2023 EULAR classification criteria for hand osteoarthritis.

OBJECTIVES: The objective of this study is to develop classification criteria for overall hand osteoarthritis (OA), interphalangeal OA and thumb base OA based on self-reported data and radiographic features. METHODS: The classification criteria sets were developed in three phases. In phase 1, we identified criteria that discriminated hand OA from controls. In phase 2, we used a consensus-based decision analysis approach to derive a clinician-based evaluation of the relative importance of the criteria. In phase 3, we refined the scoring system, determined the cut-offs for disease classification and compared the sensitivity and specificity of the European Alliance of Associations for Rheumatology (EULAR) criteria with the 1990 American College of Rheumatology (ACR) criteria. RESULTS: In persons with hand symptoms and no other disease (including psoriasis) or acute injury that can explain the hand symptoms (mandatory criteria), hand OA can be classified based on age, duration of morning stiffness, number of joints with osteophytes and joint space narrowing, and concordance between symptoms and radiographic findings. Using a sum of scores based on each diagnostic element, overall hand OA can be classified if a person achieves 9 or more points on a 0-15 scale. The cut-off for interphalangeal OA and thumb base OA is 8 points. While the EULAR criteria demonstrated better sensitivity than the ACR criteria in the phase 1 data set, the performance of the two criteria sets was similar in two external cohorts. CONCLUSIONS: International experts developed the EULAR criteria to classify overall hand OA, interphalangeal OA and thumb base OA in clinical studies using a rigorous methodology.

Bone health assessment in adults with fragility fracture risk factors between 2002-2014: a retrospective cohort study.

BACKGROUND: Lifetime risk of fragility fractures is 50% in post-menopausal women and 20% in men aged >50 years. Identifying people at high risk facilitates early intervention and reduction of biopsychosocial morbidity associated with these fractures. AIM: To explore if bone health assessment (BHA) rates differ between women and men aged ≥50 years with fragility fracture risk factors. DESIGN & SETTING: A primary care-based cohort study in North Staffordshire, UK. METHOD: Patients were identified from the Consultations in Primary Care Archive (CiPCA) database between 2002 and 2014 with one or more fragility fracture risk factors (previous fractures, falls, and prolonged steroid use). Evaluation of BHA within 12 months of presentation of the first risk factor was carried out by searching for codes for fracture risk assessment tools (FRAX and QFracture), bone density measurement, specialist service referral, or if bone-protection medication was started. RESULTS: A total of 15 581 patients with risk factors were identified; men represented 40.4% of the cohort. The study found 1172 (7.5%) had BHA performed within 1 year of presentation, and 8.9% of women and 5.5% of men had BHAs, which was found with strong statistical evidence (χ2 = 59.88, P = 1 × 10-14). This relationship prevailed after adjusting for other covariates, such as comorbidity and number of consultations, with an odds ratio of 1.25 (95% confidence interval [CI] = 1.08 to 1.43). CONCLUSION: This study has shown that rates of BHA were generally low and even lower in men compared with women. Primary care clinicians should be alert to fragility fracture risk factors in both men and women to enable early assessment and intervention.

Development of radiographic classification criteria for hand osteoarthritis: a methodological report (Phase 2).

OBJECTIVES: In Phase 1 of developing new hand osteoarthritis (OA) classification criteria, features associated with hand OA were identified in a population with hand complaints. Radiographic findings could better discriminate patients with hand OA and controls than clinical examination findings. The objective of Phase 2 was to achieve consensus on the features and their weights to be included in three radiographic criteria sets of overall hand OA, interphalangeal OA and thumb base OA. METHODS: Multidisciplinary, international expert panels were convened. Patient vignettes were used to identify important features consistent with hand OA. A consensus-based decision analysis approach implemented using 1000minds software was applied to identify the most important features and their relative importance influencing the likelihood of symptoms being due to hand OA. Analyses were repeated for interphalangeal and thumb base OA. The reliability and validity of the proposed criteria sets were tested. RESULTS: The experts agreed that the criteria sets should be applied in a population with pain, aching or stiffness in hand joint(s) not explained by another disease or acute injury. In this setting, five additional criteria were considered important: age, morning stiffness, radiographic osteophytes, radiographic joint space narrowing and concordance between symptoms and radiographic findings. The reliability and validity were very good. CONCLUSION: Radiographic features were considered critical when determining whether a patient had symptoms due to hand OA. The consensus-based decision analysis approach in Phase 2 complemented the data-driven results from Phase 1, which will form the basis of the final classification criteria sets.

Improving uptake of Fracture Prevention drug treatments: a protocol for Development of a consultation intervention (iFraP-D).

INTRODUCTION: Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work. METHODS AND ANALYSIS: The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial. ETHICS AND DISSEMINATION: Ethical approval was obtained from North West-Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations. TRIAL REGISTRATION NUMBER: researchregistry5041.

Development, spread and impact of primary care and musculoskeletal communities of practice to assist rapid translation of evidence into practice.

BACKGROUND: Embedding research into practice is challenging. Barriers include: a shortage of time, lack of understanding of the evidence and a poor support in the clinical setting. A community of practice (CoP) model has been used to address these issues. Three 'Evidence into Practice' groups use a CoP model to assist the rapid translation of evidence into practice in primary and secondary care settings. We describe how a CoP model supports the functions, operations and outputs of three 'Evidence into Practice Groups'. METHOD: A CoP model is used to engage a broad range of clinicians, researchers, managers, patients and librarians in the complex process of acquiring research knowledge and then translating knowledge into practice. The CoP principles of Domain, Community and Practice are used to describe three 'Evidence into Practice Groups' who cater for different elements of the care and academic sector and engage a range of professional groups. This includes primary and secondary care engaging professionals such as general practitioners (GP), practice nurses, allied health professionals, researchers and librarians. All groups are clinically led, academically supported and follow similar processes to identify the best evidence and translate it into practice. As the groups reflect the context in which they work they have different operational arrangements for example frequency and time of meetings. RESULTS: The CoP model enabled three 'Evidence into Practice Groups' over time to: engage over 180 clinical and academic staff; answer 130 clinical questions; improve clinical care, gain funding for two randomised controlled trials (enrolled over n = 7000 participants) and identify areas for further research, quality improvement audit and training. CONCLUSION: The CoP model encourages the rapid translation of evidence into practice by engaging staff to identify areas of clinical concern in their own context, thereby stimulating their interest and involvement. This creates a meaningful link between research and practice. Clinical leadership and the CoP model ensure that practice change is quick and efficient. This model can be replicated at scale. Consideration needs to be given to the key ingredients to achieve impact.

Development and validation of prediction models to estimate risk of primary total hip and knee replacements using data from the UK: two prospective open cohorts using the UK Clinical Practice Research Datalink.

OBJECTIVES: The ability to efficiently and accurately predict future risk of primary total hip and knee replacement (THR/TKR) in earlier stages of osteoarthritis (OA) has potentially important applications. We aimed to develop and validate two models to estimate an individual's risk of primary THR and TKR in patients newly presenting to primary care. METHODS: We identified two cohorts of patients aged ≥40 years newly consulting hip pain/OA and knee pain/OA in the Clinical Practice Research Datalink. Candidate predictors were identified by systematic review, novel hypothesis-free 'Record-Wide Association Study' with replication, and panel consensus. Cox proportional hazards models accounting for competing risk of death were applied to derive risk algorithms for THR and TKR. Internal-external cross-validation (IECV) was then applied over geographical regions to validate two models. RESULTS: 45 predictors for THR and 53 for TKR were identified, reviewed and selected by the panel. 301 052 and 416 030 patients newly consulting between 1992 and 2015 were identified in the hip and knee cohorts, respectively (median follow-up 6 years). The resultant model C-statistics is 0.73 (0.72, 0.73) and 0.79 (0.78, 0.79) for THR (with 20 predictors) and TKR model (with 24 predictors), respectively. The IECV C-statistics ranged between 0.70-0.74 (THR model) and 0.76-0.82 (TKR model); the IECV calibration slope ranged between 0.93-1.07 (THR model) and 0.92-1.12 (TKR model). CONCLUSIONS: Two prediction models with good discrimination and calibration that estimate individuals' risk of THR and TKR have been developed and validated in large-scale, nationally representative data, and are readily automated in electronic patient records.