The longitudinal relationship between hand, hip and knee osteoarthritis and cardiovascular events: a population-based cohort study

OBJECTIVE

In this population-based cohort study, we examined the association between the presence of symptomatic osteoarthritis (OA) and risk for cardiovascular (CV) events.

METHOD

A cohort aged ≥55 years recruited from 1996 to 98 was followed through provincial health administrative data to 2014. Demographics, joint complaints and functional limitations were collected. Hip, knee and hand OA were defined using a validated definition. Using Cox-regressions, the relationship between OA and a composite CV outcome (myocardial infarction (MI), stroke, angina, heart failure, revascularization) was assessed controlling for age, body mass index (BMI), sex, pre-existing metabolic factors, comorbidities, income status, primary care exposure and functional limitations.

RESULTS

18,490 participants were included: median age was 68 years, 60.3% were female; 24.4% met criteria for OA (10.0% hip, 15.3% knee, 16.0% hand), 16.3% self-reported limitation in grip and 25.4% in walking. Over a median 13.4 years, 31.9% experienced a CV event. Controlling for all but walking limitation, a dose-response relationship was observed between number of joints affected by knee/hip OA and CV risk (HR 2 hips/knees vs none: 1.13, 95% CI 1.03-1.23; 3+ hips/knees: 1.22, 95% CI 1.09-1.36). This relationship became non-significant additionally controlling for difficulty walking. Self-reported difficulty walking was associated with a 30% increased hazard for CV events. The effect of hand OA was not significant.

CONCLUSION

In a large population cohort, a greater burden of hip/knee OA was associated with higher CV risk; the relationship was explained by OA-related difficulty walking. Increased attention to management of OA with a view to improving mobility has potential to reduce CV events.

The assessment of musculoskeletal pain

Musculoskeletal (MSK) pain has a major impact on people's quality of life. Chronic MSK pain causes sleep interruption, fatigue, depressed mood, activity limitations and participation restrictions. The impact of MSK pain is influenced by contextual factors, including comorbidity, arthritis coping efficacy and access to MSK care. Thus, MSK pain assessment warrants a bio-psychosocial perspective that includes pain, its downstream effects and contextual factors. Such an approach should incorporate elicitation of symptoms using patient-report questionnaires and physical examination to help localize the pain and assess for signs of inflammation, tenderness on palpation, pain on motion, joint instability and malalignment. Using such an approach to the assess chronic pain in MSK conditions has potential to improve our ability to target the right treatment to the right patient, resulting in improved outcomes.

Obstructive sleep apnoea is not a risk factor for incident hospitalised depression: a historical cohort study

We evaluated whether obstructive sleep apnoea (OSA) was related to the incidence of hospitalisation for depression, a robust end-point that is unlikely to result from misdiagnosis.

All adults referred with suspected OSA who underwent a diagnostic sleep study at a large urban academic hospital between 1994 and 2010 and were linked to provincial health administrative data between 1991 and 2015 were included. Cox regression analysis was used to investigate the association between OSA symptoms and severity and incident hospitalised depression, the primary outcome.

Over a median follow-up of 9.7 years, 136 (1.3%) out of 10 149 participants were hospitalised for depression. A significant crude effect of OSA symptoms (waking unrefreshed and impact on memory and concentration) on hospitalised depression became nonsignificant after controlling for confounders. Apnoea–hypopnoea index was not significantly associated with the outcome: adjusted hazard ratio (33 versus6 events·h−1) 1.13 (95% CI 0.91–1.40). Factors associated with hospitalised depression were female sex, younger age, use of hypnotics, alcoholism and unemployment.

In a large clinical cohort with suspected OSA, controlling for confounders, OSA symptoms and severity were not related to the risk of hospitalisation for depression, suggesting that previously reported links between OSA and depression may be due to overlapping diagnostic criteria. However, our findings cannot exclude a potential link between OSA and milder depression.

Osteoarthritis-related difficulty walking and risk for diabetes complications

OBJECTIVES

To examine the effect of Osteoarthritis (OA)-related difficulty walking on risk for diabetes complications in persons with diabetes and OA.

DESIGN

A population cohort aged 55+ years with symptomatic hip and knee OA was recruited 1996-98 and followed through provincial administrative data to 2015 (n = 2,225). In those with confirmed OA (examination and radiographs) and self-reported diabetes at baseline (n = 359), multivariate Cox regression modeling was used to examine the relationship between baseline difficulty walking (Health Assessment Questionnaire (HAQ) difficulty walking score; use of walking aid) and time to first diabetes-specific complication (hospitalization for hypo- or hyperglycemia, infection, amputation, retinopathy, or initiation of chronic renal dialysis) and cardiovascular (CV) events.

RESULTS

Participants' mean baseline age was 71.4 years; 66.9% were female, 77.7% had hypertension, 54.0% had pre-existing CV disease, 42.9% were obese and 15.3% were smokers. Median HAQ difficulty walking score was 2/3 indicating moderate to severe walking disability; 54.9% used a walking aid. Over a median 6.1 years, 184 (51.3%) experienced one or more diabetes-specific complications; 191 (53.2%) experienced a CV event over a median 5.7 years. Greater baseline difficulty walking was associated with shorter time to the first diabetes-specific complication (adjusted HR per unit increase in HAQ walking 1.24, 95% CI 1.04-1.47, P = 0.02) and CV event (adjusted HR for those using a walking aid 1.35, 95% CI 1.00-1.83, P = 0.04).

CONCLUSIONS

In a population cohort with OA and diabetes, OA-related difficulty walking was a significant - and potentially modifiable - risk factor for diabetes complications.

Frequency of and variation in low-value care in primary care: a retrospective cohort study

BACKGROUND

Low-value care, defined as care with a lack of benefit, can lead to higher health care costs, inconvenience to patients and, in some cases, harm to patients. The objectives of this study are to conduct exploratory analyses to understand how frequently selected low-value tests are ordered, to assess the degree of variation in ordering that exists across regions and practices, and to identify services that may warrant further investigation and targeted interventions.

METHODS

We conducted a population-based retrospective cohort study using administrative health care databases from Ontario to identify rates of use of the following low-value services between fiscal years 2008/09 and 2012/13: computed tomography (CT) or magnetic resonance imaging (MRI) after a diagnosis of low back pain, Papanicolaou testing in women less than 21 years of age or older than 69 years of age and repeated dual-energy X-ray absorptiometry (DEXA) scanning within 2 years of an index scan. Regional and practice-level rates were calculated. Bivariate analyses were conducted to explore associations between patient factors and repeat DEXA scans.

RESULTS

Repeated DEXA scans were the most common service (21.0%), whereas cervical cancer screening among women less than 21 years of age or older than 69 years of age (8.0%) and CT or MRI imaging for low back pain (4.5%) were less common. There was substantial variation across practices with rates of repeated DEXA scans, ranging from 4.0% to 54.9%, and cervical cancer screening, ranging from 0.9% to 35.2%. Patients with a high-risk index DEXA were more likely to receive a repeat scan (28.1%) than those with a baseline (8.9%) or low-risk (8.1%) scan.

INTERPRETATION

There is significant, practice-level variation in the frequency of low-value testing for DEXA scans, back imaging and cervical cancer screening. There is a particular need for interventions that aim to reduce unnecessary DEXA scans.

Cross-cultural validation of the ICOAP and physical function short forms of the HOOS and KOOS in a multi-country study of patients with hip and knee osteoarthritis

OBJECTIVE

To evaluate the internal consistency and construct validity of the Physical Function short-forms for the Hip and Knee Injury Osteoarthritis Outcome Scores (HOOS-PS/KOOS-PS) and the Intermittent and Constant Osteoarthritis Pain (ICOAP) in a nine country study of patients consulting for total hip or knee replacement (THR or TKR).

METHODS

Patients completed HOOS-PS or KOOS-PS, ICOAP and Western Ontario and McMaster Universities' Osteoarthritis Index (WOMAC) pain and physical function subscales at their consultation visit. Internal consistency was calculated using Cronbach's alpha. The association of HOOS-PS/KOOS-PS and ICOAP with WOMAC pain and function subscales was calculated with Spearman correlation coefficients with 95% confidence intervals.

RESULTS

HOOS-PS/KOOS-PS and ICOAP demonstrated high internal consistency across countries (alpha 0.75-0.96 (hip) and 0.76-0.95 (knee)). Both HOOS-PS and KOOS-PS demonstrated high correlations (0.76-0.90 and 0.75-0.91, respectively) with WOMAC function in all countries. ICOAP exhibited moderate to high correlations with WOMAC pain and function subscales (0.53-0.84 (hip) and 0.43-0.84 (knee)).

CONCLUSION

The psychometric properties of the HOOS-PS/KOOS-PS, and ICOAP were maintained across all countries.

Development and Alpha-testing of a Stepped Decision Aid for Patients Considering Nonsurgical Options for Knee and Hip Osteoarthritis Management

Objective.

To develop an innovative stepped patient decision aid (StDA) comparing the benefits and harms of 13 nonsurgical treatment options for managing osteoarthritis (OA) and to evaluate its acceptability and effects on informed decision making.

Methods.

Guided by the Ottawa Decision Support Framework and the International Patient Decision Aid Standards, the process involved (1) developing a decision aid with evidence on 13 nonsurgical treatments from the 2012 American College of Rheumatology OA clinical practice guidelines; and (2) interviewing patients with OA and healthcare providers to test its acceptability and effects on knowledge and decisional conflict.

Results.

The StDA helped make the decision explicit, and presented evidence on 13 OA treatments clustered into 5 steps or levels according to their benefits and harms. Probabilities of benefits and harms were presented using pictograms of 100 faces formatted to allow comparisons across sets of options. It also included a values clarification exercise and knowledge test. Feedback was obtained from 49 patients and 7 healthcare providers. They found that the StDA presented evidence in a clear manner, and helped patients clarify their values and make an informed decision. Some participants found that there was too much information and others said that there was not enough on each treatment option.

Conclusion.

This innovative StDA allows patients to consider both the evidence and their values for multiple options. The findings are being used to revise and plan future evaluation. The StDA is an example of how research evidence in guidelines can be implemented in practice.

Primary care physicians' perceptions about and confidence in deciding which patients to refer for total joint arthroplasty of the hip and knee

OBJECTIVE

The purpose of this study is to examine the perceptions of primary care physicians (PCPs) regarding indications, contraindications, risks and benefits of total joint arthroplasty (TJA) and their confidence in selecting patients for referral for TJA.

DESIGN

PCPs recruited from among those providing care to participants in an established community cohort with hip or knee osteoarthritis (OA). Self-completed questionnaires were used to collect demographic and practice characteristics and perceptions about TJA. Confidence in referring appropriate patients for TJA was measured on a scale from 1 to 10; respondents scoring in the lowest tertile were considered to have 'low confidence'. Descriptive analyses were conducted and multiple logistic regression was used to determine key predictors of low confidence.

RESULTS

212 PCPs participated (58% response rate) (65% aged 50+ years, 45% female, 77% >15 years of practice). Perceptions about TJA were highly variable but on average, PCPs perceived that a typical surgical candidate would have moderate pain and disability, identified few absolute contraindications to TJA, and overestimated both the effectiveness and risks of TJA. On average, PCPs indicated moderate confidence in deciding who to refer. Independent predictors of low confidence were female physicians (OR = 2.18, 95% confidence interval (CI): 1.06-4.46) and reporting a 'lack of clarity about surgical indications' (OR = 3.54, 95% CI: 1.87-6.66).

CONCLUSIONS

Variability in perceptions and lack of clarity about surgical indications underscore the need for decision support tools to inform PCP - patient decision making regarding referral for TJA.

Symptom assessment in knee osteoarthritis needs to account for physical activity level

OBJECTIVE

Pain is not always correlated with severity of radiographic osteoarthritis (OA), possibly because people modify activities to manage symptoms. Measures of symptoms that consider pain in the context of activity level may therefore provide greater discrimination than a measure of pain alone. We undertook this study to compare discrimination provided by a measure of pain alone with that provided by combined measures of pain in the context of physical activity across radiographic OA severity levels.

METHODS

This was a cross-sectional study nested within the Osteoarthritis Initiative (OAI). The population was drawn from 2,127 persons enrolled in an OAI accelerometer monitoring substudy, including those with and those without knee OA. Two composite pain and activity knee symptom (PAKS) scores were calculated as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score (plus 1) divided by a physical activity measure (step count for the first PAKS score [PAKS1 score] and activity count for the second PAKS score [PAKS2 score]). Symptom score discrimination across Kellgren/Lawrence (K/L) grades was evaluated using histograms and quantile regression.

RESULTS

A total of 1,806 participants (55.5% of whom were women) were included (mean ± SD age 65.1 ± 9.1 years, mean ± SD body mass index 28.4 ± 4.8 kg/m(2) ). The WOMAC pain score, but not the PAKS scores, exhibited a floor effect. The adjusted median WOMAC pain scores by K/L grades 0-4 were 0, 0, 0, 1, and 3, respectively. The adjusted median PAKS1 scores were 24.9, 26.0, 32.4, 46.1, and 97.9, respectively, and the adjusted median PAKS2 scores were 7.2, 7.2, 9.2, 12.9, and 23.8, respectively. The PAKS scores had more statistically significant comparisons between K/L grades than did the WOMAC pain score.

CONCLUSION

Symptom assessments incorporating pain and physical activity did not exhibit a floor effect and were better able to discriminate radiographic severity than an assessment of pain alone, particularly in milder disease. Pain in the context of physical activity level should be used to assess knee OA symptoms.

A Call for Evidence-based Decision Making When Selecting Outcome Measurement Instruments for Summary of Findings Tables in Systematic Reviews: Results from an OMERACT Working Group

OBJECTIVE

Systematic reviews often struggle with how to combine information when more than 1 instrument is used across studies being synthesized. Different techniques have been suggested based on frequency of use in the literature, or on consensus. We explore an approach blending 2 initiatives: OMERACT (Outcome Measurement in Rheumatology) and COSMIN (Consensus On Selection of Measurement Instruments), and investigate the effects of an evidence-based measurement approach on selection of outcomes.

METHODS

Readings were circulated to attendees registered for a preconference workshop on pain measurement. Three instruments were considered and exercises conducted to engage people in the content and measurement performance of these tools. Consensus was sought that an evidence-based approach could be created for selection of instruments for summary of findings (SoF) tables.

RESULTS

The blending of COSMIN and OMERACT approaches led to an evidence-based approach that depended both on a clear definition of target concept and a review of measurement performance of the instrument. Participants emphasized that conceptual clarity and practical considerations should come before measurement property results.

CONCLUSION

Evidence-based approaches can be adopted for selection of instruments for SoF tables. A research agenda was formulated.

Arthritis has an impact on the daily lives of Canadians young and old: results from a population-based survey

Background

There is a perception that the impacts of arthritis are greatest among older adults. However, the effect of age on health-related outcomes in individuals with arthritis has not been explicitly studied. This study examined whether the physical and mental health impacts of arthritis are greater in older (75+ years) versus younger (20–44, 45–64 and 65–74 years) Canadian adults.

Methods

Data were from the arthritis component of the 2009 Survey on Living with Chronic Diseases in Canada. The responses were weighted to be representative of Canadians (≥20 years) with arthritis. Associations between age and the prevalence of severe/frequent joint pain, severe/frequent fatigue, sleep limitations, instrumental activities of daily living (IADLs) limitations, high levels of stress, suboptimal general and suboptimal mental health, were examined descriptively prior to conducting multivariate log-binomial regression analyses.

Results

A total of 4565 respondents completed the survey (78 % response rate). Individuals with arthritis were mostly female (63 %), of working age (57 %) and overweight or obese (67 %). Upon adjusting for covariates, younger (20–44 years) and/or middle aged (45–64 years) adults were more likely than those older (75+ years) to report severe/frequent joint pain, sleep limitations, high levels of stress and suboptimal mental health. After adjusting for covariates, age was not associated with IADL limitations, severe/frequent fatigue or suboptimal general health.

Conclusions

Contrary to the belief that older adults with arthritis experience more severe physical and mental health outcomes, we found that older adults were less likely to report worse outcomes than younger adults. In light of these findings, public health messaging should stress that arthritis does not just affect the elderly and emphasize the importance of timely diagnosis and management at all ages in order to prevent or, minimize arthritis-related impairment.

Report from the OMERACT Hand Osteoarthritis Working Group: Set of Core Domains and Preliminary Set of Instruments for Use in Clinical Trials and Observational Studies

Objective.

During OMERACT 12, a workshop was held with the aim to endorse a core set of domains for 3 settings: clinical trials of symptom and structure modification and observational studies. Additional goals were to endorse a core set of contextual factors for these settings, and to define preliminary instruments for each core domain. Finally, an agenda for future research in hand osteoarthritis (OA) was to be proposed.

Methods.

Literature reviews of preliminary instruments for each core domain of the proposed core set for hand OA in the settings described above. Literature review of radiographic scoring methods and modern imaging in hand OA were also performed. Proposed contextual factors for a core set were identified through 2 Delphi exercises with participation of hand OA experts, patient partners, and OMERACT participants.

Results.

Results from Delphi exercises and systematic literature reviews were presented and discussed. It was agreed that a preliminary core domain set for the setting clinical trials of symptom modification should contain at least “pain, physical function, patient global assessment, joint activity and hand strength.” The settings clinical trial of structure modification and observational studies would in addition include structural damage. Preliminary instruments for the proposed domains were agreed on. A list of prioritized contextual factors was defined and endorsed for further research. A research agenda was proposed for domain instrument validation according to the OMERACT Filter 2.0.

Conclusion.

Preliminary core sets for clinical trials of symptom and structure modification and observational studies in hand osteoarthritis, including preliminary instruments and contextual factors, were agreed upon during OMERACT 12.

The relation between total joint arthroplasty and risk for serious cardiovascular events in patients with moderate-severe osteoarthritis: propensity score matched landmark analysis

STUDY QUESTION

What are the rates of serious cardiovascular events in those who undergo primary total joint arthroplasty (TJA) compared with those who do not within three years of initial assessment?

SUMMARY ANSWER

Undergoing elective primary TJA within three years of initial assessment was associated with a significant 12.4% absolute reduction in subsequent risk of serious cardiovascular events.

WHAT IS KNOWN AND WHAT THIS PAPER ADDS

Osteoarthritis is associated with increased mortality, particularly secondary to cardiovascular disease, with the risk for mortality proportional to the degree of disability secondary to the arthritis. This study suggests that management of hip or knee osteoarthritis with arthroplasty decreases the risk for subsequent serious cardiovascular events.

Improving Value in Musculoskeletal Care Delivery: AOA Critical Issues

Improving value in musculoskeletal health care has emerged as an important objective in both the United States and Canada. In order to achieve this objective, providers need to have a clear definition of value and an infrastructure for measuring outcomes of interest to patients and costs over the episode of care. Although national patient registries have been established in the United States and Canada, they nevertheless lag behind other registries worldwide in terms of collecting patient-reported outcomes and capturing data from a wide cross-section of hospitals and physicians. With the help of professional medical societies and the creation of national initiatives, patient-reported outcomes data collection on a large scale may be possible, but many challenges remain regarding implementation. Alternatives to the fee-for-service payment model, including pay-for-reporting and pay-for-performance, may help incentivize physicians and health-care providers to obtain and improve on patient-reported outcomes data collection. Other payment reforms, such as bundled payments, have been piloted in certain regions, but their sustainability and long-term success are unclear at this time. Novel health-care delivery strategies aimed at improving quality, coordinating multispecialty care, and enhancing patient participation in shared decision-making have shown promise in improving patient-centered outcomes, but delivery models continue to vary greatly throughout the United States and Canada. The current status of musculoskeletal health-care delivery requires substantial change before the goal of improving patient outcomes and lowering health-care costs can be achieved.

Outcome Domains and Measures in Total Joint Replacement Clinical Trials: Can We Harmonize Them? An OMERACT Collaborative Initiative

Objective.

To develop a plan for harmonizing outcomes for people undergoing total joint replacement (TJR), to achieve consensus regarding TJR outcome research.

Methods.

The TJR working group met during the 2014 Outcome Measures in Rheumatology (OMERACT) 12 meeting in Budapest, Hungary. Multiple conference calls preceded the face-to-face meeting. Brief presentations were made during a 1.5-h meeting, which included an overview of published systematic reviews of TJR trials and the results of a recent systematic review of TJR clinical trial outcome domains and measures. This was followed by discussion of potential core set areas/domains for TJR clinical trials (as per OMERACT Filter 2.0) as well as the challenges associated with the measurement of these domains.

Results.

Working group participants discussed which TJR clinical trial outcome domains/areas map to the inner versus outer core for core domain set. Several challenges were identified with TJR outcomes including how to best measure function after TJR, elucidating the source of the pre- and post-TJR joint pain being measured, joint-specific versus generic quality of life instruments and the importance of patient satisfaction and revision surgery as outcomes. A preliminary core domain set for TJR clinical trials was proposed and included pain, function, patient satisfaction, revision, adverse events, and death. This core domain set will be further vetted with a broader audience.

Conclusion.

An international effort with active collaboration with the orthopedic community to standardize key outcome domains and measures is under way with the TJR working group. This effort will be further developed with new collaborations.

Osteoarthritis year in review 2014: clinical

A systematic search was conducted for the time period April 1 2013 to March 30 2014 using PubMed to identify major osteoarthritis (OA) clinical research themes of the past year. Articles within each theme were selected for inclusion in this review based on study quality and relevance. Two major themes emerged, which relate to the current understanding of OA as a heterogeneous condition with multiple pathogenic mechanisms and clinical manifestations. Theme 1 stems from the role of systemic inflammation in OA pathogenesis, and the concept of 'metabolic OA'. Over the past year, research has examined the effect of OA on incidence and progression of other 'metabolic syndrome'-related conditions, especially cardiovascular disease (CVD) and diabetes and the impact of multi-morbidity on the clinical management of OA. Theme 2 focuses on the concept of personalized medicine as it relates to the treatment of OA. It is hypothesized that the modest efficacy of available OA treatments is a result of inclusion of heterogeneous groups of OA patients in clinical trials. Prognostic studies in the past year have been helpful in identifying 'OA phenotypes' that are more or less likely to respond to treatments--e.g., the presence of synovitis on imaging, central pain sensitization on quantitative sensory testing (QST), or coping efficacy by self-reported patient questionnaire. Their findings are being increasingly used to target interventions to these identified 'OA responder' subgroups with the hopes that treatment effect will be amplified.

You'll know when you're ready: a qualitative study exploring how patients decide when the time is right for joint replacement surgery

Background

While some studies have identified patient readiness as a key component in their decision whether to have total joint replacement surgery (TJR), none have examined how patients determine their readiness for surgery. The study purpose was to explore the concept of patient readiness and describe the factors patients consider when assessing their readiness for TJR.

Methods

Nine focus groups (4 pre-surgery, 5 post-surgery) were held in four Canadian cities. Participants had been either referred to or seen by an orthopaedic surgeon for TJR or had undergone TJR. The method of analysis was qualitative thematic analysis.

Results

There were 65 participants, 66% female and 34% male, 80% urban, with an average age of 65 years (SD 10). Readiness reflected both the surgeon’s advice that the patient was clinically ready for surgery and the patient’s feeling that they were both mentally and physically ready for surgery. Mental readiness was described as an internal state or feeling of being ready or prepared while physical readiness was described as being physically fit and in good shape for surgery. Factors associated with readiness included: 1) pain: its severity, the ability to cope with it, and how it affected their quality of life; 2) mental preparation; 3) physical preparation; 4) the optimal timing of surgery, including age, anticipated rate of deterioration, prosthesis lifespan and the length of the waiting list.

Conclusions

Patient readiness should be assessed prior to TJR. By assessing patient readiness, health professionals can elucidate and deal with concerns and fears, understand and calibrate expectations, assess coping strategies, and use this information to help determine optimal timing, both before and after the surgical consultation.

Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial

IMPORTANCE

Hospital readmissions are common and costly, and no single intervention or bundle of interventions has reliably reduced readmissions. Virtual wards, which use elements of hospital care in the community, have the potential to reduce readmissions, but have not yet been rigorously evaluated.

OBJECTIVE

To determine whether a virtual ward-a model of care that uses some of the systems of a hospital ward to provide interprofessional care for community-dwelling patients-can reduce the risk of readmission in patients at high risk of readmission or death when being discharged from hospital.

DESIGN, SETTING, AND PATIENTS

High-risk adult hospital discharge patients in Toronto were randomly assigned to either the virtual ward or usual care. A total of 1923 patients were randomized during the course of the study: 960 to the usual care group and 963 to the virtual ward group. The first patient was enrolled on June 29, 2010, and follow-up was completed on June 2, 2014.

INTERVENTIONS

Patients assigned to the virtual ward received care coordination plus direct care provision (via a combination of telephone, home visits, or clinic visits) from an interprofessional team for several weeks after hospital discharge. The interprofessional team met daily at a central site to design and implement individualized management plans. Patients assigned to usual care typically received a typed, structured discharge summary, prescription for new medications if indicated, counseling from the resident physician, arrangements for home care as needed, and recommendations, appointments, or both for follow-up care with physicians as indicated.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of hospital readmission or death within 30 days of discharge. Secondary outcomes included nursing home admission and emergency department visits, each of the components of the primary outcome at 30 days, as well as each of the outcomes (including the composite primary outcome) at 90 days, 6 months, and 1 year.

RESULTS

There were no statistically significant between-group differences in the primary or secondary outcomes at 30 or 90 days, 6 months, or 1 year. The primary outcome occurred in 203 of 959 (21.2%) of the virtual ward patients and 235 of 956 (24.6%) of the usual care patients (absolute difference, 3.4%; 95% CI, -0.3% to 7.2%; P = .09). There were no statistically significant interactions to indicate that the virtual ward model of care was more or less effective in any of the prespecified subgroups.

CONCLUSIONS AND RELEVANCE

In a diverse group of high-risk patients being discharged from the hospital, we found no statistically significant effect of a virtual ward model of care on readmissions or death at either 30 days or 90 days, 6 months, or 1 year after hospital discharge.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01108172.

Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study

OBJECTIVES

To identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified.

DESIGN

Propensity score matched cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

37,881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery.

MAIN OUTCOME MEASURE

The rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery.

RESULTS

Multivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done ≤ 35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v 1.3%, P=0.006; NNH 172) and revision (1.5% v 1.0%, P=0.03; NNH 204).

CONCLUSIONS

In a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery.

Impact of physician specialty on classification of physician-perceived patient severity for patients with osteoarthritis

BACKGROUND

Physicians often classify patients' osteoarthritis (OA) severity subjectively. As treatment decisions are influenced by severity classifications, it is important to understand the factors that influence physicians' OA severity ratings. This research sought to empirically identify physician and patient characteristics that lead to a patient being perceived as having more severe OA.

METHODS

Data were analyzed from the OA IX Disease Specific Program, a large cross-sectional survey of OA physicians and patients in Germany, the UK, and USA between September 2011 and January 2012. Eligible, consenting physicians completed a Patient Record Form (PRF) for 10 consecutive OA patients. The PRF asked physicians to report the patient's demographics [age, gender, body mass index (BMI), ethnicity], their assessment of the patients' symptom severity, treatment, probability for surgery, to rate their overall OA severity (mild, moderate or severe) and the factors that had influenced the rating. Chi-squared tests and analysis of variance were used to identify patient characteristics that significantly impacted physicians' OA severity ratings. Controlling for the significant patient characteristics, we then examined the impact of physician specialty on physician's OA severity ratings. Finally, we investigated the differences in physician-reported factors that influenced the physicians' rating of patients' severity between physician specialties.

RESULTS

Three hundred and sixty-three physicians [220 primary care physicians (PCPs), 48 rheumatologists, 95 orthopedic surgeons] recruited 3561 patients. Patients with greater age and BMI, worse symptoms and greater health care use were given higher OA severity ratings. Controlling for these factors, orthopedic surgeons rated their OA patients as more severe than PCPs and rheumatologists [adjusted odds ratio (OR) 1.8, 95% confidence interval (CI) 1.4-2.4]. Specialists (rheumatologists and orthopedic surgeons) were more likely than PCPs to use joint spaced narrowing based on X-ray and severity of joint deterioration radiographic severity to assess patients' OA severity (joint space narrowing: 79% and 78% vs 55%, P < 0.0001).

CONCLUSIONS

Patient age, BMI, presence and severity of symptoms and health care use significantly impacted physicians' OA severity ratings, but radiographic changes appeared to be given greater weight among orthopedic surgeons and rheumatologists than PCPs when assessing patient severity. Whether these differences translate into different treatment recommendations for similar patients is unknown, and warrants study.