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Kuhrij LS, Marang-van de Mheen PJ, van Lier L, Alimahomed R, Nelissen RGHH, van Bodegom-Vos L. Reduction in use of MRI and arthroscopy among patients with degenerative knee disease in independent treatment centers versus general hospitals: a time series analysis. Int J Qual Health Care 2024; 36:mzae004. [PMID: 38252692 PMCID: PMC10849166 DOI: 10.1093/intqhc/mzae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/16/2023] [Accepted: 01/21/2024] [Indexed: 01/24/2024] Open
Abstract
The use of MRI and arthroscopy are considered low-value care in most patients with degenerative knee disease. To reduce these modalities, there have been multiple efforts to increase awareness. Reductions have been shown for general hospitals (GH), but it is unclear whether this may be partly explained by a shift of patients receiving these modalities in independent treatment centers (ITCs). The aims of this study were to assess (i) whether the trend in use of MRI and arthroscopy in patients with degenerative knee disease differs between ITCs and GH, and (ii) whether the Dutch efforts to raise awareness on these recommendations were associated with a change in the trend for both types of providers. All patients insured by a Dutch healthcare insurer aged ≥50 years with a degenerative knee disease who were treated in a GH or ITC between July 2014 and December 2019 were included. Linear regression was used with the quarterly percentage of patients receiving an MRI or knee arthroscopy weighted by center volume, as the primary outcome. Interrupted time-series analysis was used to evaluate the effect of the Dutch efforts to raise awareness. A total of 14 702 patients included were treated in 90 GHs (n = 13 303, 90.5%) and 29 ITCs (n = 1399, 9.5%). Across the study period, ITCs on an average had a 16% higher MRI use (P < .001) and 9% higher arthroscopy use (P = .003). MRI use did not change in both provider types, but arthroscopy use significantly decreased and became stronger in ITCs (P = .01). The Dutch efforts to increase awareness did not significantly influence either MRI or arthroscopy use in ITCs (P = .55 and P = .84) and GHs (P = .13 and P = .70). MRI and arthroscopy uses were higher in ITCs than GHs. MRI use did not change significantly among patients ≥ 50 years with degenerative knee disease in both provider types between 2014 and 2019. MRI- and arthroscopy use decreased with ITCs on average having higher rates for both modalities, but also showing a stronger decrease in arthroscopy use. The Dutch efforts to increase awareness did not accelerate the already declining trend in the Netherlands.
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Affiliation(s)
- Laurien S Kuhrij
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Lisanne van Lier
- Zorg & Zekerheid, Haagse Schouwweg 12, Leiden 2332 KG, the Netherlands
| | - Razia Alimahomed
- Zorg & Zekerheid, Haagse Schouwweg 12, Leiden 2332 KG, the Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, Leiden 2333 ZA, the Netherlands
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2
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Perna A, Proietti L. Editorial on: Musculoskeletal Rehabilitation: Current Challenges and New Perspectives. J Clin Med 2023; 12:3981. [PMID: 37373675 DOI: 10.3390/jcm12123981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Musculoskeletal disorders are among the leading causes of disability and chronic pain worldwide, and their impact is expected to increase in the coming years [...].
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Affiliation(s)
- Andrea Perna
- Departments of Orthopedic and Traumatology, Fondazione Casa Sollievo della Sofferenza, San Giovanni Rotondo, 71013 Foggia, Italy
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luca Proietti
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Goyal T, Tripathy SK, Schuh A, Paul S. Total knee arthroplasty after a prior knee arthroscopy has higher complication rates: a systematic review. Arch Orthop Trauma Surg 2022; 142:3415-3425. [PMID: 34542652 DOI: 10.1007/s00402-021-04175-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/09/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE This article aimed to study in a systematic manner outcomes and complication rates after total knee arthroplasty (TKA) in patients who have undergone a prior knee arthroscopy for osteoarthritis. Our hypothesis was that a prior knee arthroscopy may be detrimental to the outcomes of knee arthroplasty in the future. METHODS Electronic searches were performed for all studies published before June 2020. We included studies in which at least one group had a non-ligament knee arthroscopy surgery prior to primary knee arthroplasty. MINORS (Methodological index for non-randomized studies) criteria was used to assess the methodological quality of all the studies. RESULTS Seven retrospective studies were included in the systematic review. The total number of TKA without prior arthroscopies was 138,630, and the total TKA after a prior arthroscopy was 4372. Of the five studies that reported functional outcomes, three studies reported no difference, whereas two studies reported worse outcomes in patients with a prior knee arthroscopy. Higher rates of prosthetic joint infection and overall complications were seen in patients with a prior knee arthroscopy. CONCLUSION Total knee arthroplasty, when preceded by knee arthroscopy for osteoarthritis may lead to an increase in complication rates like prosthetic joint infections, revision, and re-operations. However, no significant differences were observed in patient-reported functional outcomes and range of joint motion. An association with postoperative complications after subsequent TKA should be a deterrent in advocating this procedure in an arthritic knee. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India
| | | | - Alexander Schuh
- Kliniken des Landkreises Neumarkt i.d.OPf, Nürnberger Str. 12, 92318, Neumarkt, Germany
| | - Souvik Paul
- Department of Orthopaedics, All India Institute of Medical Sciences, Bathinda, Punjab, 151001, India.
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Rietbergen T, Marang-van de Mheen PJ, de Graaf J, Diercks RL, Janssen RPA, van der Linden-van der Zwaag HMJ, van den Akker-van Marle ME, Steyerberg EW, Nelissen RGHH, van Bodegom-Vos L, Hofstee DJ, van Geenen RCI, Koenraadt KLM, Onderwater JPAH, Kleinlugtenbelt YV, Gosens T, Klos TVS, Rijk PC, Dijkstra B, Zeegers AVCM, Hoogeslag RAG, Veld MHAHI, Polak AA, Pereira NRP, Vervest TMJS, van der Veen HC, Lopuhaä N. A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:4134-4143. [PMID: 35391552 PMCID: PMC9668785 DOI: 10.1007/s00167-022-06949-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/15/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the effectiveness of a tailored intervention to reduce low value MRIs and arthroscopies among patients ≥ 50 years with degenerative knee disease in 13 Dutch orthopaedic centers (intervention group) compared with all other Dutch orthopaedic centers (control group). METHODS All patients with degenerative knee disease ≥ 50 years admitted to Dutch orthopaedic centers from January 2016 to December 2018 were included. The tailored intervention included participation of clinical champions, education on the Dutch Choosing Wisely recommendation for MRI's and arthroscopies in degenerative knee disease, training of orthopaedic surgeons to manage patient expectations, performance feedback, and provision of a patient brochure. A difference-in-difference analysis was used to compare the time trend before (admitted January 2016-June 2017) and after introduction of the intervention (July 2017-December 2018) between intervention and control hospitals. Primary outcome was the monthly percentage of patients receiving a MRI or knee arthroscopy, weighted by type of hospital. RESULTS 136,446 patients were included, of whom 32,163 were treated in the intervention hospitals. The weighted percentage of patients receiving a MRI on average declined by 0.15% per month (β = - 0.15, P < 0.001) and by 0.19% per month for arthroscopy (β = - 0.19, P < 0.001). However, these changes over time did not differ between intervention and control hospitals, neither for MRI (β = - 0.74, P = 0.228) nor arthroscopy (β = 0.13, P = 0.688). CONCLUSIONS The extent to which patients ≥ 50 years with degenerative knee disease received a MRI or arthroscopy declined significantly over time, but could not be attributed to the tailored intervention. This secular downward time trend may reflect anoverall focus of reducing low value care in The Netherlands. LEVEL OF EVIDENCE III.
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Affiliation(s)
- T. Rietbergen
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - P. J. Marang-van de Mheen
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - J. de Graaf
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - R. L. Diercks
- grid.4494.d0000 0000 9558 4598Department of Orthopaedics, University Medical Center Groningen, Groningen, The Netherlands
| | - R. P. A. Janssen
- grid.414711.60000 0004 0477 4812Department of Orthopaedic Surgery and Trauma, Maxima Medical Center, Eindhoven, The Netherlands ,grid.6852.90000 0004 0398 8763Orthopaedic Biomechanics, Department Of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands ,grid.448801.10000 0001 0669 4689Chair Value-Based Health Care, Fontys University of Applied Sciences, Eindhoven, The Netherlands
| | | | - M. E. van den Akker-van Marle
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - E. W. Steyerberg
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - R. G. H. H. Nelissen
- grid.10419.3d0000000089452978Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - L. van Bodegom-Vos
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC Leiden, The Netherlands
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Chan EW, Chaulk RC, Cheng Y, Shin J. No decrease in incidence of arthroscopic meniscectomy in a Canadian province. Knee Surg Sports Traumatol Arthrosc 2021; 29:4223-4231. [PMID: 33745007 DOI: 10.1007/s00167-021-06534-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/09/2021] [Indexed: 01/05/2023]
Abstract
PURPOSE Arthroscopic meniscectomy (APM) is the most common procedure in orthopedic surgery, despite increasing evidence questioning its benefit over conservative management for treatment of degenerative meniscal tears. The purpose of this study is to determine the epidemiology and trends of APM in Saskatchewan, a Canadian province, over a 20 year period. METHODS Physician billing codes were used to identify patients who underwent APM in Saskatchewan between January 1, 1998 and December 31, 2017. Records were obtained from eHealth Saskatchewan, a provincial health database. Data was analyzed for overall incidence and age-specific trends of APM. RESULTS A total of 35,099 APMs were performed during the study period. The population of Saskatchewan ranged from 992,314 to 1,150,782 (median 1,017,368) during this time interval, with 81 orthopedic surgeons performing APM. Overall incidence rate of APM did not change significantly over time. No decrease was observed in patients presumed to have degenerative tears (≥ 50 years). The number of meniscectomies in patients ≥ 50 years was significantly greater during the second decade of study compared to the first (OR 1.48, p < 0.01). Conversely, the increase in incidence rate among older patients was not statistically significant (R2 = 0.125, n.s.). CONCLUSION Overall incidence rate of APM in Saskatchewan has not decreased during the last 20 years. Furthermore, APM frequency increased over time for individuals ≥ 50 years. Several regional factors may have contributed to these findings, including the large proportion of Saskatchewan residents engaged in physically demanding work and barriers to accessing physiotherapy services. Given recent evidence disputing the benefit of APM over conservative measures, this study highlights the need for improved dissemination of evidence, as well as the importance of an individualized treatment plan to address patient-specific factors. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Emily W Chan
- Department of Surgery, University of Saskatchewan College of Medicine, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada. .,Division of Orthopedic Surgery, University of Saskatchewan College of Medicine, Saskatoon, Canada.
| | - Richard C Chaulk
- Department of Surgery, University of Saskatchewan College of Medicine, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada
| | - Yanzhao Cheng
- Department of Surgery, University of Saskatchewan College of Medicine, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada
| | - Jason Shin
- Department of Surgery, University of Saskatchewan College of Medicine, 107 Wiggins Road, Saskatoon, SK, S7N 5E5, Canada.,Division of Orthopedic Surgery, University of Saskatchewan College of Medicine, Saskatoon, Canada.,Dr. F. H. Wigmore Regional Hospital, Moose Jaw, Canada
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6
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Egerton T, Hinman RS, Hunter DJ, Bowden JL, Nicolson PJA, Atkins L, Pirotta M, Bennell KL. PARTNER: a service delivery model to implement optimal primary care management of people with knee osteoarthritis: description of development. BMJ Open 2020; 10:e040423. [PMID: 33033032 PMCID: PMC7542957 DOI: 10.1136/bmjopen-2020-040423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/14/2020] [Accepted: 09/06/2020] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Implementation strategies, such as new models of service delivery, are needed to address evidence practice gaps. This paper describes the process of developing and operationalising a new model of service delivery to implement recommended care for people with knee osteoarthritis (OA) in a primary care setting. METHODS Three development stages occurred concurrently and iteratively. Each stage considered the healthcare context and was informed by stakeholder input. Stage 1 involved the design of a new model of service delivery (PARTNER). Stage 2 developed a behavioural change intervention targeting general practitioners (GPs) using the behavioural change wheel framework. In stage 3, the 'Care Support Team' component of the service delivery model was operationalised. RESULTS The focus of PARTNER is to provide patients with education, exercise and/or weight loss advice, and facilitate effective self-management through behavioural change support. Stage 1 model design: based on clinical practice guidelines, known evidence practice gaps in current care, chronic disease management frameworks, input from stakeholders and the opportunities and constraints afforded by the Australian primary care context, we developed the PARTNER service-delivery model. The key components are: (1) an effective GP consultation and (2) follow-up and ongoing care provided remotely (telephone/email/online resources) by a 'Care Support Team'. Stage 2 GP behavioural change intervention: a multimodal behavioural change intervention was developed comprising a self-audit/feedback activity, online professional development and desktop software to provide decision support, patient information resources and a referral mechanism to the 'Care Support Team'. Stage 3 operationalising the 'care support team'-staff recruited and trained in evidence-based knee OA management and behavioural change methodology. CONCLUSION The PARTNER model is the result of a comprehensive implementation strategy development process using evidence, behavioural change theory and intervention development guidelines. Technologies for scalable delivery were harnessed and new primary evidence was generated as part of the process.Trial registration number ACTRN12617001595303 (UTN U1111-1197-4809).
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Affiliation(s)
- Thorlene Egerton
- Centre for Health Exercise & Sports Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Rana S Hinman
- Centre for Health Exercise & Sports Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - David J Hunter
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
- Department of Rheumatology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jocelyn L Bowden
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, Sydney, New South Wales, Australia
- Department of Rheumatology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Philippa J A Nicolson
- Centre for Health Exercise & Sports Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lou Atkins
- Centre for Behaviour Change, UCL, London, UK
| | - Marie Pirotta
- Department of General Practice, University of Melbourne, Melbourne, Victoria, Australia
| | - Kim L Bennell
- Centre for Health Exercise & Sports Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Kenihan L, McTier L, Phillips NM. Patients' expectations and experiences of stem cell therapy for the treatment of knee osteoarthritis. Health Expect 2020; 23:1300-1309. [PMID: 32794633 PMCID: PMC7696136 DOI: 10.1111/hex.13113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/17/2020] [Accepted: 07/09/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Stem cell therapy is a novel treatment option for people living with osteoarthritis. Research investigating stem cell therapy for this debilitating condition has predominantly involved the pathogenesis of the cells and efficacy of the treatment. There is little understanding of patients' expectations and experiences of stem cell therapy treatment. OBJECTIVE To explore the expectations and experiences of people undergoing stem cell therapy for the treatment of knee osteoarthritis. DESIGN An exploratory, descriptive, qualitative study using semi-structured interviews was conducted. SETTING AND PARTICIPANTS Participants were recruited into two groups: (a) Expectations Group (n = 15); the expectations of stem cell treatment were explored with participants that were yet to commence stem cell therapy. (b) Experiences Group (n = 15); the experiences of stem cell therapy were explored with participants 12 months after their initial stem cell treatment. Transcripts were analysed using thematic analysis to identify themes in both groups. RESULTS Themes for the Expectations Group were active involvement in the treatment; treatment will improve symptoms; and benefits of treatment outweigh the risks. Themes for the Experiences Group were symptoms of treatment; satisfaction with treatment; and anticipation of further improvement. DISCUSSION AND CONCLUSIONS The findings are the first qualitative study to represent patients' perspective on expectations and experiences of stem cell therapy for knee osteoarthritis. They provide insight into the potential areas for improvement within this field to aid patients' preparation and approach to the treatment, promoting patient-centred care.
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Affiliation(s)
| | - Lauren McTier
- Centre for Quality and Patient Safety ResearchSchool of Nursing and MidwiferyDeakin UniversityGeelongVIC.Australia
| | - Nicole M. Phillips
- Centre for Quality and Patient Safety ResearchSchool of Nursing and MidwiferyDeakin UniversityGeelongVIC.Australia
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de Steiger RN. Best evidence, but does it really change practice? BMJ Qual Saf 2020; 29:358-360. [PMID: 31907324 DOI: 10.1136/bmjqs-2019-010513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Richard N de Steiger
- Department of Surgery, Epworth Health Care, University of Melbourne, Parkville, Victoria, Australia
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9
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Rietbergen T, Diercks RL, Anker-van der Wel I, van den Akker-van Marle ME, Lopuhaä N, Janssen RPA, van der Linden-van der Zwaag HMJ, Nelissen RGHH, Marang-van de Mheen PJ, van Bodegom-Vos L. Preferences and beliefs of Dutch orthopaedic surgeons and patients reduce the implementation of "Choosing Wisely" recommendations in degenerative knee disease. Knee Surg Sports Traumatol Arthrosc 2020; 28:3101-3117. [PMID: 31555844 PMCID: PMC7511282 DOI: 10.1007/s00167-019-05708-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 09/11/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to assess which factors were associated with the implementation of "Choosing Wisely" recommendations to refrain from routine MRI and arthroscopy use in degenerative knee disease. METHODS Cross-sectional surveys were sent to 123 patients (response rate 95%) and 413 orthopaedic surgeons (response rate 62%) fulfilling the inclusion criteria. Univariate and multivariate logistic regression analyses were used to identify factors associated with implementation of "Choosing Wisely" recommendations. RESULTS Factors reducing implementation of the MRI recommendation among patients included explanation of added value by an orthopaedic surgeon [OR 0.18 (95% CI 0.07-0.47)] and patient preference for MRI [OR 0.27 (95% CI 0.08-0.92)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own MRI experience than existing evidence [OR 0.41 (95% CI 0.19-0.88)] and higher estimated patients' knowledge to participate in shared decision-making [OR 0.38 (95% CI 0.17-0.88)]. Factors reducing implementation of the arthroscopy recommendation among patients were orthopaedic surgeons' preferences for an arthroscopy [OR 0.03 (95% CI 0.00-0.22)] and positive experiences with arthroscopy of friends/family [OR 0.03 (95% CI 0.00-0.39)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own arthroscopy experience than existing evidence [OR 0.17 (95% CI 0.07-0.46)] and belief in the added value [OR 0.28 (95% CI 0.10-0.81)]. CONCLUSIONS Implementation of "Choosing Wisely" recommendations in degenerative knee disease can be improved by strategies to change clinician beliefs about the added value of MRIs and arthroscopies, and by patient-directed strategies addressing patient preferences and underlying beliefs for added value of MRI and arthroscopies resulting from experiences of people in their environment. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- T Rietbergen
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - R L Diercks
- Department of Orthopaedics, University Medical Center Groningen, Groningen, The Netherlands
| | - I Anker-van der Wel
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - M E van den Akker-van Marle
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - N Lopuhaä
- ReumaNederland, Amsterdam, The Netherlands
| | - R P A Janssen
- Department of Orthopaedics, Máxima Medical Center, Eindhoven, The Netherlands
| | | | - R G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - P J Marang-van de Mheen
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - L van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Postzone J10-s, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
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Klein J, McColl G. Cognitive dissonance: how self-protective distortions can undermine clinical judgement. MEDICAL EDUCATION 2019; 53:1178-1186. [PMID: 31397007 DOI: 10.1111/medu.13938] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/27/2019] [Accepted: 06/21/2019] [Indexed: 06/10/2023]
Abstract
CONTEXT When errors occur in clinical settings, it is important that they are recognised without defensiveness so that prompt corrective action can be taken and learning can occur. Cognitive dissonance - the uncomfortable tension we experience when we hold two or more inconsistent beliefs - can hinder our ability to respond optimally to error. OBJECTIVES The aim of this paper is to describe the effects of cognitive dissonance, a construct developed and tested in social psychology. We discuss the circumstances under which dissonance is most likely to occur, provide examples of how it may influence clinical practice, discuss potential remedies and suggest future research to test these remedies in the clinical context. METHODS We apply research on cognitive dissonance from social psychology to clinical settings. We examine the factors that make dissonance most likely to occur. We illustrate the power of cognitive dissonance through two medical examples: one from history and one that is ongoing. Finally, we explore moderators at various stages of the dissonance process to identify potential remedies. RESULTS We show that there is great opportunity for cognitive dissonance to distort judgements, delay optimal responses and hinder learning in clinical settings. We present a model of the phases of cognitive dissonance, and suggestions for preventing dissonance, reducing the distortions that can arise from dissonance and inhibiting dissonance-induced escalation of commitment. CONCLUSIONS Cognitive dissonance has been studied for decades in social psychology but has not had much influence on medical education research. We argue that the construct of cognitive dissonance is very relevant to the clinical context and to medical education. Dissonance has the potential to interfere with learning, to hinder the process of coping effectively with error, and to make the accepting of change difficult. Fortunately, there is the potential to reduce the negative impact of cognitive dissonance in clinical practice.
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Affiliation(s)
- Jill Klein
- Department of Medical Education, Melbourne Medical School, University of Melbourne, Carlton, Victoria, Australia
- Melbourne Business School, University of Melbourne, Carlton, Victoria, Australia
| | - Geoff McColl
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Diab DG, Elmaddawy AA, Elganainy A. Intra-Articular Morphine versus Dexmedetomedine for Knee Arthroscopy under Local Anesthesia. Anesth Essays Res 2019; 13:7-12. [PMID: 31031472 PMCID: PMC6444968 DOI: 10.4103/aer.aer_154_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Knee arthroscopy has both diagnostic and therapeutic applications which can be performed under general, regional, or local anesthesia. Morphine is used as an additive to local anesthetics. Dexmedetomedine, the highly selective alpha-2 (α2)-adrenoceptor agonist with the sedative and analgesic effect can be used also to augment local anesthetic effect. Patients and Methods: Sixty patients submitted for elective knee arthroscopy whose age between 25 and 45 years, of either sex, the American society of anethesiologists physical status Classes I and II at a university hospital were enrolled in this study. Patients were classified into two groups. Morphine Group (M) (n = 30): Patients received 20 ml of 0.5% bupivacaine plus 5 ml of 0.2% lidocaine with epinephrine 1:200,000 plus 1 mg morphine. Dexmedetomedine Group (D) (n = 30): Patients received 20 ml of 0.5% bupivacaine plus 5 ml of 0.2% lidocaine with epinephrine 1:200,000 plus 1 μg/kg dexmedetomedine. Results: Demographic data of patients showed no significant difference among the studied groups. Heart rate (HR) was significantly lower in (D) Group compared to that of (M) Group 5 min from the start of procedure to immediately postoperatively. Moreover, (D) Group showed a significant decrease in HR 10 min up to 35 min intraoperatively compared to the basal value. Furthermore, mean arterial blood pressure (MBP) was significantly lower in (D) Group compared to that of (M) Group 15 min from the start of surgery up to 1 h postoperatively. Furthermore, (D) Group showed a significant decrease in MBP 15 min intraoperative up to 2 h postoperatively compared to the basal value. While there was no significant difference in (visual analogue score [VAS], onset and total consumption of ketorolac, surgeon and patients’ satisfaction, side effects in (D) Group compared to (M) Group, respectively. Conclusion: Addition of either morphine or dexmedetomidine to bupivacaine intraarticularly improved both intraoperative anesthesia and postoperative analgesia with minimal side effects or complications in knee arthroscopy, with superiority of dexmedetomidine compared to morphine on hemodynamic stability.
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Affiliation(s)
- Doaa Galal Diab
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Alaaeldin Adel Elmaddawy
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Padwal JA, Burton BN, Fiallo AA, Swisher MW, Gabriel RA. The association of neuraxial versus general anesthesia with inpatient admission following arthroscopic knee surgery. J Clin Anesth 2019; 56:145-150. [PMID: 30807886 DOI: 10.1016/j.jclinane.2019.01.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVE Arthroscopic knee procedures are increasingly being performed in an outpatient setting. Appropriate intraoperative anesthesia is vital to prevent complications such as unanticipated hospital admission. We examined differences in complications between general (GA) vs neuraxial anesthesia (NA) as the primary anesthetic for patients undergoing arthroscopic knee procedures. DESIGN This was a retrospective cohort study. We queried the National Surgical Quality Improvement Program for arthroscopic knee procedures performed between 2007 and 2016. We compared postoperative complication rates between propensity-matched cohorts (NA vs GA). The anesthesia groups were matched based on age, race, BMI, gender, diabetes, smoking history, COPD, CHF, functional status, HTN, ASA class, steroid use, bleeding disorder history, and readmission status. Univariable and multivariable logistic regression were used to compare factors associated with inpatient admission - defined as hospital length of stay >1 day. PATIENTS A total of 57,494 patients were included - 55,257 GA and 2237 NA patients. MAIN RESULTS Among the matched cohorts, NA patients were significantly more likely to be admitted to the hospital postoperatively (p < 0.001). Neuraxial anesthesia (OR 5.93, 95% CI 4.90-7.21) use was also significant in the final multivariable regression model for inpatient admission. Additional significant predictors for inpatient admission included history of bleeding disorder (OR 5.44, 95% CI 2.14-12.76), Asian race (OR 6.47, 95% CI 4.90-8.56), COPD (OR 3.10, 95% CI 1.94-4.82), diabetes (OR 1.90, 95% CI 1.43-2.49), and increased operation time (OR 3.01, 95% CI 2.69-3.37). CONCLUSIONS NA was significantly associated with inpatient admission following knee arthroscopy. Further research should focus on examining the reason for this association and methods to reduce inpatient admission for patients undergoing arthroscopic knee procedures using neuraxial anesthesia.
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Affiliation(s)
- Jennifer A Padwal
- School of Medicine, University of California, San Diego-9500 Gilman Drive, San Diego, CA 92093, United States of America.
| | - Brittany N Burton
- School of Medicine, University of California, San Diego-9500 Gilman Drive, San Diego, CA 92093, United States of America.
| | - Alfredo A Fiallo
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, UCSD Medical Cent Hillcrest, 200 W. Arbor Drive, San Diego, CA 92103-8770, United States of America.
| | - Matthew W Swisher
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, UCSD Medical Cent Hillcrest, 200 W. Arbor Drive, San Diego, CA 92103-8770, United States of America.
| | - Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, UCSD Medical Cent Hillcrest, 200 W. Arbor Drive, San Diego, CA 92103-8770, United States of America; Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, San Diego - 9500 Gilman Dr. MC 0728, La Jolla, CA 92093-0728, United States of America.
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Law GW, Lee JK, Soong J, Lim JWS, Zhang KT, Tan AHC. Arthroscopic debridement of the degenerative knee - Is there still a role? ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2018; 15:23-28. [PMID: 30581756 PMCID: PMC6289903 DOI: 10.1016/j.asmart.2018.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 11/16/2018] [Accepted: 11/20/2018] [Indexed: 01/03/2023]
Abstract
Objectives The role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. There are however, limited studies on the management of the subgroup of significantly symptomatic patients who remain refractory to maximal conservative treatment and are poor candidates for knee replacement surgery.We propose that with careful patient selection, arthroscopic debridement can provide good symptomatic relief with sustained benefits in the degenerative knee. Methods We performed a retrospective, single-surgeon study of 180 consecutive knee arthroscopies performed in 169 patients, aged 40 years and above, who had mechanical symptoms affecting their daily lives and underwent arthroscopic debridement after failure of a minimum 2 months of optimized medical and physical therapy. Severity of the knee osteoarthritis on plain radiographs was assessed using the Kellgren-Lawrence classification.Functional and satisfaction scores were assessed using Oxford Knee Score, Koos Knee Survey, Short Form-36, Numeric Pain Rating Scale, and questions adapted from the North American Spine Society Questionnaire. Results Excellent functional outcomes and patient satisfaction were reported in the majority of patients over the follow-up timeframe of 2-8 years. The mean pre-operative Kellgren-Lawrence score was 2.02 (SD 0.580). Significant improvements compared to pre-operative scores were seen across all scoring systems tested. 90% of patients reported good to excellent results. Conclusion Arthroscopic knee debridement can provide good symptomatic relief and sustained benefits in significantly symptomatic patients with early degenerative knees who have failed conservative management. This is most useful in patients with mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis.
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Holtedahl R, Brox JI, Aune AK, Nguyen D, Risberg MA, Tjomsland O. Changes in the rate of publicly financed knee arthroscopies: an analysis of data from the Norwegian patient registry from 2012 to 2016. BMJ Open 2018; 8:e021199. [PMID: 29909370 PMCID: PMC6009626 DOI: 10.1136/bmjopen-2017-021199] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To examine rates of publicly financed knee arthroscopic surgery in Norway between 2012 and 2016. DESIGN Analysis of anonymised data from the National Patient Registry. INTERVENTIONS Beginning in 2012, South-Eastern Norway Regional Health Authority implemented administrative measures to bring down rates of knee arthroscopy. Similar measures were not introduced in the other three Regional Health Authorities. MAIN OUTCOME MEASURES We analysed annual national rates of publicly financed knee arthroscopies in 2012 and 2016. We compared the rates in South-Eastern Norway Regional Health Authority with corresponding rates in the rest of the country. Variations by county, public hospital versus publicly reimbursed private hospital, gender and age were also assessed. RESULTS The overall annual rate of arthroscopic procedures declined by 33% from 2012 to 2016, from 310 to 207 per 100 000 inhabitants, respectively. Hospitals in South-Eastern Norway Regional Health Authority reported a 48% reduction, compared with mean 13% in the other three Regional Health Authorities. In public hospitals, rates decreased nationally by 42%, while rates in publicly reimbursed private hospitals increased by 12%. Rates in publicly reimbursed private hospitals decreased by 30% in South-Eastern Norway Regional Health Authority but increased by 63% in the other Regional Health Authorities. The proportion of patients ≥50 years (excluding meniscal repairs) in Norway was 54% in 2012 and fell to 46% in 2016. Average rates per county varied by a factor of 3:1. CONCLUSION We report a marked overall reduction of knee arthroscopic procedures from 2012 to 2016 in publicly funded hospitals. The largest decrease was reported in South-Eastern Norway Regional Health Authority, and this coincides in time with implemented administrative measures. The results suggest that the trend of increasing rates of knee arthroscopies can be reversed through purposeful professional and administrative interventions.
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Affiliation(s)
- Robin Holtedahl
- Department of Habilitation and Rehabilitation, Innlandet Hospital Trust-Division Ottestad, Ottestad, Norway
| | - Jens Ivar Brox
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
- Medical Faculty, University of Oslo, Oslo, Norway
| | | | - Daniel Nguyen
- South-Eastern Norway Regional Health Authority, Hamar, Norway
| | - May Arna Risberg
- Department of Sports Medicine, Norwegian School of Sport Sciences, Oslo, Norway
| | - Ole Tjomsland
- South-Eastern Norway Regional Health Authority, Hamar, Norway
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A controlled before-after study to evaluate the effect of a clinician led policy to reduce knee arthroscopy in NSW. BMC Musculoskelet Disord 2018; 19:148. [PMID: 29769120 PMCID: PMC5956807 DOI: 10.1186/s12891-018-2043-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 04/08/2018] [Indexed: 01/04/2023] Open
Abstract
Background Clinical evidence shows knee arthroscopy has little benefit for degenerative conditions and considerable variation in the incidence of knee arthroscopy in Australia has been identified. This study aimed to evaluate a clinician-led evidence-based policy which was implemented in one local health district in New South Wales (NSW) in 2012 to reduce the use of knee arthroscopy for patients aged 50 years or over. Methods Trends in rates and volume of knee arthroscopy for patients 50 years or over in NSW between 2004 and 2015 by district were examined. Changes at four hospitals that adopted the policy were assessed by a quasi-experimental before and after study design with control groups, using the generalised estimating equations (GEE) Poisson model. Each case hospital was matched with four control hospitals in terms of the volume of knee arthroscopy surgeries performed in the five years prior to the intervention. Results Between 2004 and 2015, the number of knee arthroscopies in NSW initially increased and then decreased after 2011, with considerable variation across districts. While an overall reducing trend in NSW was observed between 2011 and 2015 (39%), a 58% reduction (95% CI: 55–62%) was found in the intervention district, including the private sector, being the greatest reduction found in all districts. The GEE Poisson results show that, compared with control hospitals, the number of knee arthroscopy was significantly reduced by 56% (95% CI: 11%–79%) at four hospitals that adopted the policy during the follow-up period (p = 0.02). Conclusions Clinicians in one local health district initiated a policy to restrict knee arthroscopy for patients aged 50 years or over, which may explain the greater reduction seen in that district compared to all others, despite an overall decrease noted in the state. A significant reduction found at intervened hospitals proved the effect of the policy, suggesting that the implementation of a simple clinical governance process may help reduce inappropriate surgery. Electronic supplementary material The online version of this article (10.1186/s12891-018-2043-5) contains supplementary material, which is available to authorized users.
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Siemieniuk RAC, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. Br J Sports Med 2018; 52:313. [PMID: 29449218 PMCID: PMC5867409 DOI: 10.1136/bjsports-2017-j1982rep] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia
- South Western Sydney Clinical School, UNSW, Australia
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Joint Research, OLVG, Amsterdam, The Netherlands
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Faculty of Dentistry, Universidad de Chile, Independencia, Santiago, Chile
| | | | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Malvern, Victoria, Australia
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund Faculty of Medicine, Lund University, Lund, Sweden
| | | | | | - Lise Helsingen
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Nina Rydland Olsen
- Department of Occupational Therapy, Physiotherapy and Radiography, Faculty of Health and Social sciences, Bergen University College, Bergen, Norway
| | | | - Louise Hailey
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Annette Kristiansen
- Department of Health and Science, University of Oslo, Oslo, Norway
- Department of Medicine, Hospital Innlandet Trust, Gjøvik, Norway
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Buchbinder R, Bourne A. Content analysis of consumer information about knee arthroscopy in Australia. ANZ J Surg 2018; 88:346-353. [DOI: 10.1111/ans.14412] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/01/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Rachelle Buchbinder
- Monash Department of Clinical Epidemiology; Cabrini Institute; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine, Monash University; Melbourne Victoria Australia
| | - Allison Bourne
- Monash Department of Clinical Epidemiology; Cabrini Institute; Melbourne Victoria Australia
- Department of Epidemiology and Preventive Medicine; School of Public Health and Preventive Medicine, Monash University; Melbourne Victoria Australia
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Cicuttini FM, Teichtahl AJ, Wang Y. Hip arthroscopy for femoroacetabular impingement: use escalating beyond the evidence. Med J Aust 2017; 206:424-426. [PMID: 28566064 DOI: 10.5694/mja16.00821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/18/2016] [Indexed: 11/17/2022]
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Siemieniuk RAC, Harris IA, Agoritsas T, Poolman RW, Brignardello-Petersen R, Van de Velde S, Buchbinder R, Englund M, Lytvyn L, Quinlan C, Helsingen L, Knutsen G, Olsen NR, Macdonald H, Hailey L, Wilson HM, Lydiatt A, Kristiansen A. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ 2017; 357:j1982. [PMID: 28490431 PMCID: PMC5426368 DOI: 10.1136/bmj.j1982] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ian A Harris
- South Western Sydney Clinical School, UNSW, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Joint Research, OLVG, 1090 HM Amsterdam, The Netherlands
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
- Faculty of Dentistry, Universidad de Chile, Independencia, Santiago, Chile
| | | | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Vic 3004, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute; Suite 41 Cabrini Medical Centre, Malvern Vic, 3144, Australia
| | - Martin Englund
- Clinical Epidemiology Unit, Orthopaedics, Department of Clinical Sciences Lund Faculty of Medicine, Lund University, SE-221 85 Lund, Sweden
| | - Lyubov Lytvyn
- Oslo University Hospital, Blindern 0317 Oslo, Norway
| | | | - Lise Helsingen
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Blindern 0317 Oslo, Norway
| | | | - Nina Rydland Olsen
- Department of Occupational Therapy, Physiotherapy and Radiography, Faculty of Health and Social sciences, Bergen University College, 5020 Bergen, Norway
| | | | - Louise Hailey
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7HE, UK
| | | | | | - Annette Kristiansen
- Department of Health and Science, University of Oslo, Oslo, Norway
- Department of Medicine, Hospital Innlandet Trust, Gjøvik, Norway
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The incidence and impact of arthroscopy in the year prior to total knee arthroplasty. Knee 2017; 24:396-401. [PMID: 28081897 DOI: 10.1016/j.knee.2016.12.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 11/16/2016] [Accepted: 12/12/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prior knee surgery and arthroscopy is known to increase complications and re-operations in subsequent total knee arthroplasty (TKA). We set out to examine the time dependant effect of arthroscopy on Patient Reported Outcome Measures following subsequent TKA. METHODS A retrospective review of theatre and clinical records identified 186 patients who underwent TKA within a year of arthroscopy (2009-2013). Oxford knee score (OKS) data was compared with a published cohort from the same department (1708 patients). RESULTS One hundred and eighty six patients were identified who underwent TKA within a year of arthroscopy; 112 females, 74 males; mean age 64 (SD 10); mean BMI 31.4 (SD 4.6). There was no significant difference between groups with respect to sex, age, BMI, or pre-operative OKS. One hundred and three patients underwent TKA within six months of arthroscopy. This group had a significant reduction in OKS compared to the previously published cohort (32.8 vs 36.3, p<0.005). There was no significant difference in OKS when TKA was performed more than six months after arthroscopy (35.3). The re-operation rate was 14% in the arthroscopy group, with a revision rate of 3.8% vs 1.6% in a previously published large cohort from the same institution. CONCLUSIONS There appears to be a negative impact of arthroscopy in relation to subsequent TKA which seems to be time dependent. TKA should not routinely be performed within six months of arthroscopy. This should inform guidelines on the management knee osteoarthritis.
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Lisik JP, Dowsey MM, Petterwood J, Choong PFM. Review of knee arthroscopic practice and coding at a major metropolitan centre. ANZ J Surg 2016; 87:380-384. [PMID: 27677890 DOI: 10.1111/ans.13664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 01/11/2016] [Accepted: 05/12/2016] [Indexed: 01/29/2023]
Abstract
BACKGROUND Arthroscopic knee surgery has been a topic of significant controversy in recent orthopaedic literature. Multiple studies have used administrative (Victorian Admitted Episodes Dataset and Centre for Health Record Linkage) data to identify trends in practice. This study explored the usage and reporting of arthroscopic knee surgery by conducting a detailed audit at a major Victorian public hospital. METHODS A database of orthopaedic procedures at St Vincent's Hospital Melbourne was used to retrospectively identify cases of knee arthroscopy from 1 December 2011 to 1 April 2014. Procedures were categorized as diagnostic or interventional, and native and prosthetic joints were analysed separately. Procedure codes were reviewed by comparing a registrar, auditor and hospital coders for agreement. RESULTS Of the 401 cases for analysis, 375 were conducted in native knees and 26 in prosthetic joints. Of native knees, 369 (98.4%) were considered interventional. The majority of these were conducted for meniscal pathology (n = 263, 70.1%), osteoarthritis (OA) (n = 25, 6.7%) and infection (n = 28, 7.6%). Comparison of codes assigned by different parties were found to be between 57% (k = 0.324) and 70% (k = 0.572) agreement, but not statistically significant. CONCLUSIONS In this study, the most common indication for arthroscopy was meniscal pathology. Arthroscopy was rarely performed for OA in the absence of meniscal pathology. Diagnostic arthroscopy was rarely performed in the native knee, and fair to moderate agreement existed between parties in assigning Medicare Benefits Schedule procedure codes.
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Affiliation(s)
- James P Lisik
- Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Michelle M Dowsey
- Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Joshua Petterwood
- Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Peter F M Choong
- Department of Surgery, The University of Melbourne, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Orthopaedics, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Hall M, Juhl CB, Lund H, Thorlund JB. Knee Extensor Muscle Strength in Middle-Aged and Older Individuals Undergoing Arthroscopic Partial Meniscectomy: A Systematic Review and Meta-Analysis. Arthritis Care Res (Hoboken) 2016; 67:1289-1296. [PMID: 25776139 DOI: 10.1002/acr.22581] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 01/19/2015] [Accepted: 03/10/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE People with meniscal tears are at high risk to develop or progress to knee osteoarthritis. Knee extensor weakness is considered a risk factor for osteoarthritis and is often reported in these individuals. The purpose of this systematic review and meta-analysis was to investigate knee extensor strength in people undergoing an arthroscopic partial meniscectomy (APM). METHODS Six databases (Medline, CINAHL, SPORTDiscus, Embase, PEDro, and AMED) were searched up to June 22, 2014. Studies that measured knee extensor muscle strength in people age ≥30 years undergoing APM for a meniscal tear and used either a healthy control group or the contralateral leg to compare knee extensor muscle strength were included. Methodological quality was assessed using guidelines from the Centre for Reviews and Dissemination. RESULTS Eleven studies, in which participants were predominantly male, were included (n = 596). A moderate reduction in muscle strength was observed prior to APM compared to controls (standardized mean difference [SMD] 0.58, 95% confidence interval [95% CI] 0.04, 1.13) and continued up to 6 months postsurgery (SMD range -2.42 to -0.47). There was no difference in muscle strength at 2 years post-APM (SMD -0.01 [95% CI -0.36, 0.35]), while a moderate reduction was again apparent at 4 years post-APM (SMD -0.56, [95% CI -1.20, 0.08]) compared to controls. CONCLUSION Our findings suggest that middle-aged and older individuals undergoing APM have reduced knee extensor muscle strength in the operated leg compared to control data. As meniscus pathology and knee extensor muscle weakness are risk factors for osteoarthritis, these results highlight the clinical importance of addressing muscle weakness in these individuals.
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Affiliation(s)
- Michelle Hall
- University of Melbourne, Melbourne, Victoria, Australia
| | - Carsten B Juhl
- Copenhagen University Hospital, Gentofte, and University of Southern Denmark, Odense, Denmark
| | - Hans Lund
- Bergen University College, Bergen, Norway, and University of Southern Denmark, Odense, Denmark
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Arthroscopy for Knee Osteoarthritis Has Not Decreased After a Clinical Trial. Clin Orthop Relat Res 2016; 474:489-94. [PMID: 26290345 PMCID: PMC4709284 DOI: 10.1007/s11999-015-4514-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple clinical trials have shown that arthroscopy for knee osteoarthritis is not efficacious. It is unclear how these studies have affected orthopaedic practice in the USA. QUESTIONS/PURPOSES We questioned whether, in the Veterans Health Administration system, rates of knee arthroscopy in patients with osteoarthritis have changed after publication of the initial clinical trial by Moseley et al. in 2002, and whether rates of arthroplasty within 2 years of arthroscopy have changed during the same period. METHODS Patients 50 years and older with knee osteoarthritis who underwent arthroscopy between 1998 and 2010 were retrospectively identified and an annual arthroscopy rate was calculated from 1998 through 2002 and from 2006 through 2010. Patients who underwent knee arthroplasty within 2 years of arthroscopy during each period were identified, and a 2-year conversion to arthroplasty rate was calculated. RESULTS Between 1998 and 2002, the annual arthroscopy rate decreased from 4% to 3%. Of these arthroscopies, 4% were converted to arthroplasty within 2 years. Between 2006 and 2010, the annual arthroscopy rate increased from 3% to 4%. Of these arthroscopies, 5% were converted to arthroplasty within 2 years. CONCLUSIONS Rates of arthroscopy in patients with knee osteoarthritis and conversion to arthroplasty within 2 years have not decreased with time. It may be that evidence alone is not sufficient to alter practice patterns or that arthroscopy rates for arthritis for patients in the Veterans Health Administration system were already so low that the results of the initial clinical trial had no substantial effect. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Lohmander LS, Thorlund JB, Roos EM. Routine knee arthroscopic surgery for the painful knee in middle-aged and old patients--time to abandon ship. Acta Orthop 2016; 87:2-4. [PMID: 26634953 PMCID: PMC4940586 DOI: 10.3109/17453674.2015.1124316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- L Stefan Lohmander
- Orthopedics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense
- Department of Orthopedics and Traumatology, Odense University Hospital, Odense, Denmark
| | - Jonas B Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense
| | - Ewa M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense
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Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Br J Sports Med 2015; 49:1229-35. [PMID: 26383759 PMCID: PMC4602246 DOI: 10.1136/bjsports-2015-h2747rep] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASURES Pain and physical function. DATA SOURCES Systematic searches for benefits and harms were carried out in Medline, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2014. Only studies published in 2000 or later were included for harms. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials assessing benefit of arthroscopic surgery involving partial meniscectomy, debridement, or both for patients with or without radiographic signs of osteoarthritis were included. For harms, cohort studies, register based studies, and case series were also allowed. RESULTS The search identified nine trials assessing the benefits of knee arthroscopic surgery in middle aged and older patients with knee pain and degenerative knee disease. The main analysis, combining the primary endpoints of the individual trials from three to 24 months postoperatively, showed a small difference in favour of interventions including arthroscopic surgery compared with control treatments for pain (effect size 0.14, 95% confidence interval 0.03 to 0.26). This difference corresponds to a benefit of 2.4 (95% confidence interval 0.4 to 4.3) mm on a 0-100 mm visual analogue scale. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found (effect size 0.09, -0.05 to 0.24). Nine studies reporting on harms were identified. Harms included symptomatic deep venous thrombosis (4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures), pulmonary embolism, infection, and death. CONCLUSIONS The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014009145.
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Affiliation(s)
- J B Thorlund
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - C B Juhl
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
- Department of Orthopedics, Copenhagen University Hospital, Gentofte, Denmark
| | - E M Roos
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - LS Lohmander
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
- Department of Orthopedics and Traumatology, Odense University Hospital, Odense, Denmark
- Department of Orthopedics, Clinical Sciences Lund, University of Lund, Sweden
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Scott IA, Duckett SJ. In search of professional consensus in defining and reducing low‐value care. Med J Aust 2015; 203:179-81. [DOI: 10.5694/mja14.01664] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/23/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Ian A Scott
- Princess Alexandra Hospital, Brisbane, QLD
- University of Queensland, Brisbane, QLD
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Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015; 350:h2747. [PMID: 26080045 PMCID: PMC4469973 DOI: 10.1136/bmj.h2747] [Citation(s) in RCA: 216] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine benefits and harms of arthroscopic knee surgery involving partial meniscectomy, debridement, or both for middle aged or older patients with knee pain and degenerative knee disease. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASURES Pain and physical function. DATA SOURCES Systematic searches for benefits and harms were carried out in Medline, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to August 2014. Only studies published in 2000 or later were included for harms. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials assessing benefit of arthroscopic surgery involving partial meniscectomy, debridement, or both for patients with or without radiographic signs of osteoarthritis were included. For harms, cohort studies, register based studies, and case series were also allowed. RESULTS The search identified nine trials assessing the benefits of knee arthroscopic surgery in middle aged and older patients with knee pain and degenerative knee disease. The main analysis, combining the primary endpoints of the individual trials from three to 24 months postoperatively, showed a small difference in favour of interventions including arthroscopic surgery compared with control treatments for pain (effect size 0.14, 95% confidence interval 0.03 to 0.26). This difference corresponds to a benefit of 2.4 (95% confidence interval 0.4 to 4.3) mm on a 0-100 mm visual analogue scale. When analysed over time of follow-up, interventions including arthroscopy showed a small benefit of 3-5 mm for pain at three and six months but not later up to 24 months. No significant benefit on physical function was found (effect size 0.09, -0.05 to 0.24). Nine studies reporting on harms were identified. Harms included symptomatic deep venous thrombosis (4.13 (95% confidence interval 1.78 to 9.60) events per 1000 procedures), pulmonary embolism, infection, and death. CONCLUSIONS The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014009145.
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Affiliation(s)
- J B Thorlund
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - C B Juhl
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark Department of Orthopedics, Copenhagen University Hospital, Gentofte, Denmark
| | - E M Roos
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark
| | - L S Lohmander
- University of Southern Denmark, Department of Sports Science and Clinical Biomechanics, Campusvej 55, 5230 Odense M, Denmark Department of Orthopedics and Traumatology, Odense University Hospital, Odense, Denmark Department of Orthopedics, Clinical Sciences Lund, University of Lund, Sweden
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Buchbinder R, Maher C, Harris IA. Setting the research agenda for improving health care in musculoskeletal disorders. Nat Rev Rheumatol 2015; 11:597-605. [DOI: 10.1038/nrrheum.2015.81] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Allen KD, Bierma-Zeinstra SMA, Foster NE, Golightly YM, Hawker G. OARSI Clinical Trials Recommendations: Design and conduct of implementation trials of interventions for osteoarthritis. Osteoarthritis Cartilage 2015; 23:826-38. [PMID: 25952353 DOI: 10.1016/j.joca.2015.02.772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 02/02/2023]
Abstract
Rigorous implementation research is important for testing strategies to improve the delivery of effective osteoarthritis (OA) interventions. The objective of this manuscript is to describe principles of implementation research, including conceptual frameworks, study designs and methodology, with specific recommendations for randomized clinical trials of OA treatment and management. This manuscript includes a comprehensive review of prior research and recommendations for implementation trials. The review of literature included identification of seminal articles on implementation research methods, as well as examples of previous exemplar studies using these methods. In addition to a comprehensive summary of this literature, this manuscript provides key recommendations for OA implementation trials. This review concluded that to date there have been relatively few implementation trials of OA interventions, but this is an emerging area of research. Future OA clinical trials should routinely consider incorporation of implementation aims to enhance translation of findings.
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Affiliation(s)
- K D Allen
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA; Department of Medicine, University of North Carolina, Chapel Hill, NC, USA; Health Services Research and Development, Department of Veterans Affairs Medical Center, Durham, NC, USA.
| | - S M A Bierma-Zeinstra
- Department of General Practice, Erasmus MC - University Medical Center Rotterdam, The Netherlands; Department of Orthopaedic Surgery, Erasmus MC - University Medical Center Rotterdam, The Netherlands.
| | - N E Foster
- Arthritis Research UK Primary Care Centre, Institute of Primary Care and Health Sciences, Keele University, Keele, UK.
| | - Y M Golightly
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA; Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA.
| | - G Hawker
- Department of Medicine, University of Toronto, Canada; Women's College Research Institute, Women's College Hospital, University of Toronto, Canada.
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Perceptions of orthopaedic surgeons regarding arthroscopic surgery for osteoarthritis of the knee - an international survey. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Knee osteoarthritis and role for surgical intervention: lessons learned from randomized clinical trials and population-based cohorts. Curr Opin Rheumatol 2014; 26:138-44. [PMID: 24378932 DOI: 10.1097/bor.0000000000000022] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Over the last decade, there has been increased recognition of the importance of high-quality randomized controlled trials in determining the role of surgery for knee osteoarthritis. This review highlights key findings from the best available studies, and considers whether or not this knowledge has resulted in better evidence-based care. RECENT FINDINGS Use of arthroscopy to treat knee osteoarthritis has not declined despite strong evidence-based recommendations that do not sanction its use. A large randomized controlled trial has demonstrated that arthroscopic partial meniscectomy followed by a standardized physical therapy program results in similar improvements in pain and function at 6 and 12 months in comparison to physical therapy alone in patients with knee osteoarthritis and a symptomatic meniscal tear, confirming the findings of two previous trials. Two recent randomized controlled trials have demonstrated that decision aids help people to reach better-informed decisions about total knee arthroplasty. A majority of studies have indicated that for people with obesity the positive results of total knee arthroplasty may be compromised by postoperative complications, particularly infection. SUMMARY More efforts are needed to overcome significant evidence-practice gaps in the surgical management of knee osteoarthritis, particularly arthroscopy. Decision aids are a promising tool.
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Katz JN, Brownlee SA, Jones MH. The role of arthroscopy in the management of knee osteoarthritis. Best Pract Res Clin Rheumatol 2014; 28:143-56. [PMID: 24792949 DOI: 10.1016/j.berh.2014.01.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Technological advances throughout the 20th century enabled an increase in arthroscopic knee surgery, particularly arthroscopic debridement for osteoarthritis (OA) and arthroscopic partial meniscectomy for symptomatic meniscal tear in the setting of OA. However, evaluation of the outcomes of these procedures lagged behind their rising popularity. Not until the early 2000s were rigorous outcomes studies conducted; these showed that arthroscopic debridement for OA was no better than a sham procedure in relieving knee pain or improving functional status, and that patients who underwent arthroscopic partial meniscectomy for a degenerative meniscal tear generally did not show more improvement than those who underwent sham meniscal resection or an intensive course of physical therapy. Though the number of arthroscopic knee procedures for OA performed each year has begun to decline, there remains a significant gap between the evidence and actual practice. Further investigation is needed to shore up the evidence base and bring policy and practice in line with rigorous research.
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Affiliation(s)
- Jeffrey N Katz
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Orthopedic and Arthritis Center for Outcomes Research, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA.
| | - Sarah A Brownlee
- Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Morgan H Jones
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Bohensky M, Barker A, Morello R, De Steiger RN, Gorelik A, Brand C. Geographical variation in incidence of knee arthroscopy for patients with osteoarthritis: a population-based analysis of Victorian hospital separations data. Intern Med J 2014; 44:537-45. [PMID: 24697847 DOI: 10.1111/imj.12438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 03/16/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND/AIM To evaluate the frequency and geographical variation in knee arthroscopy for adults (>25 years) with a concomitant diagnosis of osteoarthritis. METHODS This was a retrospective cohort study of hospital separations involving an elective knee arthroscopy in public and private hospitals in Victoria, Australia. Participants included patients receiving knee arthroscopies with a diagnosis code indicating osteoarthritis (OA) from 1 July 2008 to 30 June 2009. Records were excluded if the patient was under 25 years or their arthroscopy involved a ligament reconstruction. Crude rates per 100 000 population and negative binomial regression offset by total knee arthroscopy volume were used to analyse differences by region. RESULTS There were 9620 arthroscopic procedures meeting the inclusion criteria. There were 5500 (57.2%) admissions where the principal diagnosis was knee OA (gonarthrosis) and 3510 (36.5%) where the principal diagnosis indicated a mechanical derangement and there was a primary or associated diagnosis of OA. When we examined the incidence rate ratios (IRR) by region, after adjustment for relevant factors and accounting for the total knee arthroscopy volume within each region, we identified significant variation in knee arthroscopy rates for patients with OA. The region with the highest adjusted IRR was Barwon South Western (IRR: 1.26, 95% confidence interval (CI): 1.16-1.36) and the region with lowest adjusted incidence rate ratio was the Gippsland region (IRR: 0.89, 95% CI: 0.80-0.98). CONCLUSIONS We identified considerable geographical variation in arthroscopies for people with OA across Victoria. Further investigation is needed to understand whether this variation is a reflection of differences in OA prevalence, clinical decision-making or access.
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Affiliation(s)
- M Bohensky
- Melbourne EpiCentre, Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia; Melbourne Health, Melbourne, Victoria, Australia
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Bohensky MA, Ackerman I, DeSteiger R, Gorelik A, Brand CA. Lifetime Risk of Total Knee Replacement and Temporal Trends in Incidence by Health Care Setting, Socioeconomic Status, and Geographic Location. Arthritis Care Res (Hoboken) 2014; 66:424-31. [DOI: 10.1002/acr.22122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 08/08/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Megan A. Bohensky
- Melbourne EpiCentre, Royal Melbourne Hospital, and The University of Melbourne; Parkville, Victoria Australia
| | - Ilana Ackerman
- Melbourne EpiCentre, Royal Melbourne Hospital, and The University of Melbourne; Parkville, Victoria Australia
| | | | - Alexandra Gorelik
- Melbourne EpiCentre, Royal Melbourne Hospital; Parkville, Victoria Australia
| | - Caroline A. Brand
- Melbourne EpiCentre, Royal Melbourne Hospital, and The University of Melbourne; Parkville, Victoria Australia
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Harris IA, Madan NS, Naylor JM, Chong S, Mittal R, Jalaludin BB. Trends in knee arthroscopy and subsequent arthroplasty in an Australian population: a retrospective cohort study. BMC Musculoskelet Disord 2013; 14:143. [PMID: 23617303 PMCID: PMC3648388 DOI: 10.1186/1471-2474-14-143] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 04/19/2013] [Indexed: 02/01/2023] Open
Abstract
Background Knee arthroscopy is a common procedure in orthopaedic surgery. In recent times the efficacy of this procedure has been questioned with a number of randomized controlled trials demonstrating a lack of effect in the treatment of osteoarthritis. Consequently, a number of trend studies have been conducted, exploring rates of knee arthroscopy and subsequent conversion to Total Knee Arthroplasty (TKA) with varying results. Progression to TKA is seen as an indicator of lack of effect of primary knee arthroscopy. The aim of this paper is to measure overall rates of knee arthroscopy and the proportion of these patients that undergo subsequent total knee arthroplasty (TKA) within 24 months, and to measure trends over time in an Australian population. Methods We conducted a retrospective cohort study of all adults undergoing a knee arthroscopy and TKA in all hospitals in New South Wales (NSW), Australia between 2000 and 2008. Datasets obtained from the Centre for Health Record Linkage (CHeReL) were analysed using negative binomial regression. Admission rates for knee arthroscopy were determined by year, age, gender and hospital status (public versus private) and readmission for TKA within 24 months was calculated. Results There was no significant change in the overall rate of knee arthroscopy between 2000 and 2008 (-0.68%, 95% CI: -2.80 to 1.49). The rates declined in public hospitals (-1.25%, 95% CI: -2.39 to -0.10) and remained relatively steady in private hospitals (0.42%, 95% CI: -1.43 to 0.60). The proportion of patients 65 years or over undergoing TKA within 24 months of knee arthroscopy was 21.5%. After adjusting for age and gender, there was a significant decline in rates of TKA within 24 months of knee arthroscopy for all patients (-1.70%, 95% CI:-3.13 to -0.24), patients admitted to private hospitals (-2.65%, 95% CI: -4.06 to -1.23) and patients aged ≥65 years (-3.12%, 95% CI: -5.02 to -1.18). Conclusions Rates of knee arthroscopy are not increasing, and the proportion of patients requiring a TKA within 24 months of a knee replacement is decreasing in the age group most likely to have degenerative changes in the knee.
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Affiliation(s)
- Ian A Harris
- South Western Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia
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Affiliation(s)
- Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Health, Melbourne, VIC
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | - Ian A Harris
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW
- Whitlam Orthopaedic Research Centre, Sydney, NSW
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