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Health status of individuals referred to first-line intervention for hip and knee osteoarthritis compared with the general population: an observational register-based study
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Department of Physiotherapy, Rehabilitation Centre, Ryhov County Hospital, Jönköping, Sweden.ORCID iD: 0000-0003-3403-229x
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine. Linköping University, Faculty of Medicine and Health Sciences.ORCID iD: 0000-0003-3527-5488
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Futurum - Academy for Health and Care, Region of Jönköping County, Jönköping, Sweden.ORCID iD: 0000-0002-1766-5899
Department of Clinical Sciences Lund, Orthopaedics, Faculty of Medicine, Lund University, Lund, Sweden.ORCID iD: 0000-0002-0319-458X
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2021 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 11, no 9, article id e049476Article in journal (Refereed) Published
Abstract [en]

Objectives

To describe the prevalence of comorbidities in a population referred to standardised first-line intervention (patient education and exercise) for hip and knee osteoarthritis (OA), in comparison with the general population. Furthermore, we aimed to evaluate if eventual differences were associated with socioeconomic inequalities.

Design

Register-based study.

Setting

Primary healthcare, Sweden.

Participants

Individuals with hip and/or knee OA included in the Better Management for Patients with Osteoarthritis Register between 2008 and 2016 and and an age-matched, sex-matched and residence-matched reference cohort (1:3) from the general Swedish population.

Outcome measures

Comorbidities were identified with the RxRisk Index, the Elixhauser Comorbidity Index and the Charlson Comorbidity Index, and presented with descriptive statistics as (1) individual diseases, (2) disease categories and (3) scores for each index. The prevalence of comorbidities in the two populations was tested using logistic regression, with separate analyses for age groups and the most affected joint. We then adjusted the analyses for socioeconomic status.

Results

In this OA population, 85% had >= 1 comorbidity compared with 78% of the reference cohort (OR; 1.62 (95% CI 1.59 to 1.66)). Cardiovascular/blood diseases were the most common comorbidities in both populations (OA, 59%; reference, 54%), with OR; 1.22 (95% CI 1.20 to 1.24) for the OA population. Younger individuals with OA were more comorbid than their matched references overall, and population differences decreased with age (eg, >= 3 comorbidities, aged <= 45 years OR; 1.74 (95% CI 1.52 to 1.98), >= 81 years OR; 0.95 (95% CI 0.87 to 1.04)). Individuals with knee OA were more comorbid than those with hip OA overall. Adjustment for socioeconomic status did not change the estimates.

Conclusion

Comorbidities were more common among individuals with hip and knee OA than among matched references from the general population. The differences could not be explained by socioeconomic status.

Place, publisher, year, edition, pages
London, United Kingdom: BMJ Publishing Group Ltd, 2021. Vol. 11, no 9, article id e049476
Keywords [en]
General Medicine
National Category
Physiotherapy
Identifiers
URN: urn:nbn:se:liu:diva-179771DOI: 10.1136/bmjopen-2021-049476ISI: 000698586600033PubMedID: 34518262Scopus ID: 2-s2.0-85115277176OAI: oai:DiVA.org:liu-179771DiVA, id: diva2:1599558
Note

Funding: AFA Insurance, Sweden; Futurum -Academy for Health and Care, Region Jönkoping County, Sweden; Medical Research Council of Southeast Sweden

Available from: 2021-10-01 Created: 2021-10-01 Last updated: 2023-08-28Bibliographically approved
In thesis
1. Hip and Knee Osteoarthritis: Who Are the Patients Referred to First-Line Intervention and What Happens to Them?
Open this publication in new window or tab >>Hip and Knee Osteoarthritis: Who Are the Patients Referred to First-Line Intervention and What Happens to Them?
2023 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: First-line intervention to address osteoarthritis (OA) should include patient education, exercise therapy, and weight control if needed. Replacement surgery may be appropriate for patients who do not receive sufficient relief from non-surgical interventions. However, predicting the course of OA can be challenging. Some patients experience stable symptoms over time, while others may have a rapid increase in pain and functional impairment. This thesis aims to improve understanding of which patients are referred to first-line intervention for hip and knee OA and to identify factors that affect long-term outcomes in these patients.

Methods: The thesis includes studies of patients with hip and knee OA referred to a standardized first-line intervention programme. Study A (papers I, II, IV, V) is a register-based observational study that uses the Swedish Osteoarthritis Register (SOAR) to identify an OA population (n = 72 069). Data from the SOAR was merged with data from the Swedish Arthroplasty Register, Statistics Sweden and the National Board of Health and Welfare. The study also includes a matched reference cohort (n = 216 207) from the general Swedish population for comparison. Papers I and II compare socioeconomic status (SES) and comorbidities of the OA population in the SOAR with the reference cohort. Study B (paper III) is a qualitative study involving 16 patients with hip and knee OA who expressed a desire for surgery at referral to first-line intervention. The study includes interviews regarding the patients’ perspectives on healthcare and self-management of OA. Paper IV examines the time to replacement surgery and prognostic factors for surgery in the OA population. Paper V identifies factors associated with poorer patient-reported outcomes 1 year after hip replacement surgery.

Results: The OA population had higher SES and higher odds of having comorbidities than the reference cohort. The differences in comorbidities were greater in younger individuals and those with knee OA. Patients who expressed a desire for surgery before participating in first-line intervention described their perspectives on healthcare and self-management as a multifaceted picture of needs, expectations, and individual choices. Findings range from a passive approach towards managing the OA, described as a lack of control, a sense of being left alone by healthcare, having doubts and mistrusting the care provided, to a more active attitude manifested as a will to take control over the OA, instead of the OA taking control over the patient’s life. Of the patients registered in the SOAR, 46% with hip OA and 20% with knee OA were estimated to progress to replacement surgery within 5 years. The strongest prognostic factors were expressing a desire for surgery and having more severe OA symptoms. In addition, higher SES and the presence of comorbidities had an impact on the risk of progression to surgery. Among those who had undergone a hip replacement, 5%–11% showed poor patient-reported outcomes regarding pain, health-related quality of life, and satisfaction 1 year after surgery. Factors associated with poor outcomes were being older, classified as Charnley C (musculoskeletal comorbidities), or having several comorbidities, particularly depression.

Conclusions: Higher SES in the OA population referred to first-line intervention than in the general population indicates that OA care in Sweden may not be equal. The higher prevalence of comorbidities in the OA population suggests that OA care should include improving overall health. Furthermore, first-line OA intervention should be tailored to each patient’s perspectives to achieve the lifestyle changes that the interventions strive to accomplish, especially in patients expressing a desire for surgery at referral. Patients with hip and knee OA differ in their progression to surgery. Those with hip OA tend to progress faster and undergo replacement surgery more often than those with knee OA. Expressing a desire for surgery and having severe OA symptoms are prognostic factors, but other non-OA-related factors play a significant role. However, a large proportion of patients with OA do not require surgery within 5 years after referral to first-line intervention, especially those with knee OA. Identifying depression at the stage of referral to first-line OA intervention would allow increased time to optimize treatments and may help improve patient-reported outcomes after surgery.

Abstract [sv]

Bakgrund: Grundbehandling vid artros innefattar patientutbildning, träning och vid behov viktkontroll. Hos patienter som inte får tillräcklig effekt av icke-kirurgiska behandlingar kan protesoperation vara aktuellt. Sjukdomens förlopp är dock svårt att förutse. Många har stabila symtom över tid medan andra snabbt får tilltagande smärta och försämrad funktion.

Övergripande syfte: Att öka förståelsen kring vilka patienter som hänvisas till grundbehandling för höft- och knäartros i primärvården, och att identifiera faktorer som kan påverka långtidsutfall hos dessa individer.

Metod: Denna avhandling består av två studier uppdelade i fem delarbeten, där alla fokuserar på patienter i det stadie då de har sökt vård för artrossymtom och sen blivit hänvisade till att delta i standardiserad grundbehandling. Studie A (delarbete I, II, IV, V) är en registerbaserad observationsstudie som inkluderar patienter med höft- och knäartros som registrerats i Svenska Artrosregistret mellan maj 2008 och december 2016 (n = 72 069). Data på dessa patienter har sambearbetats med data från Svenska Ledprotesregistret, Statistiska Centralbyrån och Socialstyrelsen. Studien inkluderar även en referenskohort från den svenska normalbefolkningen för jämförelse, matchad på ålder, kön och bostadslän (n = 216 207). I delarbete I och II studeras socioekonomi och samsjuklighet i artrospopulationen i Svenska Artrosregistret, i jämförelse med referenskohorten. Studie B med delarbete III är en kvalitativ studie där patienter som uttrycker ett önskemål om att bli opererade före deltagande i grundbehandling intervjuas om deras perspektiv på sjukvård och egenvård vid artros (n = 16). Delarbete IV studerar tid till protesoperation hos artrospopulationen och prognostiska faktorer för progression till protesoperation. Delarbete V identifierar faktorer som är assocerade med sämre patientrapporterat utfall 1 år efter höftprotesoperation.

Resultat: Artrospopulationen hade högre socioekonomi och mer samsjuklighet jämfört med referenskohorten. Störst var skillnaderna i samsjuklighet hos patienter med knäartros och hos yngre individer. Patienter som uttryckte ett önskemål om att bli opererade före deltagande i grundbehandling, beskrev en mångfaciliterad bild av sjukvård och egenvård vid artros, utifrån sina egna behov, förväntningar och individualla val. Fynden sträckte sig från ett passivt förhållningssätt i att hantera artros, beskrivet som en brist på kontroll, en känsla av att vara lämnad ensam av sjukvården, att ha tvivel och misstro mot den vård som erbjuds, till en mer aktiv inställning manifesterat som en vilja att ta kontroll över sjukdomen istället för att den ska ta kontroll över patientens liv. Av de patienter som var registrerade i Svenska Artrosregistret, uppskattades 46% av de med höftartros och 20% av de med knäartros progrediera till en protesoperation inom 5 år. De starkast prognostiska faktorerna var önskemål om operation och att ha svårare artrossymtom. Flera faktorer som inte var direkt relaterade till artrossymtomen var också prognostiska för framtida protesoperation, men skiljde sig mellan höft- och knäartros, såsom högre socioekonomi, samsjuklighet, artros i flera leder, bilateral artros och övervikt/fetma. Bland de som genomgått en höftprotesoperation uppvisade 5-11% sämre patientrapporterat utfall efter operation i form av bristande förbättring i smärta, hälsorelaterad livskvalité eller att inte vara nöjda 1 år efter operationen. Faktorer associerade med sämre utfall var att vara äldre eller vara klassificerad som Charnley Class C (muskuloskeletal samsjuklighet), eller att ha mera samsjuklighet, särskilt depression.

Konklusion: Högre socioekonomi hos artrospopulationen än normalbefolkningen indikerar att grundbehandling vid artros kanske inte når socioekonomiskt mer missgynnade grupper i vårt samhälle. Detta är problematiskt eftersom de ofta också har en högre sjukdomsbörda. Den högre prevalensen av samsjuklighet i artrospopulationen visar på vikten av att artrosvård innefattar insatser för att även förbättra den allmänna hälsan. Vidare bör grundbehandling vid artros individualiseras efter varje patients perspektiv för att uppnå de livsstilsförändringar som behandlingarna strävar efter att åstadkomma, särskilt hos patienter som uttrycker ett önskemål om operation när de hänvisas till grundbehandling. Fynden visade också att patienter med höftartros progredierar till operation fortare och i högre utsträckning än de med knäartros. Önskemål om operation och att ha svårare artrossymtom före deltagandet i grundbehandling var de starkaste prognostiska faktorerna för progression, men flera andra, icke-artrosrelaterade faktorer är också viktiga såsom högre socioekonomi och samsjuklighet. Många patienter med artros tycks dock inte vara aktuella för protesoperation inom 5 år efter hänvisning till grundbehandling, detta gäller särskilt för de med knäartros. Slutligen, visade sig depression vara en viktig faktor att identifiera före grundbehandling, då det skulle ge ökad tid för att optimera behandling och därigenom kunna bidra till att förbättra patientrapporterat utfall efter protesoperation.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2023. p. 101
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1861
National Category
Physiotherapy Orthopaedics
Identifiers
urn:nbn:se:liu:diva-197030 (URN)10.3384/9789180752176 (DOI)9789180752169 (ISBN)9789180752176 (ISBN)
Public defence
2023-09-22, Originalet, Qulturum, Building B4, Länssjukhuset Ryhov, Jönköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2023-08-18 Created: 2023-08-18 Last updated: 2023-08-18Bibliographically approved

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