Anthony V. Perruccio

A longitudinal study to explain the pain-depression link in older adults with osteoarthritis.

To evaluate whether osteoarthritis (OA) pain determines depressed mood, taking into consideration fatigue and disability and controlling for other factors.

The relative impact of 13 chronic conditions across three different outcomes

Study objective: Previous estimates of individual and population attributable risks for adverse outcomes due to chronic conditions have considered only a limited number of conditions and outcomes, with some studies using inappropriate formulae or methods of estimation. This study re-examines the magnitude of individual and population attributable risks for a wide range of conditions and various health outcomes. Design: Log-Poisson regression was used to calculate prevalence ratios as an indicator of individual risk and population-associated fractions of 13 chronic conditions, examining activity limitations, self-rated health and physician visits. The effect of multimorbidity on prevalence ratios was examined. Setting: Canada, 2000–01. Participants: Nationally representative sample of Canadians aged 12+ years (n _ 130 880). Main results: At the individual level, fibromyalgia/chronic fatigue syndrome and cancer, and to a lesser extent stroke and heart disease, were associated with an increased risk of both activity limitations and a self-rated health status of fair or poor; high blood pressure was associated with four or more physician visits in the previous 12 months. In contrast, population attributable fractions were substantial for arthritis/rheumatism, heart disease, back problems and high blood pressure across all outcomes. Adjustment for multimorbidity resulted in a marked decreases in prevalence ratios. Conclusions: Differences in the ranking of individual risks and population attributable fractions for different diseases and outcomes are substantial. This needs to be taken into account when setting priorities, as interventions may need to be targeted to different conditions depending on which aspects of health are being considered, and whether the focus is on individuals, such as in clinical care, or improving the health of the population.

Association of regional racial/cultural context and socioeconomic status with arthritis in the population: A multilevel analysis

OBJECTIVE To examine the extent to which differences in individual- and regional-level socioeconomic status and racial/cultural origin account for geographic variations in the prevalence of self-reported arthritis, and to determine whether regional characteristics modify the effect of individual characteristics associated with reporting arthritis. METHODS Analyses were based on the 2000-2001 Canadian Community Health Survey (>15 years, n = 127,513). Arthritis was self-reported as a long-term condition diagnosed by a health professional. A 2-level logistic regression model was used to identify predictors of reporting arthritis. Individual-level variables included age, sex, income, education, immigration status, racial/cultural origin, smoking, physical activity, and body mass index. Regional-level variables included the proportion of low-income families, low education, unemployment, recent immigrants, Aboriginals, and Asians. RESULTS At the individual level, age, sex, low income, low education, Aboriginal origin, current smoking, and overweight/obesity were positively associated with reporting arthritis; recent immigration and Asian origin were negatively associated with reporting arthritis. At the regional level, percentages of low-income families and the Aboriginal population were independently associated with reporting arthritis. Regional income and racial/cultural origin moderated the effects of individual income and racial/cultural origin; low-income individuals residing in regions with a higher proportion of low-income families reported arthritis more than low-income individuals living in better-income regions. CONCLUSION Both individual and regional factors were found to contribute to variations in the prevalence of arthritis, although significant unexplained variation remained. Further research is required to better understand the mechanisms that underlie these regional effects and to identify other contributing factors to the remaining variation.

Characterizing self-rated health during a period of changing health status

Self-rated health (SRH) is among the most frequently assessed health perceptions. The purpose of this study was to assess the tenability of the recently proposed distinctions of SRH, as a spontaneous assessment of overall health, or as an enduring self-concept. Individuals (n = 449) undergoing total joint replacement for hip or knee osteoarthritis in Toronto, Canada were followed over 6 months of recovery. Health questionnaires, completed pre-surgery, and at 3 and 6 months post-surgery, included measures of pain, physical function, sports/recreation, fatigue, anxiety, depression, social participation, passive/active recreation, and community access. Structural equation modeling was used for the analyses. SRH was found to be responsive to current and changing mental well-being throughout the six months of recovery. Current SRH strongly predicted future SRH. In this clinical sample undergoing significant changes in health status, SRH displayed both enduring and spontaneous features; evidence is provided that both operate simultaneously. SRH may prove to be a simple yet critical health measure for identifying individuals who would benefit most from targeted interventions for improving overall health.

Measuring Expectations in Orthopaedic Surgery: A Systematic Review

BackgroundAdvances in the surgical treatment of musculoskeletal conditions have resulted in an interest in better defining and understanding patients’ expectations of these procedures, but the best ways to do this remain a topic of considerable debate.Questions/purposes(1) What validated instruments for the assessment of patient expectations of orthopaedic surgery have been used in published studies to date? (2) How were these expectation measures developed and validated? (3) What unvalidated instruments for the assessment of patient expectations have been used in published studies to date?MethodsA systematic literature search was performed using the OVID Medline and EMBASE databases, in duplicate, to identify all studies that assessed patient expectations in orthopaedic surgery. Sixty-six studies were ultimately included in the present review.ResultsSeven validated expectation instruments were identified, all of which use patient-reported questionnaires. Five were specific to a particular procedure or affected anatomic location, whereas two were broadly applicable. Details of reliability and validity testing were available for all but one of these instruments. Forty additional unvalidated expectation assessment tools were identified. Thirteen were based on existing clinical outcome tools, and the others were study-specific, custom-developed tools. Only one of the unvalidated tools was used in more than one study.ConclusionsSeveral validated expectation instruments have been developed for use by patients undergoing orthopaedic surgery. However, many tools have been reported without evidence of testing and validation. The wide range of untested instruments used in single studies substantially limits the interpretation and comparison of data concerning patient expectations.

A Canadian population-based study of vision problems: Assessing the significance of socioeconomic status

OBJECTIVE To examine the relationship between age, gender, socioeconomic status, and 3 chronic conditions (glaucoma, cataracts, and diabetes) and corrected and uncorrected vision problems, and to document the prevalence of visual problems in Canada across the adult age range. DESIGN Cross-sectional, representative, population-based study. PARTICIPANTS Health survey respondents (n = 113 212, aged ≤20 years). METHODS Data are from a 2000-2001 Canadian health survey. Self-reported data included sociodemographic/economic characteristics, vision problems, eye care professional consultations, and medical conditions. Prevalence estimates were calculated; multinomial logistic regression examined the relationship between indicated variables and vision problems, generally and by type. RESULTS Fifty-seven percent of adults reported some form of vision problem, the majority corrected by lenses. Blindness was reported by 0.09% of adults. Increasing age, being female, and having a low income and lower educational attainment were significantly associated with reported vision problems. However, age and gender were not significant determinants of the type of vision problem. Cataracts, diabetes, and glaucoma in particular, were significantly associated with reported vision problems. CONCLUSIONS Socioeconomic characteristics may underscore the socioeconomic burden of visual impairments in the population and highlight obstacles to eye service utilization among subgroups. This information is essential to establishing the need for treatment and management services, developing targeted screening programmes, and identifying priority areas of research.

Psychometric properties of the French translation of the reduced KOOS and HOOS (KOOS-PS and HOOS-PS)

OBJECTIVE To evaluate the psychometric properties of the French KOOS physical function (KOOS-PS) and HOOS physical function (HOOS-PS), specifically its feasibility, reliability, construct validity, and responsiveness. METHODS Consecutive outpatients consulting for primary knee or hip osteoarthritis (OA) in a rheumatology department were included. During the initial assessment, patients were asked to complete the Knee injury and Osteoarthritis Outcome Score (KOOS) or Hip disability and Osteoarthritis Outcome Score (HOOS) questionnaire and the OsteoArthritis Knee and Hip Quality Of Life questionnaire (OAKHQOL). The patients were given a second KOOS or HOOS questionnaire to complete and return by mail 2 weeks later. Feasibility was assessed by calculating the percentage of missing items and the floor and ceiling effects. Test-retest reliability was evaluated using the intra-class correlation coefficient (ICC). Convergent and divergent construct validity was determined by comparing the results of the KOOS-PS or HOOS-PS and OAKHQOL questionnaires using Spearmans rank test. Responsiveness was evaluated using data obtained in other hip or knee OA patients prior to and 1 month after intra-articular hyaluronic acid injection, using standardized response mean (SRM) and effect-size (ES). RESULTS Eighty-seven patients with knee OA and 50 hip OA patients were included. The KOOS-PS and HOOS-PS scores were obtained for all patients as there were no missing items. Neither a floor nor a ceiling effect was observed. The ICC of KOOS-PS and HOOS-PS was 0.861 (0.763-0.921) and 0.859 (0.725-0.929), respectively. A strong or moderate correlation was observed, as expected, between KOOS-PS, HOOS-PS, and the OAKHQOL physical activities, pain, and mental health domains. A weak correlation was observed, as expected, between KOOS-PS, HOOS-PS, and the other OAKHQOL domains, except for a moderate correlation between the KOOS-PS and social functioning. The responsiveness was demonstrated with SRM and ES of 0.80 and 0.51 (KOOS-PS), 1.10 and 0.62 (HOOS-PS), respectively. CONCLUSION The French versions of KOOS-PS and HOOS-PS are reliable, valid, and responsive questionnaires for capturing functional disability in people with knee and hip OA.

Benefits Gained, Benefits Lost: Comparing Baby Boomers to Other Generations in a Longitudinal Cohort Study of Self-Rated Health

UNLABELLED POLICY POINTS: Despite beliefs that baby boomers are healthier than previous generations, we found no evidence that the health of baby boomers is substantially different from that of the previous or succeeding cohorts. The effects of increased education, higher income, and lower smoking rates on improving self-rated health were nearly counterbalanced by the adverse effect of increasing body mass index (BMI). Assumptions that baby boomers will require less health care as they age because of better education, more prosperity, and less propensity to smoke may not be realized because of increases in obesity. CONTEXT Baby boomers are commonly believed to be healthier than the previous generation. Using self-rated health (SRH) as an indicator of health status, this study examines the effects of age, period, and birth cohort on the trajectory of health across 4 generations: World War II (born between 1935 and 1944), older baby boomers (born between 1945 and 1954), younger baby boomers (born between 1955 and 1964), and Generation X (born between 1965 and 1974). METHODS We analyzed Canadas longitudinal National Population Health Survey 1994-2010 (n = 8,570 at baseline), using multilevel growth models to estimate the age trajectory of SRH by cohort, accounting for period and incorporating the influence of changes in education, household income, smoking status, and body mass index (BMI) on SRH over time. FINDINGS SRH worsened with increasing age in all cohorts. Cohort differences in SRH were modest (p = 0.034), but there was a significant period effect (p = 0.002). We found marked cohort effects for increasing education, income, and BMI, and decreasing smoking from the youngest to the oldest cohorts, which were much reduced (education and smoking) or removed (income and BMI) once period was taken into account. At the population level, multivariable analysis showed the benefits of increasing education and income and declines in smoking on the trajectory of improving SRH were almost counterbalanced by the effects of increasing BMI (obesity). CONCLUSIONS We found no evidence to support the expectation that baby boomers will age more or less healthily than previous cohorts did. We also found that increasing BMI has likely undermined improvements in health that might have otherwise occurred, with possible implications for the need for health care. Period effects had a more profound effect than birth cohort effects. This suggests that interventions to improve health, such as reducing obesity, can be targeted to the entire, or a major portion of the, population and need not single out particular birth cohorts.

Do women have poorer outcomes following total knee replacement

OBJECTIVE To investigate whether women have poorer pain and functional outcomes following total knee replacement (TKR) and to investigate factors that may contribute to this poorer outcome. METHODS In a cohort of 494 people, outcomes were the Pain and Function/Daily Activity subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 6 and 12 months post-surgery. Sequential multivariable regression analyses evaluated the following independent variables: (1) sex; (2) sex and age; (3) sex, age and pre-surgery score for respective outcome measures; and, (4) model 3 and body mass index (BMI), education, low back pain (LBP), depression, comorbidities, and symptomatic joint count. RESULTS The sample included 323 women and 171 men. Women were significantly worse on several factors pre-surgery: pain: 39.0 vs 44.9, P = 0.002; function: 47.7 vs 55.0, P < 0.0001; depression 5.6 vs 4.7, P = 0.006; obesity (BMI ≥30): 54.2 vs 36.3%, P = 0.0002; and, symptomatic joint count: ≥4: 61.3 vs 44.4%, P = 0.002. Women had worse outcomes for pain (72.2 vs 76.1, P = 0.04) and function (75.2 vs 80.5, P = 0.007) at 6 months. This effect was attenuated by adding pre-surgery pain/function. However, the magnitude of the association of pre-surgery pain/function was reduced when LBP, depression, BMI, education level, joint count and comorbidity count were added suggesting association with pre-surgery pain and function. Twelve month results were similar. CONCLUSION Women appear to have worse outcomes than men possibly due to a putative pre-operative profile across many factors. Consideration of TKR when impairments in pain and function are less severe along with interventions that address mood and comorbidity may improve outcomes for women having TKR.

Minimally clinically important improvement: all non-responders are not really non-responders an illustration from total knee replacement

yDivision of Health Care and Outcomes Research, Toronto Western Research Institute, University Health Network, Toronto, Canada zArthritis Community Research and Evaluation Unit, Toronto Western Research Institute, University Health Network, Toronto, Canada xDepartment of Physical Therapy, University of Toronto, Toronto, Canada kDepartment of Rehabilitation Science, University of Toronto, Toronto, Canada { Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada # Institute of Medical Science, University of Toronto, Toronto, Canada yyDepartment of Orthopaedic Surgery, Toronto Western Hospital, University of Toronto, Toronto, Canada zzDepartment of Orthopaedics, Lund University, Lund, Sweden xxDepartment of Clinical Sciences Lund, Lund University, Lund, Sweden kk The Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark {{Department of Orthopaedics and Traumatology, University of Southern Denmark, Denmark