Few geographic and socioeconomic variations exist in primary total shoulder arthroplasty: a multi-level study of Australian registry data

Limited value of current shoulder arthroplasty registries in evidence-based shoulder surgery: a review of 7 national registries

National shoulder arthroplasty registries are currently used to assess incidence, indication, type of prosthesis and revision, but they seem to lack sufficient information to lead to evidence based decision-making in shoulder surgery. There appears to be a large difference in registered parameters and outcome measurement per country. First we investigated whether existing registries have sufficient common datasets to enable pooling of data. Second, we determined whether known risk factors for prosthetic failure are being recorded. Through a non-systematic literature review studies on registries were analyzed for included parameters. Seven national registries were scrutinized for the data collected and these were classified according to categories of risk factors for failure: patient-, implant and surgeon related, and other parameters. This shows a large heterogeneity of registered parameters between countries. The majority of parameters shown to be relevant to outcome and failure of shoulder prostheses are not included in the studied registries. International agreement on parameters and outcome measurement for registries is paramount to enable pooling and comparison of data. If we intend to use the registries to provide us with evidence to improve prosthetic shoulder surgery, we need adjustment of the different parameters to be included.

A Geographic Population-level Analysis of Access to Total Shoulder Arthroplasty in the State of Texas

INTRODUCTION

Managing costs and improving access to care are two important goals of healthcare policy. The purposes of this study were to (1) evaluate the changes in distribution of total shoulder arthroplasty (TSA) cases in the state of Texas from 2010 to 2015 and (2) to evaluate patient access to TSA surgery centers as measured by driving miles.

METHODS

Inpatient (IP) and outpatient (OP) records were obtained from 2010 to 2015 from the Texas Department of State Health Services. All primary elective anatomic or reverse TSAs for patients with Texas-based home residence zip codes were included. Driving miles between patient zip codes and their chosen TSA surgery centers were estimated, and the results were compared between IP (high-volume [HV-IP] or low-volume [LV-IP]) and OP centers. Paired student t-tests, multivariate regressions, and mixed-model analysis of variance (ANOVA) were performed for volume comparisons, interactions between TSA centers types, and yearly trend data, respectively.

RESULTS

Between 2010 and 2015, a total of 21,092 TSA procedures were performed across 321 surgery centers in the state of Texas (19,629 IP [93.1%] and 1,463 OP [6.9%]). During this time, the cumulative volume of IP TSA per 100,000 Texas residents increased by 109.1%, whereas the cumulative volume of OP TSA increased by 143.7%. Approximately 85.5% of included patients resided within 50 miles of any TSA surgery center; however, only 47.0% of the total Texas population resided within 50 miles of any TSA surgery center. This relationship remained true at every time point irrespective of their volume designations (OP, IP, HV-IP, and LV-IP).

CONCLUSION

Despite the overall increase in TSA volume over time, the majority all TSA utilization in the state of Texas occurred in patients who resided within 50 miles of a TSA center. Increasing volume seems to reflect concentration of care into HV-IP and OP centers. Strategies to improve access to TSA care for underserved areas should be considered.

LEVEL OF EVIDENCE

Level II.

Treatment of active rheumatoid arthritis: comparison of patients younger vs older than 75 years (CORPUS cohort)

Objectives: Little information is available on the characteristics of elderly patients starting TNFα antagonist treatment for rheumatoid arthritis (RA). The objective of this work was to compare prescription patterns in RA patients younger vs. older than 75 years.

Methods: Biologic-naive patients with active RA (DAS28 > 3.2) despite first-line therapy were included between 2007 and 2009 in the prospective, multicentre, longitudinal, observational, population-based CORPUS-RA cohort. TNFα antagonist users were defined as having received at least one TNFα antagonist during the first study year. The groups < 75 years and ≥ 75 years were compared regarding comorbidities, inflammation (CRP and ESR), disease activity (DAS28), disability (HAQ-DI), number of physician visits, and treatment. To verify the impact of the cut off, we also compared patients aged 70 years or more to patients younger than 70 years.

Results: Of 543 RA patients, 382 had complete one-year follow-up data, including 114 TNFα antagonist users, 3 (6%) among the 49 patients aged 75 years or over and 111 (32%) of the 333 patients younger than 75 years (p < 0.01). Disease activity in the two age groups was similar at inclusion and after one year. Comorbidities and a history of auto-immunity were more common in the older group. Compared to their younger counterparts, the older patients received glucocorticoids more often (p = 0.003) and synthetic disease-modifying anti-rheumatic drugs less often (p = 0.01).

Conclusion: TNFα antagonists are used less often and glucocorticoids more often in elderly patients with active RA compared to their younger counterparts. The fact that this study was performed in 2007–9 is a limitation in terms of relevance to today’s patients and further studies should be conducted in new cohorts of active RA.

Generation and characterization of a high affinity anti-human FcRn antibody, rozanolixizumab, and the effects of different molecular formats on the reduction of plasma IgG concentration

Rozanolixizumab (UCB7665), a humanized high-affinity anti-human neonatal Fc receptor (FcRn) monoclonal antibody (IgG4P), has been developed to reduce pathogenic IgG in autoimmune and alloimmune diseases. We document the antibody isolation and compare rozanolixizumab with the same variable region expressed in various mono-, bi- and trivalent formats. We report activity data for rozanolixizumab and the different molecular formats in human cells, FcRn-transgenic mice, and cynomolgus monkeys. Rozanolixizumab, considered the most effective molecular format, dose-dependently and selectively reduced plasma IgG concentrations in an FcRn-transgenic mouse model (no effect on albumin). Intravenous (IV) rozanolixizumab dosing in cynomolgus monkeys demonstrated non-linear pharmacokinetics indicative of target-mediated drug disposition; single IV rozanolixizumab doses (30 mg/kg) in cynomolgus monkeys reduced plasma IgG concentration by 69% by Day 7 post-administration. Daily IV administration of rozanolixizumab (initial 30 mg/kg loading dose; 5 mg/kg daily thereafter) reduced plasma IgG concentrations in all cynomolgus monkeys, with low concentrations maintained throughout the treatment period (42 days). In a 13-week toxicology study in cynomolgus monkeys, supra-pharmacological subcutaneous and IV doses of rozanolixizumab (≤ 150 mg/kg every 3 days) were well tolerated, inducing sustained (but reversible) reductions in IgG concentrations by up to 85%, with no adverse events observed. We have demonstrated accelerated natural catabolism of IgG through inhibition of IgG:FcRn interactions in mice and cynomolgus monkeys. Inhibition of FcRn with rozanolixizumab may provide a novel therapeutic approach to reduce pathogenic IgG in human autoimmune disease. Rozanolixizumab is being investigated in patients with immune thrombocytopenia (NCT02718716) and myasthenia gravis (NCT03052751).

Circulating Levels of Osteoprotegerin, Osteocalcin and Osteopontin in Patients with Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

OBJECTIVE

Currently published data regarding the potential role of osteoprotegerin (OPG), osteocalcin (OCN) and osteopontin (OPN) for the discrimination between rheumatoid arthritis (RA) and osteoarthritis (OA) are contradictory. To derive a more precise evaluation, a meta-analysis was performed.

METHODS

Published literatures comparing plasma/serum OPG, OCN and OPN levels between RA group and OA controls were searched in PubMed, Embase and the Cochrane Library. The Newcastle-Ottawa Scale was used to assess the study quality. Pooled standard mean difference (SMD) with 95% confidence interval (CI) was calculated by random-effect model analysis. Heterogeneity test was performed by the Q statistic and quantified using I².

RESULTS

Nine studies including 438 RA patients and 255 OA patients were finally incorporated in the meta-analysis after examining title, type, abstracts and full text. The results showed that RA patients had higher plasma/serum OPN (pooled SMD = -2.57, 95% CI = -4.72 to -0.41) levels when compared to OA patients. No significant difference in plasma/serum OPG (pooled SMD = -0.29, 95% CI = -1.07‒0.49) and OCN (pooled SMD = -0.09, 95% CI = -0.48‒0.31) levels were found between RA patients and OA patients. Subgroup analysis indicated that plasma/serum OPG levels had no significant differences between RA patients and OA patients in Europe and Asian.

CONCLUSIONS

Overall, there is no significant difference in circulating OPG and OCN levels between RA patients and OA patients. However, plasma/serum OPN level is significantly higher in RA patients compared with OA patients.

Geographic region, socioeconomic position and the utilisation of primary total joint replacement for hip or knee osteoarthritis across western Victoria: a cross-sectional multilevel study of the Australian Orthopaedic Association National Joint Replacement Registry

Compared to urban residents, those in rural/regional areas often experience inequitable healthcare from specialist service providers. Independent of small between-area differences in utilisation, socially advantaged groups had the greatest uptake of joint replacement. These data suggest low correlation between 'need' vs. 'uptake' of surgery in rural/regional areas.

BACKGROUND AND PURPOSE

Compared to urban residents, those in rural and regional areas often experience inequitable healthcare from specialist service providers, often due to geographical issues. We investigated associations between socioeconomic position (SEP), region of residence and utilisation of primary total knee replacement (TKR) and/or total hip replacement (THR) for osteoarthritis.

DESIGN AND METHODS

As part of the Ageing, Chronic Disease and Injury study, we extracted data from the Australian Orthopaedic Association National Joint Replacement Registry (2011-2013) for adults that utilised primary TKR (n = 4179; 56% female) and/or THR (n = 3120; 54% female). Residential addresses were matched with the Australian Bureau of Statistics (ABS) 2011 census data: region of residence was defined according to local government areas (LGAs), and area-level SEP (quintiles) defined using an ABS-derived composite index. The ABS-determined control population (n = 591,265; 51% female) excluded individuals identified as cases. We performed multilevel logistic regression modelling using a stratified two-stage cluster design.

RESULTS

TKR was higher for those aged 70-79 years (AOR 1.4 95%CI 1.3-1.5; referent = 60-69 years) and in the most advantaged SEP quintile (AOR 2.1, 95%CI 1.8-2.3; referent = SEP quintile 3); results were similar for THR (70-79 years = AOR 1.7, 95%CI 1.5-1.8; SEP quintile 5 = AOR 2.5, 95%CI 2.2-2.8). Total variances contributed by the variance in LGAs were 2% (SD random effects ± 0.28) and 3% (SD ± 0.32), respectively.

CONCLUSION

Independent of small between-LGA differences in utilisation, and in contrast to the expected greater prevalence of osteoarthritis in disadvantaged populations, we report greater TKR and THR in more advantaged groups. Further research should investigate whether more advantaged populations may be over-serviced.