Practical and Ethical Considerations of Using Personal DNA Tests with Middle-School-Aged Learners.

Personalized genetic information is not widely utilized as a resource in learning environments, in part because of concerns about data privacy and the treatment of sensitive personal information. Here we describe the implementation of a curriculum centered on analyzing personalized genetic-ancestry test results during two-week science summer camps for middle-school-aged youth. Our research focused on how the examination of personalized DNA results affected learners' subsequent perceptions and performance, as measured by in-camp pre- and post-tests and surveys, analysis of voluntary student talk captured by audio and video recordings, and periodic one-on-one post-camp follow-ups. The curriculum was grounded in Next Generation Science Standards (NGSS) and focused around the central question of "Who am I?" Campers approached this question via guided lessons designed to shed light on their genetic uniqueness, the many attributes of their genotype and phenotype shared with others, their more distant genetic and evolutionary ancestries, and their roles as active agents in the healthy continuation of their lives. Data relevant to these questions came from edited subsets of ancestry-informative single-nucleotide polymorphisms (SNPs) and phenotype-related SNPs from the campers' genotype results, which their parents had received from a direct-to-consumer vendor. Our approaches to data privacy and the discovery, disclosure, and discussion of sensitive information on paternity, carrier status, and ancestry can be usefully applied and modified for many educational contexts. On the basis of our pilot implementations, we recommend additional and expanded research on how to incorporate personalized genetic ancestry information in a variety of learning contexts.

Precocious subcutaneous abdominal stem cell development to adipocytes in normal-weight women with polycystic ovary syndrome.

OBJECTIVE: To examine whether abnormal subcutaneous (SC) abdominal adipose stem cell (ASC) development to adipocytes in polycystic ovary syndrome (PCOS) correlates with hyperandrogenism. DESIGN: Prospective cohort study. SETTING: Academic medical center. PATIENT(S): Eight normal-weight women with PCOS and eight normoandrogenic ovulatory (control) women matched for age and body mass index. INTERVENTION(S): Circulating hormone and metabolic measurements, intravenous glucose tolerance testing, total body dual-energy X-ray absorptiometry, and SC abdominal fat biopsy. MAIN OUTCOME MEASURE(S): In vitro ASC commitment to preadipocytes (ZFP423 protein expression, day 0.5), preadipocyte differentiation to adipocytes (PPARγ gene expression, day 3) and adipocyte lipid content (Oil-Red-O fluorescence, day 12) comparisons correlated with clinical outcomes. RESULT(S): In women with PCOS, SC abdominal ASCs compared with those of control women showed exaggerated commitment to preadipocytes and had greater lipid content in newly formed adipocytes after in vitro maturation. In all women combined, ZFP423 protein expression negatively correlated with fasting plasma glucose levels whereas the lipid content of newly formed adipocytes positively correlated with both PPARγ gene expression and serum free testosterone levels. CONCLUSION(S): In normal-weight women with PCOS compared with the control group, exaggerated SC abdominal ASC commitment to preadipocytes and enhanced adipocyte lipid content during maturation in vitro negatively and positively correlate with circulating fasting glucose and androgen levels, respectively, as a possible mechanism to maintain glucose-insulin homeostasis when fat accretion is accelerated.

High frequency detection of Toxoplasma gondii DNA in human neonatal tissue from Libya.

BACKGROUND: Toxoplasma gondii is a parasite that causes significant disease in humans. Toxoplasmosis is normally asymptomatic, unless associated with congenital transmission, or in immunocompromised people. Congenital transmission generally occurs at low frequencies. In this study, we use PCR to investigate possible congenital transmission of T. gondii during pregnancy in a cohort of mothers from Libya. METHODS: Two hundred and seventy two pregnant women (producing 276 neonates) were recruited to obtain umbilical cord tissue from their neonates at birth; DNA was extracted from that tissue and tested for T. gondii DNA using two specific PCR protocols based on the sag 1 and sag 3 genes. RESULTS: Toxoplasma gondii DNA was detected in the umbilical cord DNA from 27 of the 276 neonates giving a prevalence of 9.9% (95% CI 6.8-13.9%). Compared with more commonly reported rates of congenital transmission of 0.1% of live births, this is high. There was no association of infection with unsuccessful pregnancy. CONCLUSIONS: This study shows a high frequency presence of T. gondii DNA associated with neonatal tissue at birth in this cohort of 276 neonates from Libya. Although PCR cannot detect living parasites, there is the possibility that this indicates a higher than usual frequency of congenital transmission.

Prevalence and risk factors for periprosthetic fracture in older recipients of total hip replacement: a cohort study.

BACKGROUND: The growing utilization of total joint replacement will increase the frequency of its complications, including periprosthetic fracture. The prevalence and risk factors of periprosthetic fracture require further study, particularly over the course of long-term follow-up. The objective of this study was to estimate the prevalence and risk factors for periprosthetic fractures occurring in recipients of total hip replacement. METHODS: We identified Medicare beneficiaries who had elective primary total hip replacement (THR) for non-fracture diagnoses between July 1995 and June 1996. We followed them using Medicare Part A claims data through 2008. We used ICD-9 codes to identify periprosthetic femoral fractures occurring from 2006-2008. We used the incidence density method to calculate the annual incidence of these fractures and Cox proportional hazards models to identify risk factors for periprosthetic fracture. We also calculated the risk of hospitalization over the subsequent year. RESULTS: Of 58,521 Medicare beneficiaries who had elective primary THR between July 1995 and June 1996, 32,463 (55%) survived until January 2006. Of these, 215 (0.7%) developed a periprosthetic femoral fracture between 2006 and 2008. The annual incidence of periprosthetic fracture among these individuals was 26 per 10,000 person-years. In the Cox model, a greater risk of periprosthetic fracture was associated with having had a total knee replacement (HR 1.82, 95% CI 1.30, 2.55) or a revision total hip replacement (HR1.40, 95% CI 0.95, 2.07) between the primary THR and 2006. Compared to those without fractures, THR recipients who sustained periprosthetic femoral fracture had three-fold higher risk of hospitalization in the subsequent year (89% vs. 27%, p<0.0001). CONCLUSION: A decade after primary THR, periprosthetic fractures occur annually in 26 per 10,000 persons and are especially frequent in those with prior total knee or revision total hip replacements.

Trends in prescription of opioids from 2003-2009 in persons with knee osteoarthritis.

OBJECTIVE: Osteoarthritis (OA) of the knee is a painful condition affecting ∼13% of persons ages >65 years. We sought to examine whether the use of opioids in older persons with OA has increased over the past decade and what patient characteristics may correlate with their use. METHODS: We assembled national cohorts of individuals with knee OA using data from the 2003, 2006, and 2009 waves of the Medicare Current Beneficiary Survey. The survey data contained information on demographics, health status, and prescribed medications linked to Medicare claims. We used multivariate logistic regression to establish whether opioid use changed over time and to identify factors associated with greater opioid use. The outcome was defined as receiving ≥1 opioid prescription in the study year. RESULTS: The mean age and sex were similar across years (77 years and 69% women, respectively). There was a significant increase in opioid prescribing between 2003 and 2009, with 31% of patients receiving opioids in 2003, 39% in 2006, and 40% in 2009 (odds ratio [OR] 1.5, 95% confidence interval [95% CI] 1.1-2.0 for 2006 and 2009 compared with 2003). Independent correlates of opioid use across time periods included female sex (OR 1.5, 95% CI 1.2-2.0), functional limitation (OR 2.1, 95% CI 1.6-2.7), poor self-reported health status (OR 1.6, 95% CI 1.2-2.0), chronic obstructive pulmonary disease (OR 1.4, 95% CI 1.0-1.8), and musculoskeletal disease besides OA (OR 1.9, 95% CI 1.2-2.8). CONCLUSION: As the prevalence and incidence of knee OA continues to increase, the public health impact of greater opioid use should be monitored carefully.

Comparative risk of fracture in men and women with HIV.

CONTEXT: Men and women with HIV have an increased risk of fracture compared with individuals without HIV; however, it is unknown if women with HIV fracture at higher rates than men. OBJECTIVE: We aimed to compare the incidence rates (IR) of fractures between men and women with HIV. DESIGN: The study was designed as a cohort study, examining medical records from November 2001 to August 2012. SETTING: The study was performed using records from two tertiary-care hospitals in Boston, Massachusetts. PATIENTS: The study patients were adults with HIV: this was defined by diagnosis codes for HIV on two visits, at least one prescription for antiretroviral therapy, and at least 18 years of age. INTERVENTION: IRs per 1000 person-years of all fractures and fractures at osteoporotic sites were calculated. We calculated IRs within age and gender strata and estimated IR ratios (IRR) between men and women. MAIN OUTCOME MEASURE: The main outcome measure was fracture at any site. RESULTS: We identified a cohort of 3161 HIV-infected patients (869 women and 2292 men) with a total of 587 fractures. The IRR of all fractures was 1.00 (95% confidence interval [CI] 0.83-1.19) between men and women. The IR of fractures at osteoporotic sites among men was 15.2 (95% CI 12.7-17.6) per 1000 person-years compared with 12.1 (95% CI 8.6-15.6) in women, with IRR of 1.26 (95% CI 0.90-1.75). Men had similar or higher IRs than women for osteoporotic site fractures across most age groups. CONCLUSIONS: This study found similar rates of fracture in men and women with HIV. Further studies validating these findings are required to determine whether men with HIV should be screened for osteoporosis.

Aggregate health burden and the risk of hospitalization in older persons post hip replacement surgery.

BACKGROUND: We sought to understand the association between aggregate health burden-chronic conditions, functionally limiting health problems and mental well-being-and the likelihood of hospitalization among older persons post hip replacement surgery. METHODS: Eight hundred and twenty-eight Medicare recipients from three U.S. states completed a questionnaire 3 years postsurgery. Using administrative data (Medicare Provider Analysis and Review), participants were prospectively followed for 12 months postquestionnaire to capture hospitalizations. Using logistic regression, demographic, socioeconomic, and behavioral characteristics and medical comorbidities were considered as predictors. Subsequently, musculoskeletal (MSK) functional and geriatric problems were added as predictors, then mental well-being and activity limitations. Path analysis was employed to elucidate interrelationships between these predictors, investigating whether mediated effects through mental well-being and activity limitations were operational. RESULTS: Mean age was 76 years (range: 67-96); 63% were women; 23% had ≥1 hospitalization(s). When medical comorbidity, MSK limitations, and geriatric problems were considered, each was independently associated with hospitalization (odds ratios: 1.3, 1.1, 1.2, respectively). When mental well-being and activity limitations were added, these variables were predictive of hospitalization (odds ratios: 1.2, 1.1, respectively), while MSK limitations and geriatric problems were no longer predictive. Path analysis results suggested that the influence of medical comorbidity and MSK and geriatric problems were mediated through mental well-being and activity limitations. CONCLUSIONS: Several health domains predict hospitalization, beyond and including medical comorbidity. Efforts aimed at delaying/minimizing hospitalizations in this population should consider an array of domains for potentially targeted intervention. These findings can serve as a baseline against which future research can assess the impact of changes to the health care system.

Risk factors for revision of primary total hip replacement: results from a national case-control study.

OBJECTIVE: To study the risk factors for revision of primary total hip replacement (THR) in a US population-based sample. METHODS: Using Medicare claims, we identified beneficiaries from 29 US states who underwent primary THR between July 1, 1995 and June 30, 1996, with followup through December 31, 2008. Potential cases had International Classification of Diseases, Ninth Revision, Clinical Modification codes indicating a revision THR. Each case was matched by state with 1 control THR recipient who was alive and unrevised when the case had a revision THR. We abstracted hospital records to document potential risk factors. We examined the associations between preoperative factors and revision risk using multivariate conditional logistic regression. RESULTS: The analysis data set contained 719 of 836 case-control pairs with complete data for analysis variables. The factors associated with higher revision odds in multivariate models were age ≤75 years at primary surgery (odds ratio [OR] 1.52 [95% confidence interval (95% CI) 1.20-1.92]), height in the highest tertile (OR 1.40 [95% CI 1.06-1.85]), weight in the highest tertile (OR 1.66 [95% CI 1.24-2.22]), cemented femoral component (OR 1.44 [95% CI 1.10-1.87]), prior contralateral primary THR (OR 1.36 [95% CI 1.05-1.76]), other prior orthopedic surgery (OR 1.45 [95% CI 1.13-1.84]), and living with others (versus alone; OR 1.26 [95% CI 0.99-1.61]). CONCLUSION: This first US population-based case-control study of risk factors for revision of primary THR showed that younger, taller, and heavier patients and those receiving a cemented femoral component had a greater likelihood of undergoing a revision THR over a 12-year followup period. Effects of age and body size on revision risk should be addressed by clinicians with patients considering primary THR.

Twelve-year risk of revision after primary total hip replacement in the U.S. Medicare population.

BACKGROUND: There is limited population-based literature on rates and risk factors for revision following primary total hip replacement. METHODS: We performed a retrospective cohort study of Medicare beneficiaries who had elective total hip replacement for osteoarthritis between July 1, 1995, and June 30, 1996. Patients were followed with use of Medicare claims through 2008. The primary end point was revision total hip replacement as indicated by hospital discharge codes according to the International Classification of Diseases, Ninth Revision. We used the Kaplan-Meier method to plot the risks of revision and of death over a twelve-year follow-up period. We used Cox proportional hazard regression models to identify preoperative risk factors for revision of primary total hip replacement. We conducted sensitivity analyses to account for competing risks of major comorbid conditions. RESULTS: The risk of revision total hip replacement for patients remaining alive was approximately 2% per year for the first eighteen months and then 1% per year for the remainder of the follow-up period. The absolute risk of death over the twelve-year follow-up period exceeded the risk of revision total hip replacement by a factor of ten (59% vs. 5.7%) in patients older than seventy-five years at the time of primary total hip replacement and by a factor of three (29% vs. 9.4%) in patients sixty-five to seventy-five years old at the time of surgery. In multivariate Cox proportional hazard models, the relative risk of revision was higher in men than in women (hazard ratio [HR], 1.23; 95% confidence interval [95% CI], 1.15, 1.31) and in patients sixty-five to seventy-five years of age at the time of primary total hip replacement than in those over seventy-five years (HR, 1.47; 95% CI, 1.37, 1.58). Patients of surgeons who performed fewer than six total hip replacements annually in the Medicare population had a higher risk of revision than those whose surgeons performed more than twelve per year (HR, 1.21; 95% CI, 1.12, 1.32). CONCLUSIONS: Efforts to reduce the number of revision hip arthroplasties should be targeted at revisions occurring in the first eighteen months following the index arthroplasty, when revision risk is higher, and at younger patients, who are more likely to survive long enough to require revision. .

Emergency provider attitudes and barriers to universal HIV testing in the emergency department.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recently published recommendations for routine, voluntary human immunodeficiency virus (HIV) testing of adults in all health care settings, including the emergency department (ED). STUDY OBJECTIVE: The objective of this study was to examine the willingness of ED providers to offer HIV testing, as well as their perceived barriers to implementation of these guidelines. METHODS: Before the establishment of a routine HIV testing program in the ED, a 21-item survey was used to assess ED providers' knowledge, attitudes, and perceived challenges to HIV testing. Six months after program initiation, the identical survey was re-administered to determine whether HIV testing program experience altered providers' perceptions. RESULTS: There were 108 of 146 (74%) providers who completed both the pre- and post-implementation surveys. Although the majority of emergency providers at 6 months were supportive of an ED-based HIV testing program (59/108 [55%]), only 38% (41/108) were willing to offer the HIV test most or all of the time. At 6 months, the most frequently cited barriers to offering a test were: inadequate time (67/108 [62%]), inadequate resources (65/108 [60%]), and concerns regarding provision of follow-up care (64/108 [59%]). CONCLUSIONS: After the implementation of a large-scale HIV testing program in an ED, the majority of emergency providers were supportive of routine HIV testing. Nevertheless, 6 months after program initiation, providers were still reluctant to offer the test due to persistent barriers. Further studies are needed to identify feasible implementation strategies that minimize barriers to routine HIV testing in the ED.

Estimating proximity to care: are straight line and zipcode centroid distances acceptable proxy measures?

BACKGROUND: Spatial accessibility of healthcare may be measured by proximity of patient residence to health services, typically in driving distance or driving time. Precise driving distances and times are rarely available. Although straight line distances between zipcode centroids and between precise address locations are used as proxy measures for distance to care, the accuracy of these measures has received little study. METHODS: Among a cohort of Medicare beneficiaries, actual driving distances and times between patient residence and clinic were obtained from commercial software (MapQuest). We used a split-sample design to build and validate linear regression models that predict actual driving distances and times from estimated distances between zipcode centroids and between precise residential and hospital locations, adjusting for urban/suburban/rural residential status. RESULTS: On average, predicted driving distances and times were larger than actual values. Zipcode centroid distances alone predicted longer driving distances than observed values: rural +19% (3.2 miles), suburban +23% (3.7 miles), and urban +27% (2.0 miles). Predicted time was 36% (9.4 min) longer in rural, 32% (6.8 min) longer in suburban, and 38% (4.7 min) longer in urban areas than observed values. Including urban/suburban/rural categorization of residence improved the accuracy of predicted driving distance and time for suburban and urban areas but diminished accuracy for rural areas. Similar trends were observed for distance estimates from precise locations. CONCLUSIONS: Distances between zipcode centroids and precise residential/hospital locations provide reasonable estimates of driving distance and time for epidemiologic research. Estimates are improved for suburban and urban residences when data are augmented by urban categorization.

Predictive value of Medicare claims data for identifying revision of index hip replacement was modest.

OBJECTIVE: To determine the positive predictive value of Medicare claims for identifying revision of total hip replacement (THR), a frequent marker of THR quality and outcome. STUDY DESIGN AND SETTING: We obtained Medicare Part A (Hospital) claims from seven states on patients that had primary THR from July 1995 through June 1996. We searched claims to determine whether these THR recipients had a subsequent revision THR through December 2006. We selected a sample of subjects with codes indicating both index primary and subsequent revision THR. We obtained medical records for both procedures to establish whether the revision occurred on the same side as index primary THR. RESULTS: Three hundred seventy-four subjects had codes indicating primary THR in 1995-96 and subsequent revision. Seventy-one percent (95% confidence interval: 66, 76) of the revisions were performed on the index joint and would be correctly attributed as revisions of the index THR, using Medicare claims data. CONCLUSION: Claims data on revision THR that do not contain information on the side that was operated on are ambiguous with respect to whether the revision was performed on the index or contralateral side. Claims-based analyses of revisions after an index THR should acknowledge and adjust for this source of potential misclassification.

Choice of hospital for revision total hip replacement.

BACKGROUND: Little is known about how often patients have revision total hip replacement in the same hospital in which they had the primary procedure. METHODS: We examined Medicare claims data to identify patients who had primary total hip replacement from July 1995 to June 1996 and subsequently had revision through December 31, 2006. We examined whether the revision was performed in the same or different hospital from the primary procedure, with different hospitals being categorized as being in a lower, a higher, or the same hospital volume stratum. Hospital strata included twenty-five or fewer cases of total hip replacement annually in the Medicare population, twenty-six to fifty cases, fifty-one to 100 cases, and >100 cases. We calculated the number of revisions generated (primary procedures eventuating in revision) by hospitals in each volume stratum and the number of revisions performed in these hospitals. RESULTS: Of 4448 revision procedures, 3306 (74%) were performed in hospitals in the same volume stratum as the hospital where the primary procedure was performed. Four hundred twenty-nine revisions (9.6%) were performed in a lower-volume hospital, and 713 (16%) were performed in a higher-volume hospital. Thirty-one (3%) of 960 patients who had revision within one year after the primary total hip replacement had the revision in a lower-volume center, compared with 204 (15%) of 1393 who had revision more than six years after the primary procedure (odds ratio = 4.6 ; 95% confidence interval, 3.0 to 6.8). The ratio of revisions performed to revisions generated was 1.21 for the highest-volume centers and 0.86 for the lowest-volume centers. CONCLUSIONS: Of 4448 revisions examined in this study, 429 (<10%) were performed in centers with a lower volume of total hip replacement than the center at which the initial hip replacement was performed, whereas 713 (16%) were performed in higher-volume centers. Higher-volume centers performed 21% more revisions than they generated (531 revisions performed, compared with 438 generated). These data will help to inform health-care policy with regard to the utilization of resources for revision total hip replacement.

Impact of knee osteoarthritis on health care resource utilization in a US population-based national sample.

OBJECTIVE: We sought to estimate the impact of knee osteoarthritis (OA) on health care utilization. RESEARCH DESIGN: Using the 2003 Medicare Current Beneficiary Survey, a population-based survey of Medicare beneficiaries linked to Medicare claims, we selected a national cohort of community-dwelling persons aged 65 and older with knee OA and a sex- and age-matched comparison cohort without any form of OA. We distinguished following 4 components of health care utilization: physician (MD) office visits, non-MD office visits, inpatient hospital stays, and emergency department visits. We built multiple regression models to determine whether knee OA affects utilization, controlling for comorbidity count, obesity, functional limitation, education, race, and working status. RESULTS: A total of 545 Medicare Current Beneficiary Survey participants with knee OA were matched with 1090 OA-free individuals. Mean age in both cohorts was 76 years; approximately 70% were female. Knee OA and OA-free subjects differed significantly in obesity (Knee OA: 37%, OA-free: 20%), % with >or=2 comorbidities (Knee OA: 69%, OA-free: 43%), and functional limitation (Knee OA: 42%, OA-free: 26%). In multivariable regression models, the knee OA cohort had on average 6.0 more annual MD visits (95% confidence interval [CI]: 4.7, 7.4) and 3.8 more non-MD visits (95% CI: 2.8, 4.7) than the OA-free cohort. The knee OA cohort also had 28% more hospital stays (odds ratio [OR] = 1.3, 95% CI: 1.0, 1.6), a difference attributable to total joint replacements. CONCLUSIONS: This first national, population-based study of health care utilization in persons with knee OA documents considerable excess utilization attributable to knee OA, independent of comorbidity, and other patient characteristics.

Ambulatory visit utilization in a national, population-based sample of adults with osteoarthritis.

OBJECTIVE: To estimate the proportion of adults with osteoarthritis (OA) seeing various medical providers and ascertain factors affecting the likelihood of a patient seeing an OA specialist. METHODS: We used data from the Medical Expenditures Panel Survey, a stratified random sample of the noninstitutionalized civilian population. We classified adults as having symptomatic OA if their medical conditions included at least 1 occurrence of the International Classification of Diseases, Ninth Revision Clinical Modification, codes 715, 716, or 719, and if they reported joint pain, swelling, or stiffness during the previous 12 months. For the purpose of our analysis, we defined rheumatologists, orthopedists, and physical therapists as OA specialists. We first estimated the proportion of OA individuals seen by OA specialists and other health care providers in a 1-year period. We then used logistic regression to estimate the impact of demographic and clinical factors on the likelihood of an individual seeing an OA specialist. RESULTS: A total of 9,933 persons met the definition of OA, representing 22.5 million adults in the US. Of these persons, 92% see physicians during the year, 34% see at least 1 OA specialist, 25% see an orthopedist, 11% see a physical therapist, and 6% see a rheumatologist. Higher educational attainment, having more comorbidities, and residing in the northeastern US are significant positive predictors for a patient seeing an OA specialist. Significant negative predictors for seeing an OA specialist are being unmarried but previously married and having no health insurance. CONCLUSION: Most adults with OA do not visit OA specialists. Those without insurance and with lower levels of education are less likely to see these specialists.

Development and validation of an index of musculoskeletal functional limitations.

BACKGROUND: While musculoskeletal problems are leading sources of disability, there has been little research on measuring the number of functionally limiting musculoskeletal problems for use as predictor of outcome in studies of chronic disease. This paper reports on the development and preliminary validation of a self administered musculoskeletal functional limitations index. METHODS: We developed a summary musculoskeletal functional limitations index based upon a six-item self administered questionnaire in which subjects indicate whether they are limited a lot, a little or not at all because of problems in six anatomic regions (knees, hips, ankles and feet, back, neck, upper extremities). Responses are summed into an index score. The index was completed by a sample of total knee replacement recipients from four US states. Our analyses examined convergent validity at the item and at the index level as well as discriminant validity and the independence of the index from other correlates of quality of life. RESULTS: 782 subjects completed all items of the musculoskeletal functional limitations index and were included in the analyses. The mean age of the sample was 75 years and 64% were female. The index demonstrated anticipated associations with self-reported quality of life, activities of daily living, WOMAC functional status score, use of walking support, frequency of usual exercise, frequency of falls and dependence upon another person for assistance with chores. The index was strongly and independently associated with self-reported overall health. CONCLUSION: The self-reported musculoskeletal functional limitations index appears to be a valid measure of musculoskeletal functional limitations, in the aspects of validity assessed in this study. It is useful for outcome studies following TKR and shows promise as a covariate in studies of chronic disease outcomes.

Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume.

BACKGROUND: Total knee arthroplasty (TKA) relieves pain and improves quality of life for persons with advanced knee osteoarthritis. However, to our knowledge, the cost-effectiveness of TKA and the influences of hospital volume and patient risk on TKA cost-effectiveness have not been investigated in the United States. METHODS: We developed a Markov, state-transition, computer simulation model and populated it with Medicare claims data and cost and outcomes data from national and multinational sources. We projected lifetime costs and quality-adjusted life expectancy (QALE) for different risk populations and varied TKA intervention and hospital volume. Cost-effectiveness of TKA was estimated across all patient risk and hospital volume permutations. Finally, we conducted sensitivity analyses to determine various parameters' influences on cost-effectiveness. RESULTS: Overall, TKA increased QALE from 6.822 to 7.957 quality-adjusted life years (QALYs). Lifetime costs rose from $37,100 (no TKA) to $57 900 after TKA, resulting in an incremental cost-effectiveness ratio of $18,300 per QALY. For high-risk patients, TKA increased QALE from 5.713 to 6.594 QALY, yielding a cost-effectiveness ratio of $28,100 per QALY. At all risk levels, TKA was more costly and less effective in low-volume centers than in high-volume centers. Results were insensitive to variations of key input parameters within policy-relevant, clinically plausible ranges. The greatest variations were seen for the quality of life gain after TKA and the cost of TKA. CONCLUSIONS: Total knee arthroplasty appears to be cost-effective in the US Medicare-aged population, as currently practiced across all risk groups. Policy decisions should be made on the basis of available local options for TKA. However, when a high-volume hospital is available, TKAs performed in a high-volume hospital confer even greater value per dollar spent than TKAs performed in low-volume centers.

A randomized controlled trial of an intervention to reduce low literacy barriers in inflammatory arthritis management.

OBJECTIVE: Test the efficacy of educational interventions to reduce literacy barriers and enhance health outcomes among patients with inflammatory arthritis. METHODS: The intervention consisted of plain language information materials and/or two individualized sessions with an arthritis educator. Randomization was stratified by education level. Principal outcomes included adherence to treatments, self-efficacy, satisfaction with care, and appointment keeping. Secondary outcomes included health status and mental health. Data were collected at baseline, six, and twelve months post. RESULTS: Of the 127 patients, half had education beyond high school and three quarters had disease duration greater than five years. There were no differences in the primary outcome measures between the groups. In mixed models controlling for baseline score and demographic factors, the intervention group showed improvement in mental health score at six and twelve months (3.0 and 3.7 points, respectively), while the control group showed diminished scores (-4.5 and -2.6 points, respectively) (p=0.03 and 0.01). CONCLUSION: While the intervention appears to have had no effect on primary outcomes, further studies with continued attention to literacy are warranted. Study site and disease duration must be considered as participants in this study had higher than average health literacy and had established diagnoses for years prior to this study. PRACTICE IMPLICATIONS: The study offers insight into an application of many of the protocols currently recommended to ameliorate effects of limited literacy.

Rapid HIV testing program implementation: lessons from the emergency department.

BACKGROUND: The US Centers for Disease Control and Prevention (CDC) guidelines and the World Health Organization (WHO) both recommend HIV testing in health-care settings. However, neither organization provides prescriptive details regarding how these recommendations should be adapted into clinical practice in an emergency department. METHODS: We have implemented an HIV-testing program in the ED of a major academic medical center within the scope of the Universal Screening for HIV Infection in the Emergency Room (USHER) Trial-a randomized clinical trial evaluating the feasibility and cost-effectiveness of HIV screening in this setting. RESULTS AND CONCLUSION: Drawing on our collective experiences in establishing programs domestically and internationally, we offer a practical framework of lessons learned so that others poised to embark on such HIV testing programs may benefit from our experiences.

Risk factors for cardiovascular complications following total joint replacement surgery.

OBJECTIVE: To determine risk factors for cardiac complications following total joint replacement (TJR) surgery. METHODS: We performed a case-control study of patients who had undergone a primary or revision total knee or total hip replacement surgery. Cases consisted of those who received a TJR and experienced a cardiac complication during the surgical admission period (myocardial infarction [MI], congestive heart failure [CHF], unstable angina, arrhythmia, symptomatic hypotension, or pulmonary embolus). Controls consisted of those who received a TJR and did not experience a cardiac complication during the surgical admission period. Controls were matched to the cases for age at surgery, year of surgery, and surgeon. Case and control status and identification of potential risk factors were ascertained by review of medical records. Conditional logistic regression analysis was used to identify independent predictors of cardiac complications. RESULTS: The sample included 209 cases and 209 controls. Factors associated with a higher risk of cardiac complications included a history of arrhythmia (adjusted odds ratio [OR] 2.6 [95% confidence interval (95% CI) 1.5-4.3]), a history of coronary artery disease, MI, CHF, or valvular heart disease (OR 1.6 [95% CI 0.9-2.6]), revision surgery (OR 2.2 [95% CI 1.2-3.9]), and bilateral surgery (adjusted OR 3.5 [95% CI 1.6-8.0]). Even though controls were matched for age (within age brackets), age was still associated with a higher risk of cardiac complications (OR 1.7 [95% CI 0.9-3.4]). CONCLUSION: This case-control study identified 2 new risk factors for cardiac complications following TJR: bilateral and revision surgery. The study also confirmed previously documented risk factors, including older age at surgery and a history of arrhythmia and of other cardiac problems. These findings should help clinicians anticipate and prevent cardiac complications following TJR surgery.