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Pang L, Xue X, He Y, Wang C, Han L, Li M, Qi H, Li C, Lu J. The Effect of Decrease in Serum Urate for the Risk of Gout Flares During Urate-Lowering Therapy Initiation Among Chinese Male Gout Patients: A Prospective Cohort Study. J Inflamm Res 2023; 16:3937-3947. [PMID: 37706063 PMCID: PMC10497051 DOI: 10.2147/jir.s424820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023] Open
Abstract
Purpose Higher baseline serum urate or higher initial urate-lowering medication dose increased risk of gout flares during urate-lowering therapy (ULT) initiation. The decrease in serum urate may play a crucial role in this process. Therefore, we aim to explore the relationship between decrease in serum urate and the risk of gout flares during ULT initiation. Patients and Methods A 12-week prospective cohort study of Chinese male gout patients was conducted at Shandong Provincial Clinical Research Center for Immune Diseases and Gout in China. Patients were grouped by baseline serum urate (7-7.9 mg/dL, 8-8.9 mg/dL and ≥9 mg/dL). All patients received febuxostat 20 mg daily during weeks 0-4, then escalated to 40mg during weeks 4-12 if serum urate >6mg/dL. The main outcomes were the number of gout flares and the decrease in serum urate. Poisson regression was performed. Results A total of 282 participants were enrolled, of whom 260 completed (84, 87 and 89 in each group) from March 2021 to December 2021. A 44.2% of all participants experienced at least one gout flare. In the multivariate Poisson regression 1, Δ serum urate 0-12 weeks (IRR 1.184, 95% CI, 1.062-1.320; P=0.002), the number of gout flares before treatment 1 year (1.017, 1.010-1.024; P<0.001) and tophus (1.580, 1.023-2.440; P=0.039) were independently associated with the number of gout flares. While in the multivariate Poisson regression 2, baseline serum urate (1.256, 1.050-1.503; P=0.013) and the number of gout flares before treatment 1 year (1.014, 1.007-1.022; P<0.001) were independently associated with the number of gout flares, Δ serum urate 0-12 weeks (1.055, 0.923-1.207; P=0.433) was no longer a risk factor. Conclusion ULT-induced gout flares depend on the degree of decrease in serum urate, which is affected by baseline serum urate. Higher baseline serum urate and greater decrease in serum urate lead to higher risk of gout flares.
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Affiliation(s)
- Lei Pang
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
| | - Xiaomei Xue
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
| | - Yuwei He
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
| | - Can Wang
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
| | - Lin Han
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
| | - Maichao Li
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
| | - Han Qi
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
| | - Changgui Li
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
| | - Jie Lu
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, 266003, People’s Republic of China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, 266003, People’s Republic of China
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Stamp LK, Farquhar H, Pisaniello HL, Vargas-Santos AB, Fisher M, Mount DB, Choi HK, Terkeltaub R, Hill CL, Gaffo AL. Management of gout in chronic kidney disease: a G-CAN Consensus Statement on the research priorities. Nat Rev Rheumatol 2021; 17:633-641. [PMID: 34331037 PMCID: PMC8458096 DOI: 10.1038/s41584-021-00657-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 11/08/2022]
Abstract
Gout and chronic kidney disease (CKD) frequently coexist, but quality evidence to guide gout management in people with CKD is lacking. Use of urate-lowering therapy (ULT) in the context of advanced CKD varies greatly, and professional bodies have issued conflicting recommendations regarding the treatment of gout in people with concomitant CKD. As a result, confusion exists among medical professionals about the appropriate management of people with gout and CKD. This Consensus Statement from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) discusses the evidence and/or lack thereof for the management of gout in people with CKD and identifies key areas for research to address the challenges faced in the management of gout and CKD. These discussions, which address areas for research both in general as well as related to specific medications used to treat gout flares or as ULT, are supported by separately published G-CAN systematic literature reviews. This Consensus Statement is not intended as a guideline for the management of gout in CKD; rather, it analyses the available literature on the safety and efficacy of drugs used in gout management to identify important gaps in knowledge and associated areas for research.
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Affiliation(s)
| | | | - Huai Leng Pisaniello
- Discipline of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Ana B Vargas-Santos
- Department of Internal Medicine, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Mark Fisher
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
- Prima CARE, Fall River, MA, USA
| | - David B Mount
- Renal Divisions, Brigham and Women's Hospital, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Hyon K Choi
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert Terkeltaub
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Catherine L Hill
- Discipline of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Angelo L Gaffo
- University of Alabama at Birmingham, Birmingham, AL, USA
- Birmingham VA Medical Center, Birmingham, AL, USA
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Helget LN, England BR, Roul P, Sayles H, Petro AD, Michaud K, Mikuls TR. Incidence, Prevalence, and Burden of Gout in the Veterans Health Administration. Arthritis Care Res (Hoboken) 2021; 73:1363-1371. [PMID: 32475070 DOI: 10.1002/acr.24339] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/22/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the prevalence, incidence, and burden of gout in the Veterans Health Administration (VHA) from 2005 to 2014. METHODS We used national VHA data from January 1999 to December 2014 to determine the annual incidence and prevalence of gout in the VHA. Gout burden to the VHA was determined by the proportion of patients with an encounter related to gout. Rates of urate-lowering therapy (ULT) and opiate use were determined annually. Characteristics of those with and without gout were compared using 2014 data. RESULTS From 2005 to 2014, gout prevalence in the VHA increased from 4.2% to 5.8%, while disease incidence ranged from 5.8 to 7.4 cases per 1,000 patient-years. Gout prevalence was highest among men, older patients, and non-Hispanic black patients. During 2014, 4.0% of all inpatient or outpatient encounters and 1.3% of hospitalizations were gout related. Administration of ULT remained stable over the 10-year period, with 46% of gout patients receiving ULT in 2014. In contrast, 16.4% of prevalent gout patients were receiving a weak opioid in 2014, nearly doubling the prescription rate of weak opioids in 2005, while the use of stronger opioids did not change significantly over this period. Patients with gout had greater comorbidity and health care utilization than patients without gout. CONCLUSION The burden posed by gout in the VHA is considerable and increased between 2005 and 2014. While the use of ULT has remained stable, the use of opioid therapy has increased among patients with gout.
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Affiliation(s)
- Lindsay N Helget
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Bryant R England
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Punyasha Roul
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Alison D Petro
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Kaleb Michaud
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
| | - Ted R Mikuls
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center, Omaha, Nebraska
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Singh JA, Cleveland JD. Serious Infections in Patients With Gout in the US: A National Study of Incidence, Time Trends, and Outcomes. Arthritis Care Res (Hoboken) 2021; 73:898-908. [PMID: 32248660 DOI: 10.1002/acr.24201] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 03/24/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To study the epidemiology of serious infections in patients hospitalized with gout. METHODS We identified patients with gout hospitalized with a primary diagnosis of pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections (SSTIs), or opportunistic infections (OIs) in a US National Inpatient Sample from 1998 to 2016 and examined factors associated with utilization and mortality. RESULTS We noted 1,140,085 hospitalizations of patients with serious infections and gout (11% of all hospitalizations of patients with gout; 1998-2000 [8.9%], 2015-2016 [14.5%]). Compared to patients without gout, patients with gout hospitalized with serious infections were older (median age 65 versus 74 years), more of them had a Charlson-Deyo comorbidity index score ≥2 (42% versus 65%), and fewer were female (53% versus 35%) or non-White (40% versus 35%), respectively. The most common infection was pneumonia (52%) in 1998-2000 and sepsis (52%) in 2015-2016. Median hospital charges and hospital stays were higher for patients with sepsis and OIs in 2015-2016 ($41,000-$42,000; 5.1-5.5 days) versus those with UTI, pneumonia, or SSTIs ($15,000-$17,000; 3.0-3.9 days). Compared to patients with sepsis, the multivariable-adjusted odds of health care utilization and in-hospital mortality were significantly lower for patients with UTI, SSTIs, and pneumonia, and non-home discharge or in-hospital mortality were lower in patients with OIs. Among patients hospitalized with infections, older age, Medicaid coverage, a higher Charlson-Deyo comorbidity index score, Black race, and Northeast and nonrural hospital location were associated with significantly higher health care utilization and mortality, while female sex, Medicare insurance, and lower income were associated with higher utilization. CONCLUSION Given an increasing rate of serious infections, especially sepsis and pneumonia, in individuals with gout, development of effective interventions targeting factors associated with health care utilization and mortality will improve outcomes and reduce burden.
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Coffey CM, Sandhu AS, Crowson CS, Asante D, Matteson EL, Osborn TG, Warrington KJ, Makol A. Outpatient healthcare utilization among incident cases of systemic sclerosis: results from a population-based US cohort (1988-2016). Scand J Rheumatol 2021; 51:323-328. [PMID: 34232106 DOI: 10.1080/03009742.2021.1932581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is a complex, heterogeneous connective tissue disease with multiorgan dysfunction. This study aimed to compare healthcare utilization among incident cases of SSc versus age- and gender-matched comparators. METHOD A population-based cohort of physician-diagnosed patients with SSc in Olmsted County, MN, USA, from 1 January 1988 to 31 December 2016 was assembled. A 2:1 cohort of age- and gender-matched non-SSc subjects was randomly selected for comparison. Patients were followed until death, migration from Olmsted County, or 31 December 2017. Outpatient utilization data were obtained beginning 12 months before the SSc incidence/index date and compared using negative binomial and multinomial models. Services were summarized as visit-days to avoid overestimation of services provided. RESULTS The study included 69 incident SSc cases and 138 non-SSc comparators (mean ± sd age 57 ± 16 years at diagnosis/index, 90% female). Patients with SSc had higher utilization of outpatient physician, laboratory, and combined radiology visit-days annually for the year before and for each of the first 5 years after diagnosis than comparators. Among patients with SSc, healthcare utilization was highest during the year of SSc diagnosis. Rate ratios comparing utilization in patients with and without SSc ranged from 1.8 to 3.0 for all comparisons. CONCLUSION Higher utilization of outpatient physician, laboratory, and radiology visit-days was observed among patients with SSc compared to non-SSc subjects throughout 5 years of disease duration, indicating high and continued care needs in this patient population. The highest utilization of services among SSc patients occurred during the year of SSc diagnosis.
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Affiliation(s)
- C M Coffey
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - A S Sandhu
- Department of Internal Medicine, Kettering Medical Center, Kettering, OH, USA
| | - C S Crowson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - D Asante
- Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - E L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.,Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - T G Osborn
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - K J Warrington
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - A Makol
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Urits I, Smoots D, Anantuni L, Bandi P, Bring K, Berger AA, Kassem H, Ngo AL, Abd-Elsayed A, Manchikanti L, Urman R, Kaye AD, Viswanath O. Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review. Pain Ther 2020; 9:129-142. [PMID: 32100225 PMCID: PMC7203307 DOI: 10.1007/s40122-020-00158-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION This compilation presents a comprehensive review of the literature on common chronic pain conditions of the hand. It briefly presents these common conditions with their biological background, diagnosis, and common management options. It then presents and compares the latest literature available for injection techniques to treat these diagnoses and compares the available evidence. METHODS A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "hand pain", "injection techniques", "steroid injection", "chronic pain", "osteoarthritis", "rheumatoid arthritis", "carpal tunnel syndrome", "De Quervain's tenosynovitis", "ganglion cyst", "gout", "Raynaud's", and "stenosing tenosynovitis". RESULTS Hand pain is a common condition with 9.7% prevalence in men and 21.6% in women and can cause significant morbidity and disability. It also carries a significant cost to the individuals and the healthcare system, totaling in $4 billion dollars in 2003. Injection therapy is an alternative when conservative treatment fails. Osteoarthritis is the most common chronic hand pain syndrome and affects about 16% of the population. Its mechanism is largely mechanic, and as such, there is controversy if steroid injections are of benefit. Hyaluronic acid (HA) appears to provide substantial relief of pain and may increase functionality. More studies of HA are required to make a definite judgment on its efficacy. Similarly, steroid ganglion cyst injection may confer little benefit. Carpal tunnel syndrome is a compressive neuropathy, and only temporarily relieved with injection therapy. US-guidance provides significant improvement and, while severe cases may still require surgery, can provide a valuable bridge therapy to surgery when conservative treatment fails. Similar bridging treatments and increased efficacy under US-guidance are effective for stenosing tenosynovitis ("trigger finger"), though, interestingly, inflammatory background is associated with decreased effect in this case. When the etiology of the pain is inflammatory, such as in RA, corticosteroid (CS) injections provide significant pain relief and increased functionality. They do not, however, change the course of disease (unlike DMARDs). Another such example is De-Quervain tenosynovitis that sees good benefit from CS injections, and an increased efficacy with US-guidance, and similarly are CS injections for gout. For Raynaud's phenomenon, Botox injections have encouraging results, but more studies are needed to determine safety and efficacy, as well as the possible difference in effect between primary and secondary Raynaud's. CONCLUSIONS Chronic hand pain is a prevalent and serious condition and can cause significant morbidity and disability and interferes with independence and activities of daily living. Conservative treatment remains the first line of treatment; however, when first-line treatments fail, steroid injections can usually provide benefit. In some cases, HA or Botox may also be beneficial. US-guidance is increasing in hand injection and almost ubiquitously provides safer, more effective injections. Hand surgery remains the alternative for refractory pain.
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Affiliation(s)
- Ivan Urits
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Daniel Smoots
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Lekha Anantuni
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Prudhvi Bandi
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Katie Bring
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
| | - Amnon A Berger
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Hisham Kassem
- Department of Anesthesiology, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Anh L Ngo
- Department of Pain Medicine, Pain Specialty Group, Newington, NH, USA
- Harvard Medical School, Boston, MA, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Richard Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Valley Anesthesiology and Pain Consultants-Envision Physician Services, Phoenix, AZ, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Singh JA, Cleveland JD. Socioeconomic status and healthcare access are associated with healthcare utilization after knee arthroplasty: A U.S. national cohort study. Joint Bone Spine 2020; 87:157-162. [DOI: 10.1016/j.jbspin.2019.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/27/2019] [Indexed: 01/23/2023]
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