Demographic and Clinical Factors Associated With Nonsurgical Osteoarthritis Treatment Among Patients in Outpatient Clinics

Racial Disparities in Opioid Prescribing in the United States from 2011 to 2021: A Systematic Review and Meta-Analysis

Background

This meta-analysis is an update to a seminal meta-analysis on racial/ethnic disparities in pain treatment in the United States (US) published in 2012. Since then, literature has accumulated on the topic and important policy changes were made.

Objective

Examining racial/ethnic disparities in pain management and investigating key moderators of the association between race/ethnicity and pain outcomes in the US.

Methods

We performed a systematic search of publications (between January 2011 and February 2021) from the Scopus database. Search terms included: race, racial, racialized, ethnic, ethnicity, minority, minorities, minoritized, pain treatment, pain management, and analgesia. All studies were observational, examining differences in receipt of pain prescription medication in various settings, across racial or ethnic categories in US adult patient populations. Two binary analgesic outcomes were extracted: 1) prescription of "any" analgesia, and 2) prescription of "opioid" analgesia. We analyzed these outcomes in two populations: 1) Black patients, with White patients as a reference; and 2) Hispanic patients, with non-Hispanic White patients as a reference.

Results

The meta-analysis included twelve studies, and the systematic review included forty-three studies. Meta-analysis showed that, compared to White patients, Black patients were less likely to receive opioid analgesia (OR 0.83, 95% CI [0.73-0.94]). Compared to non-Hispanic White patients, Hispanic patients were less likely to receive opioid analgesia (OR 0.80, 95% CI [0.72-0.88]).

Conclusion

Despite a decade's gap, the findings indicate persistent disparities in prescription of, and access to opioid analgesics for pain among Black and Hispanic populations in the US.

Consumer awareness and knowledge regarding use of non-steroidal anti-inflammatory drugs (NSAIDs) in a metropolitan area

Background

Non-steroidal anti-inflammatory drugs (NSAIDs) have well-known adverse effects, and numerous studies have shown inappropriate behaviors regarding their use. The primary aim of this study was to analyze the knowledge, attitudes, and behaviors regarding the use of NSAIDs simultaneously in one of the largest and most populated areas of Italy, Naples.

Methods

From 2021 December 14th to 2022 January 4th, a cross-sectional survey study was conducted among community centers, working places, and universities using a snowball sampling method. For inclusion in the study, the participants were required to be at least 18 years old and residents in the metropolitan area of Naples. Three multiple linear regression analysis (MLRA) models were developed by including variables that could potentially be associated with the following outcomes of interest: knowledge (Model I), attitudes (Model II), and behavior (Model III) regarding the use of NSAIDs.

Results

Data were acquired from 1,012 questionnaires administered to subjects evenly divided by gender with an average age of 36.8 years and revealed that only 7.9% of the participants self-admittedly did not take NSAIDs, while approximately half the participants (50%) admitted to occasionally using them. The results showed a statistically significant correlation between attitudes regarding the appropriate use of NSAIDs and less knowledge. The regression analyses indicated that behaviors regarding the appropriate use of NSAIDs were statistically significant in younger respondents, non-smokers, and those without children. These interesting results showed that behaviors regarding the appropriate use of NSAIDs were significantly higher among respondents with less knowledge and more positive attitudes.

Conclusion

According to the collected data and statistical analysis results, it is possible to identify factors that can greatly affect inappropriate behaviors regarding the use of NSAIDs and establish targeted prevention programs.

Causal relationship between several autoimmune diseases and renal malignancies: A two-sample mendelian randomization study

OBJECTIVE

Observational studies have shown an association between systemic autoimmune disease (AD) and multiple malignancies. However, due to the difficulty indetermining the temporal nature of the order, their causal relationship remains elusive. Based on pooled data from a large population-wide genome-wide association study (GWAS), this study explores the genetic causality between systemic autoimmune disease and renal malignancy.

METHODS

We took a series of quality control steps from a large-scale genome-wide association study to select single nucleotide polymorphisms (SNPs) associated with systemic autoimmune disease as instrumental variables(IVs) to analyze genetic causality with renal malignancies. Inverse variance weighting (IVW), MR- Egger, weighted median, simple model and weighted model were used for analysis. The results were mainly based on IVW (Random Effects), followed by sensitivity analysis. Inverse-Variance Weighted(IVW) and MR-Egger were used to test for heterogeneity. MR- Egger is also used for pleiotropic testing. A single SNP analysis was used to identify single nucleotide polymorphisms (SNPs) with potential impact. Odds ratio (OR) and 95% confidence interval (CI) were used to evaluate causality, and sensitivity analysis was performed to evaluate pleiotropy and instrumental validity.

RESULTS

Acute and subacute iridocylitis (P = 0.006, OR = 1.077), Ankylosing spondylitis (P = 0.002, OR = 1.051), and spondyloarthritis (P = 0.009, OR = 1.073) were positively associated with an increased risk of renal malignancy. Coxarthrosis (P = 0.008, OR = 0.483), Juvenile rheumatism (P = 0.011, OR = 0.897), and Systemic lupus erythematosus (P = 0.014, OR = 0.869) were negatively associated with an increased risk of renal malignancy. The results of sensitivity analysis were consistent without heterogeneity or pleiotropy.

CONCLUSION

Our study suggests a causal relationship between different systemic autoimmune diseases and renal malignancies. These findings prompt health care providers to take seriously the potential risk of systemic autoimmune disease and provide new insights into the genetics of kidney malignancies.

Group physical therapy for knee osteoarthritis: protocol for a hybrid type III effectiveness-implementation trial

BACKGROUND

Knee osteoarthritis (OA) is a leading cause of chronic pain and disability and one of the most common conditions treated in outpatient physical therapy (PT). Because of the high and growing prevalence of knee OA, there is a need for efficient approaches for delivering exercise-based PT to patients with knee OA. A prior randomized controlled trial (RCT) showed that a 6-session Group Physical Therapy Program for Knee OA (Group PT) yields equivalent or greater improvements in pain and functional outcomes compared with traditional individual PT, while requiring fewer clinician hours per patient to deliver. This manuscript describes the protocol for a hybrid type III effectiveness-implementation trial comparing two implementation packages to support delivery of Group PT.

METHODS

In this 12-month embedded trial, a minimum of 16 Veterans Affairs Medical Centers (VAMCs) will be randomized to receive one of two implementation support packages for their Group PT programs: a standard, low-touch support based on Replicating Effective Programs (REP) versus enhanced REP (enREP), which adds tailored, high-touch support if sites do not meet Group PT adoption and sustainment benchmarks at 6 and 9 months following launch. Implementation outcomes, including penetration (primary), adoption, and fidelity, will be assessed at 6 and 12 months (primary assessment time point). Additional analyses will include patient-level effectiveness outcomes (pain, function, satisfaction) and staffing and labor costs. A robust qualitative evaluation of site implementation context and experience, as well as site-led adaptations to the Group PT program, will be conducted.

DISCUSSION

To our knowledge, this study is the first to evaluate the impact of tailored, high-touch implementation support on implementation outcomes when compared to standardized, low-touch support for delivering a PT-based intervention. The Group PT program has strong potential to become a standard offering for PT, improving function and pain-related outcomes for patients with knee OA. Results will provide information regarding the effectiveness and value of this implementation approach and a deeper understanding of how healthcare systems can support wide-scale adoption of Group PT.

TRIAL REGISTRATION

This study was registered on March 7, 2022 at ClinicalTrials.gov (identifier NCT05282927 ).

Use of non-surgical treatments on the journey to knee replacement in patients with knee osteoarthritis: a 10-year population-based case-control study

AIM

To investigate temporal trends in primary care visits, physiotherapy visits, dispensed non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in knee osteoarthritis (OA) patients who have and have not undergone knee replacement.

METHODS

We analysed 5665 OA patients from the Skåne Healthcare Register, Sweden, who underwent knee replacement between 2015 and 2019. Controls were OA patients without knee replacement, matched 1:1 by sex, age, time and healthcare level of initial OA diagnosis, and assigned a pseudo-index date corresponding to their case's knee replacement date. Annual prevalence and prevalence ratio of primary care and physiotherapy visits, dispensed NSAIDs and opioids (all for any cause) in the 10 years before knee replacement were estimated using Poisson regression.

RESULTS

The annual prevalence of all-cause primary care visits, physiotherapy visits and opioid use was similar between cases and controls until 3 years before the index date when it started to increase among the cases. The year before the index date, the prevalence ratio (cases vs controls) for physiotherapy use was 1.8 (95% CI 1.7, 1.8), while for opioid use 1.6 (1.5, 1.7). NSAID use was consistently higher among cases, even 10 years before the index date when the prevalence ratio versus controls was 1.3 (1.2, 1.3), increasing to 1.8 (1.7, 1.9) in the year preceding the index date.

CONCLUSIONS

Management of OA patients who have and have not undergone knee replacement appears largely similar except for higher use of NSAIDs in knee replacement cases. Symptomatic treatments start to increase a few years before the surgery in knee replacement cases.

Evaluating Osteoarthritis Management Programs: outcome domain recommendations from the OARSI Joint Effort Initiative

OBJECTIVE

To develop sets of core and optional recommended domains for describing and evaluating Osteoarthritis Management Programs (OAMPs), with a focus on hip and knee Osteoarthritis (OA).

DESIGN

We conducted a 3-round modified Delphi survey involving an international group of researchers, health professionals, health administrators and people with OA. In Round 1, participants ranked the importance of 75 outcome and descriptive domains in five categories: patient impacts, implementation outcomes, and characteristics of the OAMP and its participants and clinicians. Domains ranked as "important" or "essential" by ≥80% of participants were retained, and participants could suggest additional domains. In Round 2, participants rated their level of agreement that each domain was essential for evaluating OAMPs: 0 = strongly disagree to 10 = strongly agree. A domain was retained if ≥80% rated it ≥6. In Round 3, participants rated remaining domains using same scale as in Round 2; a domain was recommended as "core" if ≥80% of participants rated it ≥9 and as "optional" if ≥80% rated it ≥7.

RESULTS

A total of 178 individuals from 26 countries participated; 85 completed all survey rounds. Only one domain, "ability to participate in daily activities", met criteria for a core domain; 25 domains met criteria for an optional recommendation: 8 Patient Impacts, 5 Implementation Outcomes, 5 Participant Characteristics, 3 OAMP Characteristics and 4 Clinician Characteristics.

CONCLUSION

The ability of patients with OA to participate in daily activities should be evaluated in all OAMPs. Teams evaluating OAMPs should consider including domains from the optional recommended set, with representation from all five categories and based on stakeholder priorities in their local context.

Variation in the utilisation of physiotherapy in patients with advanced knee osteoarthritis prior to total knee arthroplasty a systematic review

INTRODUCTION

Due to demographic changes and increasing knee osteoarthritis (KOA) prevalence, the incidence of total knee arthroplasties (TKA) is constantly rising. Clinical practice guidelines for the treatment of KOA unanimously recommend non-surgical interventions such as exercise, education, and weight reduction in overweight patients. The aim of this systematic review is to determine the proportion of patients with end-stage KOA who attended physiotherapy (PT) prior to TKA.

METHODS

A systematic literature search was carried out in the medical databases MEDLINE (via Pubmed), PEDro, and EBSCO in August of 2022. Studies were included regardless of their design, if they reported the proportion of patients with a diagnosis of primary KOA, who participated in PT prior to undergoing TKA. Study quality assessment was performed by two independent authors using the Joanna Briggs Institutes Checklist for studies reporting prevalence data. Results were presented by using a narrative synthesis.

RESULTS

Eighteen studies, comprising 579,718 patients, were identified in this systematic review. PT utilisation prior to TKA ranged from 10% to 73% for patients with advanced KOA. Only two studies showed PT utilisation rates of 60% or higher. Female gender, higher income, better socioeconomic status, higher education levels, older age were associated with PT utilisation. Data for other predicting factors was conflicting.

DISCUSSION

This review shows substantial variation in the utilisation of PT in patients with end-stage KOA. This is concerning, considering the uniform recommendation from clinical practice guidelines for non-surgical treatments like exercise and education in patients with KOA, which are mostly provided by physiotherapists.

Prescription patterns and predictors of unmet pain relief in patients with difficult-to-treat osteoarthritis in the Nordics: analyses from the BISCUITS study

OBJECTIVES

Osteoarthritis (OA) is one of the leading causes of disability worldwide. Pain is the most important symptom in OA, driving medical care, disability, reduced functionality, and decreased quality of life. The objective of this study was to describe prescription patterns of difficult-to-treat OA and explore possible predictors of unmet pain relief in Nordic patients.

METHODS

This observational cohort study included patients with a confirmed diagnosis of OA (index date) in specialty care in Sweden, Norway, Finland and Denmark between 1 January 2011 and 31 December 2012 who were followed for up to 5 years. Four subgroups were pre-defined to characterize difficult-to-treat OA: (1) ≥2 chronic comorbidities in the 3-year pre-index period; (2) top 10% of healthcare resource users, 1-year post-index; (3) ≥3 types of prescription pain medications during pre-index period to first year post-index, with ≥30 days between types; (4) having a contraindication to a nonsteroidal anti-inflammatory drug (NSAID). Patient characteristics, prescription patterns and predictors of unmet pain relief (defined as persistent opioid use, using several types of opioids or long-term NSAID use) were analyzed.

RESULTS

We identified 288,174 OA patients and the average age was 63.5 years at time of diagnosis and 58% of them were female. After 5 years, 35-50% of the patients defined as 'difficult-to-treat' had ≥1 prescription of opioids, compared to 20-25% of all OA patients (p-value <0.05). Comorbidities and disability pension were strong predictors of unmet pain relief (p-value <0.001).

CONCLUSIONS

This study shows a substantial use of pain medications (NSAID and opioids) in difficult-to-treat OA patients. These findings suggest that pain may be inadequately managed in a considerable number of patients with OA, particularly those with contraindications to an NSAID. A high comorbid and socioeconomic burden are relevant risk factors among patients who continue to use opioids for a long period of time.

What should a toolkit to aid the delivery of therapeutic exercise for hip and knee osteoarthritis look like? Qualitative analysis of an international survey of 318 researchers, clinicians, and consumers by the OARSI Rehabilitation Discussion Group

BACKGROUND

We aimed to identify important components of, and practical resources relevant for inclusion in, a toolkit to aid exercise delivery for people with hip/knee osteoarthritis.

METHOD

An online international multi-disciplinary survey was conducted across 43 countries (139 clinicians, 44 people with hip/knee osteoarthritis and 135 osteoarthritis researchers). Participants were presented with the seeding statement 'Practical resources to aid the implementation of exercise for people with hip/knee osteoarthritis should…' and asked to provide up to 10 open text responses. Responses underwent refinement and qualitative content analysis to create domains and categories.

RESULTS

Refinement of 551 open text responses yielded 72 unique statements relevant for analysis. Statements were organised into nine broad domains, suggesting that resources to aid exercise delivery should: (1) be easily accessible; (2) be of high quality; (3) be developed by, and for, stakeholders; (4) include different ways of delivering information; (5) include different types of resources to support exercise and non-exercise components of self-management; (6) include resources on recommended exercises and how to perform/progress them; (7) include tools to support motivation and track progress; (8) include resources to enable tailoring of the programme to the individual and; (9) facilitate access to professional and peer support.

CONCLUSION

Our findings identified important components of, and practical resources to include within, a toolkit to aid delivery of exercise for people with hip/knee osteoarthritis. These findings have implications for exercise providers and lay the foundation for the development of a toolkit to help ensure exercise provision aligns with current international recommendations.

The mechanism of palmatine-mediated intestinal flora and host metabolism intervention in OA-OP comorbidity rats

Background

ErXian decoction is a Chinese herbal compound that can prevent and control the course of osteoarthritis (OA) and osteoporosis (OP). OP and OA are two age-related diseases that often coexist in elderly individuals, and both are associated with dysregulation of the gut microbiome. In the initial study, Palmatine (PAL) was obtained by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and network pharmacological screening techniques, followed by 16S rRNA sequencing and serum metabolomics of intestinal contents, to explore the mechanism of PAL in the treatment of OA and OP.

Methods

The rats selected for this study were randomly divided into three groups: a sham group, an OA-OP group and a PAL group. The sham group was intragastrically administered normal saline solution, and the PLA group was treated with PAL for 56 days. Through microcomputed tomography (micro-CT), ELISA, 16S rRNA gene sequencing and non-targeted metabonomics research, we explored the potential mechanism of intestinal microbiota and serum metabolites in PAL treatment of OA-OP rats.

Results

Palmatine significantly repair bone microarchitecture of rat femur in OA-OP rats and improved cartilage damage. The analysis of intestinal microflora showed that PAL could also improve the intestinal microflora disorder of OA-OP rats. For example, the abundance of Firmicutes, Bacteroidota, Actinobacteria, Lactobacillus, unclassified_f_Lachnospiraceae, norank_f_Muribaculaceae, Lactobacillaceae, Lachnospiraceae and Muribaculaceae increased after PAL intervention. In addition, the results of metabolomics data analysis showed that PAL also change the metabolic status of OA-OP rats. After PAL intervention, metabolites such as 5-methoxytryptophol, 2-methoxy acetaminophen sulfate, beta-tyrosine, indole-3-carboxylic acid-O-sulfate and cyclodopa glucoside increased. Association analysis of metabolomics and gut microbiota (GM) showed that the communication of multiple flora and different metabolites played an important role in OP and OA.

Conclusion

Palmatine can improve cartilage degeneration and bone loss in OA-OP rats. The evidence we provided supports the idea that PAL improves OA-OP by altering GM and serum metabolites. In addition, the application of GM and serum metabolomics correlation analysis provides a new strategy for uncovering the mechanism of herbal treatment for bone diseases.

The effects and significance of gut microbiota and its metabolites on the regulation of osteoarthritis: Close coordination of gut-bone axis

Osteoarthritis (OA) is a common chronic degenerative disease of articular cartilage in middle-aged and older individuals, which can result in the joint pain and dysfunction, and even cause the joint deformity or disability. With the enhancing process of global aging, OA has gradually become a major public health problem worldwide. Explaining pathogenesis of OA is critical for the development of new preventive and therapeutic interventions. In recent years, gut microbiota (GM) has been generally regarded as a “multifunctional organ,” which is closely relevant with a variety of immune, metabolic and inflammatory functions. Meanwhile, more and more human and animal researches have indicated the existence of gut-bone axis and suggested that GM and its metabolites are closely involved in the pathogenic process of OA, which might become a potential and promising intervention target. Based on the close coordination of gut-bone axis, this review aims to summarize and discuss the mechanisms of GM and its metabolites influencing OA from the aspects of the intestinal mucosal barrier modulation, intestinal metabolites modulation, immune modulation and strategies for the prevention or treatment of OA based on perspectives of GM and its metabolites, thus providing a profound knowledge and recognition of it.

Racial and ethnic differences in the pharmacologic management of osteoarthritis: rapid systematic review

Background

Racial and ethnic disparities in osteoarthritis (OA) patients' disease experience may be related to marked differences in the utilization and prescription of pharmacologic treatments.

Objectives

The main objective of this rapid systematic review was to evaluate studies that examined race/ethnic differences in the use of pharmacologic treatments for OA.

Data sources and methods

A literature search (PubMed and Embase) was ran on 25 February 2022. Studies that evaluated race/ethnic differences in the use of OA pharmacologic treatments were included. Two reviewers independently screened titles and abstracts and abstracted data from full-text articles. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results

The search yielded 3880 titles, and 17 studies were included in this review. African Americans and Hispanics were more likely than non-Hispanic Whites to use prescription non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for OA. However, compared to non-Hispanic Whites with OA, African Americans and Hispanics with OA were less likely to receive a prescription for cyclooxygenase-2-selective NSAIDs and less likely to report the use of joint health supplements (i.e. glucosamine and chondroitin sulfate). There were minimal/no significant race/ethnic differences in the patient-reported use of the following OA therapies: acetaminophen, opioids, and other complementary/alternative medicines (vitamins, minerals, and herbs). There were also no significant race differences in the receipt of intra-articular therapies (i.e. glucocorticoid or hyaluronic acid). However, there is limited evidence to suggest that African Americans may be less likely than Whites to receive opioids and intra-articular therapies in some OA patient populations.

Conclusion

This systematic review provides an overview of the current pharmacologic options for OA, with a focus on race and ethnic differences in the use of such medical therapies.

Physical Therapy Use and Associated Factors in Adults with and without Osteoarthritis-An Analysis of the Population-Based German Health Update Study

BACKGROUND

Physical therapy (PT) is recommended as first-line management for osteoarthritis (OA). The purpose of this study was to assess the PT use among adults with OA and those without (Non-OA) and subsequently identify associated factors among these populations.

METHODS

This cross-sectional study obtained national data from the population-based German Health Update (GEDA2014/2015-EHIS) study containing 24,016 participants aged 18 years and older. Analyses were stratified by sex, age, socioeconomic status (SES), residence, smoking behavior, body mass index, pain and general health. Multivariate regression analysis was conducted to evaluate factors associated with PT use within the past 12 months.

RESULTS

PT was used more frequently in the OA population compared with the Non-OA population (35.8% vs. 18.7%). In both populations, women, participants with high SES, residence in Eastern Germany, severe pain, poor general health and non-smokers received PT more frequently. Multivariate analysis confirmed these findings, in addition to people aged 80 years and older. The influence of SES was higher among OA participants.

CONCLUSION

The underutilization of PT in OA patients (35.8%) was particularly evident among males, people with a low SES and those being older than 60 years, which aids to develop strategies increasing PT use towards guideline-oriented OA management.

Stepped Exercise Program for Patients With Knee Osteoarthritis : A Randomized Controlled Trial

BACKGROUND

Evidence-based models are needed to deliver exercise-related services for knee osteoarthritis efficiently and according to patient needs.

OBJECTIVE

To examine a stepped exercise program for patients with knee osteoarthritis (STEP-KOA).

DESIGN

Randomized controlled trial. (ClinicalTrials.gov: NCT02653768).

SETTING

2 U.S. Department of Veterans Affairs sites.

PARTICIPANTS

345 patients (mean age, 60 years; 15% female; 67% people of color) with symptomatic knee osteoarthritis.

INTERVENTION

Participants were randomly assigned in a 2:1 ratio to STEP-KOA or an arthritis education (AE) control group, respectively. The STEP-KOA intervention began with 3 months of an internet-based exercise program (step 1). Participants who did not meet response criteria for improvement in pain and function after step 1 progressed to step 2, which involved 3 months of biweekly physical activity coaching calls. Participants who did not meet response criteria after step 2 went on to in-person physical therapy visits (step 3). The AE group received educational materials via mail every 2 weeks.

MEASUREMENTS

Primary outcome was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Scores for the STEP-KOA and AE groups at 9 months were compared by using linear mixed models.

RESULTS

In the STEP-KOA group, 65% of participants (150 of 230) progressed to step 2 and 35% (81 of 230) to step 3. The estimated baseline WOMAC score for the full sample was 47.5 (95% CI, 45.7 to 49.2). At 9-month follow-up, the estimated mean WOMAC score was 6.8 points (CI, -10.5 to -3.2 points) lower in the STEP-KOA than the AE group, indicating greater improvement.

LIMITATION

Participants were mostly male veterans, and follow-up was limited.

CONCLUSION

Veterans in STEP-KOA reported modest improvements in knee osteoarthritis symptoms compared with the control group. The STEP-KOA strategy may be efficient for delivering exercise therapies for knee osteoarthritis.

PRIMARY FUNDING SOURCE

Department of Veterans Affairs, Health Services Research and Development Service.

The Role of Knowledge and Attitudes About Nonsteroidal Anti-inflammatory Drugs in Determining Treatment Use

OBJECTIVE

The objective of this study was to evaluate how patient knowledge and beliefs regarding nonsteroidal anti-inflammatory drugs (NSAIDs) may influence the use of NSAIDs for osteoarthritis (OA).

METHODS

Surveys of 334 adults with knee and/or hip OA were analyzed in this cross-sectional study. Familiarity with and perceptions of benefits/risks of NSAID use were measured to assess associations with the use of prescription and nonprescription oral NSAIDs. Multinomial logistic regression models were adjusted for sociodemographic and clinical variables.

RESULTS

In this sample, 35.9% and 35.6% reported use of oral prescription and nonprescription-only NSAIDs, respectively. Hispanic participants, compared with non-Hispanic White participants, had lower perceived benefit (P = 0.005) and risk (P = 0.001) of prescription NSAIDs. The following were associated with prescription NSAID use instead of no NSAID use: having family/friends who used prescription (relative risk ratio [RRR] 3.91; 95% confidence interval [CI] 2.05-7.47) and over-the-counter (OTC) (RRR 3.10; 95% CI 1.65-5.83) NSAIDs for OA, understanding the consequences of using both prescription (RRR 3.50; 95% CI 1.79-6.86) and OTC (RRR 2.80; 95% CI 1.39-5.65) NSAIDs, higher perceived benefit of both prescription (RRR 2.51; 95% CI 1.71-3.66) and OTC (RRR 1.44; 95% CI 1.01-2.06) NSAIDs, and lower perceived risk of both types of NSAIDs (prescription: RRR 0.63 [95% CI 0.46-0.87]; OTC: RRR 0.53 [95% CI 0.37-0.75]). Similar results were found when we assessed the relationship between these variables and OTC NSAID use versus no oral NSAID use.

CONCLUSION

Adults with knee and/or hip OA were more likely to use NSAIDs if they were more familiar with, had an increased perceived benefit of, and had a decreased perceived risk of these drugs. Patients' perceptions and beliefs about NSAIDs should be evaluated when considering them for treatment.

Risks of solid cancers in elderly persons with osteoarthritis or ankylosing spondylitis

OBJECTIVES

Patients with osteoarthritis and ankylosing spondylitis have lower cancer-related mortality than the general population. We examined risks of solid cancers at 16 sites in elderly patients with knee or hip osteoarthritis (KHOA) or ankylosing spondylitis.

METHODS

In this population-based retrospective cohort study, we used US Medicare data from 1999 to 2010 to identify cohorts of persons with KHOA or ankylosing spondylitis, and a general population group without either condition, who were followed through 2015. We compared cancer incidence among groups, adjusted for age, sex, race, socioeconomic characteristics, geographic region, smoking and comorbidities.

RESULTS

We studied 2 701 782 beneficiaries with KHOA, 13 044 beneficiaries with ankylosing spondylitis, and 10 859 304 beneficiaries in the general population group. Beneficiaries with KHOA had lower risks of cancer of the oropharynx, oesophagus, stomach, colon/rectum, hepatobiliary tract, pancreas, larynx, lung, and ovary than the general population. However, beneficiaries with KHOA had higher risks of melanoma, renal cell cancer, and cancer of the bladder, breast, uterus and prostate. Associations were similar in ankylosing spondylitis, with lower risks of cancer of the oesophagus, stomach, and lung, and higher risks of melanoma, renal cell cancer, and cancer of the renal pelvis/ureter, bladder, breast, and prostate.

CONCLUSION

Lower risks of highly prevalent cancers, including colorectal and lung cancer, may explain lower cancer-related mortality in patients with KHOA or ankylosing spondylitis. Similarities in cancer risks between KHOA and AS implicate a common risk factor, possibly chronic NSAID use.

Association of Patients' Familiarity and Perceptions of Efficacy and Risks With the Use of Opioid Medications in the Management of Osteoarthritis

OBJECTIVE

While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA.

METHODS

A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables.

RESULTS

In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02).

CONCLUSION

Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.

Preoperative medications is one of the factor affecting patient-reported outcomes after total hip arthroplasty

Although the reported clinical outcomes of total hip arthroplasty (THA) for hip osteoarthritis are satisfactory, not all patients are completely satisfied. Thus, there is interest in predicting postoperative satisfaction before surgery. The influence of comorbidities and preoperative medications on the incidence of complications and duration of hospitalization following THA has become apparent. However, studies about the associations of preoperative medication with clinical outcomes of THA are limited. Therefore, this study aimed to clarify the relationship between preoperative medications and postoperative patient-reported outcomes. This retrospective cross-sectional multicenter study enrolled post-THA patients (79 patients, 90 hips) who were examined from February to March 2019 in eight general hospitals. Outcome measures included patient-reported outcome as Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) score. Preoperative medications were investigated from medical records. Medications were categorized, and analgesics were categorized into non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, pregabalin, duloxetine, neurotropin (an extract from inflammatory rabbit skin inoculated by vaccinia virus), and opioid. To identify the factors associated with JHEQ score, the patients were divided into lower (<55 score) and higher (≥55) JHEQ score groups. Spearman rank correlation coefficient (r) showed significant difference between the total number of preoperative medications and postoperative JHEQ movement subscale (r = -0.37, p < 0.01), mental subscale (r = -0.29, p < 0.01), and JHEQ (r = -0.30, p < 0.01) scores. In the multiple logistic regression analysis, only the total number of preoperative medications was identified as a risk factor for lower JHEQ score (p < 0.01). This study clarified an inverse correlation between the total preoperative medication count and postoperative outcomes and found that larger total count of preoperative medications is a risk factor of poor postoperative patient-reported outcomes of THA.

Nonsteroidal Anti-Inflammatory Drug Use in Chronic Arthritis Pain: Variations by Ethnicity

PURPOSE

Our objective was to determine if there are ethnic differences in the use of over-the-counter (OTC) and prescription oral nonsteroidal anti-inflammatory drugs (NSAIDs) and if observed ethnic differences persist after adjustment for sociodemographic and clinical factors.

METHODS

Knee and hip osteoarthritis study participants were identified. Surveys were administered to collect sociodemographics, clinical information, and oral treatment methods for arthritis. Multivariable logistic regression models were created using a fully conditional method.

RESULTS

Hispanics (n = 130), compared to non-Hispanic whites (n = 204), were less likely to have a high school education (26.9% vs 63.2%, P <0.001), less likely to have private medical insurance (P <0.001), and more likely to have worse health (P = 0.004). OTC oral NSAID use was less common (52.9% vs 66.3%, P = 0.019), whereas prescription oral NSAID use was more common (43.4% vs 31.7%, P = 0.042) among Hispanics than non-Hispanic whites in the last 6 months. The ethnic difference in using an OTC NSAID instead of not using any oral NSAID was attenuated and no longer significant when adjusted for age, sex, education, and medical insurance (odds ratio [OR] 0.54 [95% confidence interval [CI]: 0.28-1.02]). The odds of using a prescription instead of an OTC NSAID remained significantly higher among Hispanics than non-Hispanic whites when adjusted for the same variables (odds ratio 2.17 [95% confidence interval: 1.16-4.05]).

CONCLUSIONS

Among patients with osteoarthritis, OTC NSAIDs were less commonly used but prescription NSAIDs were more commonly used by Hispanics than non-Hispanic whites. Sociodemographic factors partially mediate ethnic differences in the use of oral NSAIDs.

Implementation of a group physical therapy program for Veterans with knee osteoarthritis

Background

A previous randomized clinical trial found that a Group Physical Therapy (PT) program for knee osteoarthritis yielded similar improvements in pain and function compared with traditional individual PT. Based on these findings the Group PT program was implemented in a Department of Veterans Affairs Health Care System. The objective of this study was to evaluate implementation metrics and changes in patient-level measures following implementation of the Group PT program.

Methods

This was a one-year prospective observational study. The Group PT program involved 6 weekly sessions. Implementation metrics included numbers of referrals and completed sessions. Patient-level measures were collected at the first and last PT sessions and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; self-report of pain, stiffness and function (range 0–96)) and a 30-s chair rise test.

Results

During the evaluation period, 152 patients were referred, 80 had an initial session scheduled, 71 completed at least one session and 49 completed at least 5 sessions. The mean number of completed appointments per patient was 4.1. Among patients completing baseline and follow-up measures, WOMAC scores (n = 33) improved from 56.8 (SD = 15.8) to 46.9 (SD = 14.0); number of chair rises (n = 38) completed in 30 s increased from 10.4 (SD = 5.1) to 11.9 (SD = 5.0).

Conclusions

Patients completing the Group PT program in this implementation phase showed clinically relevant improvements comparable to those observed in the previous clinical trial that compared group and individual PT for knee osteoarthritis. These results are important because Group PT can improve efficiency and access compared with individual PT. However, there were some limitations with respect to attendance and completion rates, and program adaptations may be needed to optimize these implementation metrics. Larger, longer-term studies are required to more fully evaluate the effectiveness of this program.

Use of Recommended Non-surgical Knee Osteoarthritis Management in Patients prior to Total Knee Arthroplasty: A Cross-sectional Study

OBJECTIVE

Our aim was to assess prior use of core recommended non-surgical treatment among patients with knee osteoarthritis (OA) scheduled for total knee arthroplasty (TKA), and to assess potential patient-level correlates of underuse, if found.

METHODS

This was a cross-sectional study of patients undergoing TKA for primary knee OA at 2 provincial central intake hip and knee clinics in Alberta, Canada. Standardized questionnaires assessed sociodemographic characteristics, social support, coexisting medical conditions, OA symptoms and coping, and previous non-surgical management. Multivariable logistic regression was used to assess the patient-level variables independently associated with receipt of recommended non-surgical knee OA treatment, defined as prior use of pharmacotherapy for pain, rehabilitation strategies (exercise or physiotherapy), and weight loss if overweight or obese (body mass index ≥ 25 kg/m²).

RESULTS

There were 1273 patients included: mean age 66.9 years (SD 8.7), 39.9% male, and 44.1% had less than post-secondary education. Recommended non-surgical knee OA treatment had been used by 59.7% of patients. In multivariable modeling, the odds of having received recommended non-surgical knee OA treatment were significantly and independently lower among individuals who were older (OR 0.97, 95% CI 0.95-0.99), male (OR 0.33, 0.25-0.45), and who lacked post-secondary education (OR 0.70, 0.53-0.93).

CONCLUSION

In a large cross-sectional analysis of knee OA patients scheduled for TKA, 40% of individuals reported having not received core recommended non-surgical treatments. Older individuals, men, and those with less education had lower odds of having used recommended non-surgical OA treatments.

Hip and Knee Injuries

Hip and knee injuries are a common presenting concern for patients to a primary care office. This pathology represents a large differential and it can often be a diagnostic challenge for providers to determine the etiology of a patient's symptoms. This article discusses several of the most common causes for hip and knee pain while providing an evidence based review of physical examination maneuvers, imaging studies and treatment modalities to assist a primary care provider when encountering active patients with underlying hip or knee pain.

Social & psychological factors associated with oral analgesic use in knee osteoarthritis management

OBJECTIVE

Determine modifiable social and psychological health factors that are associated with use of oral opioid and non-opioid medications for OA.

METHODS

Patients were categorized based on use of the following oral medications: opioids (with/without other oral analgesic treatments), non-opioid analgesics, and no oral analgesic treatment. We used multinomial logistic regression models to estimate adjusted relative risk ratios (RRRs) of using an opioid or a non-opioid analgesic (vs. no oral analgesic treatment), comparing patients by levels of social support (Medical Outcomes Study scale), health literacy ("How confident are you filling out medical forms by yourself?"), and depressive symptoms (Patient Health Questionnaire-8). Models were adjusted for demographic and clinical characteristics.

RESULTS

In this sample (mean age 64.2 years, 23.6% women), 30.6% (n = 110) reported taking opioid analgesics for OA, 54.2% (n = 195) reported non-opioid use, and 15.3% (n = 55) reported no oral analgesic use. Opioid users had lower mean social support scores (10.0 vs 10.5 vs 11.9, P = 0.007) and were more likely to have moderate-severe depressive symptoms (42.7% vs 24.1% vs 14.5%, P < 0.001). Health literacy did not differ by treatment group type. Having moderate-severe depression was associated with higher risk of opioid analgesic use compared to no oral analgesic use (RRR 2.96, 95%CI 1.08-8.07) when adjusted for sociodemographic and clinical factors. Neither social support nor health literacy was associated with opioid or non-opioid oral analgesic use in fully adjusted models.

CONCLUSIONS

Knee OA patients with more severe depression symptoms, compared to those without, were more likely to report using opioid analgesics for OA.

Educational outreach visits to improve knee osteoarthritis management in primary care

BACKGROUND

Knee osteoarthritis is a common problem, but often underdiagnosed and undertreated in primary care as compared to evidence-based guidelines. Educational outreach visits are an effective strategy to improve guideline adherence, but its contribution to knee osteoarthritis management is largely unknown. The aim of this study was to evaluate the overall effectiveness of educational outreach visits on process quality indicators for knee osteoarthritis management, more specifically on the referral for physical therapy.

METHODS

An educational intervention study, non-randomized and controlled, was designed for general practitioners (GPs) in Belgium. During four months, 426 GPs were visited by academic detailers and allocated to the intervention group. The control group was selected from GPs not visited by academic detailers during the study period. Six months post-intervention, both groups received a questionnaire with two case-vignettes to measure the effectiveness of the educational outreach. Outcomes were assessed with a Belgian set of quality indicators for knee osteoarthritis management and focused on the number of prescriptions for appropriate physical therapy (i.e. muscle strengthening, aerobic, functional or range of motion exercises) and the adherence to eight additional quality indicators related to knee osteoarthritis management. For the analysis, multivariable logistic regression models were used and Generalized Estimating Equations to handle the correlation between the multiple results per GP.

RESULTS

The intervention group showed a tendency to prescribe more frequently at least one appropriate physical therapy for a case (43.8%), compared to the control group (31.3%, p = 0.057). Muscle strengthening exercises were the most frequently prescribed therapy with 37.0% in the intervention versus 26.9% in the control group. The adherence to the other quality indicators showed no significant difference between the intervention and control group and varied between 8.9 and 100% in the intervention group.

CONCLUSIONS

This intervention did not alter significantly the adherence to quality indicators and in particular the probability of prescribing physical therapy. To change general practitioners' prescription behavior, more extensive or combined interventional approaches seem warranted.

Abnormal expression of miR-4784 in chondrocytes of osteoarthritis and associations with chondrocyte hyperplasia

The aim of the present study was to assess the expression of microRNA (miRNA)-4784 in the chondrocytes of early osteoarthritis (OA) and to determine the effect of double-stranded (ds)-miRNA-4784 transfection on chondrocyte function. Following the construction of an OA rabbit model, normal chondrocytes (normal control group), OA chondrocytes obtained 4 weeks after modeling (OA at week 4 group) and 8 weeks after modeling (OA at week 8 group) were used. The relative expression of miRNA-4784 in each group was detected using reverse transcription-quantitative polymerase chain reaction (RT-qPCR). Western blotting was performed to measure the expression of type II collagen (Col2a1) and matrix metalloproteinase (MMP)-3 in each group with or without ds-miRNA-4784 transfection. The results revealed that the levels of miR-4784 in groups OA at week 4 and 8 were significantly lower than that of normal control group (P<0.05). It was also demonstrated that Col2a1 mRNA expression levels in groups OA at week 4 and 8 were 49 and 38% of that in the normal control group, respectively. Furthermore, MMP-3 mRNA expression levels increased by 3.12- and 3.95-fold in groups OA at week 4 and 8, respectively, compared with those in the normal control group (P<0.01). Following transfection with ds-miRNA-4784, Col2a1 mRNA expression levels increased by 63 and 126% compared with the levels prior to treatment in groups OA at week 4 and 8, respectively (P<0.01). The expression levels of MMP-3 mRNA in groups OA at week 4 and 8 decreased following transfection compared with the levels prior to treatment. Col2a1 and MMP-3 protein expression exhibited similar patterns to the mRNA expression. In summary, the results of the present study suggest that miRNA-4784 expression is significantly reduced in early stage OA chondrocytes. Transfection with ds-miRNA-4784 promotes the expression of Col2a1 and inhibits the MMP-3 expression in chondrocytes.