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Progression to arthroplasty surgery among patients with hip and knee osteoarthritis: a study from the Swedish BOA Register
Linköping University, Faculty of Medicine and Health Sciences. Linköping University, Department of Health, Medicine and Caring Sciences, Division of Prevention, Rehabilitation and Community Medicine. 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
Centre of Registries, Västra Götaland, Gothenburg, Sweden.
Futurum - Academy for Health and Care Jönköping Sweden.
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2022 (English)In: The Bone & Joint Journal, ISSN 2049-4394, E-ISSN 2049-4408, Vol. 104-B, no 7, p. 792-800Article in journal (Refereed) Published
Abstract [en]

AIMS: The aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.

METHODS: In this longitudinal register-based observational study, we identified 72,069 patients with hip and knee OA in the Better Management of Patients with Osteoarthritis Register (BOA), who were referred for first-line OA intervention, between May 2008 and December 2016. Patients were followed until the first primary arthroplasty surgery before 31 December 2016, stratified into a hip and a knee OA cohort. Data were analyzed with Kaplan-Meier and multivariable-adjusted Cox regression.

RESULTS: At five years, Kaplan-Meier estimates showed that 46% (95% confidence interval (CI) 44.6 to 46.9) of those with hip OA, and 20% (95% CI 19.7 to 21.0) of those with knee OA, had progressed to arthroplasty. The strongest prognostic factors were desire for surgery (hazard ratio (HR) hip 3.12 (95% CI 2.95 to 3.31), HR knee 2.72 (95% CI 2.55 to 2.90)), walking difficulties (HR hip 2.20 (95% CI 1.97 to 2.46), HR knee 1.95 (95% CI 1.73 to 2.20)), and frequent pain (HR hip 1.56 (95% CI 1.40 to 1.73), HR knee 1.77 (95% CI 1.58 to 2.00)). In hip OA, the probability of progression to surgery was lower among those with comorbidities (e.g. ≥ four conditions; HR 0.64 (95% CI 0.59 to 0.69)), with no detectable effects in the knee OA cohort. Instead, being overweight or obese increased the probability of OA progress in the knee cohort (HR 1.25 (95% CI 1.15 to 1.37)), but not among those with hip OA.

CONCLUSION: Patients with hip OA progressed faster and to a greater extent to arthroplasty than patients with knee OA. Progression was strongly influenced by patients' desire for surgery and by factors related to severity of OA symptoms, but factors not directly related to OA symptoms are also of importance. However, a large proportion of patients with OA do not seem to require surgery within five years, especially among those with knee OA. Cite this article: Bone Joint J 2022;104-B(7):792-800.

Place, publisher, year, edition, pages
London: British Editorial Society of Bone and Joint Surgery , 2022. Vol. 104-B, no 7, p. 792-800
Keywords [en]
Arthroplasty surgery, First-line intervention, Hip, Knee, Osteoarthritis, Osteoarthritis (OA), arthroplasty surgery, comorbidities, hip and knee osteoarthritis, knees, obesity, overweight, primary arthroplasty
National Category
Medical and Health Sciences Clinical Medicine Orthopaedics
Identifiers
URN: urn:nbn:se:liu:diva-192714DOI: 10.1302/0301-620X.104B7.BJJ-2021-1766.R1ISI: 000994156900003PubMedID: 35775173Scopus ID: 2-s2.0-85133266103OAI: oai:DiVA.org:liu-192714DiVA, id: diva2:1746122
Available from: 2023-03-27 Created: 2023-03-27 Last updated: 2023-08-18Bibliographically 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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