Disease burden of and expectations from surgery in patients prior to total knee arthroplasty: Results of the prospective FInGK study.

BACKGROUND: Disease burden in patients prior to total knee arthroplasty (TKA) varies widely between studies and countries. We aimed to characterize individuals undergoing TKA and examine their expectations from the surgery, focusing on variations in disease burden. METHODS: Consecutive patients undergoing primary TKA in a German university hospital were recruited. A questionnaire including information on disease burden, preoperative expectations from surgery, health care utilization, demography, and socioeconomics was collected one day prior to surgery and linked to data from medical records. Patients were categorized into disease burden quartiles using the Western Ontario and McMaster Universities Osteoarthritis Index' (WOMAC) total score. Subsequently, study population's characteristics and expectations from surgery were analyzed stratified by disease burden. RESULTS: A total of 196 patients were included (41 % male; mean age: 68.2 years). The median WOMAC was 52.0 (IQR: 41.0-58.0). Patients in Q1 were more often males (Q1: 63 % vs Q4: 29 %) and had a shorter duration of complaints with the impaired knee. They were also less restricted in social participation, reported less often signs of depression, and were less often treated with physiotherapy (Q1: 27 % vs Q4: 54 %). Furthermore, expectations from surgery were highest in patients with a low disease burden. CONCLUSION: We found large variations in disease burden with a considerable number of patients undergoing TKA whose functional capacity is still maintained and for which guideline-recommended conservative treatment options are not fully exhausted. Further research on this subgroup as well as establishing an international consensus on specific thresholds for TKA indication are needed.

The influence of obesity on functional outcomes and patient satisfaction 8 weeks after total knee arthroplasty: results of the prospective FInGK study.

OBJECTIVES: To investigate obese versus non-obese subjects´ knee joint function, stiffness, pain, expectations, and outcome satisfaction before and two months after total knee arthroplasty (TKA). METHODS: This study is a secondary analysis of data retrieved via a prospective single-centre cohort study investigating knee joint function and health care services utilization in patients undergoing TKA (FInGK Study). For the primary study, elective TKA patients were consecutively recruited between December 2019 and May 2021. Preoperative expectations, Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), surgery outcome satisfaction, and sociodemographic variables were assessed via self-reported questionnaires. In the current study, obese (Body Mass Index (BMI) ≥ 30 kg/m²) versus non-obese (BMI < 30 kg/m²) subjects' data were exploratively compared before and two months after TKA. Multivariable logistic regression assessed factors associated with TKA satisfaction two months postoperatively. Linear regression evaluated factors associated with higher WOMAC change two months postoperatively. RESULTS: A total of 241 subjects participated (response: 85.2%). Eighty-seven were non-obese (mean age: 70.7 years, 63.2% female) and 154 were obese (mean age: 67.1 years, 57.8% female). Obese subjects reported inferior pre- and postoperative pain and knee joint function compared to non-obese subjects. Yet, WOMAC scores of obese and non-obese subjects significantly improved from preoperative means of 52.6 and 46.8 to 32.3 and 24.4 after surgery, respectively. The only significant TKA satisfaction predictor was subjects' smoking status. Non-obesity and worse preoperative WOMAC scores were predictive of higher WOMAC change scores after two months. CONCLUSION: Both obese and non-obese subjects reported significant symptom improvements. However, as obese subjects' short-term outcomes were still inferior, more research on TKA rehabilitation measures adapted to the needs of this growing patient group is warranted to maximize their benefits from TKA.

Use of Physiotherapy Prior to Total Knee Arthroplasty-Results of the Prospective FInGK Study.

BACKGROUND: Data regarding physiotherapy (PT) utilization prior to total knee arthroplasty (TKA) are insufficient. Therefore, this study aims to examine which percentage of patients receive PT within 12 months prior to TKA and which factors are associated with its use. METHODS: Consecutive patients (≥18 years) undergoing primary or revision TKA in a German university hospital were recruited. A questionnaire including information on PT utilization, demography, and socioeconomics was collected one day prior to surgery and linked to medical hospital records. Multivariable logistic regression was conducted to determine variables associated with the use of PT. RESULTS: A total of 241 out of 283 (85%) patients participated (60% female; mean age: 68.4 years). Overall, 41% received PT at least once during 12 months prior to TKA, women more frequently than men (48% vs. 29%). Although high disease burden was associated with increased utilization, about one in two in this condition did not receive PT. Multivariable logistic regression showed that age 75+ years, low education level, and moderate-to-severe depressive symptoms were associated with decreased PT utilization. CONCLUSIONS: We found low use of recommended PT management in patients prior to TKA. This potential underuse was even higher in some vulnerable subgroups, indicating inequalities. Prescribers as well as patients should integrate PT more consistently into osteoarthritis management.

Health-Related Quality of Life according to Renal Function: Results from a Nationwide Health Interview and Examination Survey.

BACKGROUND: Most studies on health-related quality of life (HRQoL) in chronic kidney disease (CKD) focus on patients with end-stage kidney disease although they represent a small proportion of patients with CKD. We aimed to analyze HRQoL according to glomerular filtration rate (GFR) categories in a population-based sample of adults living in Germany. METHODS: Data from the German health interview and examination survey conducted from 2008 to 2011 were used. Participants with valid interview and examination data aged 40-79 years were included (n = 5,159). Serum creatinine levels were used to calculate estimated GFR via the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. We classified kidney function in GFR categories according to the Kidney Disease Improving Global Outcomes Initiative (KDIGO) guidelines on CKD: G1 (high): ≥90 mL/min/1.73 m2, G2 (normal): 60-89 mL/min/1.73 m2, G3a (mildly decreased): 45-59 mL/min/1.73 m2, G3b (moderately decreased): 30-44 mL/min/1.73 m2, G4/5 (severely decreased/end-stage kidney disease): <30 mL/min/1.73 m2. HRQoL was evaluated with the Short Form Health Survey (SF-36). Different multivariate linear and logistic regression models were used to analyze the association of HRQoL with GFR categories. RESULTS: Overall, 5.9% had a GFR <60 mL/min/1.73 m2 (corresponding to categories G3a, G3b, and G4/5). Compared to category G2 linear regression showed a decline in physical HRQoL in categories G3a (-2.34, p = 0.004), G3b (-5.37, p = 0.009), and G4/5 (-4.82, p = 0.117). No decline in mental HRQoL was detected with increasing GFR categories. Categories G3a to G4/5 were significantly associated with a low perceived general state of health (G3a: odds ratio [OR] = 2.03, p = 0.001; G3b: OR = 3.01, p = 0.009; G4/5: OR = 8.70, p = 0.016) when compared to category G2. CONCLUSION: In a representative sample of adults living in Germany, both physical HRQoL and the perceived general state of health are already significantly reduced in category G3a.

Physical Therapy Use and Associated Factors in Adults with and without Osteoarthritis-An Analysis of the Population-Based German Health Update Study.

BACKGROUND: Physical therapy (PT) is recommended as first-line management for osteoarthritis (OA). The purpose of this study was to assess the PT use among adults with OA and those without (Non-OA) and subsequently identify associated factors among these populations. METHODS: This cross-sectional study obtained national data from the population-based German Health Update (GEDA2014/2015-EHIS) study containing 24,016 participants aged 18 years and older. Analyses were stratified by sex, age, socioeconomic status (SES), residence, smoking behavior, body mass index, pain and general health. Multivariate regression analysis was conducted to evaluate factors associated with PT use within the past 12 months. RESULTS: PT was used more frequently in the OA population compared with the Non-OA population (35.8% vs. 18.7%). In both populations, women, participants with high SES, residence in Eastern Germany, severe pain, poor general health and non-smokers received PT more frequently. Multivariate analysis confirmed these findings, in addition to people aged 80 years and older. The influence of SES was higher among OA participants. CONCLUSION: The underutilization of PT in OA patients (35.8%) was particularly evident among males, people with a low SES and those being older than 60 years, which aids to develop strategies increasing PT use towards guideline-oriented OA management.

Should we be more aware of gender aspects in hyperuricemia? Analysis of the population-based German health interview and examination survey for adults (DEGS1).

OBJECTIVES: While gout is a well-known entity, little research has been conducted on its pathophysiology. There is growing evidence that women with hyperuricemia are at higher cardiovascular risk than men with hyperuricemia. We aim to evaluate whether gender-specific cut-offs should be considered. STUDY DESIGN: Cross-sectional study (the German Health Interview and Examination Survey for Adults; DEGS1). MAIN OUTCOME MEASURES: Self-reported gout or hyperuricemia and uric acid level. RESULTS: Of 6,918 participants (mean age 47.2 years; 50.5% females), 9.7% had had a diagnosis of hyperuricemia or gout at least once in their lifetime. Men were nearly twice as often affected as women (12.9 vs. 6.5%). In women, the prevalence of cardiovascular and renal diseases increased with higher uric acid level to a much greater extent than in men. This association remained in multivariate analyses. CONCLUSIONS: No commonly accepted cut-off value for uric acid has been established. Overall, women were at lower risk of hyperuricemia. However, women were at higher risk of having cardiovascular and renal comorbidities, even at lower uric acid levels. Our results are in line with the accumulating evidence that we should consider gender in gout and hyperuricemia.

Utilisation of outpatient physiotherapy in patients following total knee arthroplasty - a systematic review.

OBJECTIVE: Data on the utilisation of outpatient physiotherapy (PT) in patients following total knee arthroplasty (TKA) are scarce, and available studies have not been systematically synthesised. This study aims to summarise the existing literature on outpatient PT following TKA as well as to identify factors associated with its use. METHODS: A systematic literature search in MEDLINE (via PubMed), CINAHL, Scopus and PEDro was conducted in July 2020 without language restrictions. Two authors independently selected studies, extracted data and assessed study quality. The primary outcome was the proportion being treated with at least one session of outpatient PT (land- or water-based treatments supervised/provided by a qualified physiotherapist) during any defined period within 12 months following TKA. Furthermore, predictors for the use of PT were assessed. Studies including only revision surgeries or bilateral TKA were excluded. RESULTS: After screening 1934 titles/abstracts and 56 full text articles, 5 studies were included. Proportions of PT utilisation ranged from 16.7 to 84.5%. There were large variations in the time periods after hospital discharge (4 weeks to 12 months) and in the reporting of PT definitions. Female sex was associated with higher PT utilisation, and compared to patients after total hip arthroplasty, utilisation was higher among those following TKA. CONCLUSION: Despite using a broad search strategy, we found only 5 studies assessing the utilisation of PT after hospital discharge in patients with TKA. These studies showed large heterogeneity in PT utilisation, assessed time periods and PT definitions. Clearly, more studies from different countries with uniform PT definitions are needed to address this relevant public health question.

[Prevalence and Treatment of Posttraumatic Stress Disorder in Germany: An Analysis of Nationwide Health Insurance Data, 2008 vs 2017]. / Prävalenz und Versorgung der Posttraumatischen Belastungsstörung in Deutschland: Eine bundesweite Auswertung von Krankenkassendaten aus den Jahren 2008 und 2017.

OBJECTIVE: To provide German data regarding prevalence and treatment (pharmacotherapy, psychotherapy) for individuals with PTSD. METHODS: Based on BARMER health insurance data, the administrative prevalence of PTSD (ICD-10: F43.1), psychiatric comorbidity, psychotherapy and pharmacotherapy were estimated. Additionally, prevalence trends for years 2008 vs. 2017 were computed. RESULTS: In 2017, the overall PTSD prevalence was 0.7 % (females: 0.9 %, males: 0.4 %), whereas in 2008 it was 0.3 %. 74.4 % of all PTSD cases received psychotherapy, 43.6 % were prescribed an antidepressant (first choice: venlafaxine), and 14.4 % were prescribed an antipsychotic (first choice: quetiapine). CONCLUSION: Within the studied period, the administrative prevalence of PTSD has more than doubled. Still, the prevalence rate found in our study is lower than figures from epidemiological studies, thus indicating room for improvement in diagnosing PTSD.

Use of Physical Therapy in Patients With Osteoarthritis in Germany: An Analysis of a Linkage of Claims and Survey Data.

OBJECTIVE: To examine the utilization of physical therapy (PT) and predictors for its use in individuals with osteoarthritis (OA) while focusing on sociodemographic and disease-related factors. METHODS: For this cross-sectional study, 657,807 patients (age 30-79 years) diagnosed with hip, knee, or polyarticular OA were identified in claims data. In 2016, a questionnaire including information on disease status, demography, and socioeconomics was sent to a random sample of 8,995 patients stratified by sex, age, and type of diagnosis. Claims data from 2016 included the utilization and type of PT, as well as the prescribing medical specialist, and were linked to questionnaire data. Multivariable logistic regression was conducted to determine variables associated with the use of PT. RESULTS: In total, 3,564 (40%) patients completed the questionnaire and agreed to linking questionnaire and claims data (69% female, mean age 66.5 years). In 2016, 50% of the study population received PT at least once, and women received it more frequently than men (53% versus 43%). Most PT was prescribed by orthopedists (45%) and general practitioners (32%). Multivariable logistic regression showed that women, higher household income, having both hip and knee OA, lower functional status, higher disease activity, and individuals living in the eastern, southern, and western states of Germany were associated with an increased utilization of PT. CONCLUSION: Considering current guideline recommendations and that more than one-third of OA patients with high functional impairment and/or pain did not receive PT in the last 12 months, there is considerable potential for improvement. This is especially true for men and individuals with a low income.

Factors Associated with Survey Non-Response in a Cross-Sectional Survey of Persons with an Axial Spondyloarthritis or Osteoarthritis Claims Diagnosis.

Non-response in surveys can lead to bias, which is often difficult to investigate. The aim of this analysis was to compare factors available from claims data associated with survey non-response and to compare them among two samples. A stratified sample of 4471 persons with a diagnosis of axial spondyloarthritis (axSpA) and a sample of 8995 persons with an osteoarthritis (OA) diagnosis from a German statutory health insurance were randomly selected and sent a postal survey. The association of age, sex, medical prescriptions, specialist physician contact, influenza vaccination, hospitalization, and Elixhauser comorbidity index with the survey response was assessed. Multiple logistic regression models were used with response as the outcome. A total of 47% of the axSpA sample and 40% of the OA sample responded to the survey. In both samples, the response was highest in the 70-79-year-olds. Women in all age groups responded more often, except for the 70-79-year-olds. Rheumatologist/orthopedist contact, physical therapy prescription, and influenza vaccination were more frequent among responders. In the logistic regression models, rheumatologist/orthopedist treatment, influenza vaccination, and physical therapy were associated with a higher odds ratio for response in both samples. The prescription of biologic drugs was associated with higher response in axSpA. A high Elixhauser comorbidity index and opioid use were not relevantly associated with response. Being reimbursed for long-term care was associated with lower response-this was only significant in the OA sample. The number of quarters with a diagnosis in the survey year was associated with higher response. Similar factors were associated with non-response in the two samples. The results can help other investigators to plan sample sizes of their surveys in similar settings.

[Utilization of individual out-of-pocket health services (IGeL) in persons with osteoarthritis in Germany : Results of a survey from the PROCLAIR study]. / Inanspruchnahme von individuellen Gesundheitsleistungen (IGeL) bei Arthrose in Deutschland : Ergebnisse einer Befragung im Rahmen der PROCLAIR-Studie.

BACKGROUND: Little is known about the utilization of individual health services performed by a physician (IGeL) and the services and supplements provided outside a doctor's office (MuPaP) for osteoarthritis patients. OBJECTIVES: The aims of this study are to analyze the use of osteoarthritis-specific IGeL and MuPaP as well as predictors for their utilization. MATERIALS AND METHODS: For this cross-sectional study, claims data was used to identify all persons with hip, knee, or polyarticular osteoarthritis in 2014 (n = 657,807). A random sample (n = 8995) was sent a questionnaire about their usage of IGeL and MuPaP. Furthermore, the type of physicians conducting or recommending services was evaluated. Applying multivariable logistic regression, predictors associated with the utilization of IGeL, MuPaP, and overall individual health services were analyzed. RESULTS: After validating the data and osteoarthritis diagnosis, 2363 persons were enrolled (mean age: 65.5 years, 72% female). In the last 12 months, 39% of patients had used at least one IGeL (MuPaP: 76%), with 86% being primarily performed by orthopedists (MuPaP: 88% patient self-motivated). Knee osteoarthritis was associated with increased utilization of IGeL. Having female gender, higher income, residence in Western Germany, higher disease burden, and lower satisfaction with the healthcare system were influences on the use of overall individual health services. CONCLUSIONS: Since patients with high disease burden in particular tend to use these therapies with varying treatment success, detailed information, especially about the risks and existing evidence, should be a prerequisite for trustworthy doctor-patient relationships.

[Prescription frequency of physical therapy and analgesics before total hip and knee arthroplasy : An epidemiological analysis of routine health care data from Germany]. / Verordnungshäufigkeit physikalischer Therapien und Analgetika vor dem Einsatz einer Hüft- bzw. Kniegelenks-Endoprothese : Eine versorgungsepidemiologische Analyse basierend auf GKV-Routinedaten aus Deutschland.

BACKGROUND: Osteoarthritis of the hip or knee joint is a widespread disease with a strong influence on the quality of life. At present, the extent of conservative treatment with physical therapies and analgesics before the use of a total joint arthroplasty (TJA) of the hip or knee is largely unclear in Germany. OBJECTIVES: The aim was to analyze the prescription frequency according to regional and socio-demographic factors. MATERIALS AND METHODS: Based on routine health care data from BARMER insurance, patients who received a TJA of the hip or knee from 2011 to 2013 were analyzed. Included were consistently insured patients with the main discharge diagnosis of osteoarthritis who did not receive any further TJA for eight quarters before and after replacement. The prescription frequency of physical therapies and analgesics, stratified according to age groups, gender, number of comorbidities and federal state was analyzed. RESULTS: 40,242 persons with hip TJA and 35,652 persons with knee TJA were included. In the year prior to surgery, 49.4% of patients (hip TJA: 49.9%; knee TJA: 48.9%) received at least one physical therapy and 81.0% were prescribed analgesics. Regionally, the prescription frequency of physical therapies for hip TJA varied between 35.7% (Bremen) and 70.6% (Saxony) and for knee TJA between 37.6% (Saarland) and 66.9% (Saxony). CONCLUSION: The prescription frequency of physical therapy does not fully correspond to current treatment recommendations. The prescription of physical therapies in the year before the TEP shows regional differences, with fundamentally lower prescription frequencies in the former states of West Germany.

Incidence Rates of and Mortality after Hip Fracture among German Nursing Home Residents.

Little is known about hip fracture rates and post-fracture mortality among nursing home residents. This retrospective cohort study examined incidence rates (IR) of and mortality after hip fracture in this population focusing on sex differences. A cohort of >127,000 residents ≥65 years, newly admitted to German nursing homes between 2010 and 2014 were used to calculate age-, sex-, care-need- and time after admission-specific IR. To determine mortality, the Kaplan-Meier-method was applied. Using Cox regression, we studied mortality and estimated time-dependent hazard ratios (HRs). For this purpose, to each person with a hip fracture, one resident without a hip fracture was matched by sex, age and care-need using risk-set sampling. 75% were women (mean age: 84.0 years). During 168,588 person-years (PY), 8537 residents with at least one hip fracture were observed. The IR for women and men were 52.9 and 42.5/1000 PY. For both sexes, IR increased with rising age and decreased with increasing care-level. IR were highest in the first months after admission and subsequently declined afterwards. The impact of hip fractures on mortality was time-dependent. Mortality of residents with hip fracture was highest in the first two months after fracture compared to those without (HR): 2.82; 95% CI 2.57-3.11) and after six months, no differences were found (HR: 1.10; 95% CI 0.98-1.22) Further research should always include analyses stratified by sex, age and time period after admission.