Systematic review showed measures of individual burden of osteoarthritis poorly capture the patient experience

Development and validation of novel multimorbidity indices for older adults

BACKGROUND

Measuring multimorbidity in claims data is used for risk adjustment and identifying populations at high risk for adverse events. Multimorbidity indices such as Charlson and Elixhauser scores have important limitations. We sought to create a better method of measuring multimorbidity using claims data by incorporating geriatric conditions, markers of disease severity, and disease-disease interactions, and by tailoring measures to different outcomes.

METHODS

Health conditions were assessed using Medicare inpatient and outpatient claims from subjects age 67 and older in the Health and Retirement Study. Separate indices were developed for ADL decline, IADL decline, hospitalization, and death, each over 2 years of follow-up. We validated these indices using data from Medicare claims linked to the National Health and Aging Trends Study.

RESULTS

The development cohort included 5012 subjects with median age 76 years; 58% were female. Claims-based markers of disease severity and disease-disease interactions yielded minimal gains in predictive power and were not included in the final indices. In the validation cohort, after adjusting for age and sex, c-statistics for the new multimorbidity indices were 0.72 for ADL decline, 0.69 for IADL decline, 0.72 for hospitalization, and 0.77 for death. These c-statistics were 0.02-0.03 higher than c-statistics from Charlson and Elixhauser indices for predicting ADL decline, IADL decline, and hospitalization, and <0.01 higher for death (p < 0.05 for each outcome except death), and were similar to those from the CMS-HCC model. On decision curve analysis, the new indices provided minimal benefit compared with legacy approaches. C-statistics for both new and legacy indices varied substantially across derivation and validation cohorts.

CONCLUSIONS

A new series of claims-based multimorbidity measures were modestly better at predicting hospitalization and functional decline than several legacy indices, and no better at predicting death. There may be limited opportunity in claims data to measure multimorbidity better than older methods.

Impact of lower limb osteoarthritis on health-related quality of life: A cross-sectional study to estimate the expressed loss of utility in the Spanish population

Objective

Osteoarthritis of the lower limb (OALL) worsens health-related quality of life (HRQL), but this impact has not been quantified with standardized measures. We intend to evaluate the impact of OALL on HRQL through measures based on individual preferences in comparison to the general population.

Methods

A cross-sectional study was designed. A total of 6234 subjects aged 50 years or older without OALL were selected from the Spanish general population (National Health Survey 2011–12). An opportunistic sample of patients aged 50 years or older diagnosed with hip (n = 331) or knee osteoarthritis (n = 393), using the American Rheumatism Association criteria, was recruited from six hospitals and 21 primary care centers in Vizcaya, Madrid and Tenerife between January and December 2015. HRQL was measured with the EQ-5D-5L, and the results were transformed into utility scores. Sociodemographic variables (age, sex, social group, cohabitation), number of chronic diseases, and body mass index were considered. The clinical stage of OALL was collected using the Western Ontario and McMaster Universities Osteoarthritis Index and the Oxford hip score and Oxford knee score. Generalized linear models were constructed using the utility index as the dependent variable.

Results

HRQL expressed by OALL patients was significantly worse than this of the general population. After adjustment for sociodemographic and clinical characteristics, the mean utility loss was -0.347 (95% CI: -0.390, -0.303) for osteoarthritis of the hip and -0.295 (95% CI: -0.336, -0.255) for osteoarthritis of the knee. OALL patients who were treated at a hospital had an additional utility loss of -0.112 (95% CI: -0.158, -0.065).

Conclusion

OALL has a great impact on HRQL. People with OALL perceive a utility loss of approximately 0.3 points compared to the general population without osteoarthritis, which is very high in relation to the utility loss reported for other chronic diseases and for arthritis in general.

Psychometric evaluation supported construct validity, temporal stability, and responsiveness of the Osteoarthritis Questionnaire

OBJECTIVES

The Osteoarthritis Questionnaire (OA-Quest) is a new measure of individual burden of osteoarthritis, composing seven brief (4-11 items; total 42 items), independent scales. This study describes the psychometric evaluation of the OA-Quest. Specifically, temporal stability, convergent and discriminant validity, and responsiveness of the OA-Quest to joint replacement surgery were examined.

STUDY DESIGN AND SETTING

Participants were drawn from rheumatology (n = 62), orthopedic (n = 90), and community (n = 175) settings. Temporal stability of the OA-Quest was evaluated over a 2-week period and was assessed with intraclass correlation coefficients. Responsiveness was assessed with standardized effect sizes and paired samples t-tests. Convergent and discriminant validity was assessed with a multitrait multimethod confirmatory factor analysis (MTMM CFA).

RESULTS

The OA-Quest scales had high temporal stability, with intraclass correlation coefficients between 0.75 (lost productivity) and 0.94 (physical limitations) and showed improvements of expected magnitude and direction 3 months after joint replacement surgery, supporting their responsiveness. MTMM CFA supported the convergent and discriminant validity of the OA-Quest, demonstrated by adequate model fit (χ² = 483.54, df = 184, P < 0.001, comparative fit index = 0.95, Tucker-Lewis index = 0.93, root mean square error of approximation = 0.07, standardized root mean square residual = 0.06) and factor loadings of the expected magnitude and direction.

CONCLUSION

The OA-Quest has strong evidence of temporal stability, construct validity, and is responsive to change following joint replacement surgery.

Creation of a core outcome set for clinical trials of people with shoulder pain: a study protocol

Background

The selection of appropriate outcomes or domains is crucial when designing clinical trials, to appreciate the effects of different interventions, pool results, and make valid comparisons between trials. If the findings are to influence policy and practice, then the chosen outcomes need to be relevant and important to key stakeholders, including patients and the public, healthcare professionals and others making decisions about health care. There is a growing recognition that insufficient attention has been paid to the outcomes measured in clinical trials. Recent reviews of the measurement properties of patient-reported outcome measures for shoulder disorders revealed a large selection of diverse measures, many with questionable validity, reliability, and responsiveness. These issues could be addressed through the development and use of an agreed standardized collection of outcomes, known as a core outcome set (COS), which should be measured and reported in all trials of shoulder disorders. The purpose of the present project is to develop and disseminate a COS for clinical trials in shoulder disorders.

Methods/Design

The methods for the COS development will include 3 phases: (1) a comprehensive review of the core domains used in shoulder disorder trials; (2) an international Delphi study involving relevant stakeholders (patients, clinicians, scientists) to define which domains should be core; and (3) an international focus group informed by the evidence identified in phases 1 and 2, to determine which measurement instruments best measure the core domains and identification of any evidence gaps that require further empiric evidence.

Discussion

The aim of the current proposal is to convene several meetings of international experts and patients to develop a COS for clinical trials of shoulder disorders and to develop an implementation strategy to ensure rapid uptake of the core set of outcomes in clinical trials. There would be an expectation that the core set of outcomes would always be collected and reported, but it would not preclude use of additional outcomes in a particular trial.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2054-9) contains supplementary material, which is available to authorized users.

Measures for Pain and Function Assessments for Patients With Osteoarthritis

INTRODUCTION

To develop an osteoarthritis (OA) quality measure that satisfies quality-reporting initiatives, a systematic review of the literature was undertaken to identify and evaluate measures of pain and function commonly used to assess outcomes in patients with upper and lower extremity OA.

METHODS

English-language systematic reviews and meta-analyses evaluating validity of pain and function instruments in OA patients published between 1995 and 2014 were considered for inclusion. The quality of all included studies was assessed using the Appraisal of Guidelines for Research and Evaluation II instrument (AGREE II).

RESULTS

More than 90 pain and/or functional assessment tools were evaluated within the 16 systematic reviews included in this analysis. Of the 16 systematic reviews, 6 articles had high-quality study designs; the remaining 10 reviews had moderate-quality study designs.

CONCLUSION

There currently exists no OA pain and functional assessment tool capable of meeting the stringent requirements established by newer quality-reporting programs. The use of invalidated or unreliable patient-reported outcome measures may improperly estimate patient pain and functional status, which could affect treatment options, patient satisfaction, reimbursement, and/or quality of life.

LEVEL OF EVIDENCE

II.

Development and preliminary evaluation of the OsteoArthritis Questionnaire (OA-Quest): a psychometric study

OBJECTIVE

This study reports the development of the OsteoArthritis Questionnaire (OA-Quest) - a new measure designed to comprehensively capture the potentially modifiable burden of osteoarthritis.

DESIGN

Item development was guided by the a priori conceptual framework of the Personal Burden of Osteoarthritis (PBO) which captures 8 dimensions of osteoarthritis burden (Physical distress, Fatigue, Physical limitations, Psychosocial distress, Physical de-conditioning, Financial hardship, Sleep disturbances, Lost productivity). One hundred and twenty three candidate items were pretested in a clinical sample of 18 osteoarthritis patients. The measurement properties of the OA-Quest were assessed with exploratory factor analysis (EFA), Rasch modelling, and confirmatory factor analysis (CFA) in a community-based sample (n = 792).

RESULTS

EFA replicated 7 of the 8 PBO domains. An exception was PBO Fatigue domain, with items merging into the Physical distress subscale in the OA-Quest. Following item analysis, a 42-item 7-subscale questionnaire was constructed, measuring Physical distress (seven items, Cronbach's α = 0.93), Physical limitations (11 items, α = 0.95), Psychosocial distress (seven items, α = 0.93), Physical de-conditioning (four items, α = 0.87), Financial hardship (four items, α = 0.93), Sleep disturbances (five items, α = 0.96), and Lost productivity (four items α = 0.90). A highly restricted 7-factor CFA model had excellent fit with the data (χ(2)(113) = 316.36, P < 0.001; chi-square/degrees of freedom = 2.8; comparative fit index [CFI] = 0.97; root mean square error of approximation [RMSEA] = 0.07), supporting construct validity of the new measure.

CONCLUSIONS

The OA-Quest is a new measure of osteoarthritis burden that is founded on a comprehensive conceptual model. It has strong evidence of construct validity and provides reliable measurement across a broad range of osteoarthritis burden.

Relationship of Buckling and Knee Injury to Pain Exacerbation in Knee Osteoarthritis: A Web-Based Case-Crossover Study

BACKGROUND

Knee osteoarthritis (OA) is one of the most frequent causes of limited mobility and diminished quality of life. Pain is the main symptom that drives individuals with knee OA to seek medical care and a recognized antecedent to disability and eventually joint replacement. Evidence shows that patients with symptomatic OA experience fluctuations in pain severity. Mechanical insults to the knee such as injury and buckling may contribute to pain exacerbation.

OBJECTIVE

Our objective was to examine whether knee injury and buckling (giving way) are triggers for exacerbation of pain in persons with symptomatic knee OA.

METHODS

We conducted a case-crossover study, a novel methodology in which participants with symptomatic radiographic knee OA who have had knee pain exacerbations were used as their own control (self-matched design), with all data collected via the Internet. Participants were asked to log-on to the study website and complete an online questionnaire at baseline and then at regular 10-day intervals for 3 months (control periods)-a total of 10 questionnaires. They were also instructed to go to the website and complete pain exacerbation questionnaires when they experienced an isolated incident of knee pain exacerbation (case periods). A pain exacerbation "case" period was defined as an increase of ≥2 compared to baseline. At each contact the pain exacerbation was designated a case period, and at all other regular 10-day contacts (control periods) participants were asked about knee injuries during the previous 7 days and knee buckling during the previous 2 days. The relationship of knee injury and buckling to the risk of pain exacerbation was examined using conditional logistic regression models.

RESULTS

The analysis included 157 participants (66% women, mean age: 62 years, mean BMI: 29.5 kg/m(2)). Sustaining a knee injury was associated with experiencing a pain exacerbation (odds ratio [OR] 10.2, 95% CI 5.4, 19.3) compared with no injury. Knee buckling was associated with experiencing a pain exacerbation (OR 4.0, 95% CI 2.6, 6.2) compared with no buckling and the association increased with a greater number of buckling events (for ≥ 6 buckling events, OR 20.1, 95% CI 3.7, 110).

CONCLUSIONS

Knee injury and buckling are associated with knee pain exacerbation. Reducing the likelihood of these mechanical events through avoidance of particular activities and/or appropriate rehabilitation programs may decrease the risk of pain exacerbation.

Within-Day Variability of Fatigue and Pain Among African Americans and Non-Hispanic Whites With Osteoarthritis of the Knee

OBJECTIVE

Fatigue is common among persons with osteoarthritis (OA), but little is known about racial/ethnic differences in the prevalence, correlates, or dynamics of fatigue in OA. This research therefore used experience sampling methodology (ESM) to examine fatigue and pain at global and momentary levels among African Americans and non-Hispanic whites with OA.

METHODS

Thirty-nine African Americans and 81 non-Hispanic whites with physician-diagnosed knee OA completed a baseline interview and an ESM protocol assessing fatigue, pain, and mood 4 times daily for 7 days. In addition to analyzing basic group differences, multilevel modeling examined within- versus between-subject patterns and correlates of variability in momentary fatigue, controlling for demographics and other potential confounders.

RESULTS

Both racial groups experienced moderate levels of fatigue; however, there were clear individual differences in both mean fatigue level and variability across momentary assessments. Mean fatigue levels were associated with global pain and depression. Increase in fatigue over the course of the day was much stronger among non-Hispanic whites than African Americans. Momentary fatigue and pain were closely correlated. Mean fatigue predicted variability in mood; at the momentary level, both fatigue and pain were independently associated with mood.

CONCLUSION

Fatigue is a significant factor for both African Americans and non-Hispanic whites with OA, and is negatively related to quality of life. Pain symptoms, at both the momentary level and across individuals, were robust predictors of fatigue. Although overall levels of reported symptoms were similar across these 2 groups, the pattern of fatigue symptoms across the day differed.

Development of a conceptual model of cancer caregiver health literacy

Caregivers play a vital role in caring for people diagnosed with cancer. However, little is understood about caregivers' capacity to find, understand, appraise and use information to improve health outcomes. The study aimed to develop a conceptual model that describes the elements of cancer caregiver health literacy. Six concept mapping workshops were conducted with 13 caregivers, 13 people with cancer and 11 healthcare providers/policymakers. An iterative, mixed methods approach was used to analyse and synthesise workshop data and to generate the conceptual model. Six major themes and 17 subthemes were identified from 279 statements generated by participants during concept mapping workshops. Major themes included: access to information, understanding of information, relationship with healthcare providers, relationship with the care recipient, managing challenges of caregiving and support systems. The study extends conceptualisations of health literacy by identifying factors specific to caregiving within the cancer context. The findings demonstrate that caregiver health literacy is multidimensional, includes a broad range of individual and interpersonal elements, and is influenced by broader healthcare system and community factors. These results provide guidance for the development of: caregiver health literacy measurement tools; strategies for improving health service delivery, and; interventions to improve caregiver health literacy.

Effect of therapeutic aquatic exercise on symptoms and function associated with lower limb osteoarthritis: systematic review with meta-analysis

BACKGROUND

Current management of osteoarthritis (OA) focuses on pain control and maintaining physical function through pharmacological, nonpharmacological, and surgical treatments. Exercise, including therapeutic aquatic exercise (TAE), is considered one of the most important management options. Nevertheless, there is no up-to-date systematic review describing the effect of TAE on symptoms and function associated with lower limb OA.

PURPOSE

The purpose of this study was to conduct a systematic review with meta-analysis to determine the effect of TAE on symptoms and function associated with lower limb OA.

DATA SOURCES

The data sources used in this study were: MEDLINE, PubMed, EMBASE, CINAHL, PEDro, and SPORTDiscus.

STUDY SELECTION

All studies selected for review were randomized controlled trials with an aquatic exercise group and a nontreatment control group. In total, 11 studies fulfilled the inclusion criteria and were included in the synthesis and meta-analysis.

DATA EXTRACTION

Data were extracted and checked for accuracy by 3 independent reviewers.

DATA SYNTHESIS

Standardized mean difference (SMD) with 95% confidence interval (95% CI) was calculated for all outcomes. The meta-analysis showed a significant TAE effect on pain (SMD=0.26 [95% CI=0.11, 0.41]), self-reported function (SMD=0.30 [95% CI=0.18, 0.43]), and physical functioning (SMD=0.22 [95% CI=0.07, 0.38]). Additionally, a significant effect was seen on stiffness (SMD=0.20 [95% CI=0.03, 0.36]) and quality of life (SMD=0.24 [95% CI=0.04, 0.45]).

LIMITATIONS

Heterogeneity of outcome measures and small sample sizes for many of the included trials imply that conclusions based on these results should be made with caution.

CONCLUSIONS

The results indicate that TAE is effective in managing symptoms associated with lower limb OA.

A reference case for economic evaluations in osteoarthritis: an expert consensus article from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

BACKGROUND

General recommendations for a reference case for economic studies in rheumatic diseases were published in 2002 in an initiative to improve the comparability of cost-effectiveness studies in the field. Since then, economic evaluations in osteoarthritis (OA) continue to show considerable heterogeneity in methodological approach.

OBJECTIVES

To develop a reference case specific for economic studies in OA, including the standard optimal care, with which to judge new pharmacologic and non-pharmacologic interventions.

METHODS

Four subgroups of an ESCEO expert working group on economic assessments (13 experts representing diverse aspects of clinical research and/or economic evaluations) were charged with producing lists of recommendations that would potentially improve the comparability of economic analyses in OA: outcome measures, comparators, costs and methodology. These proposals were discussed and refined during a face-to-face meeting in 2013. They are presented here in the format of the recommendations of the recently published Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, so that an initiative on economic analysis methodology might be consolidated with an initiative on reporting standards.

RESULTS

Overall, three distinct reference cases are proposed, one for each hand, knee and hip OA; with diagnostic variations in the first two, giving rise to different treatment options: interphalangeal or thumb-based disease for hand OA and the presence or absence of joint malalignment for knee OA. A set of management strategies is proposed, which should be further evaluated to help establish a consensus on the "standard optimal care" in each proposed reference case. The recommendations on outcome measures, cost itemisation and methodological approaches are also provided.

CONCLUSIONS

The ESCEO group proposes a set of disease-specific recommendations on the conduct and reporting of economic evaluations in OA that could help the standardisation and comparability of studies that evaluate therapeutic strategies of OA in terms of costs and effectiveness.

The burden of osteoarthritis: development and validation of a new assessment tool (BONe'S)

OBJECTIVE

To develop and validate a specific individual burden questionnaire, BONe'S (Burden of Osteoarthritis New Scale), assessing osteoarthritis (OA) patients in the broadest sense.

RESEARCH DESIGN AND METHODS

Items included in BONe'S were identified by literature review, and patient/healthcare practitioner interviews, and refined via item reduction and exploratory factor analysis (EFA). Internal consistency was calculated using Cronbach's α; concurrent validity was assessed by calculating the correlation between BONe'S and the Short Form (SF)-12 Health Survey and Psychological General Well-Being Index (PGWBI). Discriminant validity was analyzed by age, gender and number of OA locations.

RESULTS

From an initial list of 56 items, the final BONe'S questionnaire consisted of 20 questions (5 dimensions) based on EFA. BONe'S was evaluated in patients with OA (n = 200; mean age 69.4 ± 7.0 years, 86% of patients aged >60 years, 91.5% women). BONe'S demonstrated excellent internal coherence (Cronbach's α: 0.86). Individual BONe'S dimensions correlated well with the overall BONe'S score (highest: 'Independence' [r = 0.91]; lowest: 'Hygiene & Beauty' [r = 0.56]), and to each other dimension, and also correlated well (inversely) with the SF-12 and, to a slightly lesser extent, the PGWBI. The only exception was 'Budget', but this dimension was important and relevant in the subpopulation of active OA patients (r = 0.40). The mean BONe'S score for subjects with one or two affected joints was significantly lower than for subjects with three or more affected joints. The BONe'S score also differed according to gender and age. The original French BONe'S has also been adapted (linguistically and culturally) to English, Russian and Portuguese. Limitations include the fact that BONe'S was developed in a predominantly female population, in patients receiving a pharmacological intervention, has not been evaluated in a large population and has not been compared with other OA tools, including WOMAC, Lequesne and KOOS.

CONCLUSION

The BONe'S questionnaire is a short (20-item) validated tool for evaluating the specific individual burden of OA in a holistic manner.