was to compare the measurement properties of three categorical X-ray scoring methods of knee osteoarthritis (OA), both on semiflexed and extended views.
In data obtained from trials and cohorts, X-rays were graded using Kellgren and Lawrence (KL), the OA Research Society International (OARSI) joint space narrowing score, and measurement of joint space width (JSW). JSW was analyzed as a categorical variable. Construct validity was assessed through logistic regression between X-ray stages and Western Ontario and McMaster Universities OA Index. Inter-observer reliability was assessed in 50 subjects for extended views by weighted kappa. Intra-observer reliability and sensitivity to change were assessed separately for extended and semiflexed views in 50 patients who had both views performed, over a 30-month interval, by weighted kappa and standardized response mean (SRM).
Extended views were available from three trials and two cohorts (1759 X-rays), including one trial in which both extended and semiflexed views (antero-posterior) were obtained. Correlation with clinical parameters was low for the three scoring methods, except for the single community-based cohort. Inter-rater reliability was higher for categorical JSW in extended views (kappa, 0.86 vs 0.56 and 0.48 for KL and OARSI, respectively). Intra-rater reliability was higher for categorical JSW, both in extended views (0.83 vs 0.61 and 0.71) and in semiflexed views (0.89 vs 0.50 and 0.67). Sensitivity to change was also higher for categorical JSW, particularly in semiflexed views (SRM, 0.49 vs 0.22 and 0.34).
These results indicate categorical JSW, in particular on semiflexed views, may be the preferred method to evaluate structural severity in knee OA clinical trials.
Osteoarthritis and Cartilage 08/2008; 16(7):742-8. · 3.90 Impact Factor
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ABSTRACT: OBJECTIVE: To explore family physicians' experiences and perceptions of osteoporosis and to identify their educational needs in this area. DESIGN: Qualitative study using focus groups. SETTING: Four Ontario sites: one each in Thunder Bay and Timmins, and two in Toronto, chosen to represent a range of practice sizes, populations, locations, and use of bone densitometry. PARTICIPANTS: Thirty-two FPs participated in four focus groups. Physicians were identified by investigators or local contacts to provide maximum variation sampling. METHOD: Focus groups using a semistructured interview guide were audiotaped and transcribed. The constant comparative method of data analysis was used to identify key words and concepts until saturation of themes was reached. MAIN FINDINGS: Family physicians order bone densitometry and try to manage osteoporosis appropriately, but lack a rationale for testing and are confused about management. Participants' main concern was clinical management, followed by disease prevention and their educational needs.
CONCLUSION: Family physicians are confused about how to manage osteoporosis. To reduce the burden of illness due to osteoporosis, educational interventions should be tailored to family physicians' needs.
Canadian Family Physician. 01/2003;
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ABSTRACT: The purpose of this study was to establish population values for hip function for patients of different ages using the validated WOMAC scoring system and the traditional Harris hip scoring system. A random sample of 184 individuals who had no prior history of hip or knee pain or pathology was evaluated. The average WOMAC scores for pain, function, and stiffness were 0.01, 1.8, and 0.4. The average Harris hip score was 94 +/- 8.2. No significant correlation was noted between the summary WOMAC score, the WOMAC stiffness or pain subscales, or the overall Harris hip score for any of the 3 age groups studied. Patients with complaints in other joints, such as the back and neck, had lower WOMAC and Harris hip scores. Adults who are healthy and do not have a prior history of hip or knee pathology do not show a significant decline in hip function as they grow older. A deterioration in the function of a total hip arthroplasty over time cannot be attributed solely to the aging process.
The Journal of Arthroplasty 11/2001; 16(7):901-4. · 2.38 Impact Factor
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ABSTRACT: There is ongoing controversy about who should be referred for bone mineral density (BMD) testing to estimate fracture risk and diagnose osteoporosis. The purpose of this study was to examine patterns of use of BMD testing in Ontario between 1992 and 1998.
All physician claims from the Ontario Health Insurance Plan (OHIP) claims database for BMD testing between Jan. 1, 1992, and Dec. 31, 1998, were categorized by age and sex of the patient and the specialty of the physician who ordered the test. Time trends and regional rate variation analyses were also performed. To examine the prevalence of repeat testing, an inception cohort of women who had a BMD test in 1996 was followed for 2 years from the date of first test.
From 1992 to 1998 the number of BMD tests performed per year in women increased from 34,402 to 230,936 and in men from 2,162 to 13,579. In 1998 most tests were being ordered by family physicians (80.2% in 1998 v. 52.1% in 1992). Approximately 1 in 7 women aged 55-69 years had BMD tests done in 1998. Within a 2-year period 29.3% of these women had the test repeated; the mean time between tests was 16 months. Regional rate variation analyses of BMD tests performed in 1996-1998 indicated a 235-fold variation in BMD test rates across counties in Ontario, with a range from 0.2 to 47.1 per 1000 women in the population.
The number of BMD tests performed each year in Ontario is increasing rapidly. However, the significant variation between rates of testing in different regions indicates that the diffusion of this technology may not be taking place according to population need.
Canadian Medical Association Journal 11/2000; 163(9):1139-43. · 8.22 Impact Factor
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Arthritis care and research: the official journal of the Arthritis Health Professions Association 03/2000; 13(1):62-5.
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ABSTRACT: The present study was designed to measure the longevity of knee replacements and to assess the determinants of revision knee replacements in order to enhance the potential for informed decision-making.
Data on all hospitalizations for knee replacement that occurred in Ontario, Canada, between April 1, 1984, and March 31, 1991, were acquired. To calculate the rates of revision knee replacement, two algorithms were developed: one distinguished primary knee replacements from revision knee replacements, and the second linked revision knee replacements to primary knee replacements. The Kaplan-Meier method was used to assess survivorship (absence of a revision) for primary knee replacement. A proportional-hazards regression model was estimated to assess the role of independent variables on the survival of primary knee replacements.
During the period of the study, 7.0 percent (1301) of 18,530 knee replacements were classified as revisions. Significant differences were identified between hospitalizations for primary and revision knee replacements in terms of the patient and hospital characteristics. Patients who were more than fifty-five years old, lived in a rural area, or had a diagnosis of rheumatoid arthritis had a significantly (p < 0.05) longer duration before revision than did other patients. Primary knee replacements performed in a teaching or specialty hospital had a significantly (p < 0.05) shorter duration before revision than did those performed in a non-teaching hospital. The long-term rates of revision were uniformly low. Estimates of the proportion of knee replacements that would need to be revised within seven years ranged from a low of 4.3 percent, with use of the algorithm for the longest time to revision, to a high of 8.0 percent, with use of the algorithm for the shortest time to revision.
Revision of a primary knee replacement was a rare event that depended on a patient's age, gender, and place of residence as well as on the hospital where the primary knee replacement was performed. Estimates of the rates of revision knee replacement after almost seven years ranged from a low of 4.3 percent to a high of 8.0 percent.
The Journal of Bone and Joint Surgery 06/1999; 81(6):773-82. · 3.27 Impact Factor
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ABSTRACT: This paper describes the key methodological and substantive findings of Patient Outcomes Research Teams, the first outcomes and effectiveness research centers funded by the Agency for Health Care Policy and Research. Patient Outcomes Research Teams contributed to our increased understanding of how to perform meta analysis on nontrial data, use administrative data to characterize patterns of care, develop general and disease-specific outcome measures, and disseminate important outcome information to patients and physicians to reduce practice variation. Patient Outcomes Research Teams also influenced the development of outcomes measurement in the private sector.
Annual Review of Public Health 02/1999; 20:337-59. · 5.45 Impact Factor
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ABSTRACT: A cross-sectional, community-based survey of a random sample of 1750 of 242,311 Medicare recipients was performed. The patients were at least sixty-five years old and had had a primary or revision knee replacement (either unilaterally or bilaterally) between 1985 and 1989. Three samples were surveyed separately: a national sample (to reflect the United States as a whole) and samples from Indiana and the western part of Pennsylvania (sites chosen for convenience to assess the validity of the findings for the national sample on a regional level). Each sample was stratified by race, age, residence (urban or rural), and the year of the procedure. Valid and reliable questionnaires were used to elicit the participants' assessments of pain, physical function, and satisfaction two to seven years after the knee replacement. Of the 1486 patients who were eligible for inclusion in the survey, 1193 (80.3 per cent) responded. The mean age of the respondents was 72.6 years. Eight hundred and forty-nine respondents (71.2 per cent) were white, and 849 (71.2 per cent) were women. The participants reported that they had little or no pain in the knee at the time of the survey, regardless of the age at the time of the knee replacement, the body-mass index, or the length of time since the knee replacement. After adjustment for potential confounding variables, predictors of better physical function after the replacement were an absence of problems with the contralateral knee, primary knee replacement (rather than revision) (Indiana sample only), and a lower body-mass index (Indiana and western Pennsylvania samples). Four hundred and fifteen (85.2 per cent) of the 487 patients in the national sample were satisfied with the result of the knee replacement. In what we believe to be the first community-based study of the outcome of knee replacement, patients reported having significant (p = 0.0001) and persistent relief of pain, improved physical function, and satisfaction with the result two to seven years postoperatively. The findings of the present study suggest that age and obesity do not have a negative impact on patient-relevant outcomes (pain and physical function). Dissemination of these findings has the potential to increase appropriate referrals for knee replacement and thereby reduce the pain and functional disability due to osteoarthrosis of the knee.
The Journal of Bone and Joint Surgery 03/1998; 80(2):163-73. · 3.27 Impact Factor
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ABSTRACT: To determine the relationship between regional variations in knee replacement (KR) utilization rates in Ontario, Canada, and the reported prevalence of arthritis and rheumatism as a chronic health problem.
Utilization data were acquired from the Canadian Institute for Health Information for KR procedures performed in Ontario between fiscal years 1984 and 1990. Census information was obtained from Statistics Canada. Disease prevalence data were derived from the 1990 Ontario Health Survey (OHS). Public Health Units (PHU) were used as the unit of analysis, with utilization rates defined as the number of KR performed on all PHU residents (irrespective of where these procedures were performed) divided by the population. Direct methods were used to standardize utilization for age, sex, and disease prevalence. The extremal quotient, the weighted coefficient of variation, and the systematic component of variation were used as measures of variation. The relationship between the number of KR performed in each age-sex-year strata and various demographic (age and sex), disease prevalence, and regional dummy variables was estimated using a Poisson regression model.
Regional variation in the standardized utilization of KR surgery was wide, but declined over the study period; the extremal quotient fell from 8.0 to 3.3, the weighted coefficient of variation fell from 0.49 to 0.30, and the systematic component of variation fell from 0.20 to 0.17. Variation in the provision of KR surgery remained even after controlling for the demographic composition of the population and disease prevalence. Moreover, while demographic, regional, and temporal covariates were significant (p < 0.0001) in accounting for over 90% of the variation in utilization, disease prevalence was not significant (p > 0.05).
This study merged population based reports of disease prevalence with administrative data to account for regional variations in utilization. While regional variations in KR surgery have fallen over time, variations remain even after adjusting for patient reported disease prevalence. The finding that demographic variables and the reported prevalence of disease were poorly correlated suggests that current area variation studies may not be adjusting fully for disease prevalence or severity.
The Journal of Rheumatology 12/1997; 24(12):2403-12. · 3.69 Impact Factor
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ABSTRACT: To evaluate the nature, risks, and benefits of osteoarthritis (OA) management by primary care physicians and rheumatologists.
Subjects were 419 patients followed for symptoms of knee OA by either a specialist in family medicine (FM) or general internal medicine (GIM) or by a rheumatologist (RH). Management practices were characterized by in-home documentation by a visiting nurse of drugs taken to relieve OA pain or to prevent gastrointestinal side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and by patient report (self-administered survey) of nonpharmacologic treatments. Changes in outcomes (knee pain and physical function) over 6 months were measured with the Western Ontario and McMaster Universities Osteoarthritis Index.
Patients of RHs were 2-3 years older (P = 0.035) and tended to exhibit greater radiographic severity of OA (P = 0.064) and poorer physical function (P = 0.076) at baseline than the other 2 groups. In all 3 groups, knee pain and physical function improved slightly over 6 months; however, between-group differences were not significant. Compared to drug management of knee pain by FMs or RHs, that by the GIMs was distinguished by greater utilization of acetaminophen and nonacetylated salicylates (P = 0.008), lower prescribed doses of NSAIDs (P = 0.007), and, therefore, lower risk of iatrogenic gastroenteropathy (P < 0.001). In contrast, patients of RHs were more likely than those of FMs and GIMs to report that they had been instructed in use of isometric quadriceps and range-of-motion exercises (P < or = 0.001), application of heat (P = 0.051) and cold (P < 0.001) packs, and in the principles of joint protection (P = 0.016). Neither physician specialty nor specific management practices accounted for variations in patient outcomes.
This observational study identified specialty-related variability in key aspects of the management of knee OA in the community (i.e., frequency and dosing of NSAIDs, use of nonpharmacologic modalities) that bear strong implications for long-term safety and cost. However, changes in knee pain and function over 6 months were unrelated to variations in management practices.
Arthritis care and research: the official journal of the Arthritis Health Professions Association 10/1997; 10(5):289-99.
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ABSTRACT: To clarify examine the epidemiologic evidence linking work related exposure to osteoarthritis (OA) of the hip and knee.
We investigated MEDLINE and EMBASE 1966-1994 with search terms of osteoarthritis, osteoarthrosis, arthrosis; risk factors, exposure; occupational diseases, agricultural workers' diseases, work. From 123 original studies on risk factors for OA, 17 studies were identified as providing a comparison group and relating the presence or absence of radiologically diagnosed OA to occupational factors. The quality of the methodology of each study was evaluated independently by 4 reviewers using a standardized protocol.
Common methodological problems were encountered in areas such as representatives, recall of exposure, and evaluation of exposure and outcome. These problems often made a cause-effect relationship difficult to interpret. However, 7 of the 17 studies met our criteria for good methodological quality. A critical analysis of their results led to the following conclusions: (1) A consistently positive relationship exists between work involving knee bending and knee OA in men (range of odds ratio: 1.4-6). (2) The evidence suggesting a relationship between knee OA and occupational exposure in women is inconclusive. (3) A consistently positive but weak relationship exists between work related exposure (i.e., farming in particular) and hip OA in men. We felt we could not conclude with confidence that this relationship is strong due to the potential biases that exist in each of these studies. (4) No study attempted to investigate occupational exposure and hip OA in women.
Studies suggest a strong positive relationship between work related knee bending exposure and knee OA. The evidence between work related exposure, farming in particular, and hip OA is consistently positive but weak.
The Journal of Rheumatology 09/1997; 24(8):1599-607. · 3.69 Impact Factor
