Patient acceptable symptom state (PASS): thresholds for the EQ-5D-5L and Oxford hip and knee scores for patients with total hip and knee replacement.

PURPOSE: To define patient acceptable symptom state (PASS) cut-off values for the EQ-5D-5L and Oxford hip (OHS) and knee (OKS) scores 6 and 12 months after total hip (THR) or knee (TKR) replacement. To compare PASS cut-off values for the EQ-5D-5L scored using: (1) the Canadian value set, (2) the crosswalk value set, and (3) the equal weighted Level Sum Score (LSS). METHODS: We mailed questionnaires to consecutive patients following surgeon referral for primary THR or TKR and at 6 and 12 months post-surgery. Patient reported outcome measures (PROMs) were the EQ-5D-5L, the OHS, and OKS. We assessed PASS cut-off values for PROMs using percentile and ROC methods, with the Youden Index. RESULTS: Five hundred forty-two surgical patients (mean age, 64 years, 57% female, 49% THR) completed baseline and 12-month questionnaires. 89% of THR and 81% of TKR patients rated PASS as acceptable at 12 months. PASS cut-off values for THR for the EQ-5D-5L (Canadian) were 0.85 (percentile) and 0.84 (Youden) at 12 months. Cut-off values were similar for the LSS (0.85 and 0.85) and lower for the crosswalk value set (0.74 and 0.73), respectively. EQ-5D-5L cut-off values for TKR were Canadian, 0.77 (Percentile) and 0.78 (Youden), LSS, 0.75 and 0.80, and crosswalk, 0.67 and 0.74, respectively. Cut-off values 6 and 12 months post-surgery ranged from 38 to 39 for the OHS, and 28 to 36 for the OKS (range 0 worst to 48 best). CONCLUSION: PASS cut-off values for the EQ-5D-5L and Oxford scores varied, not only between methods and timing of assessment, but also by different EQ-5D-5L value sets, which vary between countries. Because of this variation, PASS cut-off values are not necessarily generalizable to other populations of TJR patients. We advise caution in interpreting PROMs when using EQ-5D-5L PASS cut-off values developed in different countries. A standardization of methods is needed before published cut-off values can be used with confidence in other populations.

Relationship Between Patient-Reported Readiness for Total Knee Arthroplasty and Likelihood of a Good Outcome at One-Year Follow-Up.

OBJECTIVE: To determine the relationship between patients' preoperative readiness for total knee arthroplasty (TKA) and surgical outcome at 1 year post-TKA. METHODS: This prospective cohort study recruited patients with knee osteoarthritis (OA) who were ≥30 years and were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who underwent primary unilateral TKA completed questionnaires prior to TKA to assess pain using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), physical disability using the Knee Injury and Osteoarthritis Outcome Score physical function short form, perceived arthritis coping efficacy, general self-efficacy, depressed mood using the Patient Health Questionnaire 8, body mass index, comorbidities, and TKA readiness (patient acceptable symptom state; willingness to undergo TKA); these same individuals also completed the above questionnaires 1 year post-TKA to assess surgical outcomes. A good TKA outcome was defined as an individual having improved knee symptoms, measured using the Osteoarthritis Research Society International-Outcome Measures in Rheumatology responder criteria, and overall satisfaction with results of the TKA. Poisson regression with robust error estimation was used to estimate the relative risk (RR) of a good outcome for exposures, before and after controlling for covariates. RESULTS: Of 1,272 TKA recipients assessed at 1 year post-TKA, 1,053 with data for the outcome assessed in the study were included (mean ± SD age 66.9 ± 8.8 years; 58.6% female). Most patients (87.8%) were definitely willing to undergo TKA and had "unacceptable" knee symptoms (79.7%). Among patients who underwent TKA, 78.1% achieved a good outcome. Controlling for pre-TKA OA-related disability, arthritis coping efficacy, comorbid hip symptoms, and depressed mood, definite willingness to undergo TKA and unacceptable knee symptoms were associated with a greater likelihood of a good TKA outcome, with adjusted RRs of 1.18 (95% confidence interval [95% CI] 1.04-1.35) and 1.14 (95% CI 1.02-1.27), respectively. CONCLUSION: Among patients who underwent TKA for knee OA, patients' psychological readiness for TKA and willingness to undergo TKA were associated with a greater likelihood of a good outcome. Incorporation of these factors in TKA decision-making may enhance patient outcomes and appropriate the use of TKA.

Patients' Preoperative Expectations of Total Knee Arthroplasty and Satisfaction With Outcomes at One Year: A Prospective Cohort Study.

OBJECTIVE: To assess the relationship between patients' expectations for total knee arthroplasty (TKA) and satisfaction with surgical outcome. METHODS: This prospective cohort study recruited patients with knee osteoarthritis (OA) ages ≥30 years who were referred for TKA at 2 hip/knee surgery centers in Alberta, Canada. Those who received primary, unilateral TKA completed questionnaires pre-TKA to assess TKA expectations (17-item Hospital for Special Surgery [HSS] TKA Expectations questionnaire) and contextual factors (age, sex, Western Ontario and McMaster Universities Osteoarthritis Index pain score, Knee Injury and Osteoarthritis Outcome Score physical function short form [KOOS-PS], 8-item Patient Health Questionnaire depression scale, body mass index [BMI], comorbidities, and prior joint replacement), and 1-year post-TKA to assess overall satisfaction with TKA results. Using multivariate logistic regression, we examined the relationship between TKA expectations (HSS TKA outcomes considered to be very important) and postoperative satisfaction (very satisfied versus somewhat satisfied versus dissatisfied). Adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated. RESULTS: At 1 year, 1,266 patients with TKA (92.1%) reported their TKA satisfaction (mean ± SD age 67.2 ± 8.8 years, 60.9% women, and mean BMI 32.6 kg/m2 ); 74.7% of patients were very satisfied, 17.1% were somewhat satisfied, and 8.2% were dissatisfied. Controlling for other factors, an expectation of TKA to improve patients' ability to kneel was associated with lower odds of satisfaction (adjusted OR 0.725 [95% CI 0.54-0.98]). An expectation of TKA to improve psychological well-being was associated with lower odds of satisfaction for individuals in the lowest tertile of pre-TKA KOOS-PS scores (adjusted OR 0.49 [95% CI 0.28-0.84]), but higher odds for those in the highest tertile (adjusted OR 2.37 [95% CI 1.33-4.21]). CONCLUSION: In patients with TKA, preoperative expectations regarding kneeling and psychological well-being were significantly associated with the level of TKA satisfaction at 1 year. Ensuring that patients' expectations are achievable may enhance appropriate provision of TKA.

Patient expectations and satisfaction 6 and 12 months following total hip and knee replacement.

PURPOSE: To assess (1) patient expectations before total hip (THR) and knee (TKR) replacement; (2) which expectations are met and unmet 6 and 12 months post-surgery; (3) the role of unmet expectations in satisfaction. METHODS: Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR. Patients listed their own expectations and also completed the Hospital for Special Surgery (HSS) Expectation Survey. We used content analysis to group expectations into themes. At 6 and 12 months post-surgery, patients were given a copy of their own list of individual expectations and reassessed each one as met or unmet. We also assessed fulfilled HSS expectations and satisfaction with surgery. RESULTS: The sample of 556 patients (49% THR, 57% female) had a mean age of 64 years (SD10). The five most frequent expectation themes were pain relief, mobility, walking, physical activities, and daily activities. Of these, physical activities had the lowest percentage met 12 months post-surgery. 95% (THR) and 87% (TKR) were satisfied/very satisfied with their surgery 12 months post-surgery. Very satisfied patients had a significantly greater percentage of met expectations (96% THR; 92% TKR) than dissatisfied patients (42% THR; 12% TKR). Although most expectations listed by patients were included in the HSS surveys, some were not, particularly for TKR. From 6 to 12 months, there was a significant increase in patient satisfaction for self-care, daily activities, and met expectations for THR and pain relief, self-care, daily activities, and recreational activities for TKR. CONCLUSIONS: Expectations should be explicitly addressed before surgery, including a discussion of realistic expectations, particularly for physical activities.

Comparing the validity and responsiveness of the EQ-5D-5L to the Oxford hip and knee scores and SF-12 in osteoarthritis patients 1 year following total joint replacement.

PURPOSE: (1) To assess responsiveness of the EQ-5D-5L compared to Oxford hip and knee scores and the SF-12 in osteoarthritis patients undergoing total hip (THR) or knee (TKR) replacement surgery; (2) to compare distribution and anchor-based methods of assessing responsiveness. METHODS: Questionnaires were mailed to consecutive patients following surgeon referral for primary THR or TKR and 1 year post-surgery. We assessed effect size (ES), standardized response mean (SRM), and standard error of measurement (SEM). Minimum important difference (MID) was the mean change in patients reporting somewhat better in hip or knee, health in general, and those who were satisfied with surgery (5-point scales). Responders were compared using MID versus 1 and 2SEM. RESULTS: The sample of 537 (50% TKR) was composed of 56% female with a mean age of 64 years (SD 10). EQ-5D-5L ES was 1.86 (THR) and 1.19 (TKR) compared to 3.00 and 2.05 for Oxford scores, respectively. MID for the EQ-5D-5L was 0.22 (THR) and 0.20 (TKR) for patients who rated their hip or knee as somewhat better. There was a wide variation in the MID and the percentage of responders, depending on the joint, method of assessment, and the outcome measure. The percent agreement of responder classification using 2SEM vs. MID ranged from 79.6 to 99.6% for the EQ-5D-5L and from 69.4 to 94.8% for the Oxford scores. CONCLUSIONS: Responsiveness of the EQ-5D-5L was acceptable in TKR and THR. Caution should be taken in interpreting responder to TJR based on only one method of assessment.

Single-entry models (SEMs) for scheduled services: Towards a roadmap for the implementation of recommended practices.

BACKGROUND: Long waiting times for elective services continue to be a challenging issue. Single-entry models (SEMs) are used to increase access to and flow through the healthcare system. This paper provides a roadmap for healthcare decision-makers, managers, physicians, and researchers to guide implementation and management of successful and sustainable SEMs. METHODS: The roadmap was informed by an inductive qualitative synthesis of the findings from a deliberative process (a symposium on SEMs, with clinicians, researchers, senior policy-makers, healthcare managers, and patient representatives) and focus groups with the symposium participants. RESULTS: SEMs are a promising strategy to improve the management of referrals and represent one approach to reduce waiting times. The SEMs roadmap outlines current knowledge about SEMs and critical success factors for SEMs' implementation and management. CONCLUSIONS: This SEM roadmap is intended to help clinicians, decision-makers, managers, and researchers interested in developing new or strengthening existing SEMs. We consider this roadmap to be a living document that will continue to evolve as we learn more about implementing and managing sustainable SEMs.

What is the influence of single-entry models on access to elective surgical procedures? A systematic review.

BACKGROUND: Single-entry models (SEMs) for the management of patients awaiting elective surgical services are designed to increase access and flow through the system of care. We assessed scope of use and influence of SEMs on access (waiting times/throughput) and patient-centredness (patient/provider acceptability). METHODS: Systematic review of articles published in 6 relevant electronic databases included studies from database inception to July 2016. Included studies needed to (1) report on the nature of the SEM; (2) specify elective service and (3) address at least 1 of 3 research questions related to (1) scope of use of SEMs; (2) influence on timeliness and access; (3) patient-centredness and acceptability. Article quality was assessed using a modified Downs and Black checklist. RESULTS: 11 studies from Canada, Australia and the UK were included with mostly weak observational design-2 simulations, 5 before-after, 2 descriptive and 2 cross-sectional studies. 9 studies showed a decrease in patient waiting times; 6 showed that more patients were meeting benchmark waiting times; and 5 demonstrated that waiting lists decreased using an SEM as compared with controls. Patient acceptability was examined in 6 studies, with high levels of satisfaction reported. Acceptability among general practitioners/surgeons was mixed, as reported in 1 study. Research varied widely in design, scope, reported outcomes and overall quality. CONCLUSIONS: This is the first review to assess the influence of SEMs on access to elective surgery for adults. This review demonstrates a potential ability for SEMs to improve timeliness and patient-centredness of elective services; however, the small number of low-quality studies available does not support firm conclusions about the effectiveness of SEMs to improve access. Further evaluation with higher quality designs and rigour is required.

Perspectives of Canadian Stakeholders on Criteria for Appropriateness for Total Joint Arthroplasty in Patients With Hip and Knee Osteoarthritis.

OBJECTIVE: As rates of total joint arthroplasty (TJA) for osteoarthritis (OA) rise, there is a need to ensure appropriate use. We undertook this study to develop criteria for appropriate use of TJA. METHODS: In prior work, we used qualitative methods to separately assess OA patients' and arthroplasty surgeons' perceptions regarding appropriateness of patient candidates for TJA. The current study reviewed the appropriateness themes that emerged from each group, and a series of statements were developed to reflect each unique theme or criterion. A group of arthroplasty surgeons then indicated their level of agreement with each statement using electronic voting. Where ≤70% agreed or disagreed, the criterion was discussed and revised, and revoting occurred. In standardized telephone interviews, OA patient focus group participants indicated their level of agreement with each revised criterion. RESULTS: Qualitative research in 58 OA patients and 14 arthroplasty surgeons identified 11 appropriateness criteria. Member-checking in 15 surgeons (including 5 who had participated in the qualitative study) resulted in agreement on 6 revised criteria. These included evidence of arthritis on joint examination, patient-reported symptoms negatively impacting quality of life, an adequate trial of appropriate nonsurgical treatment, realistic patient expectations of surgery, mental and physical readiness of patient for surgery, and patient-surgeon agreement that potential benefits exceed risks. Thirty-six of the original 58 OA patient focus group participants (62.1%) participated in the member-check interviews and endorsed all 6 criteria. CONCLUSION: Patients and surgeons jointly endorsed 6 criteria for assessment of TJA appropriateness in OA patients. Prospective validation of these criteria (assessed preoperatively) as predictive of postoperative patient-reported outcomes is under way and will inform development of a surgeon-patient decision-support tool for assessment of TJA appropriateness.

Reliability and validity of the EQ-5D-5L compared to the EQ-5D-3L in patients with osteoarthritis referred for hip and knee replacement.

PURPOSE: To assess the test-retest reliability of the EQ-5D-5L (5L) and compare the validity of the 5L and EQ-5D-3L (3L) in osteoarthritis patients referred to an orthopaedic surgeon for total joint replacement. METHODS: We mailed questionnaires to 306 consecutive patients following referral and a second questionnaire after 2 weeks to assess reliability. Questionnaires included the 5L, EQ-VAS, Short Form-12, Oxford hip and knee scores, pain VAS, and the 3L. We compared the ceiling effect, redistribution properties, convergent and discriminant validity, and discriminatory power of the 5L and 3L. RESULTS: We obtained 176 respondents (response rate 58 %), 60 % female, 64 % knee patients, mean age 65 years (SD 11), with no significant differences between responders versus non-responders. Intraclass correlation coefficients were 0.61-0.77 for the 5L dimensions and 0.87 for the 5L index. For the 3L, most patients used level 2 (some/moderate problems) for mobility (87 %), usual activities (78 %), and pain/discomfort (71 %). In comparison, 5L responses were spread out with only 52, 42, and 50 %, respectively, using the middle level. All convergent validity coefficients were stronger with the 5L (Spearman coefficients 0.51-0.75). Absolute informativity (Shannon's index) showed higher results for all dimensions of the 5L compared with the 3L (average difference 0.74). Relative informativity (Shannon's evenness index) showed an increase from the 3L to the 5L in mobility, usual activities, and pain/discomfort. CONCLUSIONS: The 5L provided stronger validity evidence than the 3L, especially for dimensions relevant to this patient population-mobility, usual activities, and pain/discomfort.

You'll know when you're ready: a qualitative study exploring how patients decide when the time is right for joint replacement surgery.

BACKGROUND: While some studies have identified patient readiness as a key component in their decision whether to have total joint replacement surgery (TJR), none have examined how patients determine their readiness for surgery. The study purpose was to explore the concept of patient readiness and describe the factors patients consider when assessing their readiness for TJR. METHODS: Nine focus groups (4 pre-surgery, 5 post-surgery) were held in four Canadian cities. Participants had been either referred to or seen by an orthopaedic surgeon for TJR or had undergone TJR. The method of analysis was qualitative thematic analysis. RESULTS: There were 65 participants, 66% female and 34% male, 80% urban, with an average age of 65 years (SD 10). Readiness reflected both the surgeon's advice that the patient was clinically ready for surgery and the patient's feeling that they were both mentally and physically ready for surgery. Mental readiness was described as an internal state or feeling of being ready or prepared while physical readiness was described as being physically fit and in good shape for surgery. Factors associated with readiness included: 1) pain: its severity, the ability to cope with it, and how it affected their quality of life; 2) mental preparation; 3) physical preparation; 4) the optimal timing of surgery, including age, anticipated rate of deterioration, prosthesis lifespan and the length of the waiting list. CONCLUSIONS: Patient readiness should be assessed prior to TJR. By assessing patient readiness, health professionals can elucidate and deal with concerns and fears, understand and calibrate expectations, assess coping strategies, and use this information to help determine optimal timing, both before and after the surgical consultation.

Patient factors in referral choice for total joint replacement surgery.

BACKGROUND: Although the option of next available surgeon can be found on surgeon referral forms for total joint replacement surgery, its selection varies across surgical practices. OBJECTIVES: Objectives are to assess the determinants of (a) a patient's request for a particular surgeon; and (b) the actual referral to a specific versus the next available surgeon. METHODS: Questionnaires were mailed to 306 consecutive patients referred to orthopedic surgeons. We assessed quality of life (Oxford Hip and Knee scores, Short Form-12, EuroQol 5D, Pain Visual Analogue Scale), referral experience, and the importance of surgeon choice, surgeon reputation, and wait time. We used logistic regression to build models for the 2 objectives. RESULTS: We obtained 176 respondents (response rate, 58%), 60% female, 65% knee patients, mean age of 65 years, with no significant differences between responders versus nonresponders. Forty-three percent requested a particular surgeon. Seventy-one percent were referred to a specific surgeon. Patients who rated surgeon choice as very/extremely important [adjusted odds ratio (OR), 6.54; 95% confidence interval (CI), 2.57-16.64] and with household incomes of $90,000+ versus <$30,000 (OR, 5.74; 95% CI, 1.56-21.03) were more likely to request a particular surgeon. Hip patients (OR, 3.03; 95% CI, 1.18-7.78), better Physical Component Summary-12 (OR, 1.29; 95% CI, 1.02-1.63), and patients who rated surgeon choice as very/extremely important (OR, 3.88; 95% CI, 1.56-9.70) were more likely to be referred to a specific surgeon. CONCLUSIONS: Most patients want some choice in the referral decision. Providing sufficient information is important, so that patients are aware of their choices and can make an informed choice. Some patients prefer a particular surgeon despite longer wait times.

A biologic pharmacosurveillance program for rheumatoid arthritis: a single-center experience.

We have reviewed the experience in a single center of a biologic register for rheumatoid arthritis patients. Over the past decade, the entry demographics show that we are treating patients at an earlier stage and with slightly less severe disease. Our outcomes measured by the percentage in DAS28 remission are comparable with national databases. We were surprised by the small number who were switched from their first biologic to a second (27 %), but this might reflect the lack of a firm "treat to target" approach. Our use of concomitant methotrexate/leflunomide is less than we would have liked and thought, but our use of concomitant corticosteroids is much less than normally seen. A single-center registry can provide useful monitoring and quality assurance data and stimulate change.

Suppression of inflammation and effects on new bone formation in ankylosing spondylitis: evidence for a window of opportunity in disease modification.

OBJECTIVES: Although MRI data supports a link between spinal inflammation and formation of new bone in ankylosing spondylitis, anti-tumour necrosis factor α therapies have not been shown to prevent new bone formation. The authors aimed to demonstrate that while acute lesions resolve completely, more advanced lesions, characterised by evidence of reparation, are associated with new bone formation. METHODS: MRI scans were performed at baseline, 12 and 52 weeks in 76 ankylosing spondylitis patients recruited to a placebo-controlled trial of adalimumab therapy. New syndesmophytes were assessed on lateral radiographs of the cervical and lumbar spine at baseline and 104 weeks. Anonymised MRI scans were read independently by two readers who recorded the presence/absence of acute (type A) and advanced (type B) vertebral corner inflammatory lesions (CIL) and fat lesions. The authors used generalised linear latent and mixed models analysis to adjust for the extent of syndesmophytes/ankylosis at baseline. RESULTS: New syndesmophytes developed significantly more frequently from type B CIL (16.7%) compared with type A CIL (2.9%) (p=0.002) or no CIL (2.5%) (p<0.0001). This was also observed for both baseline and new vertebral corner fat lesions evolving over 52 weeks (11.1% (p<0.001) and 6.8% (p=0.03), respectively). The association with type B CIL (OR (95% CI 3.88, 1.20 to -12.57) and fat (OR 95% CI 4.83, 2.38- to 9.80), p<0.0001) was significant after adjustment for the extent of syndesmophytes/ankylosis at baseline. CONCLUSIONS: Our data supports the hypothesis that new bone formation is more likely in advanced inflammatory lesions and proceeds through a process of fat metaplasia, supporting a window of opportunity for disease modification.

Preliminary validation of a self-reported screening questionnaire for inflammatory back pain.

OBJECTIVE: Inflammatory back pain (IBP) is an important feature of axial spondyloarthritis (SpA) that is poorly recognized in primary care, perhaps delaying diagnosis of SpA. We aimed to develop and validate a self-report questionnaire using important domains reported by patients with IBP. METHODS: We developed a 6-item questionnaire assessing spinal/hip stiffness, nocturnal pain, diurnal variation, effects of exercise/rest, and peripheral joint pain/swelling. This was compared with the Calin questionnaire and the domains comprising the Assessment of Spondyloarthritis International Society (ASAS) criteria for IBP in 220 patients with established axial SpA and 66 patients with mechanical back pain followed in tertiary care rheumatology clinics. The classification utility of each item was evaluated using sensitivity, specificity, and likelihood ratio (LR). Multivariable logistic regression was used to analyze different combinations of items to develop candidate scoring systems. RESULTS: The single item "diurnal variation" had the highest combination of sensitivity (49%) and specificity (92%) for IBP (positive LR 5.95, 95% CI 2.54-13.94), outperforming the Calin and ASAS IBP criteria, which had sensitivities of 83% and 59%, specificities 42% and 66%, positive LR 1.42 and 1.72, negative LR 0.41 and 0.62, respectively. Classification utility of this item was even higher in SpA patients with disease duration < 6 years (sensitivity 48%, specificity 96%, positive LR 12, negative LR 0.54). The other 5 items did not improve classification utility in any combination. CONCLUSION: Assessment of a single self-reported item, "diurnal variation," had substantial classification utility for IBP. This domain is not addressed in existing criteria for IBP, indicating a potentially important omission.

The importance of patient expectations as a determinant of satisfaction with waiting times for hip and knee replacement surgery.

OBJECTIVES: The disconfirmation model hypothesizes that satisfaction is a function of a perceived discrepancy from an initial expectation. Our objectives were: (1) to test the disconfirmation model as it applies to patient satisfaction with waiting time (WT) and (2) to build an explanatory model of the determinants of satisfaction with WT for hip and knee replacement. METHODS: We mailed 1000 questionnaires to 2 random samples: patients waiting or those who had received a joint replacement within the preceding 3-12 months. We used ordinal logistic regression analysis to build an explanatory model of the determinants of satisfaction. RESULTS: Of the 1330 returned surveys, 1240 contained patient satisfaction data. The sample was 57% female; mean age was 70 years (SD 11). Consistent with the disconfirmation model, when their WTs were longer than expected, both waiting (OR 5.77, 95% CI 3.57-9.32) and post-surgery patients (OR 6.57, 95% CI 4.21-10.26) had greater odds of dissatisfaction, adjusting for the other variables in the model. Compared to those who waited 3 months or less, post-surgery patients who waited 6 to 12 months (OR 2.59, 95% CI 1.27-5.27) and over 12 months (OR 3.30, 95% CI 1.65-6.58) had greater odds of being dissatisfied with their waiting time. Patients who felt they were treated unfairly had greater odds of being dissatisfied (OR 4.74, 95% CI 2.60-8.62). CONCLUSIONS: In patients on waiting lists and post-surgery for hip and knee replacement, satisfaction with waiting times is related to fulfillment of expectations about waiting, as well as a perception of fairness. Measures to modify expectations and increase perceived fairness, such as informing patients of a realistic WT and communication during the waiting period, may increase satisfaction with WTs.

Focal fat lesions at vertebral corners on magnetic resonance imaging predict the development of new syndesmophytes in ankylosing spondylitis.

OBJECTIVE: Focal fat infiltration is frequently visible on magnetic resonance imaging (MRI) of the spine in patients with ankylosing spondylitis (AS) and likely reflects postinflammatory tissue metaplasia. To support the concept of coupling between inflammation and new bone formation, we tested the hypothesis that focal fat infiltration at a vertebral corner is more likely to evolve into a de novo syndesmophyte. METHODS: MRI scans were obtained at baseline and radiographs were obtained at baseline and 2 years in 100 AS patients from 2 cohorts: a clinical trial cohort (n = 38) and an observational cohort (n = 62). In the clinical trial cohort, patients were randomized to receive anti-tumor necrosis factor (anti-TNF) therapy or placebo for 12-24 weeks and then open-label treatment for 2 years. In the observational cohort, patients received either standard therapy (n = 36) or anti-TNF therapy (n = 26) for 2 years. Vertebral corner inflammation and fat infiltration were assessed independently by pairs of readers who were blinded with regard to the radiographic findings. RESULTS: New syndesmophytes developed significantly more frequently in vertebral corners with fat in both the clinical trial (10.2%) and the observational (6.5%) cohort as compared to those without either feature on baseline MRI (3.1% [P = 0.008] and 1.4% [P = 0.0002], respectively). Adjusting for within-patient variations in baseline syndesmophytes/ankylosis, vertebral corners that were fat-positive/inflammation-positive significantly predicted new syndesmophytes, with an odds ratio (OR) of 7.6 (95% confidence interval [95% CI] 1.5-38.5 [P = 0.01]), while a model that included baseline variations in both fat and inflammation showed an OR of 5.8 (95% CI 2.2-15.3 [P < 0.001]) for inflammation and an OR of 1.9 (95% CI 0.9-4.1 [P = 0.1]) for fat. CONCLUSION: Our data lend support to the hypothesis that inflammatory lesions evolve into new bone through a process of tissue metaplasia that includes fat infiltration.

Relative urgency for referral from primary care to rheumatologists: the Priority Referral Score.

OBJECTIVE: Timely access to rheumatology consultation is fundamental to appropriate and effective management of patients with musculoskeletal and autoimmune diseases. Yet, for a variety of reasons, limited and delayed access is commonplace. Moreover, information exchange for referral is often inadequate or poorly communicated. The objective of this work was to improve referral from primary care to rheumatology by formulating and testing a clinically coherent, reliable, and non-diagnosis-dependent Priority Referral Score (PRS). METHODS: Using a deliberative process, a clinical panel of 10 primary care providers (PCPs) and rheumatology specialists reviewed clinical case scenarios and engaged in a highly iterative process to develop criteria, definitions, and weights for the PRS, a linear 100-point scale to rate the relative urgency of referral. Following tool formulation, clinicians uninvolved with the process tested the PRS against their clinical judgment. RESULTS: The PRS comprises 8 criteria, with 2-4 levels for each criterion, and each having a weight generated through conjoint analysis, which forced choices around the comparative urgency of all of the criteria and levels. The PRS showed a strong correlation between clinical rankings of rheumatologists and PCPs in both the deliberative panel, and the physicians subsequently involved in the testing of the PRS. CONCLUSION: No standardized priority-setting criteria are available for the full range of primary care referrals to rheumatologists. The PRS had face value with panelists and provided acceptable interrater and intrarater reliability when tested with other rheumatologists and PCPs. Pilot testing with other clinicians and in other settings is justified and prerequisite to use in clinical practice.

Systematic assessment of inflammation by magnetic resonance imaging in the posterior elements of the spine in ankylosing spondylitis.

OBJECTIVE: Magnetic resonance imaging (MRI) is sensitive for scoring inflammatory lesions in the spine, but attention has primarily focused on vertebral bodies, and no study has systematically examined the posterior elements. We aimed to systematically determine the frequency and distribution of inflammatory changes in the posterior elements of the spine using MRI, and to assess the reliability of their detection and their impact on discrimination of spinal MRI. METHODS: We scanned 32 patients recruited to placebo-controlled trials of anti-tumor necrosis factor therapy. Inflammatory lesions were detected by systematic review of consecutive sagittal STIR slices of the entire spine. Two readers evaluated pretreatment and posttreatment scans, blinded to treatment and time point. Inflammation was scored dichotomously (present/absent) in each posterior structure. Reproducibility was assessed by calculating random model variance components and generalizability coefficients, and discrimination by using Guyatt's effect size. RESULTS: Most patients (87.5%) had > or =1 lesion in the posterior elements (mean +/- SD number of affected spinal levels per patient 6.7 +/- 5.3), and they were detected most frequently in the thoracic spine. Interobserver reproducibility for total lesion count was very good to excellent for lesions in the thoracic spine and transverse and spinous processes. The addition of a simple dichotomous method for scoring posterior element inflammation substantially enhanced the discrimination observed using established MRI methods for scoring vertebral body inflammation. CONCLUSION: Inflammatory lesions in the posterior elements were present in the majority of patients with AS, and standard MRI protocols of the spine should be modified to ensure adequate visualization of posterolateral structures.

'There are too many of us to fix.' Patients' views of acceptable waiting times for hip and knee replacement.

OBJECTIVES: To assess patients' views of maximum acceptable waiting times (MAWT) for hip and knee replacement, associated factors and the accuracy of self-reported waiting times. METHODS: We mailed 1000 questionnaires each to two random samples of patients either waiting for or who had received an arthroplasty within the preceding 3-12 months. We used linear regression to assess the determinants of patient MAWT, and content analysis to assess reasons for MAWT and ideal waiting time. RESULTS: Of the 1330 responses, 1127 had MAWT data. The sample was 57% women; mean age was 70 +/- 11 years. Median self-reported and actual waiting time was eight months (Spearman correlation = 0.70). Median MAWT was four months and ideal waiting time was two months. The most frequent reasons for MAWT were pain, quality of life and needing time to prepare for surgery. A longer MAWT was associated with younger age, group (waiting), a longer self-reported waiting time, better EQ-5D index, an acceptable waiting time, a perception of fairness and a view that others worse off on the list should go ahead. CONCLUSIONS: Patients' views of acceptable waiting times are important for a fair process of establishing waiting time benchmarks for joint replacement.