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The Global Economic Cost of Osteoarthritis: How the UK Compares

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  • Royal London Hospital, Barts Health NHS Trust, London

Abstract and Figures

Aims. To examine all relevant literature on the economic costs of osteoarthritis in the UK, and to compare such costs globally. Methods. A search of MEDLINE was performed. The search was expanded beyond peer-reviewed journals into publications by the department of health, national orthopaedic associations, national authorities and registries, and arthritis charities. Results. No UK studies were identified in the literature search. 3 European, 6 North American, and 2 Asian studies were reviewed. Significant variation in direct and indirect costs were seen in these studies. Costs for topical and oral NSAIDs were estimated to be £19.2 million and £25.65 million, respectively. Cost of hip and knee replacements was estimated to exceed £850 million, arthroscopic surgery for osteoarthritis was estimated to be £1.34 million. Indirect costs from OA caused a loss of economic production over £3.2 billion, £43 million was spent on community services and £215 million on social services for osteoarthritis. Conclusions. While estimates of economic costs can be made using information from non-published data, there remains a lack of original research looking at the direct or indirect costs of osteoarthritis in the UK. Differing methodology in calculating costs from overseas studies makes direct comparison with the UK difficult.
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Hindawi Publishing Corporation
Arthritis
Volume 2012, Article ID 698709, 6pages
doi:10.1155/2012/698709
Review Article
The Global Economic Cost of Osteoarthritis:
How the UK Compares
A.Chen,C.Gupte,K.Akhtar,P.Smith,andJ.Cobb
MSKLab,ImperialCollege,LondonW68RF,UK
Correspondence should be addressed to A. Chen, alvinm.chen@gmail.com
Received 30 May 2012; Accepted 30 August 2012
Academic Editor: Charles J. Malemud
Copyright © 2012 A. Chen et al. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Aims. To examine all relevant literature on the economic costs of osteoarthritis in the UK, and to compare such costs globally.
Methods. A search of MEDLINE was performed. The search was expanded beyond peer-reviewed journals into publications by
the department of health, national orthopaedic associations, national authorities and registries, and arthritis charities. Results.No
UK studies were identified in the literature search. 3 European, 6 North American, and 2 Asian studies were reviewed. Significant
variation in direct and indirect costs were seen in these studies. Costs for topical and oral NSAIDs were estimated to be £19.2
million and £25.65 million, respectively. Cost of hip and knee replacements was estimated to exceed £850 million, arthroscopic
surgery for osteoarthritis was estimated to be £1.34 million. Indirect costs from OA caused a loss of economic production over
£3.2 billion, £43 million was spent on community services and £215 million on social services for osteoarthritis. Conclusions. While
estimates of economic costs can be made using information from non-published data, there remains a lack of original research
looking at the direct or indirect costs of osteoarthritis in the UK. Diering methodology in calculating costs from overseas studies
makes direct comparison with the UK dicult.
1. Introduction
Musculoskeletal diseases remain one of the most common
causes for severe long-term pain and disability. The increas-
ing significance of musculoskeletal disorders has prompted
the United Nations, the World Health Organization, and 37
countries to spearhead a campaign to recognise and address
the burden of musculoskeletal disorders such as arthritis,
proclaiming it to be the Bone and Joint Decade (2000–2010)
[1], and to advance understanding and treatment of mus-
culoskeletal disorders through prevention, education, and
research.
Within the envelope of musculoskeletal disorders, Oste-
oarthritis represents a complex musculoskeletal disorder
with multiple genetic, constitutional, and biomechanical risk
factors. It represents the most common form of joint disease
and disability in older people and ranks amongst the top 5
causes of disability [2].
The economic costs of osteoarthritis can be broken down
into direct costs and indirect costs. Direct costs represent the
pharmacological/nonpharmacological treatments, including
surgery, as well as use of hospital resources and management
of complications arising from the treatment of osteoarthritis.
Indirect costs represent loss of time from work, decreased
productivity because of pain, care-giver time, premature
mortality, and disability compensation/benefits. These costs
are summarised in Tabl e 1,below.
A third category sometimes considered is that of intan-
gible costs. These are defined as the pain and suering
experienced by the patient as a result of the disease; the
reduction in the patient’s quality of life. They remain an area
of controversy, with only a few studies making the attempt to
estimate them [3].
2. Aims
The aim of this paper is to examine all relevant literature on
the economic costs of Osteoarthritis in the UK, and to see
what comparisons can be made regarding such costs in the
UK and other countries in North America, Europe, and Asia.
2Arthritis
Tab le 1
Direct costs Indirect costs Intangible costs
Costs of surgery Loss of productivity Pain and suering
Hospital resources Absenteeism Decreased quality of life
Caregiver time Premature mortality Potential depression/anxiety
Pharmacological and nonpharmacological treatment Disability payments/benefits
Costs of side eects from treatments
Research
3. Methods
A comprehensive review of the literature was performed
using a computerised bibliographical search of MEDLINE
databases from 1946 to 31st Dec 2011. English language
articles were reviewed that contained the words “economic
cost,” “direct cost,” or “indirect cost” in combination with
“osteoarthritis” in either their title or abstract.
To expand the review beyond only published studies,
an internet search was made for publications from the UK
Department of Health, the National Institute for Clinical
Excellence, the UK National Joint Registry, Hospital Episode
Statistics, and charities Arthritis Research (UK) and Arthritis
Care, and all publications were reviewed for information
on costs for osteoarthritis. Further internet searches were
made for publications from the British Orthopaedic Asso-
ciation, the Royal College of Surgeons, the Royal College of
Physicians, and the Royal College of General Practitioners.
Publications from American Association of Orthopaedic
Surgeons and other regional orthopaedic associations in
Europe and Asia were also reviewed.
4. Results
4.1. What Do We Know about OA Costs in North America?
Studies on prevalence of osteoarthritis in the United States
have shown that osteoarthritis aects 13.9% of adults aged
25 and older, and 33.6% of those over the age of 65, with an
approximate 27 million Americans of all ages suering from
disease [4].
Much of the data available on osteoarthritis in the
United States is derived from studies conducted in the
1960s and 1970s. The Framingham study [5]represented
one of the early studies to associate increasing age with
worsening knee arthritis. This study, which began in 1948,
was initially designed to look at cardiovascular risk factors in
a representative sample of people in the adult population of
Framingham, MA. The study’s patients were examined every
2 years since inception. This same cohort of patients was used
by Felson et al. to look at the prevalence of knee osteoarthritis
approximately 36 years after the start of the study. The age
of the patients in the study ranged from 63 to 94, and a
total of 1805 patients were studied. The study confirmed
that radiographic evidence of OA increased with age, with
a higher prevalence of OA changes in women, as well as a
significantly higher proportion of women with symptomatic
OA.
Lethbridge-c¸ejku et al. [6] examined discharge data
from the National Hospital Discharge Survey and concluded
that Osteoarthritis accounts for 55% of all arthritis related
hospital admissions, with 409 000 such admissions in 1997.
The annual cost of knee and hip replacements in 1997 was
estimated at $7.9 billion (£4.7 billion) [6]. Less than 10 years
later in 2004, the number of hospital admissions had risen to
632 000 and the annual total cost of joint replacements rose
to $22.6 billion (£13.8 billion) [7].
Buckwalter et al. [8] used data drawn from national
data sets collected by the U.S. Bureau of Labor Statistics,
the U.S. National Center for Health Statistics, as well as
existing cost estimates for arthritis in the literature, used
proportional attributable risk models and the human capital
method to break down costs into direct and indirect costs.
From this study, an estimated $3.4–$13.2 billion (£2 billion–
£8 billion) is spent annually on job-related OA costs in the
USA. Meanwhile, Kotlarz et al., in 2010, using evidence from
the national health survey data from 1996–2005, looked at
absenteeism as a result of osteoarthritis. This study, estimated
the indirect cost of the absenteeism to be approximately
US$10.3 billion [9]. The study also confirmed that the costs
for women were larger (US$ 5.5 billion compared to US$4.8
billion), and that absenteeism was less in subjects with lower
education and those in minority groups.
A survey done by Gupta et al, in ON, Canada in 2005,
estimated that the indirect costs incurred by a patient aged
over 55 with hip or knee arthritis may be much higher than
previously estimated when compared to direct costs ($12 990
or £8183 annually for the former, and $2300 or £1449 for the
latter) [10]. Indirect costs were incurred mostly for time lost
from employment and for unpaid informal caregivers, with
caregiver time accounting for 40% of indirect costs. It should
be noted that the authors in this study based the costs on the
monthly wage for a professional homemaker or housekeeper
as caregiver occupation was unknown. This averaged at US$
1278 (£824) per month, which may explain the relatively
higher costs reported.
March and Bachmeier (1997) looked at the global cost of
osteoarthritis and found the cost of osteoarthritis in the USA,
Canada, UK, France, and Australia to account for between 1–
2.5% of the gross national product (GNP) for those countries
[11].
4.2. How Do Recent Studies in Europe Compare? Loza et al.,
in their Spanish study, assessed the burden of knee and
hip osteoarthritis by examining 1071 patients across all the
Arthritis 3
provinces of Spain [12]. The average annual cost for OA
per patient was estimated at C1502 (£1260), with direct
costs representing 86% (£1084) of the total cost. Indirect
costs were much lower (14% or £176) and mainly involved
domestic help.
In contrast to this, the COART study [13]inFrance
attempted to estimate the overall financial cost of osteoar-
thritis to the country. The study concluded that osteoarthritis
remained a major public burden, with direct costs in 2002
exceeding 1.6 billion Euros, about 1.7% of the expenses
of the French Health system. Over 13 million visits were
made to physicians for osteoarthritis. Medication costs were
570 million euros and inpatient treatment amounted to 820
million Euros. During the period of the study, 80 000 total
hip replacements and 38 000 total knee replacements were
performed per year, at a cost of C5600 per THR and C4500
per TKR. The study compared the costs to a previous study
by Levy et al. [14] in 1993 and found that the prevalence of
the disease had risen by 54%, and the direct medical costs by
156%.
In Italy, Leardini et al. examined the economics of
osteoarthritis of the knee in 2004. They used a bottom-
up method, utilising data collected from each patient,
and reviewed patients across 29 medical institutes. They
concluded that the direct costs came to C934 (£785) and
indirect costs C1236 (£1039) per patient per year [15].
4.3. Is the Situation DierentinAsia? There have been fewer
studies with regard to economic costs of osteoarthritis in
India, China or Southeast Asia compared with countries in
the western hemisphere.
In contrast to the Western literature, Woo et al., in
their Hong Kong [16] study estimated that the cost of
osteoarthritis accounted for 0.28% of the GNP of Hong
Kong, between HK $3.2–$3.9 billion (£253 million–£308
million). The direct costs ranged from HK $4860–$11180
(£384–£883) and indirect costs HK$3300–$6640 (£261–
£525) per person annually.
Xie et al. assessed indirect costs in Singapore for OA
and noted that there were estimated at between US$1000–
1200 (£610–£730), around 2.8% and 3.3% of the annual
household income [3]. The authors here acknowledged that
these costs likely represented the lower end of the scale,
as costs such as loss of productivity of caregivers were
not estimated. The study was also one of the few that
attempted to address and estimate intangible costs using the
willingness to pay (WTP) method. In economics, this model
represents the maximum amount a person would be willing
to pay, sacrifice, or exchange in order to avoid something
undesired, in this case, the pain and suering associated
with osteoarthritis. The authors here estimated the intangible
costs at US$ 1200 (£775) per year.
4.4. What Do We Know about the Economic Cost of
OA in the UK?
4.4.1. The Prevalence of OA. The Arthritis Research Council
(UK) estimated in 2002 that at least 4.4 million patients
in the UK have X-ray evidence of moderate-to-severe
osteoarthritis in their hands, while 550 000 have similar
evidence of osteoarthritis in their knees, and 210 000 have
evidence of this in their hips [17].
Pye et al., in 2004, showed that almost 8.5 million people
in the UK have X-ray evidence of osteoarthritis in their
spine, with back pain being the most frequent symptom [18].
While predominantly a disease of the elderly, an estimated
6% of adults aged 30 and above have both knee pain and
radiographic changes of osteoarthritis [18].
The Royal College of General Practitioners estimated in
2006 that in the UK over 1 million adults consult their GP
each year with symptoms of osteoarthritis [19]. Another
study in 2007 showed that consultations for osteoarthritis
account for 15% of all musculoskeletal consultations in those
aged 45 and over, rising to 25% in those aged 75 and over
[20]. The cost per consultation is estimated at £36 for a 12-
minute consultation [21].
During the year from 1999-2000, there were 114,500
hospital admissions related to osteoarthritis in the UK
[17]. The latest Hospital Episode Statistics (HES) data
(2010-2011) have shown a significant increase in hospital
admissions, for hip and knee arthritis alone, the combined
figure was 181,350 admissions [20]. When the diagnoses
for polyarthritis and “other arthritis”–but not rheumatoid
conditions or crystal arthropathy are included, the total
number of admissions in 2010/11 was 207,041, representing
an 80% increase compared with figures of 10 years ago.
Surprisingly, there are no published studies in the liter-
ature with regard to direct or indirect costs of osteoarthritis
in the UK. Data, however, is instead only available from a
variety of other sources.
4.5. What Information Is Available from Other Sources about
Costs in the UK?
4.5.1. Direct Costs. The National Institute of Clinical Excel-
lence (NICE) recently published a costing report in 2008
with regard to implementing the guidelines for treatment
of osteoarthritis [22]. In the report, NICE estimated the
prevalence of osteoarthritis in the UK to be a total of 2.8
million patients, based on symptomatic diagnosis in patients
aged over 45. The analysis covered the management of
osteoarthritis in all such patients.
The cost of topical and oral nonsteroidal anti-
inflammatories (NSAIDs) was estimated using prescribing
data from 2005/06 [22]. An estimated 167 000 people
who had a diagnosis of osteoarthritis were found to have
been prescribed topical NSAIDs, and it was estimated that
50% (1.4 million patients) of patients with osteoarthritis
were prescribed oral NSAIDs. The annual cost in 2005/06
of prescribing topical NSAIDs was £8.5 million and £25
million for oral NSAIDs. The cost for topical NSAID
prescriptions was anticipated to double, and the cost of
oral treatment reduced by 10%, if the new guidelines are
followed. Adjusting for inflation, in 2010 prices, this would
equate to £19.2 million and £25.65 million, respectively.
The cost of iatrogenic events related to NSAID use is
also substantial. NSAID-related iatrogenic events have been
4Arthritis
estimated to be between £32–£70 per patient prescribed an
NSAID in the UK. This equates to a total cost of £44.8–£98
million per year (£56.9–£124.4 million at 2010 prices) [23].
The cost of proton pump inhibitor (PPIs) prescription
for use with NSAID treatment was £26 000 in 2005/06 but
expected to rise significantly to £10.5 million (£11.6 million
in 2010) with implementation of the new guidance.
The 2005/06 Hospital Episode statistics stated that the
total number of people aged 45 and over who received
arthroscopic lavage and debridement for knee osteoarthritis
was approximately 20 000. The national tarifor arthro-
scopies set by the Health Resource Group in 2008/09 was
£1264, resulting in a cost £25 million for such treatment.
It should be noted that NICE expected the cost of this
to fall dramatically (by 19000 patients), with guidelines
restricting the use of arthroscopic treatment to patients
with “mechanical” symptoms such as locking or giving way.
The new cost for arthroscopic treatment of osteoarthritis is
calculated (£1264 ×1000 patients) at £1.26 million (£1.3
million in 2010).
4.5.2. Economics of Joint Replacement. According to the 8th
annual report of the NJR, published September 2011 [22],
a 76 759 primary total hip replacements were performed
in 2010, a 6% increase from 2009. The revision “burden”
was approximately 11% with 7852 hips revised in 2010.
A total of 81979 knee replacements were done in 2010,
representing an increase of 5.7% when compared with 2009.
The revision “burden” here was less, at just over 6% requiring
revision in 2010. The proportion of total knee replacements
to unicondylar knee replacements and patella-femoral knee
replacements have remained largely the same for the last few
years.
While there are other causes for joint replacement
surgery, osteoarthritis remains the most frequent cause for
hip replacement (93% of primary hip replacements in 2010)
and knee replacement (97% of primary knee replacements in
2010).
The costs of hip and knee replacements vary considerably
from trust to trust in the UK with no set national price
for implants, and the cost also being significantly dependant
on length of hospital stay. The tarireimbursement paid
to the trust in one study [24] in 2005/06 was £6000 for
a primary total hip replacement and £6800 for a primary
total knee replacement. The national tarifor 2010 was set
at £5552 for an uncomplicated total hip replacement and
£5198 for a similar total knee replacement. This leads to an
estimated cost of £426 million for total hip replacements and
£426 million for primary total knee replacements, giving a
combined total cost for primary hip and knee replacements
of £852 million in 2010. This represents a substantial increase
in costs over the last 10 years, when compared to the
expenditure of £405 million in 2000 for 44 000 hip and 35
000 knee replacements [17]. Even adjusting for inflation, this
cost would only be £514 million in 2010, representing a 66%
increase in the last 10 years. Figure 1 summarises the UK
direct costs.
0
100
200
300
400
500
600
700
800
900
Millions £
NSAIDs
PPIs
Arthroscopy
NSAIDs
PPIs
NSAIDs iatrogenic
Arthroscopy
Joint replacement
NSAIDs
iatrogenic
Joint
replacement
Cost of OA in the UK
44.8 11.6 98 1.3
852
Figure 1
4.5.3. Indirect Costs. Osteoarthritis has a significant negative
impact on the UK economy with an estimated total cost of
1% of GNP [25]. The Department of Work and Pensions
estimates that 36 million work days were lost because
of osteoarthritis in 2002, resulting in a loss of economic
production over £3.2 billion; while at the same time, £43
million was spent on community services and £215 million
spent on social services for osteoarthritis [26].
Arthritis remains the most common condition for people
to receive the Disability Living Allowance (DLA), with £2.41
billion paid to people claiming incapacity benefit due to
arthritis and related conditions in 2001 [26]. More than half
a million people receive the DLA because of arthritis, more
than the total for heart disease, stroke, chest disease, and
cancer combined [16]. Only around 1 in 200 of those on
benefit later returns to work [27].
The most recent review of disability costs in the UK
was done by Dame Carol Black [28] in her review of the
health of the working age population. Unfortunately, the
review did not oer a breakdown of the components in
musculoskeletal disability costs, and so, despite the report,
the exact contribution of OA to such costs in the UK remains
unknown.
5. Discussion
The review demonstrates that osteoarthritis represents an
increasing economic burden to all countries, both from
direct costs and indirect costs. Economic data on osteoarthri-
tis has been made dicult because of problems defining the
prevalence and incidence of the disease. There is only sparse
literature available regarding economic costs in the east, but
what is more surprising is the lack of clear costing studies in
the west, especially in the UK.
Direct costs may vary from country to country, which is
to be expected given their dierent health systems, and even
between institutions in a country. Significant variability is
seen from these studies, making direct comparison dicult.
Compounding the problem is the fact that the methodology
Arthritis 5
Tab le 2
Author Year of study Country Cost studied
Individual cost per
annum (2010 £) per
OA patient
Population
cost per annum
(2010 £)
McClean et al. 1993 USA Direct costs £1526 US $548 million
Lanes et al. 1994 USA Direct costs £496 N/A
Buckwater et al. 2000 USA Indirect costs N/A £2 billion–£8 billion
Kotlartz et al. 2005 USA Indirect costs £355 £7.25 billion
Maetzel et al. 2000 Canada Direct costs
Indirect costs
£3162
£1407
N/A
N/A
Gupta et al. 2002 Canada Direct costs
Indirect costs
£1768
£9986
N/A
N/A
Loza et al. 2003 Spain Direct costs
Indirect costs
£1292
£209
£4.04 billion
£654 million
Le Pen et al. 2003 France Direct costs £316 £1.58 billion
Leardini et al. 2001 Italy Direct costs
Indirect costs
£ 981
£1299
N/A
N/A
Woo et al. 2001 Hong Kong Direct costs
Indirect costs
£6561
£620
£323 million
(combined cost)
Xie et al. 2005 Singapore Indirect costs £610–£730 N/A
used in estimating these costs can vary from study to study,
and not all studies give a clear breakdown of the calculation
of the direct costs involved [29].
Furthermore, in the studies that provide a breakdown of
the direct costs, few include the cost of alternative therapies
in the treatment of osteoarthritis. There is evidence that
nearly half (47%) of older patients in one American study
[30] used an alternative type of therapy, and these costs are
considerable (US$ 1127 or £723 per annum). Hence, the true
economic burden of direct costs in osteoarthritis is likely to
be significantly higher than most of these studies indicate.
The significant variability in indirect costs from these
studies is also a concern. This is likely to be due to the
lack of a standardized method to estimate indirect costs–
unfortunately, there remains at present no good evidence to
support one preferred method over the others [29]. Most
studies conclude that indirect costs, however, represent a
largely underestimated economic burden to country, and as
such, these estimates may just be the tip of the iceberg.
6. Conclusion
Our review of the literature suggests that while there are a
large number of studies on economic costs of osteoarthritis,
from multiple countries, the information available in the
literature remains patchy and dicult to interpret. Some
studies focus on the macroeconomic angle, looking at costs
at a national scale or costs per capita while others focus on
costs from the view of the individual patient with OA. Other
studies are only specific for arthritis of a single joint. Even
with studies compatible from this point of view, the varied
methodology and lack of standardization of costing make it
impossible to accurately compare economic costs, whether
direct or indirect. These studies are summarized in Tabl e 2.
Despite such diculties, one conclusion does seem clear
from these studies: that such costs are very substantial and
are continuing to rise.
The continuing lack of published data regarding direct
and indirect OA costs in the UK, especially from the patient
perspective, shows that more research into this area is vital.
This will allow us to fully appreciate the healthcare burden of
OAintheUK,aswellastomakemoreaccuratefinancial
planning for the provision for healthcare services for the
treatment of OA in the subsequent decade to come.
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... The healthcare burden related to OA is growing and in many developed countries is considered unsustainable. For example in Spain and Italy-two of the countries with the longest life expectancy in Europe-the average annual cost for OA medications per patient was estimated between €1000 and 1500 per year [5,6]. Globally costs take on an even more impressive aspect. ...
... In the UK, the expenses for non-steroidal anti-inflammatory drugs were estimated at around £20 million; the cost of arthroscopic surgery for OA was estimated to be £1.34 million; hip and knee replacements were estimated to exceed £850 million; and indirect costs from OA, such as social and community services, caused a significant loss of economic production of over £3.2 billion. In addition, in France, OA is a conspicuous public burden, with direct costs of about 1.7% of the expenses of the French Health system, staying just below €2 billion [5]. The American College of Rheumatology and the Arthritis Foundation recommend weight management, exercise therapy, some types of bracing (tibiofemoral), and patient education (PE) as first-line interventions for lower-limb OA [7]. ...
Article
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(1) Background: Patient education (PE), exercise therapy, and weight management are recommended as first-line interventions for hip and knee osteoarthritis (OA). Evidence supporting the effectiveness of exercise therapy and weight management in people with lower-limb OA has been synthesized in recent studies. However, according to the Osteoarthritis Research Society International , PE is often considered a standard of care and the inclusion of this as a first-line intervention for people with knee OA in clinical practice guidelines is often supported by limited evidence. The aim of this review is to evaluate the effects of PE on pain and function and how it impacts on conservative treatment. (2) Methods: This is a literature review of studies investigating the effect of patient education on pain and function and its impact on conservative treatment in elderly patients with pain related to hip and knee OA. PRISMA guidelines were followed during the design, search, and reporting stages of this review. The search was carried out in the PubMed database. (3) Results: A total of 1732 studies were detected and analyzed by performing the proposed searches in the detailed databases. After removing duplicates and analyzing the titles and abstracts of the remaining articles, 20 studies were ultimately selected for this review. Nineteen of these twenty articles showed positive results in pain or function in patients with pain related to hip and knee OA. (4) Conclusions: PE seems to be effective in reducing pain and improving function in patients with pain related to hip and knee OA. Furthermore patient education seems to positively impact the conservative treatment with which it can be associated.
... campaigns which must make the assumption that its target population have the good foot health required to be able to carry out these activities. Yet despite the lack of attention to and value placed on foot health, foot problems and osteoarthritis are predicted to continue to escalate in their societal and economic demand (Chen et al. 2012). As these programmes to aid the prevention of diabetes, obesity, heart conditions and strokes are the focus of good health, they require an appropriate level of foot health in the first instance to be achievable by the general population. ...
Thesis
Introduction The prevalence of foot osteoarthritis (OA) is less well understood than hip, knee and hand OA. The foot is undoubtedly more complex, and investigators have been challenged in defining which joints to investigate and by the need for improved methodological standardisation across studies. As such, the prevalence and natural history of osteoarthritis and the relevance of co-existing pain in the foot have not yet been widely explored. The aim of this thesis was to improve understanding of foot osteoarthritis by examining techniques used to define foot osteoarthritis and by description of the prevalence, distribution and natural history of radiographic foot osteoarthritis and co-existing foot pain in an established UK population-based cohort of women, ‘The Chingford 1000 Women Study’. Methods Study 1: The author (PMc) undertook training by an experienced radiographer in scoring foot osteoarthritis using a validated foot atlas (The La Trobe Foot Atlas). Employing archived foot radiographs (n = 20 paired feet) Chingford 1000 Women study: year 6, 1995) intra-rater reliability was established for five individual joints in both feet (percentage close agreement ranged from 47.6% to 85.7% for osteophytes and from 33.3% to 81% for joint space narrowing). Subsequently a sample of foot radiographs (n=218) that included all remaining participants in the Chingford 1000 Women Study who returned for the year ‘23’ visit (mean (SD) for age: 75.5 (5.1)) were scored. A range of prevalence estimates of osteoarthritis at the foot and individual joint level were examined that relate to discordance between different techniques of interpretation. The findings from this study supported the use of the La Trobe Foot Atlas (LFA) to identify foot osteoarthritis in existing current and historical radiographs of established large population cohorts. Study 2: A cross-sectional study design was used in which returning participants at year ‘23’ (2013-2015) from the Chingford 1000 Women study were investigated for presence of radiographic foot osteoarthritis and co-existing foot pain. Presence of radiographic foot osteoarthritis was scored according to LFA and self-reported foot pain was primarily defined and assessed using the non-side specific question “have you ever had pain in your feet which has lasted one day or longer?” Data from 332 women were included in this study. Of these 91.3% had radiographic foot osteoarthritis in any joint affecting either foot. When examining individual joints, the rank order of radiographic osteoarthritis was; 2nd cuneo-metatarsal joint (78.9%), 1st cuneo-metatarsal joint
... Royal College of General Practitioners (GPs) reports that over 1 million individuals consult their GP with OA symptoms (Chen et al., 2012). Jordan et al. (2006) stated that the incidence of a new GP consultation for adults with knee pain aged over 50 years is 10% each year. ...
Article
Background: Non-pharmacological interventions such as education, exercise, and weight loss (if necessary) are core to the management of Osteoarthritis (OA). The role of nurses in managing symptomatic knee OA has been advocated but whether nurses can deliver such interventions as a complex package of care is unknown. The overall aim of this research was to develop and test the feasibility of a nurse-led complex intervention for knee pain comprising non-pharmacological and pharmacological components. The specific objectives of this thesis were to: 1) Systematically review the literature evaluating complex interventions for knee pain due to OA, 2) Evaluate fidelity of delivery of a nurse-led non-pharmacological complex intervention for knee pain, 3) Assess the acceptability of the non-pharmacological component of the intervention, issues faced in delivery, and resolve possible challenges. Methods: Systematic review and meta-analysis of complex interventions for knee pain due to OA: A systematic literature search was conducted on MEDLINE, EMBASE, AMED, PsycINFO, and CINAHL up until September 29th, 2020. Randomised Controlled Trials (RCTs) comprising at least patient education, exercise, and weight loss interventions were searched. Data were extracted by a single reviewer and cross-checked by two others. Standardised mean differences (SMD) and 95% confidence intervals (CI) were calculated using the random-effects model. The risk of bias was assessed with the Revised Cochrane risk-of-bias tool, and intervention reporting with the template for intervention description and replication (TIDieR) checklist. The primary outcome of interest was knee pain. Package development phase: 18 participants with knee pain (five with mild severity, eight with moderate, and five with severe) participated in a single-arm study. The fidelity and acceptability of a nurse-led non-pharmacological intervention comprising assessment, education, exercise, use of hot/cold treatments, footwear modification, walking aids, and weight-loss advice (if required), delivered in 4 sessions over 5 weeks were evaluated. Fidelity of delivery of intervention: Each intervention session with every participant was video recorded and formed part of the fidelity assessment. Self-reported fidelity checklists were completed by the research nurse after each session and by an independent researcher, after viewing the video recordings blinded to nurse ratings. Fidelity scores (%), percentage agreement, and 95% Confidence Intervals (CI) were calculated. Two semi-structured interviews were conducted with the research nurse. Acceptability assessment of the non-pharmacological components: Eighteen adults with chronic knee pain (defined as pain for longer than three months) were recruited from the community. The intervention comprised holistic assessment, education, exercise, weight- loss advice (where appropriate), and advice on adjunctive treatments such as hot/cold treatments, footwear modification, and walking aids. Participants had one-to-one semi- structured interviews at the end of the intervention. The nurse was interviewed after the last visit of the last participant. These were audio-recorded and transcribed verbatim. Themes were identified by one author (PAN) using framework analysis of the transcripts and cross-checked by another (AF). Results: Systematic review ad meta-analysis of complex interventions: We reviewed 2,649 titles and abstracts in the systematic search. The screening process identified twenty RCTs recruiting 3,069 participants with knee OA. Twelve RCTs were included in the meta- analysis. More than half of the studies were judged to be of high quality. The completeness of intervention reporting was poor. Complex interventions for OA produced moderate benefit for pain relief (-0.47, 95% CI -0.77, -0.16) and physical function (-0.49, 95% CI -0.72, -0.25). However, studies delivering non-pharmacological interventions for knee OA rarely reported both fidelity of delivery and acceptability of non-pharmacological interventions. Fidelity of delivery of intervention: Fourteen participants completed all visits. 62 treatment sessions took place. Nurse self-report and assessor video rating scores for all 62 treatment sessions were included in the fidelity assessment. Overall fidelity was higher on nurse self- report (97.7%) than on objective video-rating (84.2%). The percentage agreement between nurse self-report and video-rating was 73.3% (95% CI: 71.3 - 75.3). Fidelity was lowest for advice on footwear and walking aids. The nurse reported difficulty advising on thermal treatments, footwear, and walking aids, and did not feel confident negotiating achievable and realistic goals with participants. The nurse found the discussion of goal setting to be challenging. Acceptability assessment of the non-pharmacological components: Most participants found the advice from the nurse easy to follow and were satisfied with the package, though some felt that too much information was provided too soon. The intervention changed their perception of managing knee pain, learning that it can be improved with self-management. However, participants thought that the most challenging part of the intervention was fitting the exercise regime into their daily routine. Conclusion: A non-pharmacological package of care comprising patient education, exercise, and weight loss advice is more beneficial than usual care or any other single non- pharmacological component. A trained research nurse could deliver such a non- pharmacological package of care with high fidelity and acceptability for the participants and the nurse delivering the intervention. Future research should consider measuring the fidelity of delivery of intervention and acceptability in a real-world primary-care setting before evaluating it further in a multicentre RCT. Measuring the extent to which components are delivered as intended across different settings and populations, fidelity research may assist to understand which intervention components are effective and in which situations.
... Femoroacetabular impingement affects individuals at a stage in their lives when they should be contributing tax to public service funds. The longterm sequelae of femoroacetabular impingement may precipitate joint degeneration [3] and lead to further healthcare expenditure in later life [4]. ...
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Article
Background: Knee osteoarthritis (KOA) is a common cause of chronic musculoskeletal pain and disability as well as a socioeconomic burden on healthcare services globally. Numerous clinical trials indicated that traditional Chinese medicine (TCM) may effectively improve the clinical symptoms of KOA patients. However, the comparative efficacy and safety of different TCM therapies in patients with KOA is not yet clear. In order to evaluate the efficacy and safety of TCM for KOA, we will conduct a systematic review and network meta-analysis on the existing randomized controlled trials (RCTs). Methods: A systematic literature search will be conducted in PubMed, Web of Science, Embase, EBSCO, Cochrane Library, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and the VIP Database for Chinese Technical Periodicals up to February 2022 to identify the relevant RCTs. The primary outcomes are visual analog scale, Western Ontario and McMaster Universities Osteoarthritis Index, Lysholm score, and Lequesne index. Secondary outcomes include the total clinical effective rate and adverse events. Study quality will be evaluated using the Cochrane risk of bias tool (RoB 2.0) for RCTs. Data analysis will be performed using Stata and WinBUGS. The quality of evidence will be assessed using the Grades of Recommendations Assessment Development and Evaluation. Results: The results of this study will be submitted to a peer-reviewed journal for publication. Conclusions: This study will provide evidence-based medical evidence for the treatment of KOA with TCM therapies and offer better assistance for clinical practice. Protocol registration number: INPLASY202230008.
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Opening wedge high tibial osteotomy (OWHTO) is a surgical procedure often used to eliminate the effects of knee osteoarthritis, a disease that is becoming more widespread worldwide. Optimizing the geometric planning of this operation is a very important preparatory step for the success of the intervention and rapid postoperative recovery. This optimization is performed in two main directions. The first direction evaluates the intraoperative behavior of the tibia during the osteotomy by optimizing four geometric parameters that characterize geometric planning. The second direction aims at a postoperative evaluation of the flat tibia-osteosynthesis assembly taking into account the optimal position on the medial–lateral articular line through which the corrected mechanical axis of the tongue passes and implicitly offloads the transfer from the medial area to the side of the knee. The research methods used are exclusively computer-assisted such as: computer-aided design (hereinafter CAD) for geometric modeling of the tibia taking into account the real bone structure, the finite element method (hereinafter FEM) for performing numerical analyses and design of the experiment (hereinafter DOE) for the design of the research. The results obtained are eloquent and clearly presented and can be important elements for orthopedic doctors at the geometric planning stage of the OWHTO.
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Background: Osteoarthritis of the knee is a common degenerative musculoskeletal condition. Thai Medicinal Plant-4 (TMP-4) cream is made up of Garcinia mangostana peel, Sesamum indicum seeds, Glycine max (L.) Merr. seeds, and Centella asiatica leaves, all of which have anti-inflammatory and analgesic properties. The present study aimed at determining the efficacy and safety of TMP-4 cream versus diclofenac gel in the treatment of symptomatic osteoarthritis of the knee. Methods: A randomized-controlled trial was conducted to assess knee pain on a scale of 100 mm Visual Analog Scale (VAS) and other key metrics, including VAS knee stiffness, a modified 10-step stair climb test, a timed up and go test, the Knee Injury and Osteoarthritis Outcome Score, and safety outcomes, following administration of either TMP-4 cream or diclofenac gel for 4 weeks. Results: A total of 199 patients with moderate knee pain intensity were randomly assigned to either TMP-4 cream or diclofenac gel (allocation ratio 1 : 1). The mean changes of VAS knee pain in the TMP-4 cream and diclofenac gel groups were -31.68 ± 14.18 mm and -31.09 ± 12.41 mm, respectively, (mean difference = -0.58, 95% confidence interval = -4.37-3.20, P=0.761). The upper limit of 95% confidence interval for the comparison between TMP-4 cream and diclofenac gel was within the predefined margin of 7 mm for noninferiority. The safety was comparable between the two interventions. Conclusions: TMP-4 cream was noninferior to diclofenac gel in relieving osteoarthritic knee pain and may be considered as an alternative therapeutic option in the treatment of symptomatic osteoarthritis of the knee.
Article
Background Mechanical-based therapies are not yet recommended to manage osteoarthritis (OA). This systematic review and meta-analysis aim to assess the effects of passive mechanical-based therapies (isolated or combined with other therapies) on patients with knee OA compared to placebo, other isolated or combined interventions. Methods Pubmed, Cochrane, Web of Science and EMBASE were searched up to December 2020. We included randomized and non-randomized trials using therapeutic ultrasound, phonophoresis, extracorporeal shockwave therapy (ESWT) and vibration (single or combined with other therapies) compared to placebo, and/or other physical therapies groups. Biochemical, patient-reported, physical and imaging outcome measures were retrieved. We judged risk of bias using the RoB2 tool for randomized studies, the ROBINS-I tool for non-randomized studies, and the GRADE to interpret certainty of results. Results We included 77 clinical studies. Ultrasound and ESWT statistically improved pain and disability comparing to placebo (combined or not with other therapies), and when added to other therapies versus other therapies alone. Ultrasound was statistically inferior to phonophoresis (combined or not with other therapies) in reducing pain and disability for specific therapeutic gels and/or combined therapies. Vibration plus exercise statistically improved pain relief and function versus exercise alone. All meta-analyses showed very-low certainty of evidence, with 15 of 42 (38%) pooled comparisons being statistically significant (weak to large effect). Conclusions Despite the inconsistent evidence with very-low certainty, the potential benefits of passive mechanical-based therapies should not be disregard and cautiously recommended that clinicians might use them in some patients with knee OA.
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Knee osteoarthritis is a common cause of knee pain in middle aged and elderly patients presenting in Orthopaedic Outpatient clinics in Nigeria. This study compared the pain control using the visual analog scores (VAS), improvement in function using the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) scores. Patients over 40 years with radiographically and clinically confirmed osteoarthritis of the knee (Kellegren and Lawrence Grade 1 and 2) who met study criteria were recruited with informed consent taken. The patients were randomized into 2 groups. Group A had a single intra-articular injection of 20mg triamcinolone acetonide (Kenalog) and Group B had oral Meloxicam (Melocap) 7.5mg for 12 weeks. They had functional and pain scoring at intervals of 0, 1, 6, and 12 weeks using a (WOMAC) and the VAS respectively. Both study groups showed statistical difference in pain control (VAS) over the study period in the 6 th and 12 th week. There was however a statistically significant change in functional scores (WOMAC) in both study groups at Week 1, 6, and 12 (p<0.05). Introduction Osteoarthritis of the knee is a common cause of knee pain in the middle-aged and elderly presenting at the Orthopedic Outpatient clinic. In the United States, it is the most frequent cause of disability in adults affecting about 27million people [1]. In Nigeria, many hospital-based reviews have shown that osteoarthritis is quite common, the knee is the most affected joint and there is a female preponderance [2, 3, 4]. It is characterized by joint pain and dysfunction and in the advanced stages by limb deformity, muscle atrophy and contractures [5]. Osteoarthritis is the commonest cause of disability in older adults, the fourth commonest cause of hospitalization and leading indication for joint replacement surgeries with a total cost of $42.3 billion in 2009 for hip and knee replacements in the United States of America alone [1]. The primary changes occur within the articular cartilage which is later followed by changes in the subchondral bone [6, 7]. Articular cartilage is rich in extracellular matrix, relatively avascular, lacking lymphatics and nerve supply and chondrocytes make up about 1% of its mass. There is little or no cell death or cell division in normal adult articular cartilage. The chondrocytes are responsible for the synthesis and breakdown of the cartilaginous matrix [7, 8, 9]. Osteoarthritis results from failure of the chondrocytes to maintain homeostasis between synthesis and degradation of extracellular matrix components. This leads to increased water component and decreased proteoglycan content of the extracellular matrix. There is also weakening of the collagen network due to reduced synthesis of type II collagen and breakdown of existing collagen. These changes are associated with contributions of intrinsic and extrinsic factors which further worsen the mechanical, metabolic and oxidative stress suffered by the articular cartilage [5]. Knee pain remains the commonest and most disturbing complaint in these patients and treatment is mainly symptomatic excluding joint replacement.
Article
Aim: To identify prognostic biomarker(s) for knee osteoarthritis (OA) in the Osteoarthritis Initiative (OAI) cohort. Methods: Multilevel regression was used to determine the association between baseline biomarkers and change in biomarkers from baseline to 24 months with clinical and radiographic OA progression over 48 months of follow-up. Results: Higher values of baseline urinary CTXII were consistently associated with an increased risk of OA disease progression outcomes: Kellgren & Lawrence grade (odds ratio [OR]: 1.15, 95% CI: 1.03–1.28); medial joint space narrowing (OR: 1.06, 95% CI: 1.02–1.10); lateral osteophytes (OR: 1.05, 95% CI: 1.01–1.10); joint space width (regression coefficient: -0.005, 95% CI: -0.008–0.001); and Western Ontario and McMaster Universities Arthritis Index pain scores (OR: 1.02, 95% CI: 1.01–1.04). Changes in serum PIIANP and serum COMP over 24 months were associated with clinical disease progression. Conclusion: Urinary CTXII showed stronger associations with radiographic OA and appears to be a reliable prognostic marker, while changes in other biomarkers were found in early symptomatic OA, supporting the phasic nature of OA.
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Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with gastrointestinal problems, notably dyspepsia and bleeding. These adverse effects are costly both in terms of acute hospital admissions and in co-prescribing of gastroprotective agents. The costs of these interventions has been estimated for the National Health Service (NHS) in the UK on the basis of a typical Primary Care Group (PCG) of 100,000 people, the whole population, and for the average patient prescribed an NSAID. The annual burden of NSAID-related gastrointestinal adverse effects to the NHS is large. The middle estimate for an average PCG was £435,000 (range £290,000 to £633,000). The middle estimate for the UK was £251 million (range £166 million to £367 million). The middle cost per patient prescribed an NSAID was £48 (range £32 to £70). As much as half of all acid-suppressing prescribing in the UK may be for NSAID-related gastrointestinal effects.
Article
Objective: To describe current clinical practice against the BSPAR/ARMA Standards of Care (SOCs) for children and young people (CYP) with incident JIA. Methods: Ten UK paediatric rheumatology centres (including all current centres nationally accredited for paediatric rheumatology higher specialist training) participated in a retrospective case notes review using a pretested pro forma based on the SOC. Data collected per centre included clinical service configuration and the initial clinical care for a minimum of 30 consecutive new patients seen within the previous 2 years and followed up for at least 6 months. Results: A total of 428 CYP with JIA (median age 11 years, range 1-21 years) were included, with complete data available for 73% (311/428). Against the key SOCs, 41% (175/428) were assessed ≤10 weeks from symptom onset, 60% (186/311) ≤4 weeks from referral, 26% (81/311) had eye screening at ≤6 weeks, 83% (282/341) had joint injections at ≤6 weeks, 59% (184/311) were assessed by a nurse specialist at ≤4 weeks and 45% (141/311) were assessed by a physiotherapist at ≤8 weeks. A median of 6% of patients per centre participated in clinical trials. All centres had access to eye screening and prescribed biologic therapies. All had access to a nurse specialist and physiotherapist. Most had access to an occupational therapist (8/10), psychologist (8/10), joint injection lists (general anaesthesia/inhaled analgesia) (9/10) and designated transitional care clinics (7/10). Conclusion: This first description of UK clinical practice in paediatric rheumatology benchmarked against the BSPAR/ARMA SOCs demonstrates variable clinical service delivery. Considerable delay in access to specialist care is evident and this needs to be addressed in order to improve clinical outcomes.
Article
Abstract OBJECTIVE: To estimate the direct and indirect osteoarthritis (OA)-attributable costs and predictors of costs of knee and hip OA in Spain. METHODS: This study included consecutive patients age > or = 50 years with symptomatic and radiologic knee and/or hip OA who were seen at primary care centers in all provinces of Spain. Information on demographics, health status (Short Form 12 Health Survey), comorbidities (Charlson Index), clinical (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and radiologic OA severity (Kellgren/Lawrence [K/L] scale), data related to OA health resources utilization (medical and nonmedical), and subjects' and caregivers' expenses and time lost in the previous 6 months were collected in 2 separate, structured, and detailed interviews. Costs in euros were assigned using market prices and official sources if available, and were annualized (to 2007). The predictors of costs were assessed in multivariate regression models. Costs were log-transformed before being modeled. RESULTS: A total of 1,071 subjects were analyzed (74% women, mean +/- SD age 71 +/- 9 years). Average total annual costs were euro1,502 per patient. Direct costs accounted for 86% of the total cost. We estimated a national cost of euro 4,738 million, representing 0.5% of the gross national product. Higher total costs were associated with comorbidity (Charlson Index odds ratio [OR] 1.27, 95% confidence interval [95% CI] 1.03-1.58), poorer health status (P < 0.050), worse WOMAC scores (OR 1.05, 95% CI 1.03-1.08), and grade 4 K/L scores (OR 1.76, 95% CI 1.15-2.69). CONCLUSION: The economic burden of knee and hip OA is substantial. Costs increased with comorbidity, poorer health status, and clinical and radiologic OA severity.
Article
Osteoarthritis, the clinical syndrome of joint pain and dysfunction caused by joint degeneration, affects more people than any other joint disease. There are no consistently effective methods for preventing osteoarthritis or slowing its progression, and symptomatic treatments provide limited benefit for many patients. Osteoarthritis disables about 10% of people who are older than 60 years, compromises the quality of life of more than 20 million Americans, and costs the United States economy more than $60 billion per year. The incidence of osteoarthritis rises precipitously with age; as a result, the prevalence and burden of this disorder is increasing rapidly. Study of the patterns osteoarthritis incidence and prevalence shows that it occurs frequently in the hand, foot, knee, spine and hip, but rarely in the ankle, wrist, elbow, and shoulder, and the most important universal risk factors are age, excessive joint loading, and joint injury. Analysis of the impact of osteoarthritis raises questions that include: Why does the incidence increase progressively with age? Why are some joints rarely affected? How do mechanical forces cause joint degeneration? What biologic and mechanical factors slow or accelerate the rate of joint degeneration? Answering these questions could lead to effective methods of preventing osteoarthritis and slowing its progression.
Article
To investigate the prevalence of osteoarthritis (OA) of the knee in elderly subjects, we studied the Framingham Heart Study cohort, a population-based group. During the eighteenth biennial examination, we evaluated the cohort members for OA of the knee by use of medical history, physical examination, and anteroposterior (standing) radiograph of the knees. Radiographs were obtained on 1,424 of the 1,805 subjects (79%). Their ages ranged from 63–94 years (mean 73). Radiographs were read by a radiologist who specializes in bone and joint radiology, and were graded 0–4 according to the scale described by Kellgren and Lawrence. OA was defined as grade 2 changes (definite osteophytes), or higher, in either knee. Radiographic evidence of OA increased with age, from 27% in subjects younger than age 70, to 44% in subjects age 80 or older. There was a slightly higher prevalence of radiographic changes of OA in women than in men (34% versus 31%); however, there was a significantly higher proportion of women with symptomatic disease (11% of all women versus 7% of all men; P = 0.003). The age-associated increase in OA was almost entirely the result of the marked age-associated increase in the incidence of OA in the women studied. This study extends current knowledge about OA of the knee to include elderly subjects, and shows that the prevalence of knee OA increases with age throughout the elderly years.
Article
Objective To examine the rates of use and expenditures on alternative therapies by adults with osteoarthritis (OA).Methods Adults with OA recruited from the community to participate in a randomized clinical trial recorded alternative and traditional health care use on postcard diaries. General and arthritis-specific quality of life was assessed by questionnaires.ResultsMore than 47% of participants reported using at least one type of alternative care during the 20-week intervention period. Among alternative care consumers, the most commonly used treatments were massage therapy (57%), chiropractic services (20.7%), and nonprescribed alternative medications (17.2%). Four percent of subjects reported using only alternative care during the study period. Expenditures for alternative therapy averaged $1,127 per year, compared with $1,148 for traditional therapies.Conclusion Use of and expenditures for alternative care were high among this cohort of older adults with OA. Clinicians may want to inquire about use of these therapies before recommending treatments for this condition.
Article
Objectives: To estimate indirect costs through human capital approach and intangible costs through willingness-to-pay (WTP), and identify factors potentially affecting these costs in multiethnic Asian patients with knee osteoarthritis (OA). Methods: Data were collected through face-to-face interviews among knee OA patients. Human capital approach was used to estimate indirect costs by multiplying: 1) days of absence from work because of OA, with average earnings per capita per day for working patients; or 2) productivity loss with the market price of housekeeping for retirees/homemakers. A closed-ended iterative bidding contingent valuation method was used to elicit willingness-to-pay for a hypothetical cure of OA as a proxy for intangible costs. Mann-Whitney U or Kruskal-Wallis H-tests were performed in univariate analyzes, and linear regression in multivariate analyses. Results: Indirect costs per year and intangible costs were estimated at US$1008 and US$1200, accounting for 2.8% and 3.3% of annual household income, respectively. The indirect costs were significantly higher for male or working patients, while intangible costs were higher for Chinese, working patients, with higher income, or worse global well-being. Conclusion: This study demonstrated that eliciting indirect costs through human capital approach and intangible costs through WTP are acceptable and feasible in Asian patients with knee OA. Besides the direct costs, the indirect and intangible costs for the OA patients could be substantial.