2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

OBJECTIVE: To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. METHODS: We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. RESULTS: Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. CONCLUSION: This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-From evidence-based medicine to the real-life setting.

The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) published a treatment algorithm for the management of knee osteoarthritis (OA) in 2014, which provides practical guidance for the prioritization of interventions. Further analysis of real-world data for OA provides additional evidence in support of pharmacological interventions, in terms of management of OA pain and function, avoidance of adverse events, disease-modifying effects and long-term outcomes, e.g., delay of total joint replacement surgery, and pharmacoeconomic factors such as reduction in healthcare resource utilization. This article provides an updated assessment of the literature for selected interventions in OA, focusing on real-life data, with the aim of providing easy-to-follow advice on how to establish a treatment flow in patients with knee OA in primary care clinical practice, in support of the clinicians' individualized assessment of the patient. In step 1, background maintenance therapy with symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) is recommended, for which high-quality evidence is provided only for the prescription formulations of patented crystalline glucosamine sulfate and chondroitin sulfate. Paracetamol may be added for rescue analgesia only, due to limited efficacy and increasing safety signals. Topical non-steroidal anti-inflammatory drugs (NSAIDs) may provide additional symptomatic treatment with the same degree of efficacy as oral NSAIDs without the systemic safety concerns. Oral NSAIDs maintain a central role in step 2 advanced management of persistent symptoms. However, oral NSAIDs are highly heterogeneous in terms of gastrointestinal and cardiovascular safety profile, and patient stratification with careful treatment selection is advocated to maximize the risk:benefit ratio. Intra-articular hyaluronic acid as a next step provides sustained clinical benefit with effects lasting up to 6 months after a short-course of weekly injections. As a last step before surgery, the slow titration of sustained-release tramadol, a weak opioid, affords sustained analgesia with improved tolerability.

Symptom assessment in knee osteoarthritis needs to account for physical activity level.

OBJECTIVE: Pain is not always correlated with severity of radiographic osteoarthritis (OA), possibly because people modify activities to manage symptoms. Measures of symptoms that consider pain in the context of activity level may therefore provide greater discrimination than a measure of pain alone. We undertook this study to compare discrimination provided by a measure of pain alone with that provided by combined measures of pain in the context of physical activity across radiographic OA severity levels. METHODS: This was a cross-sectional study nested within the Osteoarthritis Initiative (OAI). The population was drawn from 2,127 persons enrolled in an OAI accelerometer monitoring substudy, including those with and those without knee OA. Two composite pain and activity knee symptom (PAKS) scores were calculated as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score (plus 1) divided by a physical activity measure (step count for the first PAKS score [PAKS1 score] and activity count for the second PAKS score [PAKS2 score]). Symptom score discrimination across Kellgren/Lawrence (K/L) grades was evaluated using histograms and quantile regression. RESULTS: A total of 1,806 participants (55.5% of whom were women) were included (mean ± SD age 65.1 ± 9.1 years, mean ± SD body mass index 28.4 ± 4.8 kg/m(2) ). The WOMAC pain score, but not the PAKS scores, exhibited a floor effect. The adjusted median WOMAC pain scores by K/L grades 0-4 were 0, 0, 0, 1, and 3, respectively. The adjusted median PAKS1 scores were 24.9, 26.0, 32.4, 46.1, and 97.9, respectively, and the adjusted median PAKS2 scores were 7.2, 7.2, 9.2, 12.9, and 23.8, respectively. The PAKS scores had more statistically significant comparisons between K/L grades than did the WOMAC pain score. CONCLUSION: Symptom assessments incorporating pain and physical activity did not exhibit a floor effect and were better able to discriminate radiographic severity than an assessment of pain alone, particularly in milder disease. Pain in the context of physical activity level should be used to assess knee OA symptoms.

A reference case for economic evaluations in osteoarthritis: an expert consensus article from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).

BACKGROUND: General recommendations for a reference case for economic studies in rheumatic diseases were published in 2002 in an initiative to improve the comparability of cost-effectiveness studies in the field. Since then, economic evaluations in osteoarthritis (OA) continue to show considerable heterogeneity in methodological approach. OBJECTIVES: To develop a reference case specific for economic studies in OA, including the standard optimal care, with which to judge new pharmacologic and non-pharmacologic interventions. METHODS: Four subgroups of an ESCEO expert working group on economic assessments (13 experts representing diverse aspects of clinical research and/or economic evaluations) were charged with producing lists of recommendations that would potentially improve the comparability of economic analyses in OA: outcome measures, comparators, costs and methodology. These proposals were discussed and refined during a face-to-face meeting in 2013. They are presented here in the format of the recommendations of the recently published Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement, so that an initiative on economic analysis methodology might be consolidated with an initiative on reporting standards. RESULTS: Overall, three distinct reference cases are proposed, one for each hand, knee and hip OA; with diagnostic variations in the first two, giving rise to different treatment options: interphalangeal or thumb-based disease for hand OA and the presence or absence of joint malalignment for knee OA. A set of management strategies is proposed, which should be further evaluated to help establish a consensus on the "standard optimal care" in each proposed reference case. The recommendations on outcome measures, cost itemisation and methodological approaches are also provided. CONCLUSIONS: The ESCEO group proposes a set of disease-specific recommendations on the conduct and reporting of economic evaluations in OA that could help the standardisation and comparability of studies that evaluate therapeutic strategies of OA in terms of costs and effectiveness.

An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).

OBJECTIVES: Existing practice guidelines for osteoarthritis (OA) analyze the evidence behind each proposed treatment but do not prioritize the interventions in a given sequence. The objective was to develop a treatment algorithm recommendation that is easier to interpret for the prescribing physician based on the available evidence and that is applicable in Europe and internationally. The knee was used as the model OA joint. METHODS: ESCEO assembled a task force of 13 international experts (rheumatologists, clinical epidemiologists, and clinical scientists). Existing guidelines were reviewed; all interventions listed and recent evidence were retrieved using established databases. A first schematic flow chart with treatment prioritization was discussed in a 1-day meeting and shaped to the treatment algorithm. Fine-tuning occurred by electronic communication and three consultation rounds until consensus. RESULTS: Basic principles consist of the need for a combined pharmacological and non-pharmacological treatment with a core set of initial measures, including information access/education, weight loss if overweight, and an appropriate exercise program. Four multimodal steps are then established. Step 1 consists of background therapy, either non-pharmacological (referral to a physical therapist for re-alignment treatment if needed and sequential introduction of further physical interventions initially and at any time thereafter) or pharmacological. The latter consists of chronic Symptomatic Slow-Acting Drugs for OA (e.g., prescription glucosamine sulfate and/or chondroitin sulfate) with paracetamol at-need; topical NSAIDs are added in the still symptomatic patient. Step 2 consists of the advanced pharmacological management in the persistent symptomatic patient and is centered on the use of oral COX-2 selective or non-selective NSAIDs, chosen based on concomitant risk factors, with intra-articular corticosteroids or hyaluronate for further symptom relief if insufficient. In Step 3, the last pharmacological attempts before surgery are represented by weak opioids and other central analgesics. Finally, Step 4 consists of end-stage disease management and surgery, with classical opioids as a difficult-to-manage alternative when surgery is contraindicated. CONCLUSIONS: The proposed treatment algorithm may represent a new framework for the development of future guidelines for the management of OA, more easily accessible to physicians.

Health economics in the field of osteoarthritis: an expert's consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).

OBJECTIVES: There is an important need to evaluate therapeutic approaches for osteoarthritis (OA) in terms of cost-effectiveness as well as efficacy. METHODS: The ESCEO expert working group met to discuss the epidemiological and economic evidence that justifies the increasing concern of the impact of this disease and reviewed the current state-of-the-art in health economic studies in this field. RESULTS: OA is a debilitating disease; it is increasing in frequency and is associated with a substantial and growing burden on society, in terms of both burden of illness and cost of illness. Economic evaluations in this field are relatively rare, and those that do exist, show considerable heterogeneity of methodological approach (such as indicated population, comparator, decision context and perspective, time horizon, modeling and outcome measures used). This heterogeneity makes comparisons between studies problematic. CONCLUSIONS: Better adherence to guidelines for economic evaluations is needed. There was strong support for the definition of a reference case and for what might constitute "standard optimal care" in terms of best clinical practice, for the control arms of interventional studies.

Circulating 25-hydroxyvitamin D levels and frailty status in older women.

CONTEXT: Vitamin D deficiency and frailty are common with aging, but the association between these conditions is uncertain. OBJECTIVE: To determine the association between 25-hydroxyvitamin D (25(OH)D) levels and prevalent and incident frailty status among older women. DESIGN: Cross-sectional and longitudinal analyses of a prospective cohort study. SETTING: Four U.S. centers. PARTICIPANTS: 6307 women aged≥69 years. MAIN OUTCOME MEASURES: Frailty status classified as robust, intermediate stage, or frail at baseline; and robust, intermediate stage, frail, or dead (all-cause mortality) at follow-up an average of 4.5 years later. RESULTS: At baseline, there was a U-shaped association between 25(OH)D level and odds of frailty with the lowest risk among women with levels 20.0-29.9 ng/ml (referent group). Compared with this group, the odds of frailty were higher among those with levels<15.0 ng/ml [multivariable odds ratio (MOR) 1.47, 95% confidence interval (CI), 1.19-1.82], those with levels 15.0-19.9 ng/ml (MOR 1.24, 95% CI 0.99-1.54), and those with levels≥30 ng/ml (MOR 1.32, 95% CI 1.06-1.63). Among 4551 nonfrail women at baseline, the odds of frailty/death (vs. robust/intermediate) at follow-up appeared higher among those with levels 15.0-19.9 ng/ml (MOR 1.21, 95% CI 0.99-1.49), but the CI overlapped 1.0. The odds of death (vs. robust/intermediate/frail at follow-up) was higher among those with levels<15.0 ng/ml (MOR 1.40, 95% CI 1.04-1.88) and those with levels 15.0-19.9 ng/ml (MOR 1.30, 95% CI 0.97-1.75), although the latter association did not quite reach significance. CONCLUSION: Lower (<20 ng/ml) and higher (≥30 ng/ml) levels of 25(OH)D among older women were moderately associated with a higher odds of frailty at baseline. Among nonfrail women at baseline, lower levels (<20 ng/ml) were modestly associated with an increased risk of incident frailty or death at follow-up.

Infections requiring hospitalization in the abatacept clinical development program: an epidemiological assessment.

INTRODUCTION: Patients with rheumatoid arthritis (RA) have an increased risk of infection and this risk appears to be higher with anti-TNF (tumor necrosis factor) agents. We pooled data from the cumulative abatacept RA clinical development program, both double-blind and open-label periods, to estimate the incidence rates (IRs) of infections requiring hospitalization including pneumonia and opportunistic infections, in comparison with RA patients treated with non-biologic disease-modifying antirheumatic drugs (DMARDs) from several reference cohorts. METHODS: Infections reported in seven abatacept clinical trials of RA patients (double-blind and open-label periods) were tabulated. Comparisons were made between the observed IRs in abatacept-treated patients and those in over 133,000 patients exposed to non-biologic DMARDs in six reference RA cohorts. Age- and sex-adjusted IRs of infections requiring hospitalization, including pneumonia (most frequent hospital infection), were used to estimate the expected IRs with abatacept by the method of indirect adjustment. Standardized incidence ratios (SIR) and 95% CI were calculated comparing incidence in the cumulative abatacept experience with incidence in each RA cohort. RESULTS: A total of 1,955 (double-blind period) and 4,134 (double-blind + open-label periods with a cumulative exposure of 8,392 person-years) abatacept-treated RA patients were analyzed. Observed IRs for infections requiring hospitalization during the double-blind period were 3.05 per 100-patient years for abatacept-treated patients and 2.15 per 100 patient years for placebo. In the cumulative population, observed IR for infections requiring hospitalization was 2.72 per 100-patient years. Rates for abatacept were similar to expected IRs based on other RA non-biologic DMARD cohorts. CONCLUSIONS: IRs of infections requiring hospitalization and pneumonia in abatacept trials are consistent with expected IRs based on reference RA DMARD cohorts. RA patients are at higher risk of infection compared with the general population, making the RA DMARD cohorts an appropriate reference group. The safety of abatacept, including incidence of infections requiring hospitalization, will continue to be monitored in a post-marketing surveillance program.

Caregiving, metabolic syndrome indicators, and 1-year decline in walking speed: results of Caregiver-SOF.

BACKGROUND: Chronic stress may lead to health decline through metabolic syndrome. Thus, persons in stressful caregiving situations who also have more indicators of metabolic syndrome may experience more decline than other caregivers or noncaregivers. METHODS: The sample included 921 women (338 caregivers and 583 noncaregivers) from the Caregiver-Study of Osteoporotic Fractures study. Participants had home-based baseline and 1-year follow-up interviews between 1999 and 2003. At baseline, caregivers were categorized as long term ((3)4 years) versus short term (<4 years), and caring for someone with Alzheimer's disease/dementia or not. A metabolic risk composite score was the sum of four indicators: body mass index (3)30, and diagnosis or using medications for hypertension, diabetes, or high cholesterol. Walking speed (m/second) was measured at both interviews. RESULTS: Walking speed declined for the total sample (adjusted mean = -0.005 m/second, +/-0.16) over an average of 1.04 years (+/-0.16). Overall, caregiving was not associated with decline. Increasing metabolic risk score was associated with greater decline for the total sample and long-term and dementia caregivers, but not other caregivers or noncaregivers. Metabolic risk score modified the adjusted associations between years of caregiving and dementia caregiving with walking speed decline (p values for interaction terms were 0.039 and 0.057, respectively). The biggest declines were in long-term caregivers and dementia caregivers who also had 3-4 metabolic indicators (-0.10 m/second and -0.155 m/second, respectively). CONCLUSIONS: Walking speed declined the most among older women who had both stressful caregiving situations and more metabolic syndrome indicators, suggesting these caregiver subgroups may have increased risk of health decline.

Health of community-dwelling adults with mobility limitations in the United States: incidence of secondary health conditions. Part II.

OBJECTIVE: To compare incident health conditions that occurred over a 2-year period in nationally representative groups of adults with mobility, nonmobility, and no limitations. DESIGN: Data were collected prospectively from a probability subsample of households that represent the civilian, noninstitutionalized U.S. population. SETTING: Five rounds of household interviews were conducted over 2 years. PARTICIPANTS: Data were analyzed on the same respondents from the 1996-1997 Medical Expenditure Panel Survey (MEPS) and the 1995 National Health Interview Survey Disability Supplement. Respondents were categorized into 3 groups for analysis; those with mobility limitations, nonmobility limitations, and no limitations. The analytic sample included 12,302 MEPS adults (>/=18y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number, types, and 2-year incidence of self-reported health conditions compared across groups. RESULTS: The mean number of incident conditions (95% confidence intervals [CIs]) over the 2-year period was greatest in adults with mobility limitations (mean, 4.7; 95% CI, 4.4-4.9) compared with those with nonmobility limitations (mean, 3.9; 95% CI, 3.7-4.2) or no limitations (mean, 2.6; 95% CI, 2.5-2.7). Incident conditions affected most major body systems. CONCLUSIONS: Because secondary conditions are potentially preventable, determining factors that influence their occurrence is an important public health issue requiring specific action.

Health of community-dwelling adults with mobility limitations in the United States: prevalent health conditions. Part I.

OBJECTIVE: To characterize the extent and types of prevalent health conditions among nationally representative groups of adults with mobility, nonmobility, and no limitations. DESIGN: Data were collected during 5 rounds of household interviews from a probability subsample of households that represent the civilian, noninstitutionalized U.S. population. With some exceptions, round 1 variables were used for this analysis. SETTING: Community. PARTICIPANTS: Data were analyzed on the same respondents from the 1996 to 1997 Medical Expenditure Panel Survey (MEPS) and the 1995 National Health Interview Survey Disability Supplement. Respondents were categorized into 3 groups for analysis: those with mobility limitations, nonmobility limitations; and no limitations. The analytic sample included 13,897 MEPS adults (> or =18y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number, types, and prevalence of self-reported health conditions compared across groups. RESULTS: On average, adults with mobility limitations had significantly more prevalent conditions (3.6) than those with nonmobility limitations (2.4), or no limitations (1.3). Greater comorbidity existed in the context of fewer personal resources and more than half of adults with mobility limitations were working age. CONCLUSIONS: Determining factors that influence the health of adults with mobility limitations is a critical public health issue.

Back pain exacerbations and lost productive time costs in United States workers.

STUDY DESIGN: Cross-sectional with follow-up case-control component. OBJECTIVES: To measure the prevalence of back pain (BP) and back pain exacerbations, describe BP features and functional impairment, estimate BP-related lost productive time (LPT) and costs, and assess the relation between pain exacerbations and lost productive time. SUMMARY OF BACKGROUND DATA: BP is associated with substantial lost work time. However, little is known about the extent to which BP with or without exacerbation explains lost work time. METHODS: A national telephone survey of the U.S. workforce identified 320 workers 40 to 65 years of age with BP defined by NHANES I criteria and 91 matched non-BP controls. Participants self-reported pain characteristics, lost productive time (absenteeism and presenteeism) in the previous 2 weeks, activity limitations, and demographics. A population-weighting adjustment was applied to estimates to account for selection bias and ensure that estimates of certain sample demographic subgroups' totals conformed to the Current Population Survey. RESULTS: The 2-week period prevalence of BP was 15.1%; 42% of workers with BP experienced pain exacerbations. BP prevalence was associated with demographic factors, but BP exacerbations were not. BP was reported by 42.6% of all workers. Workers with exacerbations reported more days with BP than those without exacerbations. Workers with exacerbations were significantly more likely than those without such exacerbations to report activity limitation (88.4% vs. 60.7%; P < 0.0001) and BP-related LPT (22.1% vs. 13.0%; P = 0.0259). BP in workers 40 to 65 years of age costs employers an estimated $7.4 billion/year. Workers with BP exacerbations account for 71.6% of this cost. CONCLUSIONS: Workers with BP exacerbations account for a disproportionate share of the cost of BP-related lost productive time.

Pain exacerbation as a major source of lost productive time in US workers with arthritis.

OBJECTIVE: To estimate the prevalence of arthritis and arthritis pain exacerbations in US workers including impact on functioning and lost productive work time (LPT). METHODS: The research was conducted as a nested case-control study of participants in the Caremark American Productivity Audit, a US national random-digit-dial survey of US workers. The sample included 329 workers ages 40-65 years meeting the First National Health and Nutrition Examination Survey criteria for arthritis, and 91 workers not meeting arthritis inclusion criteria. Participants completed a telephone interview to measure the prevalence of arthritis and pain exacerbations, LPT (in hours and dollars), functional disability using the Western Ontario and McMaster Universities Knee and Hip Osteoarthritis Index (WOMAC) and the Australian/Canadian Osteoarthritis Hand Index, and demographics. RESULTS: The prevalence of arthritis in US workers ages 40-65 years was 14.7% during the 2-week period. Pain exacerbation occurred among 38% of participants with arthritis. Workers with pain exacerbations were significantly more likely to have higher WOMAC scores (38.6 versus 29.6; P = 0.0041) and report arthritis-related LPT (24.4% versus 13.3%; P = 0.0118) than workers without exacerbations. Among those with LPT, average LPT did not differ (4.1 hours per week) between persons with and without exacerbations. The estimated annual LPT cost from arthritis in the US workforce was $7.11 billion, with 65.7% of this cost attributed to the 38% of workers with pain exacerbations. CONCLUSION: Workers with arthritis pain exacerbation account for a disproportionate share of the arthritis-related LPT cost. Stratifying workers for appropriate treatment management based on pain exacerbation status could significantly decrease arthritis-related LPT and offer employees and employers an effective return on health care use.

COX-2 selective inhibitors in the treatment of arthritis: a rheumatologist perspective.

COX-2 selective inhibitors were developed in order to provide similar efficacy to traditional nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) but with improved upper gastrointestinal safety. This paper presents an overview of randomized clinical trials demonstrating the efficacy of COX-2 selective inhibitors for the treatment of patients with arthritis, particularly osteoarthritis and rheumatoid arthritis. In osteoarthritis and rheumatoid arthritis, COX-2 selective inhibitors have been shown to be more effective than placebo and similarly effective as standard doses of nonselective NSAIDs. There are currently few randomized clinical trials comparing the efficacy of the 2 first-generation COX-2 selective inhibitors, celecoxib and rofecoxib, in osteoarthritis. Of 4 head-to-head studies comparing the 2 agents, 3 indicated similar efficacy, while the other demonstrated superiority of rofecoxib at a dose of 25 mg qd compared with celecoxib at a dose of 200 mg qd. There are no clinical trials comparing the efficacy of different agents for treatment of patients with rheumatoid arthritis. Some studies have also demonstrated efficacy for COX-2 selective inhibitors in patients with ankylosing spondylitis and gout. In aggregate, these data show that COX-2 selective inhibitors provide effective relief of pain in patients with osteoarthritis and rheumatoid arthritis, with efficacy that is similar to traditional NSAIDs. Cost-effectiveness and cost-utility studies suggest, however, that their use should be limited to patients at high risk of serious upper gastrointestinal side effects, including complicated ulcers.

Classification algorithms for hip fracture prediction based on recursive partitioning methods.

This article presents 2 modifications to the classification and regression tree. The authors improved the robustness of a split in the test sample approach and developed a cost-saving classification algorithm by selecting noninferior to the optimum splits from variables with lower cost or being used in parent splits. The new algorithm was illustrated by 43 predictive variables for 5-year hip fracture previously documented in the Study of Osteoporotic Fractures. The authors generated the robust optimum classification rule without consideration of classification variable costs and then generated an alternative cost-saving rule with equivalent diagnostic utility. A 6-fold cross-validation study proved that the cost-saving alternative classification is statistically noninferior to the optimal one. Their modified classification and regression tree algorithm can be useful in clinical applications. A dual X-ray absorptiometry hip scan and information from clinical examinations can identify subjects with elevated 5-year hip fracture risk without loss of efficiency to more costly and complicated algorithms.

Higher risk of multiple falls among elderly women who lose visual acuity.

OBJECTIVE: To determine the association between changes in visual acuity (VA) and frequent falls in older women. DESIGN: Prospective cohort study. PARTICIPANTS: Two thousand two elderly community-residing women participating in the Study of Osteoporotic Fractures with measurements of VA at baseline and a follow-up examination 4 to 6 years later (mean of 5.6 years). METHODS: Binocular VA with habitual correction was measured under standard illumination using Bailey-Lovie charts at baseline and fourth examinations. Change in VA was stratified into 5 categories: no change or VA gain, loss of 1 to 5 letters, loss of 6 to 10 letters, loss of 11 to 15 letters, and loss of >15 letters. A separate analysis considered decline in VA as the loss of >or=10 letters (>or=2 lines) on the Bailey-Lovie acuity measure between baseline and follow-up examinations. MAIN OUTCOME MEASURES: Data on falls were obtained from postcards sent every 4 months after the follow-up examination. Frequent falling was defined as >or=2 falls during a 1-year period after the follow-up examination. RESULTS: Compared with women with stable or improved VA, women with declining acuity had significantly greater odds of experiencing frequent falling during the subsequent year. Odds ratios after adjustment for baseline acuity and other confounders were 2.08 (95% confidence interval [CI]: 1.39-3.12) for loss of 1 to 5 letters, 1.85 (95% CI: 1.16-2.95) for loss of 6 to 10 letters, 2.51 (95% CI: 1.39-4.52) for loss of 11 to 15 letters, and 2.08 (95% CI: 1.01-4.30) for loss of >15 letters. In the analysis of visual decline defined as a loss of >or=10 letters, heightened risk of frequent falling was evident in each of 2 subgroups defined by splitting the sample on baseline VA, with borderline significant evidence of a more pronounced effect in those women with baseline VA of 20/40 or worse (P value for interaction, 0.083). CONCLUSIONS: Loss of vision among elderly women increases the risk of frequent falls. Prevention or correction of visual loss may help reduce the number of future falls.

Suggested guidelines for evaluation and treatment of glucocorticoid-induced osteoporosis for the Department of Veterans Affairs.

BACKGROUND: Glucocorticoid-induced osteoporosis is an important disorder in the predominantly male US veteran population. Department of Veterans Affairs facilities vary considerably in evaluation and management of glucocorticoid-induced osteoporosis. METHODS: We suggest how evaluation and management can take place in medical centers with and without bone mineral density measurements by dual energy x-ray absorptiometry (DXA). The proposed guidelines can be applied to other health care systems. RESULTS: Use of DXA can help determine fracture risk for patients taking glucocorticoid therapy and for those starting therapy for at least 3 months. Patients with low bone mineral density should be treated with a bisphosponate as should all patients about to start prednisone treatment at a dose of 7.5 mg/d or more. In facilities without DXA, most patients should be treated with bisphosphonates, the cost of which is about $30 to $35 per month. In addition, the use of urinary calcium measurements is encouraged to determine which patients might benefit from augmented vitamin D and calcium supplementation. CONCLUSION: Attention to fracture risk assessment in patients undergoing glucocorticoid therapy and timely bisphosphonate treatment should lead to fewer fractures.

Reading and interpreting economic evaluations in rheumatoid arthritis: an assessment of selected instruments for critical appraisal.

OBJECTIVE: To describe and compare the relative attributes (reliability, ease of use, applicability, and relevance) of different assessment tools for economic analyses as they pertain to rheumatoid arthritis (RA) literature. METHODS: An expert panel, comprising rheumatology researchers and clinicians, operationalized 2 economic appraisal instruments and applied them to 11 articles used for analysis. Each expert reviewed 3 articles, with each article independently reviewed by a pair of experts. A summary score for each article per appraisal instrument was calculated by dividing the number of items that received a "positive" response by the total number of items in the appraisal instrument. RESULTS: Scores for each article were similar across reviewers and appraisal instruments. CONCLUSION: There is a need for a more comprehensive approach for evaluating this rapidly growing body of economic literature that is not only valid and reliable, but also easy to apply and understand. Although consistency between reviewers was good on both guidelines, inter-guideline discrepancies were noted and reviewers reported some difficulty in using the operationalized format.