Burden of disease and management of osteoarthritis and chronic low back pain: healthcare utilization and sick leave in Sweden, Norway, Finland and Denmark (BISCUITS): study design and patient characteristics of a real world data study

Process evaluation of a randomised controlled trial - prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders (PREVSAM)

BACKGROUND

Musculoskeletal disorders are commonly treated in primary healthcare and may, if not treated adequately, entail a risk for long-term disability and sickness absence. A team-based rehabilitation intervention (PREVention of Sickness Absence for Musculoskeletal disorders, PREVSAM) was evaluated in a randomised controlled trial. The purpose of this study was to evaluate the process of implementing the PREVSAM model in primary care rehabilitation.

METHODS

This process evaluation was conducted alongside the trial, collecting quantitative and qualitative data to evaluate how the PREVSAM model was implemented, mechanisms of impact, and contextual factors. Acceptability, feasibility, appropriateness, adaptations, training and support, resources, recruitment, reach, retention, dose, fidelity, and readiness for change were investigated. Qualitative data were collected from healthcare professionals and patients.

RESULTS

Eight of 22 invited rehabilitation clinics (36%) and 28 of 54 healthcare professionals (52%) were included in the PREVSAM trial and this process evaluation. Of 507 eligible patients, 261 (51%) were included. Of those, 134 were randomised to the intervention and 129 (96%) were retained. Twelve healthcare professionals and 15 patients participated in the qualitative evaluations. The model's essential components; individual assessments and structured, team-based rehabilitation with clear division of responsibilities agreed in a joint health plan; were generally delivered according to protocol. The optional components early access to psychological treatment and workplace contact were delivered to a lesser extent. Perceived acceptability, feasibility, and appropriateness of the PREVSAM model were moderate to high. Several contextual barriers, in the form of missing prerequisites, affected the implementation. Qualitative data showed that the model, with its holistic view, was appreciated by both healthcare professionals and patients.

CONCLUSIONS

This process evaluation suggests that PREVSAM is acceptable, feasible and appropriate for patients with MSDs reporting psychological risk factors associated with increased risk for sickness absence. While essential components were implemented with fidelity for most patients, optional components were not. This variability reflects the complexity of the model, its mandatory and optional components, contextual barriers, and the person-centred approach meeting individual patient needs. As all model components were not delivered to all patients, the intervention may have been too similar to treatment as usual to detect differences on a group level. A limitation of the study is that half of the participating rehabilitation clinics withdrew prematurely.

Trajectories of opioid use among patients with low back pain: Association to work absence

BACKGROUND

Low back pain (LBP) is a leading reason for opioid use and a closer examination of opioid use and productivity losses among these patients is needed. We identify opioid use trajectories using a group-based trajectory model (GBTM) and estimate productivity losses across the trajectories.

METHODS

Patients diagnosed with LBP in Swedish specialty care between 2011 and 2015, between the ages of 20 and 60, were included. Two GBTMs were estimated on monthly opioid use (converted to oral morphine equivalents) during the two 12-month periods preceding and following diagnosis. Productivity losses were estimated using the human-capital approach.

RESULTS

In total, 147,035 patients were included. The mean age at diagnosis was 43 years of age and 49% of the patients were male. A qualitative assessment of the identified groups in the GBTM models was made based on the patterns of opioid use. We chose three pre-diagnosis groups characterized as 'Pre-low' (N = 109,492), 'Pre-increase' (N = 27,336) and 'Pre-high' (N = 10,207). Similarly, four post-diagnosis groups were chosen and characterized as 'Post-low' (N = 73,287), 'Post-decrease' (N = 39,446), 'Post-moderate' (N = 20,001) and 'Post-high' (N = 13,595). Only 50% of the patients in the 'Pre-high' group were in the 'Post-high' group. The total productivity losses by the pre-diagnosis groups were more than 2.7 billion Euros over the total 6-year study period.

CONCLUSION

This study highlights how patients with LBP and high use of opioids are highly correlated before and after diagnosis. Patients with high use of opioids also exhibit high work absence and productivity losses.

SIGNIFICANCE STATEMENT

This was the first study to estimate trajectories of opioids in the two time periods before and after a diagnosis of low back pain. For the first time, productivity losses were also estimated across the identified opioid use trajectories.

Association between Dietary total antioxidant capacity and knee osteoarthritis: a case-control study in the Iranian Population

AIM

Knee osteoarthritis (KOA) is a prevalent chronic condition associated with significant pain, disability, and healthcare costs, particularly among the elderly population. Despite the considerable burden of KOA, effective treatment options for managing the condition's underlying causes remain limited. This case-control study aims to investigate the relationship between dietary total antioxidant capacity (DTAC) and knee osteoarthritis.

METHODS

This case-control study was conducted on 105 patients with confirmed KOA and 210 controls. KOA was diagnosed based on the American College of Rheumatology criteria. Dietary total antioxidant capacity (DTAC) was calculated based on the ferric-reducing antioxidant power method.

RESULTS

The mean age and BMI of the participants were 53.6 ± 8.8 years old and 27.3 ± 2.7 kg/m2, respectively. The study participant's DTAC score ranged from 3.56 to 25.32 with a mean and SD of 12.46 ± 5.12. In the crude model, individuals in the highest quartile of DTAC score had 71% lower odds of having knee osteoarthritis compared to those in the first quartile (OR: 0.29, 95%CI: 0.15 to 0.58, P-trend < 0.001). These associations remained significant after adjustment for potential confounders including age, sex, energy intake, family history of osteoarthritis, vitamin D and calcium use, physical activity level, cigarette smoking and BMI. Although the odds of having knee osteoarthritis decreased with increasing quartiles of DTAC in both sexes, this relationship was stronger among males than females.

CONCLUSION

The results of this study showed that there was an inverse correlation between DTAC and KOA among the Iranian patients with KOA.

A randomized double-blind active-controlled clinical trial on the efficacy of topical basil (Ocimum basilicum) oil in knee osteoarthritis

Background

Basil is a widely used herb in Persian medicine and is gaining recognition as a functional food worldwide.

Aim of the study

This trial aimed to assess the effectiveness of a traditional formulation of basil oil in comparison with diclofenac gel in treating knee osteoarthritis, considering its established anti-inflammatory, anti-nociceptive, and anti-oxidative properties.

Materials and methods

One hundred eligible patients were equally randomized to the traditional basil oil (containing sesame oil) and diclofenac gel groups. They used their respective topical treatments thrice daily for 4 weeks. Various measurements were taken at the beginning of the study, 2, and 4 weeks after starting the intervention, including the 8-m walk test, knee pain (based on visual analog scale), flexion angle of the knee joint, analgesic consumption, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire.

Results

No significant differences were observed between the basil oil and diclofenac gel groups in any of the measured outcomes. However, significant improvements were noted within each group for most variables.

Conclusion

Topical application of the traditional formulation of basil oil appears to improve clinical symptoms and certain functional indicators of knee osteoarthritis to a similar extent as diclofenac gel. This suggests that basil oil could be considered an effective management option for this condition. Clinical Trial Registration: https://irct.behdasht.gov.ir/, identifier IRCT2017081711341N7.

Economic burden of osteoarthritis - multi-country estimates of direct and indirect costs from the BISCUITS study

Data from 'BISCUITS', a large Nordic cohort study linking several registries, were used to estimate differences in average direct and indirect costs between patients with osteoarthritis and controls (matched 1:1 based on birth year and sex) from the general population in Sweden, Norway, Finland and Denmark for 2017. Patients ≥18 years with ≥1 diagnosis of osteoarthritis (ICD-10: M15-M19) recorded in specialty or primary care (the latter available for a subset of patients in Sweden and for all patients in Finland) during 2011-2017 were included. Patients with a cancer diagnosis (ICD-10: C00-C43/C45-C97) were excluded. Productivity loss (sick leave and disability pension) and associated indirect costs were estimated among working-age adults (18-66 years). In 2017, average annual incremental direct costs among adults with osteoarthritis (n=1,157,236) in specialty care relative to controls ranged between €1,259 and €1,693 (p<0.001) per patient across all countries. Total average annual incremental costs were €3,224-€4,969 (p<0.001) per patient. Healthcare cost differences were mainly explained by osteoarthritis patients having more surgeries. However, among patients with both primary and secondary care data, primary care costs exceeded the costs of surgery. Primary care constituted 41 and 29 % of the difference in direct costs in Sweden and Finland, respectively. From a societal perspective, the total economic burden of osteoarthritis is substantial, and the incremental cost was estimated to €1.1-€1.3 billion yearly for patients in specialty care across the Nordic countries. When including patients in primary care, incremental costs rose to €3 billion in Sweden and €1.8 billion in Finland. Given the large economic impact, finding cost-effective and safe therapeutic strategies for these patients will be important.

Medication use and comorbidities in an increasingly younger osteoarthritis population: an 18-year retrospective open-cohort study

OBJECTIVES

As understanding of the pathogenesis and treatment strategies for osteoarthritis (OA) evolves, it is important to understand how patient factors are also changing. Our goal was to examine demographics and known risk factors of patients with OA over time.

DESIGN

Open-cohort retrospective study using electronic health records.

SETTING

Large US integrated health system with 7 hospitals, 2.6 million outpatient clinic visits and 97 300 hospital admissions annually in a mostly rural geographic region.

PARTICIPANTS

Adult patients with at least two encounters and a diagnosis of OA or OA-relevant surgery between 2001 and 2018. Because of geographic region, over 96% of participants were white/Caucasian.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

Descriptive statistics were used to examine age, sex, body mass index (BMI), Charlson Comorbidity Index, major comorbidities and OA-relevant prescribing over time.

RESULTS

We identified 290 897 patients with OA. Prevalence of OA increased significantly from 6.7% to 33.5% and incidence increased 37% (from 3772 to 5142 new cases per 100 000 patients per year) (p<0.0001). Percentage of females declined from 65.3% to 60.8%, and percentage of patients with OA in the youngest age bracket (18-45 years) increased significantly (6.2% to 22.7%, p<0.0001). The percentage of patients with OA with BMI ≥30 remained above 50% over the time period. Patients had low comorbidity overall, but anxiety, depression and gastro-oesophageal reflux disease showed the largest increases in prevalence. Opioid use (tramadol and non-tramadol) showed peaks followed by declines, while most other medications increased slightly in use or remained steady.

CONCLUSIONS

We observe increasing OA prevalence and a greater proportion of younger patients over time. With better understanding of how characteristics of patients with OA are changing over time, we can develop better approaches for managing disease burden in the future.

Problematic opioid use among osteoarthritis patients with chronic post-operative pain after joint replacement: analyses from the BISCUITS study

OBJECTIVES

Opioids are commonly used to manage pain, despite an increased risk of adverse events and complications when used against recommendations. This register study uses data of osteoarthritis (OA) patients with joint replacement surgery to identify and characterize problematic opioid use (POU) prescription patterns.

METHODS

The study population included adult patients diagnosed with OA in specialty care undergoing joint replacement surgery in Denmark, Finland, Norway, and Sweden during 1 January 2011 to 31 December 2014. Those with cancer or OA within three years before the first eligible OA diagnosis were excluded. Patients were allocated into six POU cohorts based on dose escalation, frequency, and dosing of prescription opioids post-surgery (definitions were based on guidelines, previous literature, and clinical experience), and matched on age and sex to patients with opioid use, but not in any of the six cohorts. Data on demographics, non-OA pain diagnoses, cardiovascular diseases, psychiatric disorders, and clinical characteristics were used to study patient characteristics and predictors of POU.

RESULTS

13.7% of patients with OA and a hip/knee joint replacement were classified as problematic users and they had more comorbidities and higher pre-surgery doses of opioids than matches. Patients dispensing high doses of opioids pre-surgery dispensed increased doses post-surgery, a pattern not seen among patients prescribed lower doses pre-surgery. Being dispensed 1-4,500 oral morphine equivalents in the year pre-surgery or having a non-OA pain diagnosis was associated with post-surgery POU (OR: 1.44-1.50, and 1.11-1.20, respectively).

CONCLUSIONS

Based on the discovered POU predictors, the study suggests that prescribers should carefully assess pain management strategies for patients with a history of comorbidities and pre-operative, long-term opioid use. Healthcare units should adopt risk assessment tools and ensure that these patients are followed up closely. The data also demonstrate potential areas for further exploration in improving patient outcomes and trajectories.