Patient race and surgical outcomes after total knee arthroplasty: an analysis of a large regional database.

OBJECTIVE: To examine racial differences in surgical complications, mortality, and revision rates after total knee arthroplasty. METHODS: We studied patients undergoing primary total knee arthroplasty using 2001-2007 Pennsylvania Health Care Cost Containment Council data. We conducted bivariate analyses to assess the risk of complications such as myocardial infarction, venous thromboembolism, wound infections, and failure of prosthesis, as well as 30-day and 1-year overall mortality after elective total knee arthroplasty, between racial groups. We estimated Kaplan-Meier 1- and 5-year surgical revision rates, and fit multivariable Cox proportional hazards models to compare surgical revision by race, incorporating 5 years of followup. We adjusted for patient age, sex, length of hospital stay, surgical risk of death, type of health insurance, hospital surgical volume, and hospital teaching status. RESULTS: In unadjusted analyses, there were no significant differences by racial group for either overall 30-day or in-hospital complication rates, or 30-day and 1-year mortality rates. Adjusted Cox models incorporating 5 years of followup showed an increased risk of revisions for African American patients (hazard ratio [HR] 1.39, 95% confidence interval [95% CI] 1.08-1.80), younger patients (HR 2.30, 95% CI 1.96-2.69), and lower risk for female patients (HR 0.81, 95% CI 0.71-0.92). CONCLUSION: In this sample of patients who underwent knee arthroplasty, we found no significant racial differences in major complication rates or mortality. However, African American patients, younger patients, and male patients all had significantly higher rates of revision based on 5 years of followup.

Race/ethnicity and use of elective joint replacement in the management of end-stage knee/hip osteoarthritis: a review of the literature.

Although much research has documented disparities exist for utilization of TJA, additional studies have shown that we have not narrowed the gap. Because multiple studies have shown that insurance and access to care are not necessarily underlying causes for these disparities, other studies have shown that there are real and significant differences between racial/ethnic groups in preferences for and expectations of joint arthroplasty. Additional research has established there are racial differences in certain postoperative processes and outcomes. Reasons have not been elucidated, but highlight the need for more research to understand these differences, their causes, and then to design interventions to minimize these inequalities.

Measurement and rates of persistence with and adherence to biologics for rheumatoid arthritis: a systematic review.

BACKGROUND: Biologics are an important addition to the conventional care of patients with rheumatoid arthritis (RA). Poor persistence with and adherence to biologics can undermine the effectiveness of these medications. There are no standardized methods to track persistence with and adherence to biologics. OBJECTIVE: The goal of this systematic review was to assess the methods of measurement and reported rates of persistence with and adherence to biologic regimens in patients with RA in clinical practice. METHODS: Observational studies that evaluated persistence with and adherence to biologic treatments in patients with RA were identified by searching Medline and SCI-Expanded for observational studies published in English between January 1995 and May 2009, using the following search terms: adalimumab, adherence, arthritis, biologics, compliance, discontinuation, etanercept, infliximab, persistence, RA, treatment retention, and TNF. The articles were independently reviewed to identify relevant studies and abstracted data. RESULTS: Of the 52 studies identified, 73% were based in Europe and 21% were set in the United States. All but 1 study reported measures of persistence, such as median drug survival and rates of discontinuation and retention. Four studies reported on adherence, all of which were conducted in the United States and used administrative claims data. Methods of persistence and adherence measurement were unclear or, if recorded, varied considerably across studies. Although various continuation rates (persistence) were reported across studies, the overall range of continuation at 12 months was 32.0% to 90.9%. Continuation rates were generally higher with the addition of methotrexate or other disease-modifying antirheumatic drugs. CONCLUSION: The data from the available studies on RA treatments suggest a need for better methods for tracking persistence and adherence, for examining prescribing patterns, and for identifying interventions to improve adherence.

Adherence, discontinuation, and switching of biologic therapies in medicaid enrollees with rheumatoid arthritis.

OBJECTIVE: This study examined adherence, discontinuation, and switching of rheumatoid arthritis (RA) biologics over a 1-year period after initiation of the biologic treatment in Medicaid patients with RA. METHODS: The study sample consisted of Medicaid patients with RA in California, Florida and New York who had newly initiated etanercept (n=1359), anakinra (n=267), or infliximab (n=1012) between January 1, 2000 and December 31, 2002. Adherence (proportion of days covered (PDC)≥0.80), discontinuation (90-day continuous gap), and switching (initiation of second biologic within 90days of discontinuation date of index biologic) were measured during the 12-month postindex biologic initiation. Sensitivity analyses were conducted by varying the thresholds to define these measures. Logistic regressions examined the factors associated with RA biologic adherence and discontinuation. RESULTS: Anakinra users had the lowest mean PDC (0.36) and percent adherent patients (11%) followed by etanercept users (mean PDC: 0.57; % adherent: 32%) and infliximab users (mean PDC: 0.64; % adherent: 43%). All three groups had high discontinuation rates (41% etanercept, 76% anakinra, and 41% infliximab). Few patients who discontinued the index biologic switched to another biologic. Logistic regressions found that patients in Florida had lower odds of being adherent and higher odds of discontinuing their index biologic than patients in California. Anakinra users had lower odds and infliximab users had higher odds of being adherent than etanercept users. Anakinra users had higher odds of discontinuation than etanercept users. CONCLUSION: This study highlights the poor adherence to and premature discontinuation without concurrent switching of RA biologics that should raise concern for clinicians as well as payers.

Quantitative multiplex methylation-specific PCR assay for the detection of promoter hypermethylation in multiple genes in breast cancer.

If detected early, breast cancer is eminently curable. To detect breast cancer in samples with little cellularity, a high level of sensitivity is needed. Tumor-specific promoter hypermethylation has provided such a valuable tool for detection of cancer cells in biological samples. To accurately assess promoter hypermethylation for many genes simultaneously in small samples, we developed a novel method, quantitative multiplex-methylation-specific PCR (QM-MSP). QM-MSP is highly sensitive (1 in 10(4)-10(5) copies of DNA) and linear over 5 orders of magnitude. For RASSF1A, TWIST, Cyclin D2, and HIN1, we observed significant differences in both the degree (P < 0.003) and incidence (P < 0.02) of hypermethylation between normal and malignant breast tissues. Evaluation of the cumulative hypermethylation of the four genes within each sample revealed a high level of sensitivity (84%) and specificity (89%) of detection of methylation. We demonstrate the application of this technique for detecting hypermethylated RASSF1A, TWIST, Cyclin D2, HIN1, and RARB in 50-1000 epithelial cells collected from breast ducts during endoscopy or by lavage. Such an approach could be used in a variety of small samples derived from different tissues, with these or different biomarkers to enhance detection of malignancy.