Do sex, age, and comorbidities modify the association of socioeconomic status and opioid use after total hip arthroplasty?: a population-based study from the Danish Hip Arthroplasty Register.

BACKGROUND AND PURPOSE: We aimed to examine the association between socioeconomic status (SES) markers and opioid use after primary total hip arthroplasty (THA) due to osteoarthritis, and whether sex, age, or comorbidities modify any association. METHODS: Using Danish databases, we included 80,038 patients undergoing primary THA (2001-2018). We calculated prevalences and prevalence ratios (PRs with 95% confidence intervals [CIs]) of immediate post-THA opioid use (≥ 1 prescription within 1 month) and continued opioid use (≥ 1 prescription in 1-12 months) among immediate opioid users. Exposures were individual-based education, cohabitation, and wealth. RESULTS: The prevalence of immediate opioid use was ~45% in preoperative non-users and ~60% in preoperative users (≥ 1 opioid 0-6 months before THA). Among non-users, the prevalences and PRs of continued opioid use were: 28% for low vs. 21% for high education (PR 1.28, CI 1.20-1.37), 27% for living alone vs. 23% for cohabiting (PR 1.09, CI 1.04-1.15), and 30% for low vs. 20% for high wealth (PR 1.43, CI 1.35-1.51). Among users, prevalences were 67% for low vs. 55% for high education (1.22, CI 1.17-1.27), 68% for living alone vs. 60% for cohabiting (PR 1.10, CI 1.07-1.12), and 73% for low wealth vs. 54% for high wealth (PR 1.32, CI 1.28-1.36). Based on testing for interaction, sex, age, and comorbidity did not statistically significant modify the associations. Nevertheless, associations were stronger in younger patients for all SES markers (mainly for non-users). CONCLUSION: Markers of low SES were associated with a higher prevalence of continued post-THA opioid use. Age modified the magnitude of the associations, but it was not statistically significant.

Evaluation of patient reported outcome measures and costs of managing osteoarthritis of the hip.

The number of hospital admissions for a hip prosthesis increased by more than 91% between 2002 and 2019 in Belgium (1), making it one of the most common interventions in hospitals. The objective of this study is to evaluate patient-report- ed outcomes and hospital costs of hip replacement six months after surgery. Both generic (EQ-5D) and specific (HOOS) PROMs of general hospital patients undergoing hip replacement surgery in 2021 were conducted. The results of these PROMs were then combined with financial and health management data. The mean difference (SD) in QALYs between the preoperative and postoperative phases is 0.20 QALYs (0.32 QALYs). The average cost (SD) of all stays is €4,792 (€1,640). Amongst the five dimensions evaluated in the EQ-5D health questionnaire, the 'pain' dimension seems to be associated with the greatest improvement in quality of life. As regards Belgium, the 26,066 arthroplasties performed in 2020 might constitute a gain of 123,000 years of life in good health. The relationship between QALYs and costs described in this study posits a ratio of €23,960 per year of life gained in good health. Given that in Belgium more than 3% of the hospital healthcare budget is devoted to hip prostheses, it would seem relevant to us to apply PROM tools to the entire patient population to assess treatment effectiveness more broadly, identify patient needs and, also, monitor the quality of care provided.

Effectiveness of a telehealth-delivered clinician-supported exercise and weight loss program for hip osteoarthritis - protocol for the Better Hip randomised controlled trial.

BACKGROUND: Hip osteoarthritis (OA) is a leading cause of chronic pain and disability worldwide. Self-management is vital with education, exercise and weight loss core recommended treatments. However, evidence-practice gaps exist, and service models that increase patient accessibility to clinicians who can support lifestyle management are needed. The primary aim of this study is to determine the effectiveness of a telehealth-delivered clinician-supported exercise and weight loss program (Better Hip) on the primary outcomes of hip pain on walking and physical function at 6 months, compared with an information-only control for people with hip OA. METHODS: A two-arm, parallel-design, superiority pragmatic randomised controlled trial. 212 members from a health insurance fund aged 45 years and over, with painful hip OA will be recruited. Participants will be randomly allocated to receive: i) Better Hip; or ii) web-based information only (control). Participants randomised to the Better Hip program will have six videoconferencing physiotherapist consultations for education about OA, prescription of individualised home-based strengthening and physical activity programs, behaviour change support, and facilitation of other self-management strategies. Those with a body mass index > 27 kg/m2, aged < 80 years and no specific health conditions, will also be offered six videoconferencing dietitian consultations to undertake a weight loss program. Participants in the control group will be provided with similar educational information about managing hip OA via a custom website. All participants will be reassessed at 6 and 12 months. Primary outcomes are hip pain on walking and physical function. Secondary outcomes include measures of pain; hip function; weight; health-related quality of life; physical activity levels; global change in hip problem; willingness to undergo hip replacement surgery; rates of hip replacement; and use of oral pain medications. A health economic evaluation at 12 months will be conducted and reported separately. DISCUSSION: Findings will determine whether a telehealth-delivered clinician-supported lifestyle management program including education, exercise/physical activity and, for those with overweight or obesity, weight loss, is more effective than information only in people with hip OA. Results will inform the implementation of such programs to increase access to core recommended treatments. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry (ACTRN12622000461796).

Longer-term quality of care, effectiveness, and cost-effectiveness of implementing a model of care for osteoarthritis: A cluster-randomized controlled trial.

OBJECTIVE: To assess the quality of care, effectiveness, and cost-effectiveness over 12 months after implementing a structured model of care for hip and knee osteoarthritis (OA) in primary healthcare as compared to usual care. DESIGN: In this pragmatic cluster-randomized, controlled trial with a stepped-wedge cohort design, we recruited 40 general practitioners (GPs), 37 physiotherapists (PTs), and 393 patients with symptomatic hip or knee OA from six municipalities (clusters) in Norway. The model included the delivery of a 3-hour patient education and 8-12 weeks individually tailored exercise programs, and interactive workshops for GPs and PTs. At 12 months, the patient-reported quality of care was assessed by the OsteoArthritis Quality Indicator questionnaire (16 items, pass rate 0-100%, 100%=best). Costs were obtained from patient-reported and national register data. Cost-effectiveness at the healthcare perspective was evaluated using incremental net monetary benefit (INMB). RESULTS: Of 393 patients, 109 were recruited during the control periods (control group) and 284 were recruited during interventions periods (intervention group). At 12 months the intervention group reported statistically significant higher quality of care compared to the control group (59% vs. 40%; mean difference: 17.6 (95% confidence interval [CI] 11.1, 24.0)). Cost-effectiveness analyses showed that the model of care resulted in quality-adjusted life-years gained and cost-savings compared to usual care with mean INMB €2020 (95% CI 611, 3492) over 12 months. CONCLUSIONS: This study showed that implementing the model of care for OA in primary healthcare, improved quality of care and showed cost-effectiveness over 12 months compared to usual care. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02333656.

Is There Variation in Time to and Type of Treatment for Hip Osteoarthritis Based on Insurance?

BACKGROUND: Disparities in care access based on insurance exist for total hip arthroplasty (THA), but it is unclear if these lead to longer times to surgery. We evaluated whether rates of THA versus nonoperative interventions (NOI) and time to THA from initial hip osteoarthritis (OA) diagnosis vary by insurance type. METHODS: Using a national claims database, patients who had hip OA undergoing THA or NOI from 2011 to 2019 were identified and divided by insurance type: Medicaid-managed care; Medicare Advantage; and commercial insurance. The primary outcome was THA incidence within 3 years after hip OA diagnosis. Multivariable logistic regression models were created to assess the association between THA and insurance type, adjusting for age, sex, region, and comorbidities. RESULTS: Medicaid patients had lower rates of THA within 3 years of initial diagnosis (7.4 versus 10.9 or 12.0%, respectively; P < .0001) and longer times to surgery (297 versus 215 or 261 days, respectively; P < .0001) compared to Medicare Advantage and commercially-insured patients. In multivariable analyses, Medicaid patients were also less likely to receive THA (odds ratio (OR) = 0.62 [95% confidence intervals (CI): 0.60 to 0.64] versus Medicare Advantage, OR = 0.63 [95% CI: 0.61 to 0.64] versus commercial) or NOI (OR = 0.92 [95% CI: 0.91 to 0.94] versus Medicare Advantage, OR = 0.81 [95% CI: 0.79 to 0.82] versus commercial). CONCLUSIONS: Medicaid patients experienced lower rates of and longer times to THA than Medicare Advantage or commercially-insured patients. Further investigation into causes of these disparities, such as costs or access barriers, is necessary to ensure equitable care.

Income-Related Inequality Changes in Osteoarthritis First-Line Interventions: A Cohort Study.

OBJECTIVE: To examine income-related inequality changes in the outcomes of an osteoarthritis (OA) first-line intervention. DESIGN: Retrospective cohort study. SETTING: Swedish health care system. PARTICIPANTS: We included 115,403 people (age: 66.2±9.7 years; females 67.8%; N=115,403) with knee (67.8%) or hip OA (32.4%) recorded in the "Swedish Osteoarthritis Registry" (SOAR). INTERVENTIONS: Exercise and education. MAIN OUTCOME MEASURES: Erreygers' concentration index (E) measured income-related inequalities in "Pain intensity," "Self-efficacy," "Use of NSAIDs," and "Desire for surgery" at baseline, 3-month, and 12-month follow-ups and their differences over time. E-values range from -1 to +1 if the health variables are more concentrated among people with lower or higher income. Zero represents perfect equality. We used entropy balancing to address demographic and outcome imbalances and bootstrap replications to estimate confidence intervals for E differences over time. RESULTS: Comparing baseline to 3 months, "pain" concentrated more among individuals with lower income initially (E=-0.027), intensifying at 3 months (difference with baseline: E=-0.011 [95% CI: -0.014; -0.008]). Similarly, the "Desire for surgery" concentrated more among individuals with lower income initially (E=-0.009), intensifying at 3 months (difference with baseline: E=-0.012 [-0.018; -0.005]). Conversely, "Self-efficacy" concentrated more among individuals with higher income initially (E=0.058), intensifying at 3 months (difference with baseline: E=0.008 [0.004; 0.012]). Lastly, the "Use of NSAIDs" concentrated more among individuals with higher income initially (E=0.068) but narrowed at 3 months (difference with baseline: E=-0.029 [-0.038; -0.021]). Comparing baseline with 12 months, "pain" concentrated more among individuals with lower income initially (E=-0.024), intensifying at 12 months (difference with baseline: E=-0.017 [-0.022; -0.012]). Similarly, the "Desire for surgery" concentrated more among individuals with lower income initially (E=-0.016), intensifying at 12 months (difference with baseline: E=-0.012 [-0.022; -0.002]). Conversely, "Self-efficacy" concentrated more among individuals with higher income initially (E=0.059), intensifying at 12 months (difference with baseline: E=0.016 [0.011; 0.021]). The variable 'Use of NSAIDs' was not recorded in the SOAR at 12-month follow-up. CONCLUSION: Our results highlight the increase of income-related inequalities in the SOAR over time.

Assessment of causal effects of physical activity on the risk of osteoarthritis: a two-sample Mendelian randomization study.

BACKGROUND: Growing evidence supports an association between physical activity (PA) and the risk of osteoarthritis (OA), but this may be influenced by confounding and reverse causality. Therefore, we performed a two-sample Mendelian randomization (MR) analysis to reveal the causal relationship between PA and OA. METHODS: MR was performed to explore the causation of PA and OA with genetic variants as instrumental variables. The genetic variants were derived from the summary statistics of a large genome-wide association study meta-analysis based on the European population (n = 661,399), including self-reported leisure screen time (LST) and moderate-to-vigorous physical activity (MVPA), and Arthritis Research UK Osteoarthritis Genetics Consortium cohorts (417,596, 393,873 and 403,124 for overall, hip and knee OA, respectively). The major MR analysis used in this work was the inverse variance weighted (IVW) approach, and sensitivity, pleiotropy, and heterogeneity studies were performed to evaluate the validity of the findings. RESULTS: IVW estimates indicated that LST had a risk effect on overall OA (odds ratio (OR) = 1.309, 95% confidence interval (CI): 1.198-1.430, P = 2.330 × 10-9), hip OA (OR = 1.132, 95% CI: 1.009-1.269, P = 0.034) and knee OA (OR = 1.435. 95% CI: 1.286-1.602, P = 1.225 × 10-10). In contrast, no causal relationship was found between MVPA and OA (overall OA: OR = 0.895, 95% CI: 0.664-1.205, P = 0.465; hip OA: OR = 1.189, 95% CI: 0.792-1.786, P = 0.404; knee OA: OR = 0.707, 95% CI: 0.490 -1.021, P = 0.064). In addition, we observed significant heterogeneity in instrumental variables, but no horizontal pleiotropy was detected. CONCLUSIONS: Recent findings demonstrated a protective impact of reducing LST on OA, independent of MVPA. This provides valuable insights into the role of physical activity in OA and offers lifestyle recommendations, such as reducing recreational sedentary behaviors and promoting appropriate exercise, for individuals at risk of OA.

Burden of osteoarthritis in the Netherlands: a scoping review.

OBJECTIVE: To provide an overview of societal burden of osteoarthritis (OA) in the Netherlands. METHODS: Medline (via Ovid) and Embase databases were searched in September 2022 for all publications providing prevalence/incidence, cost or health-related quality of life (HRQoL) data of OA (all sites) in the Netherlands. RESULTS: Twenty-eight original studies were included in this scoping review; twelve reporting prevalence/incidence data of OA, seven reporting data on the economic burden of OA and twelve reporting HRQoL data of patients with OA. Most of the available data were from Dutch national cohorts. The prevalence of knee OA ranged from 6% to 18% across studies, from 4% to 7% for hip OA and from 12% to 56% for hand OA. OA was shown to be associated with impairment in work participation and long-term requirement of health care utilization, translating into substantial medical costs and societal costs of lost productivity. All studies comparing HRQoL among persons with OA with control persons showed a significantly lower HRQoL in patients with OA after adjustment for age, sex, and various risk factors. CONCLUSIONS: OA is a highly prevalent disease in the Dutch population and is responsible for a significant economic and health burden.

Establishment of an ultrasound-guided protocol for the assessment of hip joint osteoarthritis in rabbits-A sonoanatomic study.

Ultrasound (US) has emerged as one of the most applied imaging tools to diagnose musculoskeletal disorders and assist in guided intra-articular administrations. Nevertheless, in evaluating the rabbit hip joint, there is a need for an ultrasonographic approach. Therefore, this study aimed to describe the hip sonoanatomy, develop and validate a US-guided protocol to assess the hip joint in rabbits and apply this protocol in vivo. This study was carried out in three phases, phase I: a pilot cadaveric study, to assess the applicability of different US approaches in the hip of rabbits and, consequently, develop a detailed US-guided protocol (2 rabbit cadavers, n = 4 hips); phase II: validation of the established US-guided protocol through a numerical scoring system in healthy joints (11 rabbit cadavers, n = 22 hips), and, lastly, phase III: application of the US-guided protocol in vivo in osteoarthritic joints (5 rabbits, n = 5 hips). A total of six planes were validated, two in the ventral approach and four in the dorsal approach. The ventral transverse plane was deemed more informative regarding the hip joint sonoanatomy, enabling the identification of a greater number of structures when compared to the other planes. Nevertheless, this study suggested that the isolated application of a plane was deemed insufficient for a complete and detailed evaluation of the hip joint anatomy, rendering it necessary to employ other planes complementarily. Furthermore, the established US-guided protocol allowed a definitive diagnosis of OA, and osteophytes and capsular hypertrophy were among the defects most frequently detected. This novel study provided US anatomical landmarks for forthcoming therapeutic research and monitoring of OA development, granting the accurate identification of osseous and cartilaginous defects.

Racial variation in healthcare resource utilization and expenditures in knee/hip osteoarthritis patients: a retrospective analysis of a Medicaid population.

BACKGROUND: Osteoarthritis (OA) is a leading cause of chronic pain and disability. Prior studies have documented racial disparities in the clinical management of OA. The objective of this study was to assess the racial variations in the economic burden of osteoarthritis within the Medicaid population. METHODS: We conducted a retrospective observational study using the MarketScan Multi-State Medicaid database (2012-2019). Newly diagnosed, adult, knee and/or hip OA patients were identified and followed for 24 months. Demographic and clinical characteristics were collected at baseline; outcomes, including OA treatments and healthcare resource use (HCRU) and expenditures, were assessed during the 24-month follow-up. We compared baseline patient characteristics, use of OA treatments, and HCRU and costs in OA patients by race (White vs. Black; White vs. Other) and evaluated racial differences in healthcare costs while controlling for underlying differences. The multivariable models controlled for age, sex, population density, health plan type, presence of non-knee/hip OA, cardiovascular disease, low back pain, musculoskeletal pain, presence of moderate to severe OA, and any pre-diagnosis costs. RESULTS: The cohort was 56.7% White, 39.9% Black and 3.4% of Other race (American Indian/Alaska Native, Hispanic, Asian, Native Hawaiian/Other Pacific Islander, two or more races and other). Most patients (93.8%) had pharmacologic treatment for OA. Inpatient admission during the 24-month follow-up period was lowest among Black patients (25.8%, p < .001 White vs. Black). In multivariable-adjusted models, mean all-cause expenditures were significantly higher in Black patients ($25,974) compared to White patients ($22,913, p < .001). There were no significant differences between White patients and patients of Other race ($22,352). CONCLUSIONS: The higher expenditures among Black patients were despite a lower rate of inpatient admission in Black patients and comparable length and number of hospitalizations in Black and White patients, suggesting that other unmeasured factors may be driving the increased costs among Black OA patients.

Higher healthcare costs were observed in Black Medicaid patients with knee/hip osteoarthritis despite lower rates of inpatient admission. We observed these differences in this Medicaid population, where socioeconomic status is more homogeneous.Black patients had significantly higher healthcare costs compared to White patients and the difference persisted even after accounting for underlying differences in Black and White patients.Higher healthcare costs among Black patients were found in both the baseline and follow-up periods overall for all types of healthcare (hospitalizations, ER, office visit, other services).Higher hospitalization costs in Black patients were observed despite lower rates of hospitalizations in Black patients. These increased costs cannot be attributed to either longer or more frequent hospitalizations; no significant difference in either the length of stay or the number of hospitalizations was observed when comparing Black patients to White patients.

Mechanical parameter assessment of fresh human cancellous bone of the femoral head in atraumatic femoral head necrosis and primary coxarthrosis.

BACKGROUND: Atraumatic femoral head necrosis is a rare pathological change of the femoral head. It is characterized by local necrosis of the cancellous bone as a result of reduced blood supply to the bone. Even today it remains unclear how to assess the hardness of the necrosis, whether it is soft tissue that is easily removed, or hard tissue that is difficult to resect. METHODS: Femoral heads with primary coxarthrosis were selected as a comparison group. For this purpose, 49 femoral heads obtained during total hip arthroplasty surgery with either condition (23 femoral head necrosis, 26 coxarthrosis) were transferred to the testing laboratory in fresh condition. Cylindrical specimens were obtained using a tenon cutter along the main trabecular load direction in the subchondral region of the femoral head. Additionally, thin bone slices were extracted proximal and distal to the specimens for density measurements. Brass plates were glued to the circular surfaces of the specimens. After curing of the adhesive, the specimens were mounted in the testing machine and destructive uniaxial compression tests were conducted. FINDINGS: The recorded mean compressive strengths and elastic moduli were almost identical for both groups, but the necrosis group showed significantly higher data scattering and range regarding the elastic modulus. The mean density of the coxarthrosis specimens was significantly higher than that of the necrotic specimens. INTERPRETATION: The mechanical properties of cancellous bone vary considerably in the presence of femoral head necrosis. The existence of hard necrosis implies a potential challenge regarding the clinical resection of these tissues.

Utilization of Total Joint Arthroplasty by Rural-Urban Designation in Patients With Osteoarthritis in a Universal Coverage System.

BACKGROUND: Utilization of total joint arthroplasty (TJA) is affected by differences linked to sex, race, and socioeconomic status; there is little information about how geographic variation contributes to these differences. We sought to determine whether discrepancies in TJA utilization exist in patients diagnosed with osteoarthritis (OA) based upon urban-rural designation in a universal coverage system. METHODS: We conducted a cohort study using data from a US-integrated healthcare system (2015 to 2019). Patients aged ≥50 years who had a diagnosis of hip or knee OA were included. Total hip arthroplasty and total knee arthroplasty utilization (in respective OA cohorts) was evaluated by urban-rural designation (urban, mid, and rural). Incidence rate ratios (IRRs) for urban-rural regions were modeled using multivariable Poisson regressions. RESULTS: The study cohort included 93,642 patients who have hip OA and 275,967 patients who had knee OA. In adjusted analysis, utilization of primary total hip arthroplasty was lower in patients living in urban areas (IRR = 0.87, 95% confidence interval = 0.81 to 0.94) compared to patients in rural regions. Similarly, total knee arthroplasty was used at a lower rate in urban areas (IRR = 0.88, 95% confidence interval = 0.82 to 0.95) compared with rural regions. We found no differences in the hip and knee groups within the mid-region. CONCLUSIONS: In hip and knee OA patients enrolled in a universal coverage system, we found patients living in urban areas had lower TJA utilization compared to patients living in rural areas. Further research is needed to determine how patient location contributes to differences in elective TJA utilization. LEVEL OF EVIDENCE: III.

The burden of osteoarthritis: Is it a rising problem?

The objective of this review is to provide an overview of the current status of osteoarthritis (OA) as one of the most common joint disorders worldwide. Despite being the 11th cause of disability globally, there has been an increase in the prevalence, annual incidence, and years lived with disability of OA, particularly in developed and developing countries. Erosive hand OA, which affects approximately 10% of the general population, has been associated with a higher clinical burden compared to non-erosive hand OA. Patients with knee and hip OA, but not hand OA, are also at an increased risk of cardiovascular disease and all-cause mortality. Furthermore, OA has a significant contribution to healthcare costs in most countries. The recent COVID-19 pandemic has further exacerbated the disease burden of OA patients due to limited access to medical and surgical treatment. With increasing life expectancy and the aging of the global population, the burden of OA is expected to worsen. Therefore, this review highlights the importance of improving population and policymaker awareness of risk factors, such as obesity and injury, as well as early intervention and management of OA to control the future burden of the disease.

A Model for Evaluating Total Costs of Care and Cost Savings of Specialty Condition-Based Care for Hip and Knee Osteoarthritis in an Integrated Practice Unit.

OBJECTIVES: The viability of specialty condition-based care via integrated practice units (IPUs) requires a comprehensive understanding of total costs of care. Our primary objective was to introduce a model to evaluate costs and potential costs savings using time-driven activity-based costing comparing IPU-based nonoperative management with traditional nonoperative management and IPU-based operative management with traditional operative management for hip and knee osteoarthritis (OA). Secondarily, we assess drivers of incremental cost differences between IPU-based care and traditional care. Finally, we model potential cost savings through diverting patients from traditional operative management to IPU-based nonoperative management. METHODS: We developed a model to evaluate costs using time-driven activity-based costing for hip and knee OA care pathways within a musculoskeletal IPU compared with traditional care. We identified differences in costs and drivers of cost differences and developed a model to demonstrate potential cost savings through diverting patients from operative intervention. RESULTS: Weighted average costs of IPU-based nonoperative management were lower than traditional nonoperative management and lower in IPU-based operative management than traditional operative management. Key drivers of incremental cost savings included care led by surgeons in partnership with associate providers, modified physical therapy programs with self-management, and judicious use of intra-articular injections. Substantial savings were modeled by diverting patients toward IPU-based nonoperative management. CONCLUSIONS: Costing models involving musculoskeletal IPUs demonstrate favorable costs and cost savings compared with traditional management of hip or knee OA. More effective team-based care and utilization of evidence-based nonoperative strategies can drive the financial viability of these innovative care models.

CycLing and EducATion (CLEAT): protocol for a single centre randomised controlled trial of a cycling and education intervention versus standard physiotherapy care for the treatment of hip osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a chronic degenerative joint disorder for which there is no known cure. Non-surgical management for people with mild-to-moderate hip OA focuses mainly on alleviating pain and maximising function via the National Institute for Health and Care Excellence (NICE) recommended combination of education and advice, exercise, and, where appropriate, weight loss. The CHAIN (Cycling against Hip pAIN) intervention is a group cycling and education intervention conceived as a way of implementing the NICE guidance. METHODS: CycLing and EducATion (CLEAT) is a pragmatic, two parallel arm, randomised controlled trial comparing CHAIN with standard physiotherapy care for the treatment of mild-to-moderate hip OA. We will recruit 256 participants referred to the local NHS physiotherapy department over a 24-month recruitment period. Participants diagnosed with hip OA according to NICE guidance and meeting the criteria for GP exercise referral will be eligible to participate. Primary outcome is the difference in Hip Disability and Osteoarthritis Outcome Score (HOOS) function, daily living subscale between those receiving CHAIN and standard physiotherapy care. Secondary outcomes include performance-based functional measures (40 m walking, 30s chair stand and stair climb tests), ability for patient to self-care (patient activation measure) and self-reported health-related resource use including primary and secondary care contacts. The primary economic endpoint is the number of quality adjusted life years (QALYs) at 24 weeks follow-up. The study is funded by the National Institute for Health Research, Research for Patient Benefit PB-PG-0816-20033. DISCUSSION: The literature identifies a lack of high-quality trials which inform on the content and design of education and exercise in the treatment of patients with hip OA and explore cost-effectiveness. CLEAT is a pragmatic trial which seeks to build further evidence of the clinical benefits of the CHAIN intervention compared to standard physiotherapy care within a randomised, controlled trial setting, and examine its cost-effectiveness. TRIAL REGISTRATION NUMBER: ISRCTN19778222. Protocol v4.1, 24th October 2022.

High and low value care recommended and undertaken prior to knee or hip arthroplasty: a survey study.

INTRODUCTION: National and international clinical practice guidelines have stratified the value of osteoarthritis (OA) interventions. Interventions with strong evidence supporting effectiveness and benefit are 'high value care'. Appointment attendance, audits and practitioner surveys are widely used to determine frequency of recommendations and adherence to high value care. Greater patient reported data is needed in this evidence base. OBJECTIVE: To describe the frequency of high and low value care being recommended and undertaken by individuals awaiting OA-related lower limb arthroplasty. To examine sociodemographic or disease-related variables associated with being recommended different levels of care. METHODS: A cross-sectional survey of 339 individuals was conducted in metropolitan and regional hospitals and surgeon consultation rooms across New South Wales (NSW), Australia. Individuals attending pre-arthroplasty clinics/appointments for primary arthroplasty of the hip and/or knee were invited to participate. Respondents were asked what intervention(s) they were recommended by healthcare practitioners, or other sources of information, and what they had undertaken within two years prior to hip or knee arthroplasty. Interventions were classified as core, recommended, and low value care aligned with the Osteoarthritis Research Society International (OARSI) guidelines. We considered core and recommended interventions high value. The proportion of recommended and undertaken interventions were calculated. We used backwards stepwise multivariate multinomial regression to address aim three. RESULTS: Simple analgesics were most frequently recommended (68% [95% CI 62.9 to 73.1]). 24.8% [20.2 to 29.7] of respondents were recommended high value care only. 75.2% [70.2 to 79.7] of respondents were recommended at least one low value intervention. More than 75% of recommended interventions were undertaken. Respondents awaiting hip arthroplasty, living outside a major city and without private health insurance had greater odds of recommended rather than core interventions being advised. CONCLUSION: While high value interventions are being recommended to individuals living with OA, in most cases they are combined with recommendations for low value care. This is concerning given the high rates of uptake for recommended interventions. Based on patient reported data, disease-related and sociodemographic variables influence the level of care recommended.

Disease burden and costs for patients with hip and knee osteoarthritis and chronic moderate-to-severe refractory pain on treatment with strong opioids in Spain.

INTRODUCTION AND OBJECTIVES: To determine the disease burden and costs in patients with hip or knee OA and chronic moderate-to-severe refractory pain, receiving strong opioids in Spain. MATERIALS AND METHODS: This was a 36-month longitudinal secondary analysis of the real-word OPIOIDS study. Patients aged ≥18 years with hip or knee OA and chronic moderate-to-severe refractory pain receiving strong opioids were considered. The disease burden included analgesia assessments (NRS scale), cognitive functioning (MMSE scale), basic activities of daily living (Barthel index), and comorbidities (severity and frequency). Costs due to the use of healthcare resources and productivity loss were estimated. RESULTS: 2832 patients were analyzed; age was 72.0 years (SD=14.3), 76.8% were women. Patients had mainly been treated with fentanyl (n=979; 37.6%), tapentadol (n=625; 24.0%), oxycodone (n=572; 22.0%), and buprenorphine (n=425; 16.3%). Pain intensity decreased by 1 point (13.7%), with a 2.6-point decline in the cognitive scale (14.3%, with a 5.3%-increase in patients with cognitive deficit) over a mean treatment period of 384.6 days (SD: 378.8). Barthel scores decreased significantly yielding to a slightly increase in proportion of patients with severe-to-total dependency; 1.2%-2.9%. In the first year of treatment, average healthcare costs were €2013/patient, whereas the average productivity loss cost was €12,227/working-active patient. DISCUSSION AND CONCLUSIONS: Strong opioids resulted in high healthcare costs with a limited reduction in pain, an increase in cognitive deficit, and a slight increase of patients with severe to total dependency over 36 months of treatment.

The Use of Race in Risk Assessment Tools Contributes to Systemic Racism.

Many patients suffer from hip or knee osteoarthritis and elect to pursue total joint arthroplasty (TJA). Though perioperative risk is an inherent component of surgery, calculators that assess the risk of complications following TJA can help both surgeons and patients make informed decisions about the risk of surgery and aid in shared decision-making discussions. The inclusion of race in a risk calculator for readmission after TJA is flawed and unacceptable because a patient's race does not increase their risk of a complication after total joint replacement.

Assessment of Mobile Health Applications for Management of Knee and/or Hip Osteoarthritis Using the Mobile Application Rating Scale.

BACKGROUND: Mobile health applications (apps) can help individuals with knee and/or hip osteoarthritis (OA) learn about, monitor, and manage their condition. These apps have not been formally evaluated. OBJECTIVE: The aim of this study was to evaluate the publicly available mobile health apps for individuals with knee and/or hip OA using a systematic review. METHODS: We searched the Apple App Store, Android Google Play, and Amazon Appstore using the terms "arthritis," "osteoarthritis," "hip OA," "knee OA," "hip," "knee," "rehabilitation," "rehab," and "physical therapy" in December of 2021. Applications that met the inclusion/exclusion criteria were reviewed using the Mobile Application Rating Scale (MARS; 29 items across 6 sections, each rated at 1-5). RESULTS: Among 1104 identified apps, 94 met the inclusion/exclusion criteria for MARS appraisal. Fourteen apps met the predetermined score thresholds for final summary. Of the 14 apps appraised, the total overall mean app score on the MARS ranged from 3.12 to 4.20 (mean, 3.51 ± 0.37). Although app features varied, common features were symptom tracking, exercise recommendations, education, goal setting, and improving well-being. Many apps allowed for sharing with health care providers and included some measures to protect privacy. Jointfully Osteoarthritis was the top-rated app in both the Apple App Store and Android Google Play. CONCLUSIONS: The majority of the apps we identified for knee and/or hip OA did not meet predetermined score thresholds for final summary. Many failed to provide comprehensive education and deliver management plans and lacked scientific testing. Future research should focus on apps that fit the needs of health care providers and patients including quality information, structured exercise programs tailored to individual needs, secure communication methods, and health information protection.

Early Total Hip Arthroplasty is a Cost-Effective Treatment for Severe Radiographic Slipped Capital Femoral Epiphysis Over an Individual's Lifetime.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) causes degenerative changes warranting total hip arthroplasty (THA) in approximately 50% of patients by age 60 years. For severe SCFE, a reorienting intertrochanteric osteotomy (ITO) following in situ pinning (ISP) can decrease impingement with hip flexion, but by altering proximal femoral geometry, complicates subsequent conversion THA. We hypothesized that increasing implant survivorship would affect the most cost-effective treatment strategy (ISP followed by ITO [ISP + ITO] with later THA versus ISP alone [ISPa] with earlier THA) over a patient's lifetime. METHODS: A state-transition Markov model was constructed to analyze the cost-effectiveness of either ISPa or ISP + ITO over a 60-year time horizon for children who have severe, stable SCFE. Transition probabilities associated with implant and native hip survivorship, state utilities, and costs were derived from the literature. Sensitivity analyses assessed the model robustness. Incremental cost-effectiveness ratios (ICERs) were compared to a societal willingness to pay (WTP) of $100,000 per quality-adjusted life year (QALY). RESULTS: Over a 60-year horizon, ISPa was costlier ($291,836) than ISP + ITO ($75,227) but achieved overall better outcomes (51.4 QALYs ISPa versus 48.7 QALYs ISP + ITO), rendering ISPa cost-effective with an ICER of $80,980/QALY. Implant survivorship and time horizon were sensitive variables. CONCLUSION: Based upon current implant performance, ISPa with subsequent earlier THA is cost-effective when considering an individual's life expectancy and thereby deserves consideration in patients who have severe SCFE. Without clear level 1 clinical data, our economic model considers a difficult problem, while providing families and clinicians with a framework for understanding treatment options. LEVEL OF EVIDENCE: Economic and decision analysis, Level III.