Evidence-based and Patient-centered Indication for Knee Arthroplasty - Update of the Guideline. / Evidenzbasierte und patientenorientierte Indikationsstellung zur Knieendoprothese ­ Update der Leitlinie.

Knee arthroplasty is one of the most frequently performed operations in Germany, with approximately 170000 procedures per year. It is therefore essential that physicians should adhere to an appropriate, and patient-centered indication process. The updated guideline indication criteria for knee arthroplasty (EKIT-Knee) contain recommendations, which are based on current evidence and agreed upon by a broad consensus panel. For practical use, the checklist has also been updated.For this guideline update, a systematic literature research was conducted in order to analyse (inter-)national guidelines and systematic reviews focusing on osteoarthritis of the knee and knee arthroplasty, to answer clinically relevant questions on diagnostic, predictors of outcome, risk factors and contraindications.Knee arthroplasty should solely be performed in patients with radiologically proven moderate or severe osteoarthritis of the knee (Kellgren-Lawrence grade 3 or 4), after previous non-surgical treatment for at least three months, in patients with high subjective burden with regard to knee-related complaints and after exclusion of possible contraindications (infection, comorbidities, BMI ≥ 40 kg/m2). Modifiable risk factors (such as smoking, diabetes mellitus, anaemia) should be addressed and optimised in advance. After meeting current guideline indications, a shared decision-making process between patients and surgeons is recommended, in order to maintain high quality surgical management of patients with osteoarthritis of the knee.The update of the S2k-guideline was expanded to include unicondylar knee arthroplasty, the preoperative optimisation of modifiable risk factors was added and the main indication criteria were specified.

[Routine Practice Data for Health Care Analyses: Part 3 of the Manual]. / Versorgungsnahe Daten für Versorgungsanalysen ­ Teil 3 des Manuals.

Analyses of health and health care (hereafter referred to as "health care analyses") usually aim to make transparent the structures, processes, results and interrelationships of health care and to record the degree to which health care systems and their actors have achieved their goals. Health care-related data are an indispensable source of data for many health care analyses. A prerequisite for the examination of a degree of goal achievement is first of all an agreement on those goals that are to be achieved by the system and its substructures, as well as the identification of the determinants of the achievement of the objectives. Primarily it must be examined how safely, effectively and patient-centred systems, facilities and service providers are operating. It also addresses issues of need, accessibility, utilisation, timeliness, appropriateness, patient safety, coordination, continuity, and health economic efficiency and equity of health care. The results of health care include system services (outputs), on the one hand, and results (outcomes), on the other, whereby the results (patient-reported outcomes) and experiences (patient-reported experiences) reported are of particular importance. Health care analyses answer basic questions of health care research: who does what, when, how, why and with which resources and effects in routine health care. Health care analyses thus provide the necessary findings and key figures to further develop health care in order to improve the quality of health care. The applications range from capacity analyses to following innovations up to the concept of regional and supra-regional monitoring of the quality of care given to the population. Given the progress of digitalisation in Health Care, direct data from the care processes will be increasingly available for health care research. This can support care givers significantly if the findings of the studies are applied precisely and correctly within an adequate methodological frame. This can lead to measurable improved health care quality for patients. Data from the process of health care provision have a high potential. Their use needs the same scientific scrutiny as in all other scientific studies.

[Necessity and Ways to Develop Care Goals for the Health System in Germany - a Position Paper of the DNVF]. / Notwendigkeit und Wege zur Entwicklung von Versorgungszielen für das Gesundheitssystem in Deutschland ­ ein Positionspapier des DNVF.

Goals for health and health care are an indispensable basic requirement for a functioning health care system. The dilemma of the German health care system is that it has not been designed in a planned way, but that it has grown historically. In recent years, it has developed through the free play of forces into what it is today. The OECD characterizes the current state as follows: The costs of the German health system do not correspond to the often only average health outcomes for the population. To meet the legal requirements (especially SGB V §§ 12, 27 and 70), health care/the health system in Germany needs concrete goals. An orientation towards health care goals entails measures on all levels of health care: on the macro level (overall system/total population), on the meso level (subdivided according to regions, specific population groups, etc.) as well as on the micro level (patients and health care providers). Based on national and international experiences, this position paper of the DNVF e.V. (German Network for health services research) shows the potential of how operationalised health care targets can ensure effective, affordable and high-quality health care. The coalition agreement of the current government propagates a reorientation with patient-related health care goals. Now it is important to derive concrete and realisable goals from this declaration of intent and to involve all important groups in the process. In addition, values and ethical standards for implementation shall be agreed upon in this process. The Health Ministry (BMG) should facilitate and promote the process of societal will-building for the definition of national health care goals. This requires a clear political will. As a result, the National Health Care Goals are available at the end of the process, which are published and maintained together with evidence-based facts as well as valid and resilient data in a Manual "National Health Care Goals". The operational responsibility for implementation could lie with the newly to be founded Federal Institute of Public Health, as already announced in the agreement of the governing coalition. The DNVF is willing to actively participate in the development of health care targets.

Health systems strengthening to arrest the global disability burden: empirical development of prioritised components for a global strategy for improving musculoskeletal health.

INTRODUCTION: Despite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health. METHODS: Design: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1-2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions. RESULTS: Phase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening. CONCLUSION: An empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives.

[Manual for Methods and Use of Routine Practice Data for Knowledge Generation]. / Manual für Methoden und Nutzung versorgungsnaher Daten zur Wissensgenerierung.

" There are more and more good reasons for using existing care data, with the focus in particular on the use of register data. The associated, clearly structured methodological procedure has so far been insufficiently combined, prepared and presented transparently. The German Network for Health Services Research (DNVF) has therefore set up an ad hoc commission for the use of routine practice data (RWE/RWD). The rapid report prepared by IQWiG on the scientific development of concepts for "generation of care-related data and their evaluation for the purpose of benefit assessment of medicinal products according to § 35a SGB V" is an essential step for the use of register data for the generation of evidence. The "Memorandum Register - Update 2019" published by DNVF 2020 also describes the requirements and methodological foundations of registers. Best practice examples from oncology, which are based on the uniform oncological basic data set for clinical cancer registration (§ 65c SGB V), show, for example, that guidelines can be checked and recommendations for guidelines and necessary interventions can be derived in the sense of knowledge-generating health services research using register data. At the same time, however, there are no clear quality requirements and structured formal and content-related procedures in the areas of data consolidation, data verification and the use of specific methods depending on the question at hand. The previously inconsistent requirements are to be revised and a method guide for the use of suited data is to be developed and published. The first chapter of the manual on methods of care-related data explains the objective and structure of the manual. It explains why the use of the term "routine practice data" is more effective than the use of the terms Real Word Data (RWD) and Real World Evidence (RWE). By avoiding the term "real world" it should be emphasized in particular that high-quality research can also be based on routine practice data (e. g. register-based comparative studies).

Quality Improvement Initiatives in Fragility Fracture Care and Prevention.

PURPOSE OF REVIEW: This review sought to describe quality improvement initiatives in fragility fracture care and prevention. RECENT FINDINGS: A major care gap persists throughout the world in the secondary prevention of fragility fractures. Systematic reviews have confirmed that the Fracture Liaison Service (FLS) model of care is associated with significant improvements in rates of bone mineral density testing, initiation of osteoporosis treatment and adherence with treatment for individuals who sustain fragility fractures. Further, these improvements in the processes of care resulted in significant reductions in refracture risk and lower post-fracture mortality. The primary challenge facing health systems now is to ensure that best practice is delivered effectively in the local healthcare setting. Publication of clinical standards for FLS at the organisational and patient level in combination with the establishment of national registries has provided a mechanism for FLS to benchmark and improve their performance. Major efforts are ongoing at the global, regional and national level to improve the acute care, rehabilitation and secondary prevention for individuals who sustain fragility fractures. Active participation in these initiatives has the potential to eliminate current care gaps in the coming decade.

Rehabilitation 2030: A Call to Action Relevant to Improving Musculoskeletal Health Care Globally.

The profile of human health is changing across the globe such that the burden of noncommunicable diseases (NCDs), particularly musculoskeletal conditions, is becoming more profound. Such change demands that health systems adapt to better support people in maintaining a functional health state and quality of life, as life expectancy continues to increase. In parallel to the rising burden of NCDs, in particular a disability burden, the need for rehabilitation services is increasing. The World Health Organization (WHO) responded recently with "Rehabilitation 2030: A Call for Action" (February 6-7, 2017, Geneva, Switzerland) and the publication of key recommendations for action. In this editorial, the authors reflect on Rehabilitation 2030 and consider its implications for health system reform in the context of rehabilitation for musculoskeletal health. J Orthop Sports Phys Ther 2017;47(5)297-300. doi:10.2519/jospt.2017.0105.

[Medical rehabilitation from a lifespan perspective]. / Medizinische Rehabilitation unter einer Lifespan-Perspektive.

Lifespan research investigates the development of individuals over the course of life. As medical rehabilitation deals with primary and secondary prophylaxis, treatment, and compensation of chronic illnesses, a lifespan perspective is needed for the classification and diagnosis of chronic disorders, the assessment of course modifying factors, the identification of vulnerable life periods and critical incidents, the implementation of preventive measures, the development of methods for the evaluation of prior treatments, the selection and prioritization of interventions, including specialized inpatient rehabilitation, the coordination of therapies and therapists, and for evaluations in social and forensic medicine. Due to the variety of individual risk constellations, illness courses and treatment situations across the lifespan, personalized medicine is especially important in the context of medical rehabilitation, which takes into consideration hindering and fostering factors alike.

Patient preoperative expectations of total hip replacement in European orthopedic centers.

OBJECTIVE: Patient expectations have been identified as a factor that may account for individual differences in recovery after total hip replacement (THR) surgery. However, patient expectations have not been studied within a valid theoretical framework. This study employed the World Health Organization's model of health, the International Classification of Functioning, Disability and Health (ICF), to classify the content of preoperative patient expectations of THR. METHODS: A European cohort of 1,108 patients preoperatively reported 2 types of expectations. Patients reported what they anticipated surgery would enable them to do that they needed to be able to do ("need" expectation), and what they would like to be able to do ("desire" expectation) in a year's time. Free-text responses were independently classified by 2 researchers to 1 or more of the ICF constructs of impairment, activity limitation, and participation restriction. RESULTS: Interrater reliability was high (κ = ≥0.87). All patient expectations were classified to the ICF constructs. Less than 5% of patient expectations were identified as impairment, 58% of "need" expectations were identified as activity limitations, and 45% of "desire" expectations were identified as activity limitations and participation restrictions combined. CONCLUSION: The ICF is a suitable theoretical framework to study patient expectations of THR. THR targets impairment; however, few patient expectations were classified to the ICF definition of impairment. The majority of patient expectations were classified as activity limitation or a combination of activity limitation and participation restriction. Therefore, patient expectations of surgery focus on recovering valued activities rather than reversal of bodily impairments.

Strategies for prevention and management of musculoskeletal conditions. Lower limb pain.

This article summarises lower limb pathology, which results in lower limb pain. It mainly addresses injuries and deliberately omits osteoarthritis and rheumatoid arthritis, since these entities are described in detail in other chapters in this volume. As major trauma is not a focal point for rheumatologists and repetitive strain injuries of the lower limb are rare, sports and leisure injuries are the main focus. Regarding lower limb pain, this chapter describes the most important problems and quantifies the size of the problem. Furthermore, it informs the reader about different treatment modalities, their goals and methods of measuring the effectiveness of the treatment. Evidence is given for different interventions, such as lifestyle, pharmacological, surgery and rehabilitation. In addition, opportunities to apply these interventions for prevention and treatment to those who will potentially benefit most are shown. Finally, strategies (care pathways) are given for prevention and treatment based on this evidence.

Multinational survey of osteoporotic fracture management.

Osteoporosis is characterized by a decreased bone mass and an increased bone fragility and susceptibility to fracture. Patients with a fragility fracture at any site have an increased risk of sustaining future fractures. Orthopedic surgeons manage most of these fractures and are often the only physician seen by the patient. Mounting evidence that orthopedic surgeons are not well attuned to osteoporosis led the Bone and Joint Decade (BJD) and the International Osteoporosis Foundation (IOF) to survey 3,422 orthopedic surgeons in France, Germany, Italy, Spain, the United Kingdom, and New Zealand. The majority of the respondents in all countries had the opinion that the orthopedic surgeon should identify and initiate the assessment of osteoporosis in patients with fragility fractures. Heterogeneous practice pattern exist in different countries; however, identification and treatment of the osteoporotic patient seems to be insufficient in many areas: half of the orthopedic surgeons surveyed received little or no training in osteoporosis. Only approximately one in four orthopedic surgeons in France, the UK and New Zealand regarded themselves as knowledgeable about treatment modalities. Less than one-fifth of the orthopedic surgeons arranged for a surgically treated patient with a fragility fracture to have a bone mineral density (BMD) test. Twenty percent said that they never refer a patient after a fragility fracture for BMD. Only half of the orthopedic surgeons in southern Europe know about the importance of some external risk factors for hip fractures (cataracts, poor lighting, pathway obstacles, poor balance). In summary, this survey clearly indicates that many orthopedic surgeons still neglect to identify, assess and treat patients with fragility fractures for osteoporosis. More educational opportunities need to be offered to orthopedic surgeons through articles, web-based learning and educational seminars. Development of a simple clinical pathway from evidence-based guidelines is an important step to ensure that optimal care is provided for patients with fragility fractures.

Improved education in musculoskeletal conditions is necessary for all doctors.

It is likely that everyone will, at some time, suffer from a problem related to the musculoskeletal system, ranging from a very common problem such as osteoarthritis or back pain to severely disabling limb trauma or rheumatoid arthritis. Many musculoskeletal problems are chronic conditions. The most common symptoms are pain and disability, with an impact not only on individuals' quality of life but also, importantly, on people's ability to earn a living and be independent. It has been estimated that one in four consultations in primary care is caused by problems of the musculoskeletal system and that these conditions may account for up to 60% of all disability pensions. In contrast, teaching at undergraduate and graduate levels--and the resulting competence and confidence of many doctors--do not reflect the impact of these conditions on individuals and society. Many medical students do not have any clinical training in assessing patients with bone and joint problems. Under the umbrella of the Bone and Joint Decade 2000-2010, experts from all parts of the world with an interest in teaching have developed recommendations for an undergraduate curriculum to improve the teaching of musculoskeletal conditions in medical schools. The goal for each medical school should be a course in musculoskeletal medicine concentrating on clinical assessment, common outpatient musculoskeletal problems and recognition of emergencies. Improving competency in the management of musculoskeletal problems within primary care settings through improved education is the next aim, but there are needs for improvement for all professionals and at all levels within the health care system.

DNA ploidy in soft tissue sarcoma: comparison of flow and image cytometry with clinical follow-up in 93 patients.

In soft tissue sarcoma, the prognostic importance of DNA ploidy status is limited. One possible explanation may be technical; small non-diploid stemlines will be diluted in relation to the presence of normal diploid cells and may not be detected by flow cytometry (FCM). We assessed DNA ploidy status in 93 tumors with both FCM and image cytometry (ICM). ICM may permit the exclusion of non-relevant cells. The ability of the two methods to detect non-diploid stemlines was compared, as were the prognostic consequences. The patients (54 males) had a median age of 69 years. Surgical procedures were performed on all patients. None of the patients had received preoperative radiotherapy or chemotherapy. FCM and ICM were performed with standard methods. The prognostic value was assessed with univariate and multivariate analysis. In 82 of the 93 tumors, a concordant ploidy status by FCM and ICM was found. In 5 FCM type 1-2 tumors (diploid), the identification of non-diploid stemlines by ICM did not influence the metastatic rates. Increasing tumor size, histotype other than liposarcoma, increasing malignancy grade, tumor necrosis, and ICM non-diploidy were univariate prognostic factors for metastasis. In a multivariate analysis, only tumor size larger than 9 cm was a prognostic factor. In about 10% of the tumors, a discrepancy between FCM and ICM ploidy status was found, but we could not find a consistent prognostic consequence of this. Neither FCM nor ICM ploidy status was an independent prognostic factor.