Factors associated with the quality of patients' surgical decisions for treatment of hip and knee osteoarthritis

BACKGROUND

Shared decision making requires informing patients and ensuring that treatment decisions reflect their goals. It is not clear to what extent this happens for patients considering total joint replacement (TJR) for hip or knee osteoarthritis.

STUDY DESIGN

We conducted a cross-sectional mail survey of osteoarthritis patients at 4 sites, who made a decision about TJR. The survey measured knowledge and goals, the decision making process, decision confidence, and decision regret. Decision quality was defined as the percentage of patients who had high knowledge scores and received treatments that matched their goals. Multivariable regression models examined factors associated with knowledge and decision quality.

RESULTS

There were 382 patients who participated (78.6% response rate). Mean knowledge score was 61% (SD 20.7%). In multivariate linear regression, higher education, having TJR, and site were associated with higher knowledge. Many patients (73%) received treatments that matched their goals. Thirty-one percent of patients met our definition for high decision quality. Higher decision making process scores, higher quality of life scores, and site were associated with higher decision quality. Patients who had high decision quality had less regret (73.1% vs 58.5%, p = 0.007) and greater confidence (9.0 [SD 1.6] vs 8.2 [SD 2.3] out of 10, p < 0.001).

CONCLUSIONS

A third of patients who recently made a decision about osteoarthritis treatment met both criteria for a high quality decision. Controlling for treatment, patients reporting more involvement in the decision making process, higher quality of life, and being seen at a site that uses decision aids were associated with higher decision quality.

Effect of evidence and changes in reimbursement on the rate of arthroscopy for osteoarthritis

BACKGROUND

The efficacy of arthroscopic debridement or lavage for knee osteoarthritis (OA) was cast into doubt after publication of several randomized controlled trials beginning in 2002.

PURPOSE

The authors set out to determine whether evidence of ineffectiveness, along with subsequent changes in reimbursement, were followed by changes in utilization rates of arthroscopy for patients with OA.

STUDY DESIGN

Cohort study (prevalence); Level of evidence, 2.

METHODS

The Florida State Ambulatory Surgery Database was used to examine population-based rates of knee arthroscopy from 2000 to 2008 for patients with and without the diagnosis of OA; data were stratified between public and private payers. These trends were compared with patients who underwent arthroscopy for other diagnoses and were also compared with patients whose arthritis was not the primary indication for surgery.

RESULTS

A 39% decrease in the adjusted population-based rate of knee arthroscopy for OA was observed, from 12.2 per 100,000 adults in 2000 (95% CI, 9.9-14.4) to 7.7 per 100,000 adults in 2008 (95% CI, 6.7-8.6). The overall rate among individuals with a primary diagnosis of OA significantly decreased for both public (P < .001) and private insurance (P = .001) and the rate of this decrease was similar between the two insurance types (P = .610). Although the unadjusted rates for all knee arthroscopy increased over the study period, the rate of increase was slowed in the years following the publication of several randomized controlled trials and subsequent changes in reimbursement. The average effect on arthroscopy rates attributed to these events was a reduction in 12 per 100,000 private arthroscopies (95% CI, -16.3 to 40.6; P = .404) and 35.7 per 100,000 publicly insured arthroscopies (95% CI, 15.0-56.4; P = .001).

CONCLUSION

Evidence of the lack of efficacy of arthroscopy for knee OA, along with changes in reimbursement, preceded a significant decline in the population-based rates of this procedure in both publicly and privately insured patients in Florida.

Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation

BACKGROUND

A high quality decision requires that patients who meet clinical criteria for surgery are informed about the options (including non-surgical alternatives) and receive treatments that match their goals. The aim of this study was to evaluate the psychometric properties and clinical sensibility of a patient self report instrument, to measure the quality of decisions about total joint replacement for knee or hip osteoarthritis.

METHODS

The performance of the Hip/Knee Osteoarthritis Decision Quality Instrument (HK-DQI) was evaluated in two samples: (1) a cross-sectional mail survey with 489 patients and 77 providers (study 1); and (2) a randomized controlled trial of a patient decision aid with 138 osteoarthritis patients considering total joint replacement (study 2). The HK-DQI results in two scores. Knowledge items are summed to create a total knowledge score, and a set of goals and concerns are used in a logistic regression model to develop a concordance score. The concordance score measures the proportion of patients whose treatment matched their goals. Hypotheses related to acceptability, feasibility, reliability and validity of the knowledge and concordance scores were examined.

RESULTS

In study 1, the HK-DQI was completed by 382 patients (79%) and 45 providers (58%), and in study 2 by 127 patients (92%), with low rates of missing data. The DQI-knowledge score was reproducible (ICC = 0.81) and demonstrated discriminant validity (68% decision aid vs. 54% control, and 78% providers vs. 61% patients) and content validity. The concordance score demonstrated predictive validity, as patients whose treatments were concordant with their goals had more confidence and less regret with their decision compared to those who did not.

CONCLUSIONS

The HK-DQI is feasible and acceptable to patients. It can be used to assess whether patients with osteoarthritis are making informed decisions about surgery that are concordant with their goals.

Management of Chronic Pain: Improving shared decision making in osteoarthritis

The burden of chronic pain for those who have it and their families is substantial, says Henry McQuay (doi: 10.1136/bmj.39520.699190.94), and these patients deserve better. Dawn Stacey and colleagues describe an example of quality improvement in practice for one group of people with chronic pain, those with osteoarthritis

Constrained condylar knee without stem extensions for difficult primary total knee arthroplasty

Two hundred forty-eight constrained condylar total knee arthroplasties consecutively implanted without the use of diaphyseal stem extensions were studied in 180 patients. Preoperative deformity was severe (82% Ahlbäck grade 4-5). One hundred ninety-two knees (148 patients) were reviewed at mean 47-month follow-up (range: 24-72 months). Knee Society score improved from 36 to 89 points, and function score improved from 42 to 76 points. Failure rate was 2.5% (2 infections, 1 aseptic loosening, 1 supracondylar femoral fracture, and 1 tibial post fracture). Five (2.5%) knees had patellofemoral complications. Nonprogressive radiolucent lines were present in 16% of cases. Use of a nonmodular constrained condylar knee for primary severely damaged knees demonstrated reliable short- to mid-term results with a low complication rate and questioned the routine use of intramedullary stem extensions in all such cases.

RelA is required for IL-1beta stimulation of Matrix Metalloproteinase-1 expression in chondrocytes

OBJECTIVE

Interleukin-1beta (IL-1beta) stimulates collagenase-1 (Matrix Metalloproteinase-1 (MMP-1)) expression in articular chondrocytes, leading to cleavage of type II collagen and irreversible cartilage degradation. The nuclear factor-kappa B (NF-kappaB) pathway is potently activated in IL-1beta-stimulated cells and has been implicated as an intermediate in MMP-1 gene expression. However, the roles of individual NF-kappaB family members during IL-1beta-induced MMP-1 gene expression have not been defined.

RESULTS

To address the relationship between the NF-kappaB pathway and MMP-1 gene activation in chondrocytes, primary cultured human articular chondrocyte cultures (HAC) and SW-1353 cells were stimulated with IL-1beta over a 24-h time course and MMP-1, NF-kappaB1, NF-kappaB2 and RelA gene expression was assayed. IL-1beta-induced MMP-1 expression was comparable in HAC and SW-1353 cells both temporally and quantitatively. MMP-1 gene expression was mirrored by increases in NF-kappaB gene expression, and inhibition of NF-kappaB nuclear translocation with dominant-negative IkappaBalpha reduced IL-1beta-dependent MMP-1 gene expression. IL-1beta activated the NF-kappaB pathway in chondrocytes, both through phosphorylation and transient degradation of IkappaBalpha, as well as through sustained phosphorylation of RelA. Small inhibitory RNAs (siRNA) specific for RelA resulted in significant reduction of MMP-1 mRNA, whereas siRNA for NF-kappaB1 and NF-kappaB2 augmented IL-1beta-induced MMP-1 expression.

CONCLUSIONS

Our data demonstrate that IL-1beta activation of the NF-kappaB pathway is required for IL-1beta induction of MMP-1 in chondrocytes and that RelA can work independently of NF-kappaB1 or NF-kappaB2 to activate this gene expression program.

Cost-effectiveness of unicompartmental and total knee arthroplasty in elderly low-demand patients. A Markov decision analysis

BACKGROUND

Interest in unicompartmental knee arthroplasty has recently increased in the United States, making a firm understanding of the indications for this procedure important. The purpose of this study was to examine the cost-effectiveness of unicompartmental knee arthroplasty compared with total knee arthroplasty in elderly low-demand patients.

METHODS

A Markov decision model was used to evaluate the cost-effectiveness of unicompartmental knee arthroplasty as compared with total knee arthroplasty in the elderly population. Transition probabilities were estimated from the Norwegian Arthroplasty Register and the arthroplasty literature, and costs were based on the average Medicare reimbursement for unicompartmental, tricompartmental, and revision knee arthroplasties. Outcomes were measured in quality-adjusted life-years.

RESULTS

Our model showed unicompartmental knee arthroplasty to be a cost-effective strategy for this population as long as the annual probability of revision is <4%. The cost of unicompartmental knee arthroplasty must be greater than $13,500 or the cost of total knee arthroplasty must be less than $8500 before total knee arthroplasty becomes more cost-effective.

CONCLUSIONS

Our model suggests that, on the basis of currently available cost and outcomes data, unicompartmental knee arthroplasty and total knee arthroplasty have similar cost-effectiveness profiles in the elderly low-demand patient population. However, several important parameters that could alter the cost-effectiveness analysis were identified; these included implant survival rates, costs, perioperative mortality and infection rates, and utility values achieved with each procedure. The thresholds identified in this study may help decision-makers to evaluate the cost-effectiveness of each strategy as further research characterizes the variables associate with unicompartmental and total knee arthroplasties and may be helpful for designing future appropriate clinical trials.

High failure rate of a modern, proximally roughened, cemented stem for total hip arthroplasty

The role of surface finish on the survivorship of cemented femoral stems continues to be debated. A total of 34 proximally roughened cemented stems were implanted in 33 consecutive patients undergoing total hip arthroplasty by a single surgeon. An alarmingly high failure rate was observed, prompting a retrospective chart review, analysis of radiographs, and evaluation of retrieved stems and pathological specimens. Nineteen patients were available with more than two years follow-up. Of these 19 patients, nine stems had failed (47%) due to severe osteolysis and stem loosening. Failures were significantly more common in the male gender (p<0.005), and young (p=0.05), tall (p<0.002), and heavy patients (p<0.004). All failed revised hips showed severe metallosis, with both gross and microscopic evidence of metallic shedding from the stems. Our findings suggest that this proximally roughened stem is susceptible to early failure. Failure is characterized by stem debonding, subsidence within the cement mantle, shedding of metallic and cement particles due to fretting, and rapidly progressive osteolysis. These findings have been observed with other rough surface finish cemented stems.

Interleukin-1 beta induction of matrix metalloproteinase-1 transcription in chondrocytes requires ERK-dependent activation of CCAAT enhancer-binding protein-beta

Interleukin-1 beta (IL-1beta) is a central mediator of inflammation and connective tissue destruction in rheumatoid arthritis. IL-1beta activates articular chondrocytes to produce matrix metalloproteinase-1 (MMP-1), an enzyme capable of dismantling the collagen scaffold of articular cartilage. To define the transcription factors and signaling intermediates that activate MMP-1 transcription in chondrocytes, we performed transient transfection of MMP-1 promoter constructs followed by reporter assays. These studies identified an IL-1beta-responsive region of the human MMP-1 promoter that contains a consensus CCAAT enhancer-binding protein (C/EBP) binding site. Deletion of this site reduced overall transcriptional activity of the MMP-1 promoter, as well as decreased fold induction by IL-1beta. IL-1beta stimulation of chondrocytes increased binding of C/EBP-beta to the MMP-1 C/EBP site. Extracellular signal regulated kinase (ERK) pathway-dependent phosphorylation of C/EBP-beta on threonine 235 activates this transcription factor. Here we show that IL-1beta stimulation of chondrocytes induced phosphorylation of C/EBP-beta on threonine 235, and that the ERK pathway inhibitor PD98059 reduced this phosphorylation. We further show that PD98059 reduces IL-1beta-induced MMP-1 mRNA expression in chondrocytes. Moreover, inhibition of the ERK pathway by expression of dominant-negative forms of ERK1 and ERK2 impaired the ability of IL-1beta to transactivate the MMP-1 promoter. Our findings demonstrate a novel role for C/EBP-beta in IL-1beta-induced connective tissue disease and define a new nuclear target for the ERK pathway in MMP-1 gene activation.

The use of magnetic resonance imaging to evaluate the accuracy of a handheld ultrasound machine in localizing the sciatic nerve in the popliteal fossa

BACKGROUND AND OBJECTIVE

Ultrasound has become an increasingly popular modality in facilitating the performance of peripheral nerve blocks. There is a paucity of data describing techniques of ultrasound-guided sciatic nerve blocks. By using magnetic resonance imaging (MRI) as a gold standard, the objective of this study was to describe the ability of a handheld ultrasound machine to accurately locate the sciatic nerve.

METHODS

Ten patients were prospectively enrolled and placed in the prone position. By using a 4- to 7-MHz ultrasound transducer, the sciatic nerve was visualized in short axis between 5 to 10 cm above the popliteal crease. The distance from the skin to the nerve was measured by ultrasound, and a MRI lucent marker was placed at this site. This process was repeated in one additional location. The patient was then placed supine in the MRI scanner and short-axis T1-weighted images were obtained. On the MRI image, we recreated the 2 lines extending down from the markers using the distances previously measured by ultrasound. The point of intersection of these 2 lines represents the ultrasound-determined location of the sciatic nerve, which was then compared with the midpoint of the nerve complex on MRI.

RESULTS

The sciatic nerve was easily visualized by ultrasound in all 10 patients. MRI showed the division of the sciatic nerve in 9 out of 10 patients. Ultrasound was able to confirm this division in 7 patients. The mean distance between the MRI and ultrasound midpoint location of the sciatic nerve was 2.9 +/- 1.3 mm.

CONCLUSIONS

The data presented here suggest that the specific ultrasound machine evaluated in this study can accurately localize the sciatic nerve in the popliteal fossa.

[Results of reproduction and health research, the Czech Republic 1993: Part 1]

This article "deals with two basic spheres: natality (abortion rate) and family planning. Natality was evaluated by current indicators such as specific female birth rate, by age, aggregate fertility, and/or median age at birth of the first child." Women were also asked about contraceptive use, knowledge of contraceptive methods, and reasons for use or nonuse. (SUMMARY IN ENG)

[Results of reproduction and health research, the Czech Republic, 1993: Part 2]

This article "aims at the following topics: problems of health of pregnant women, sexual behaviour of young women and attitudes towards health." Data are from a 1993 survey on reproduction and health research in the Czech Republic. (SUMMARY IN ENG)