Validation of a German version of the 'Disabilities of Arm, Shoulder and Hand' questionnaire (DASH-G)

OBJECTIVE

In 1994 the American Academy of Orthopedic Surgeons' outcome research committee developed and validated a functional outcome questionnaire for disabilities of the upper extremity (DASH). The objective of our study was to translate the DASH into German and to evaluate its reliability and validity for German-speaking patients with shoulder pain.

METHODS

Translation-backtranslation of the DASH was performed according to published guidelines. Psychometric properties and validity were assessed in 49 consecutive patients with shoulder pain originating from within the shoulder girdle. Age, duration of symptoms and current pain were obtained. Test-retest reliability was assessed in a subset of 18 patients who filled in the questionnaire 10 days later. Internal consistency was evaluated with Cronbach's alpha coefficient. Test-retest reliability was assessed using Spearman correlations and the Bland and Altman plot. To study the validity, we examined the correlation of the DASH with other measures of function of the upper extremity including the HAQ subscales relating to the upper extremity and pain measures (e.g. numerical rating scale, SF-36 pain scale). We also examined our hypothesis that the DASH is moderately correlated with measures of range-of-motion (e.g., forward flexion and abduction).

RESULT

Translation-backtranslation revealed no major difficulties. The mean age of the patients was 59 years, mean duration of symptoms 60 months and current pain score 5.6 (NRS). Test-retest reliability was 0.90 for the total DASH. The internal consistency was 0.96. Strong correlations (p<0.01) were found between the DASH and the mean among the five subscales of the HAQ representing upper extremity function (0.88) and pain as measured with the SF-36 bodily pain scale (-0.79). As hypothesized, the DASH was also moderately correlated with measures of range-of-motion (e.g. forward flexion rho=-0.49; abduction rho=-0.57).

CONCLUSION

Our data confirm that the German version of the DASH retains the characteristics of the American original and is a reliable and valid instrument to measure functional disability in German speaking patients with shoulder pain.

Independent living after fractures in the elderly

Although fractures are an important source of disability among the growing elderly populations of industrialized societies, patient-centered multidimensional outcome information is scarce. The purpose of this study was to quantify the natural history of recovery from fractures of the upper and lower extremities. From the 1994/95 WHO MONICA survey in Augsburg, Germany, we selected all persons aged 58-78 years who had experienced a fracture during the preceeding 10 years, along with a control population twice as large. The Health Assessment Questionnaire (HAQ) and the Medical Outcomes Study Short Form 36 (SF-36) were administered to these subjects in 1998. Patients' recollection of fracture type and location were validated against medical records. The most recent fracture was in the upper extremity in 45 cases, lower extremity in 55 cases and elsewhere in 46 cases. Extremity fractures resulted in persistent and measurable impairment of the activities of daily living or general quality of life in patients 65 years or older, especially if the femur was involved. More than 40% of the interindividual variation of functional disability in the study group could be explained by age, sex, history of a fracture within 12 years and perceived difficulties walking. Existing generic and specific musculoskeletal outcome measurement instruments thus allow the assessment of functional recovery and health status after fractures in an elderly population. Geriatric assessment following fractures at higher age may improve ability to live independently. Difficulty walking deserves special attention, as it is associated with more general functional disability among the elderly.

Radiographic outcome after three years of patients with early erosive rheumatoid arthritis treated with intramuscular methotrexate or parenteral gold. Extension of a one-year double-blind study in 174 patients

OBJECTIVE

To compare the radiographic outcomes after 36 months in patients with early erosive rheumatoid arthritis (RA) who were treated with methotrexate (MTX) or gold sodium thiomalate (GSTM).

METHODS

In a randomized, double-blind fashion, 174 patients from two centres were assigned to receive weekly intramuscular injections of either 15 mg MTX or 50 mg GSTM. After 12 months, the study was continued as an open prospective study for an additional 2 yr, administering the same amount of MTX and half of the GSTM dose. Radiographic outcomes were assessed by standardized methods in all patients at baseline and after 6, 12, 24 and 36 months.

RESULTS

Intention-to-treat analysis showed that patients treated with MTX had higher radiographic scores and more erosive joints at all follow-up points. However, there was no statistically significant difference between the two treatment groups. The progression rate was significantly slower during the second and third years of follow-up in both groups. Baseline and time-integrated (area under the curve over 6 months) disease activity parameters were good predictors of radiographic outcome after 3 yr. Seropositivity was not an independent predictor of progression. However, patients who were positive for rheumatoid factor had higher time-integrated disease activity (with less response to treatment) and thus their disease was significantly more progressive.

CONCLUSION

Both of the disease-modifying compounds used in this study, MTX and GSTM, were able to reduce the slope of radiographic progression during 3 yr of follow-up. There was some advantage for parenteral gold but no significant intergroup difference.

[Epidemiology of limb fractures]

To analyze age- and sex-specific frequencies of peripheral fractures, we used data from the third MONICA-Augsburg Survey (1994/95). The study comprises 2404 male and 2450 female participants (age 25 to 74 years) who were questioned regarding fracture history. We investigated fracture prevalence, age-specific incidence rates, and the circumstances under which the fractures occurred. The age-standardized, cumulative fracture prevalence among men (m) 25 to 74 years of age was 45% and among women (w) of the same age 31%. Fracture prevalence among women was more than 10% lower than among men in the younger age groups (age 25 to 64 years), but after an significant increase in the 65 to 74-year-olds the fracture prevalence corresponded to that of men (m: 42%, w: 40%). A peak of incidence rates was found among men at age 15-24 (overall incidence rate: 2017 fractures/100,000 person-years) and at age 45-54 (overall incidence rate: 1640 fractures/100,000 PY), respectively, and among women at age 65-74 (overall incidence rate: 3214 fractures/100,000 PY). The prevalence of self-reported osteoporosis (age 25 to 74 years) was higher in women (7%) than in men (1%). Falls caused 43% (w: 59%, m: 33%) of all fractures, external violence 40% (m: 47%, w: 29%), and sports activities 15% (m: 18%, w: 10%). Further investigation of risk factors related to fractures can contribute to the development of specific preventive measures in that field. In the future, the prevention and efficient treatment of an existing or an often undiagnosed osteoporosis and also the prevention of falls in elderly persons should be an important public health concern.

[Outcome measurement in musculoskeletal diseases: recommendation for a core set of scales for use in rehabilitation]

By application of a standardized core set of outcome measurement instruments, comparison between studies as well as meta-analyses in rehabilitation research can be facilitated. The German Society for Rheumatology has commissioned its working group on rehabilitation with the development of a proposal for such a core set of outcome measurement instruments. In a first step, dimensions for outcome measurement in rehabilitation were defined by a group of experts which represented rehabilitation hospitals, acute care hospitals, and research groups specialized in outcome measurement. The Delphi method was used in a multiple step consensus process. In a second step, instruments and procedures to operationalize the relevant dimensions were chosen. Reliability, validity, sensitivity to change, and practicability were used as criteria for selecting measurement instruments. The main intention of the proposed core set of outcome measurement instruments is to facilitate the processes of planning and carrying out rehabilitation research studies. Furthermore, the proposed instruments can be used for clinical documentation systems as well as for internal or external quality assurance programs.

Patientenzentrierte Evaluation des Gesundheitszustands in einem longitudinalen Qualitätsmanagementsystem im Krankenhaus (QMK)

OBJECTIVE

The objective was to assess the value of self-reported health status as an indicator of outcomes of acute hospital care, to identify potential practical limitations, and develop strategies for future applications.

METHODS

180 patients from 4 acute care hospitals in Germany participated in a comprehensive and longitudinal assessment of outcome of care in general internal medicine between 8/1/99 and 10/31/99. Self-administered SF-36 surveys were completed at admission and 4 weeks after discharge. Additionally, nurses and physicians answered questions regarding the patients' health status. Linear relations between health status assessments were quantified as correlation coefficients. Odds ratios (OR) and 95% confidence limits from multivariate logistic regression models were reported for predictors of non-returned questionnaires.

RESULTS

33% of SF-36 surveys handed out at discharge were returned. Patients with impairments and referred patients were more likely not to return the survey (OR = 1.3 [1.09; 1.66] and OR = 3.7 [1.37; 9.87]). The linear relation of SF-36 and SF-12 scores in the same patients were r = 0.95 [0.91; 0.97] for physical health and r = 0.91 [0.85; 0.94] for mental health. Physicians and nurses moderately agreed in their assessment of patients' health (r = 0.38 [0.22; 0.52]) but both professional groups showed poor agreement with self-reported health (r = 0.15 [-0.08; 0.36] and r = -0.01 [-0.23; 0.21]).

CONCLUSIONS

1. Self-reported health status should be considered in the assessment of outcomes of acute care as a dimension that is to some extent independent of health status assessment by professionals, 2. shorter instruments, i.e., the SF-12, can be used instead of the SF-36, 3. a self-reported health status assessment is feasible 4 weeks after discharge, and 4. patients with multiple impairments or those who are transferred should get specific support in the completion of questionnaires to increase response or to receive at least minimal information about their health status.

Lyme disease and preventive behaviors in residents of Nantucket Island, Massachusetts

BACKGROUND

To determine the age-specific prevalence of Lyme disease and whether preventive behaviors on Nantucket Island correlate with Lyme disease, we surveyed island residents.

METHODS

A survey with questions on Lyme disease symptoms, history, and preventive behaviors was mailed to all residents. Respondents were stratified by likelihood of having had Lyme disease. A subsample was selected for examination, and then classified according to the Lyme disease national surveillance case definition.

RESULTS

The overall lifetime prevalence of Lyme disease for Nantucket residents was 15% (CI, 10%-19.8%): 19% among females, and 11% among males. The prevalence was highest among age groups 0-16 and 30-49 years. Overall, 86% of the population practiced at least one behavior. The most frequently reported preventive behavior was checking oneself for ticks (80%), followed by wearing protective clothing (53%), avoiding tick areas (34%), and using tick repellent (11%). Younger individuals practiced fewer preventive behaviors than older individuals (p=0.001). Although males reported greater tick exposure than females, females uniformly practiced preventive behaviors more frequently (p=0.001). The practice of preventive behaviors was not associated with a history of Lyme disease, but finding more than 5 ticks per year on oneself was (p=0.001).

CONCLUSION

Lyme disease is highly prevalent on Nantucket Island. Young people are particularly at risk and health education should emphasize preventive behaviors less frequently practiced: using tick repellent, avoiding tick areas, and wearing protective clothing.

[Validity and reliability of proband recall of fractures]

The validity and reliability of patient recall of diseases depends on the kind of disease. The validity and reliability of patients' recall of fractures was assessed among the 146 cases of a nested case-control study on independent living following fractures in the elderly. On declaration of a fracture a letter was sent to the general practitioner requesting medical information on the latest fracture receiving treatment. A total of 99 medical discharge letters (68%) could be collected for further evaluation. The information on fracture localisation which was obtained both during the patients interviews 1994/95 and 1998 and through the medical discharge letters were coded with reference to the AO (Arbeitsgemeinschaft für Osteosynthesefragen)-classification and compared. The Kappa-statistic for the reliability of patient information was 0.80-0.89, and 0.77-0.89 for the validity, depending on the degree of specified concordance. Obtaining information on fractures from patients appears as a valid and reliable source of epidemiologic data. Patients who generally are affected physically or had to stay in a hospital due to a fracture or its treatment seem to have a good recall of this event. It appears that it can be remembered years after the event with sufficient reliability and validity.

[An update of the German version of AEP (Appropriateness Evaluation Protocol): metric properties and practical experiences]

The development of a German version of the Appropriateness Evaluation Protocol (AEP) allows for the first time the evaluation of hospital admissions and bed days in Germany. The instrument is based on international experience and has been adopted in cooperation with acknowledged members of German surgical and medical societies. The AEP showed excellent reliability in general internal medicine as well as in surgery. The validity is comparable to international studies, although further research is necessary. Approximately 90% of surgical cases could be evaluated according to the criteria of the AEP; the remaining patients were evaluated using the "override option". The majority of inappropriate care is due to poor documentation in medical records and management deficiencies during inpatient care.

Epidemiology of rheumatic diseases

Rheumatic diseases are among the oldest diseases recognized. The classification of rheumatic diseases is sometimes difficult due to unknown aetiology and heterogeneity in their clinical presentation. Osteoarthritis (OA) and rheumatoid arthritis (RA) are the two most common rheumatic diseases, accounting for a large percentage of disability worldwide. The economic and social burden of these diseases is great. Their impact on both individuals and society results from a decreased quality of life, lost productivity and increased costs of health care. Without appropriate approaches to patient management and control of these diseases, this impact can be expected to increase as the population ages. One of the challenges in studying OA and RA, and rheumatic diseases in general, is deriving epidemiological data that can be used to understand better the factors that contribute to the initiation and progression of these diseases. Only with such an understanding can significant progress be made in the diagnosis, treatment and management of patients.

Coexposure to Borrelia burgdorferi and Babesia microti does not worsen the long-term outcome of lyme disease

Previous studies suggest that concurrent Lyme disease and babesiosis produce a more sever illness than either disease alone. The majority of babesiosis infections, however, are subclinical. Our objective was to characterize on the basis of a total-population survey of Nantucket Island, Massachusetts, whether coexposure to Lyme disease and babesiosis causes more severe illness or poorer long-term outcomes than Lyme disease alone. In this retrospective cohort study, residents indicating a history of Lyme disease were compared with randomly selected population controls on a standardized medical history, blinded physical examination, and serological studies for Borrelia burgdorferi and Babesia microti. Serological evidence of exposure to babesiosis was not associated with increased severity of acute Lyme disease. The groups did not differ with regard to the prevalence of constitutional, musculoskeletal, or neurological symptoms a mean of 6 years after acute Lyme disease. Prior Lyme disease and serological exposure to B. microti are not associated with poorer long-term outcomes or more persistent symptoms Lyme disease alone.

[Evaluation of the North American Spine Society Instrument for assessment of health status in patients with chronic backache]

PURPOSE OF THE STUDY

The translation/back and translation and validation of the North American Spine Society (NASS) Instrument in German was published recently. This contribution aims at describing the scoring of this questionnaire.

METHOD

The scoring is oriented on the recommendations of the developing scientists of the US-American original, with whom we cooperated during the German validation.

RESULTS

The scoring algorithm is described, a program for computerized scoring in SPSS was written. Program syntax and the questionnaire are reproduced.

CONCLUSION

The contribution enables interested researchers to apply and score the NASS questionnaire in German-speaking countries.

[Evaluation of the appropriateness of hospital care in internal medicine. Reliability of a German adaptation of the procedure]

BACKGROUND AND OBJECTIVE

The evaluation of the appropriateness of hospital admissions and hospital stays has become an increasingly important issue in Germany. Evaluations by the German Physicians Review Organizations (MDS, MDK) demonstrated the need for a standardized, valid and reliable assessment tool for inappropriate hospital use. Objective of this study was to test the reliability of a German adaptation of the "Appropriateness Evaluation Protocol" (AEP).

PATIENTS AND METHODS

From the 2317 admissions to medical wards of a teaching hospital in Hessia in 1997 we randomly selected 52 patients to test the inter-rater-reliability (54% female, mean age = 66 years +/- 18). Another 49 patients were randomly selected to test the intra-rater-reliability of the AEP (53% female, mean age = 61 years +/- 20). We estimated general agreement, specific agreement and Kappa statistics for the agreement of the evaluation of hospital admissions and hospital days. 95% confidence intervals were reported.

RESULTS

The German adaptation of the AEP showed an inter-rater-agreement of 92% (88-96%) for hospital admissions and 76% (73-80%) for hospital days. Correspondingly, we observed an intra-rater-agreement of 96% (88-100%) for hospital admissions and 93% (91-95%) for hospital days. The high agreement was independent of the length of hospital stay and independent of the proportion of inappropriate hospital days.

CONCLUSION

A standard instrument for the assessment of the appropriateness of hospital care with known metric properties may be useful for quality management in hospitals and provide competitive advantages in a consolidating health care market. The AEP could be such an instrument.

[Incidence of operations in Germany via telephone survey in 4 selected cities]

Considerable regional variation of surgical procedure rates has been reported for a number of countries. Influential variables that have been discussed are patient-related, physician-related and health care system-specific factors. A representative computer-assisted telephone survey was conducted in four selected regions for a study sponsored by the German Federal Ministry of Health. These regions were the townships of Aachen and Hamm in North Rhine-Westphalia and Chemnitz and Görlitz in Saxony. During the telephone survey 1897 persons were contacted and 1041 interviews completed. Multiple logistic regression showed a surgical procedure frequency which was by 40% higher in Aachen than in Hamm. During further analysis the regional localisation was replaced by region-specific structural health care information variables. During this analysis the regional frequency of medical specialists was significant at a 5% level (odds ratio: 1.07; 95% confidence interval: 1.02-1.12). This result can be interpreted as an increase in surgical procedures by 7% for each additional specialist per 10,000 persons. However, no definite conclusion can be reached based on the available data. Intensifying the presented survey-based health services research has the potential to identify regional over- or undersupply of medical services, to objectify and accompany informational, administrative or political action and thereby to support equity in access and health care in the sense of an optimized allocation of resources.

[Corroboration of concurrent assessment of inappropriate hospitalization with retrospective evaluation based on patient records]

BACKGROUND AND PURPOSE

Since the availability of a German adaptation of the "appropriateness Evaluation Protocol" (AEP) for hospital utilization review, physicians and health care managers were concerned about a potential overestimation of the extent of inappropriate hospital use in a retrospective assessment. The objective was to assess the agreement of concurrent and retrospective assessment of inappropriate hospital use.

METHODS

The appropriateness of 42 admissions to surgical wards in a teaching hospital was tested concurrent to the admission. In 25 hospitalized patients the appropriateness of hospital days was assessed. Results were compared with the retrospective testing of the same patients after three months.

RESULTS

Agreement between concurrent and retrospective assessment within the same reviewer was 86% of admissions (95% CI = 75%-96%) and 96% of hospital days (88%-100%). Kappa showed values of 0.85 and 0.78, which can be described as excellent. A comparison of two different reviewers, one testing concurrently, the other retrospectively showed agreements of 86% and 90%. The proportion of inappropriate days was the same in both designs.

CONCLUSIONS

The results refute prior concerns that a retrospective assessment of the appropriateness of hospital use is impossible because in a retrospective design important clinical information would remain unconsidered or clinical information not yet available at that time would be used for the evaluation. The possibility of an incorrect assessment due to a retrospective design is within the variability inherent to the instrument. Despite the strong agreement, the small sample of surgical patient limits the generalizability of results.

Association between clinical factors, socioeconomic status, and organ damage in recent onset systemic lupus erythematosus

OBJECTIVE

To determine the prevalence and socioeconomic and clinical predictors of early organ damage in a cohort of patients with systemic lupus erythematosus (SLE) of 2-7 years' duration randomly sampled at 5 centers and balanced by socioeconomic status and race.

METHODS

The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index was measured in 200 patients who met the ACR criteria for SLE with a mean disease duration of 3.8 years. The SLICC/ACR scores for each organ system and the prevalence of damage within organ systems were assessed. Logistic regression analyses evaluated the simultaneous effects of age at diagnosis, disease duration, disease activity, and sociodemographic factors.

RESULTS

Sixty-one percent of the patients had damage within 7 years of onset (mean 3.8 yrs). Neuropsychiatric (20.5%) and musculoskeletal (18.5%) systems were the most frequently involved, followed by renal (15.5%) and skin (12.5%) systems, all with median SLICC/ACR organ system scores of 1. In multivariate models, African-American race was associated with skin damage but not with damage in other specific organ systems. Socioeconomic status was not associated with organ system damage. Older age at diagnosis correlated with cardiovascular, musculoskeletal, gastrointestinal, ocular, and pulmonary damage. Clinical factors such as longer disease duration correlated with higher renal and cardiovascular damage, and greater disease activity at diagnosis of SLE correlated with greater renal, musculoskeletal, and pulmonary damage.

CONCLUSION

There is evidence of organ system damage in SLE within a mean of 3.8 years after onset. We found little evidence for differences in early organ damage according to race or socioeconomic status. Damage to most organ systems was related to age at diagnosis of SLE and clinical factors such as disease duration.

[Effect size in clinical studies of patients with rheumatoid arthritis. EULAR guidelines and OMERACT core-sets]

Clinical trials in rheumatology are confronted with new challenges. The pharmaceutical industry must be more efficient in identifying and marketing new drugs, regulatory authorities require additional evidence about the effectiveness of new compounds, and the consumer including physicians require more transparency in the selection and use of appropriate outcomes in clinical trials. These challenges find their common denominator in a further standardization of clinical trials that extends beyond the application of Good Clinical Practice. For years, national and international organizations have developed recommendations for the selection of appropriate outcomes in RA clinical trials. However, these recommendations have rarely been data driven or evidence based. The international informal collaboration Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) has contributed enormously towards the application of a standardized methodology in the development of recommendations to enhance the quality of research in clinical rheumatology. The scope of this initiative goes now far beyond rheumatoid arthritis and now covers all major rheumatic conditions.

[Reproducibility of a German scale for assessing the need for inpatient treatment in surgery]

During the past years, the assessment of the appropriateness of hospital utilization has become increasingly important in the German health care system. Previous evaluations by regional review organizations in several states demonstrated the need for a standardized, reliable, and valid instrument to evaluate the appropriateness of inpatient care. Objective of the study is to test the reliability of a German adaptation of the "Appropriateness Evaluation Protocol" (AEP). Among all 2672 admissions from the department of surgery of a regional medical center during one calendar year, 54 patients were randomly selected to evaluate the inter-rater reliability and 51 patients to test intra-rater reliability. Overall agreement, specific agreement and Kappa statistics were estimated for every hospital admissions and all consecutive hospital days. The German AEP showed an inter-rater agreement of 74% (62-86%) for hospital admissions (Kappa = 0.44) and 84% (79%-88%) for all hospital days (K = 0.55). Intra-rater reliability was 88% (79%-97%) for hospital admissions (K = 0.60) and 88% (85%-92%) for all hospital days (K = 0.70). The observed agreement is independent of length of hospital stay and proportion of appropriate days. A standardized instrument with known metric properties is essential for quality management in hospitals to prepare for an increasingly consolidating health care market in Germany. The German AEP is a reliable instrument, which will allow to identify inefficiencies in the management of surgical inpatients.

Musculoskeletal and neurologic outcomes in patients with previously treated Lyme disease

BACKGROUND

Previous follow-up studies of patients with Lyme disease suggest that disseminated infection may be associated with long-term neurologic and musculoskeletal morbidity.

OBJECTIVE

To determine clinical and functional outcomes in persons who were treated for Lyme disease in the late 1980s.

DESIGN

Population-based, retrospective cohort study.

SETTING

Nantucket Island, Massachusetts.

PARTICIPANTS

186 persons who had a history of Lyme disease (case-patients) and 167 persons who did not (controls).

MEASUREMENTS

Standardized medical history, physical examination, functional status measure (Medical Outcomes Study 36-item Short Form Health Survey [SF-36]), mood state assessment (Profile of Mood States), neurocognitive tests, and serologic examination.

RESULTS

The prevalence of Lyme disease among adults on Nantucket Island was estimated to be 14.3% (95% CI, 9.3% to 19.1%). In multivariate analyses, persons with previous Lyme disease (mean time from infection to study evaluation, 6.0 years) had more joint pain (odds ratio for having joint pain in any joint, 2.1 [CI, 1.2 to 3.5]; P = 0.007), more symptoms of memory impairment (odds ratio for having any memory problem, 1.9 [CI, 1.1 to 3.5]; P = 0.003), and poorer functional status due to pain (odds ratio for 1 point on the SF-36 scale, 1.02 [CI, 1.01 to 1.03]; P < 0.001) than persons without previous Lyme disease. However, on physical examination, case-patients and controls did not differ in musculoskeletal abnormalities, neurologic abnormalities, or neurocognitive performance. Persons with previous Lyme disease who had persistent symptoms after receiving treatment (n = 67) were more likely than those who had completely recovered to have had fever, headache, photosensitivity, or neck stiffness during their acute illness (87% compared with 13%; odds ratio, 2.4 [CI, 1.0 to 5.5]; P = 0.045); however, the performance of the two groups on neurocognitive tests did not significantly differ.

CONCLUSIONS

Because persons with previous Lyme disease exhibited no sequelae on physical examination and neurocognitive tests a mean of 6.0 years after infection, musculoskeletal and neurocognitive outcomes seem to be favorable. However, long-term impairment of functional status can occur.

Superior responsiveness of the pain and function sections of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as compared to the Lequesne-Algofunctional Index in patients with osteoarthritis of the lower extremities

OBJECTIVE

To compare the responsiveness of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and a questionnaire format of the Lequesne-Algofunctional Index in patients with OA of the lower extremities.

METHODS

Longitudinal analysis of the instruments' responsiveness [standardized response mean (SRM), effect size (ES)] in ambulatory patients undergoing hip or knee arthroplasty.

RESULTS

At six months 36, and at one year 40 out of 43 patients undergoing hip (N=30) or knee arthroplasty (N=13) could be examined. Both responsiveness statistics revealed the same order of responsiveness. For both indices and for both locations, the pain sections were more responsive than the function sections. However, the WOMAC scales and the WOMAC global index (hip at 12 months: SRM=2.4; knee at 12 months: SRM=2.0 ) were more responsive than the comparable Lequesne sections and Lequesne index (hip at 12 months: SRM=2.1; knee at 12 months: SRM=1.5).

CONCLUSIONS

Although our results are based on a German version using a self-report format, the WOMAC scales appear to be more responsive than the Lequesne index in patients with OA of the lower extremities.

[Validation of the North American Spine Society Instrument for assessment of health status in patients with chronic backache]

BACKGROUND

Pain and functional limitations are the chief symptoms in patients with back pain. However, standardized assessment of these domains are still not commonplace in clinical practice. The objective of this study was the cultural adaptation and validation of the North American Spine Society (NASS) Lumbar Spine Outcome Assessment Instrument for German speaking patients with back pain.

METHODS

Translation and backtranslation of the NASS instrument was performed according to international recommendations. 56 consecutive inpatients with a confirmed diagnosis of dorsopathia completed a German version of the NASS instrument, the SF-36 and an established German instrument for back patients (FFbH-R). All patients completed the questionnaires 48 hours apart to assess test-retest reliability. Validity was assessed through correlation with corresponding subscales of the SF-36, the FFbH-R and a 0-10 pain numeric rating scale. Internal consistency and item-to-scale correlation served as statistics of reliability.

RESULTS

The two subscales of the NASS Instrument for cervical and lumbar problems correlate significantly with the corresponding subscales of the FFbH-R and the SF-36 (r = 0.28-0.83, p < 0.05) and 0.39-0.68 (p < 0.05) with a pain numeric rating scale. Test-retest reliability demonstrated intraclass correlation coefficients between 0.82 to 0.89.

CONCLUSION

The German version of the NASS Cervical and Lumbar Spine Outcome Assessment Instrument allows the standardized assessment of pain, functional limitations and neurogenic symptoms in patients with back pain and the international comparison of health states and therapeutic outcomes.

Comparative responsiveness of 3 functional indices in ankylosing spondylitis

OBJECTIVE

To compare the responsiveness of the Bath Ankylosing Spondylitis Functional Index (BASFI), the Dougados Functional Index (DFI), and the ankylosing spondylitis-specific version of the Health Assessment Questionnaire (HAQ-S).

METHODS

Using data from a placebo controlled, randomized clinical trial we designed a responsiveness model including both hypothesized improvement (n = 39; continuous diclofenac treatment) and hypothesized deterioration (n = 40; patients who withdrew from the clinical trial because of a flare) of functional performance. Instrument responsiveness was examined using 4 statistics including standardized response mean (SRM), effect size (ES), the Guyatt method, and the variance method. Ceiling and floor effects were visualized using histograms for cross sectional and time-path diagrams for longitudinal analysis.

RESULTS

The BASFI ranked superior compared to the DFI and HAQ-S in detecting both improvement and deterioration of functional performance. All 4 responsiveness statistics consistently confirmed this superiority of the BASFI. However, the median baseline scores of all 3 questionnaires were close to the lower end of the instrument and the score distribution showed skewed patterns.

CONCLUSION

The BASFI appears to be more responsive than the DFI and the HAQ-S in situations of both improvement and deterioration of functional performance. However, addition of particular difficult items may improve the performance of the BASFI as well as of the other 2 instruments.

Evaluation of a German version of the Bath Ankylosing Spondylitis Functional Index (BASFI) and Dougados Functional Index (D-FI)

OBJECTIVE

Transcultural adaptation of the two most widely used and accepted functional indices in ankylosing spondylitis, the Bath Ankylosing Spondylitis Functional Index (BASFI) and Dougados Functional Index (D-FI).

METHODS

The instruments were translated and tested for internal consistency (Cronbach's coefficient alpha), test-retest reliability (intraclass correlation coefficient, ICC), construct validity (testing for association with Schober's test, finger floor distance, occiput wall distance, frequency and duration of awakenings at night, and a visual analog scale pain), and responsiveness (standardized response mean, SRM).

RESULTS

The study sample consisted of 72 patients of a randomized, controlled clinical trial receiving either Diclofenac or placebo. Visual assessment of distribution patterns revealed a ceiling effect of both instruments. Both questionnaires had a high internal consistency (Cronbach alpha: 0.81 [BASFI], 0.85 [D-FI] and a high test-retest reliability (ICC: 0.92 [BASFI], 0.89 [D-FI]). The limited responsiveness to Diclofenac treatment (SRM: 0.46 [BASFI], 0. 33 [D-FI]) may be related to the selected study sample. The BASFI was significantly correlated with all tested validation parameters. The D-FI was only significantly correlated with finger floor distance, occiput wall distance, and duration of awakenings at night.

CONCLUSION

The transculturally adapted version of both functional indices are valid, reliable, and internally consistent. Because of psychometric advantages, the BASFI may be preferred in clinical trial settings.

[Examples and proposed solutions for methodological problems in hospital appropriateness assessment]

Inappropriate hospital care has become a recurring theme since the publication of the results of the model project on the appropriateness of hospital care (Section 275 a SGB V) by the medical service of the National Associations of Health Insurers (MDS) in Spring 1997. Nationwide, an increased number of appropriateness assessments have since been conducted by the medical service of the health insurers (MDK). The basis for an objective assessment of the appropriateness of hospital care is a diligent, comprehensive, and methodologically valid examination of the actual situation. At first, it was unknown to what extent current methods in Germany conformed to international scientific standards in Epidemiology, Biometry, and Health Services Research. Following a thorough scientific examination of several typical methodologies, it became clear that current methods are insufficient, and hence do not allow valid conclusions regarding inappropriate hospital admissions or hospital days. This statement does not deny that inappropriate hospital use is very likely, but our current assessment tools do not permit further conclusions to be drawn. The purpose of this article is to identify typical mistakes in the fundamental aspects of a valid assessment based on selected examples. Proposals are made regarding methodology and the presentation of results that follow from this critical examination.

Progression in early erosive rheumatoid arthritis: 12 month results from a randomized controlled trial comparing methotrexate and gold sodium thiomalate

OBJECTIVE

To compare radiographic outcomes in patients with active early erosive rheumatoid arthritis (RA) who were treated with methotrexate (MTX) and gold sodium thiomalate (GSTM).

METHODS

A total of 174 patients from two centres were randomly assigned to receive weekly i.m. injections for 12 months of either 15 mg MTX or 50 mg GSTM in a double-blind fashion. Radiographic evaluations including standardized scoring of 38 joints of the hands, wrists and forefeet, and count of eroded joints, were carried out at baseline and after 6 and 12 months in all patients, including withdrawals.

RESULTS

An intention-to-treat analysis revealed no statistically significant difference in the progression of radiographic scores between treatment groups after 6 months (3.4 with MTX vs 2.6 with GSTM, P = 0.66) and after 12 months (6.0 vs 4.8, P = 0.44). A similar pattern was observed for the number of joints with erosions. The slope of radiographic progression was significantly reduced in the second half-year compared to the first 6 months in both groups. Erythrocyte sedimentation rate and C-reactive protein at baseline, and the presence of rheumatoid factor (RF), were the main predictors of progression in bivariate analysis. RF remained as the only predictor for radiographic outcome in multivariable analysis.

CONCLUSION

In parallel to clinical improvement, both GSTM and MTX reduce the slope of radiographic progression in patients with active erosive RA.

Outcomes of children treated for Lyme disease

OBJECTIVE

To study the outcome of Lyme disease (LD) in children identified in a total population survey of an endemic island.

METHODS

We conducted a population-based retrospective cohort study off the coast of Massachusetts. Twenty-five children who met the Centers for Disease Control case definition for prior LD were compared with 26 children without LD from the same community. All children with LD received antibiotics during the acute phase of their disease. All 51 children were invited for a clinical evaluation, including 12-lead electrocardiogram (EKG), and measurement of antibodies to Borrelia burgdorferi by antibody-capture ELISA and Western blot.

RESULTS

At a mean of 3.2 years from the initial manifestation of LD, children with prior LD did not have a higher prevalence of musculoskeletal or neurological symptoms, examination abnormalities, abnormal EKG, or behavioral difficulties, compared to children with no history of LD.

CONCLUSION

Children who receive appropriate antimicrobial therapy for LD appear to have no demonstrable longterm morbidity.

RheumaNet--a novel Internet-based rheumatology information network in Germany

Knowledge transfer in medicine has traditionally been achieved through personal communication, the medical literature, conferences and continuous medical education. However, many of these methods of communication have the problem of currentness, and the latest knowledge is mostly transferred with a certain delay. In particular, chronic disease management is frequently burdened by missing, incomplete or delayed communication. We present the implementation of a novel, Internet-based information system (RheumaNet) to facilitate rapid communication and information transfer between the 21 German Multipurpose Arthritis Centres (MACs). Medical information, agendas, urgent notifications, guidelines, etc., can be exchanged easily via electronic mail, file transfer protocol or the World Wide Web. RheumaNet allows interactive on-line communication as a common platform for joint projects or remote consultation. It supports a set of 'core documentation' that has been used by all German MACs for several years. RheumaNet was used for the organization, on-line presentation and evaluation of the 1997 annual meeting of the German Rheumatology Society and is currently appointed to establish its public representation in the 'Web'. An on-line version of the 'Quality Assurance Textbook' of German rheumatology is achieved with database-derived 'dynamic' Web pages, allowing easy access to any information within it. Advances in the future include the development of on-line patient information bulletin boards, on-line questionnaires, the coordination of rehabilitation and educational tools for medical students, and professional training.

[Vitamin E in therapy of rheumatic diseases]

Over the past years, antioxidants, and particularly vitamin E, have received considerable attention in the treatment of human diseases. In rheumatology, interest has been given to the treatment and prevention of rheumatoid arthritis and osteoarthritis. However, the concept of using antioxidant nutrients as potential remedies is not new. As early as the sixties, first case reports have described beneficial effects of vitamin E in the therapy of osteoarthritis. Nonetheless, most of the following studies were not conducted properly, thus, not allowing valid inferences about the efficacy of vitamin E. Newer studies with sound methodology have shown a beneficial effect in rheumatic diseases, mainly in the reduction of pain. This paper reviews current and past studies about vitamin E in the treatment of rheumatic diseases.

Weighting for joint surface area improves the information provided by a reduced 28-joint articular index of swollen joints

The objective of our study was to examine whether weighting for joint surface area or recording of simultaneously tender and swollen joints increases the association of a reduced 28-joint articular index with clinical and outcome parameters. In a cross-sectional study we examined 61 consecutive outpatients with RA fulfilling the American Rheumatism Association 1987 revised criteria. Tender, swollen, and simultaneously tender and swollen joints were recorded. The association of 28- and 68-joint articular indices with clinical and outcome parameters were estimated with nonparametric correlation analyses. Weighting for joint surface yielded consistently increased correlation of clinical and outcome parameters with swollen and tender and swollen but not with tender joint counts. The correlation of the 28-joint articular and 68-articular indices with these parameters were similar. In conclusion, weighting for joint surface notably improves the information provided by swollen joint counts, whereas it does not appear to improve the information provided by tender joint counts.

Comparative responsiveness of generic versus disease-specific and weighted versus unweighted health status measures in carpal tunnel syndrome

OBJECTIVES

The authors evaluated the relative responsiveness to change of generic versus disease-specific and unweighted versus weighted health status measures in carpal tunnel syndrome (CTS).

METHODS

Data were obtained from 196 subjects followed in a prospective community-based cohort study in Maine who underwent carpal tunnel release (The Maine Carpal Tunnel Syndrome Study). Patients were evaluated before and 6 months after surgery. The disease-specific, unweighted severity score was derived from the validated Carpal Tunnel Syndrome Assessment Questionnaire. Patients were asked to rate the importance of each symptom included in the severity score. Each severity question was weighted by its importance, creating a disease-specific weighted score. Generic instruments were the SF-36, SF-12, and a Quality of Life Rating Scale. Sensitivity to change was calculated with the standardized response mean (SRM, mean change/standard deviation of change) as well as the effect size (ES, mean change/standard deviation of baseline values). The ability of the instruments to distinguish clinically important differences was assessed by correlating the changes in scores with global ratings on satisfaction and perceived improvement as external criteria.

RESULTS

The disease-specific weighted score (SRM: 1.56, ES: 1.99) was more responsive than the unweighted score (SRM: 1.36, ES: 1.57). The Quality of Life Rating Scale, SF-36, and SF-12 subscales were less sensitive to change, with standardized response means and effect sizes that ranged from -0.23 to 0.88. The ability to distinguish clinically important differences was higher for the two disease-specific scales. The coefficients of correlation with the external criteria ranged from 0.50 to 0.56 for the unweighted score and 0.56 to 0.62 for the weighted score and were significantly stronger than the correlations between external measures and the most responsive subscale of the SF-36 (Bodily Pain subscale, r = 0.36). The SF-12 health survey performed as well as the SF-36 in term of responsiveness and ability to distinguish clinically important change.

CONCLUSIONS

Disease-specific measures were superior to generic measures in capturing clinical change after carpal tunnel release, and a weighted score was slightly more responsive than the unweighted score. The SF-12 showed comparable psychometric properties compared with the longer 36-item Short-Form Survey.

Comparison of the WOMAC (Western Ontario and McMaster Universities) osteoarthritis index and a self-report format of the self-administered Lequesne-Algofunctional index in patients with knee and hip osteoarthritis

OBJECTIVE

To compare the metric properties and validity of German versions of the WOMAC (Western Ontario and McMaster Universities) and a self-administered questionnaire-format of the Lequesne-Algofunctional-Index in patients with osteoarthritis (OA) of the lower extremities.

DESIGN

Cross-sectional analysis of the instruments' internal consistency (Cronbach's coefficient alpha) and construct validity (correlation with radiological OA-severity and limitation in range-of-motion) in ambulatory patients and patients before hip arthroplasty. Test-retest reliability was assessed on a subsample after 10 days.

RESULTS

Data from 51 patients out of 91 contacted could be analyzed. Twenty-nine patients had knee and 22 patients had hip OA. Both the WOMAC and Lequesne OA-indices and their scales or sections had a satisfactory test-retest reliability (Intraclass correlation coefficient 0.43-0.96). All scales of the WOMAC were internally consistent (Cronbach's coefficient alpha 0.81-0.96) and associated with radiological OA-severity and joint range of motion. However, only the function but not the symptom sections (Cronbach's coefficient alpha knee: 0.55; hip: 0.63) of the self-administered Lequesne OA index were internally consistent for both, patients with knee and hip OA. Also, the symptom components were not or only weakly associated with radiological OA-severity and joint range of motion.

CONCLUSIONS

Although our results are based on a German version using a self-report format we may caution using the self-administered Lequesne OA index without prior testing of its metric properties and validity.

Lack of cardiac manifestations among patients with previously treated Lyme disease

BACKGROUND

Cardiac involvement is common in acute Lyme disease, and case reports suggest that cardiac abnormalities might also occur years after the primary infection.

OBJECTIVE

To determine the prevalence of cardiac abnormalities in persons with previously treated Lyme disease.

DESIGN

Population-based, retrospective cohort study with controls.

SETTING

Nantucket Island, Massachusetts.

PARTICIPANTS

From among 3703 adult respondents to a total-population (n = 6046) mail survey, 336 (176 case-patients and 160 controls) were randomly selected for clinical evaluation.

MEASUREMENTS

Current cardiac symptoms and major or minor abnormal electrocardiographic features, including heart rate; rhythm; axis; PR, QRS, and QT intervals; QRS structure; atrioventricular blocks; and ST-segment and T-wave changes.

RESULTS

Persons with Lyme disease (case-patients, n = 176) (mean duration from disease onset to study evaluation, 5.2 years) and persons without evidence of previous Lyme disease (controls, n = 160) did not differ significantly in their patterns of current cardiac symptoms and electrocardiographic findings, including heart rate (P > 0.2), PR interval (P = 0.15), QRS interval (P > 0.2), QT interval (P > 0.2), axis (P > 0.2), presence of arrhythmias (P > 0.2), first-degree heart block (P = 0.12), bundle-branch block (P > 0.2), and ST-segment abnormalities (P > 0.2). In multivariate analyses that adjusted for age, sex, and previous heart disease, a history of previously treated Lyme disease was not associated with either major (odds ratio, 0.78; P > 0.2) or minor (odds ratio, 1.09; P > 0.2) electrocardiographic abnormalities.

CONCLUSION

Persons with a history of previously treated Lyme disease do not have a higher prevalence of cardiac abnormalities than persons without a history of Lyme disease.

[Patient-centered evaluation of the illness sequelae of musculoskeletal diseases: overview of important outcome instruments]

Quality of life and patient-centered health status has received increasing attention during the last decade. Simultaneously, there have been multiple instruments to assess quality of life in a standardized way. There are several possible approaches to assess health status in a more standardized way: (1) the judgement of a health professional, (2) performing standardized activities by the patient, and (3) self report of patients with standardized questionnaires. This paper presents a selection of health status instruments that have been used successfully to assess health-related quality of life in patients with musculoskeletal diseases. The description is restricted to instruments that have sound psychometric properties and that have been published in the scientific literature.

[Patient-centered evaluation of illness outcome in musculoskeletal diseases: model of illness sequelae and definition of the concept]

Musculoskeletal conditions usually cause pain, physical, psychological and social disability, and consequently reduce a patient's quality of life. Nowadays, it is generally accepted that patients are truly capable to assess disease consequences, if they are questioned with appropriate instruments. Models of disease and the disabling process provide the conceptual background for the measurement of disease consequences. To date, standardized assessment of outcomes with psychometrically sound instruments is commonplace in clinical trials, clinical epidemiology, economic studies, and health services research. However, standardized assessment tools are not yet widely used in clinical practice.

[Patient-centered evaluation of illness outcome in musculoskeletal diseases: selection and testing of outcome instruments]

Effectiveness research, economic evaluation, epidemiologic studies of disease consequences and clinical quality management all rely on standardized assessment of disease consequences with psychometrically sound questionnaires. For scientific, ethical and economical reasons, careful selection and evaluation of instruments is critical. Selection of instruments includes searches of medical databases (e.g. MEDLINE), testing of face-validity (does the instrument measure what we intend to measure?), and compatibility (is the instrument used internationally?). Evaluation of instruments includes the assessment of reliability, internal consistency and sensitivity. Most important is careful consideration of the practical usefulness (Interpretation of scores and scales, acceptance in the study population). Contact with instrument developers is advisable (Copyright issues, scoring, current version).

[Patient-centered evaluation of illness outcome in musculoskeletal diseases: adaptation and revision of outcome instruments]

Assessment of disease consequences (outcome) requires reliable, valid, and sensitive instruments. Psychometrically sound generic health-status instruments such as the SF-36 have been validated for many languages and are available in German. Instead, most disease specific instruments have been developed in English and need to be adapted for the German language. To allow for cross-cultural comparisons and use of results across cultures, for instance, in international multicenter studies, instruments need to have both content and metric equivalence. Thus, adaptation of health-status instruments requires a standarized process including translation, backtranslation, review and assessment of metric properties (reliability, internal consistency, factors), and validity. Developments of new instruments from scratch are time and cost intensive and should only be considered if no current instrument is available. Ideally, newly developed instruments have interval-scale properties.

Economic impact of rheumatologic disorders

Universally, health care systems are currently undergoing tremendous change. It is not sufficient to demonstrate that specific medical interventions and services are effective, as third party payers have become increasingly interested in financial outcomes. Managed care has accelerated this movement and rheumatology is facing new challenges to position itself in a changing health care environment. Studies dealing with the economic burden of musculoskeletal diseases and the economic evaluation of particular services and interventions are reviewed. As the health care system shifts toward managed care, rheumatology is facing tremendous challenges to position itself in new markets.

[Is misoprostol effective in NSAID-induced gastrointestinal complications?]

Misoprostol, a synthetic prostaglandin E1, has been shown to reduce both gastric lesions and clinically relevant gastrointestinal events in patients taking NSAIDs. In patients with multiple risk factors gain in quality of life by avoidance of gastric ulcers seems to offset the loss in quality of life due to diarrhea, the most important misoprostol side effect. From a clinical-epidemiological point of view misoprostol prophylaxis thus seems reasonable in patients with multiple risk factors. Since non-use due to diarrhea varies highly among patients, individual preferences should be considered in the decision making process. From an economic point of view misoprostol prophylaxis seems justified in patients with multiple risk factors. In such patients misoprostol prophylaxis may indeed be cost-saving. However, this needs to be confirmed in further economic evaluations based on newly available effectiveness data and better data on patient preferences from large and representative samples.