Laurel A. Donnell-Fink

Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis

BACKGROUND Whether arthroscopic partial meniscectomy for symptomatic patients with a meniscal tear and knee osteoarthritis results in better functional outcomes than nonoperative therapy is uncertain. METHODS We conducted a multicenter, randomized, controlled trial involving symptomatic patients 45 years of age or older with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging. We randomly assigned 351 patients to surgery and postoperative physical therapy or to a standardized physical-therapy regimen (with the option to cross over to surgery at the discretion of the patient and surgeon). The patients were evaluated at 6 and 12 months. The primary outcome was the difference between the groups with respect to the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical-function score (ranging from 0 to 100, with higher scores indicating more severe symptoms) 6 months after randomization. RESULTS In the intention-to-treat analysis, the mean improvement in the WOMAC score after 6 months was 20.9 points (95% confidence interval [CI], 17.9 to 23.9) in the surgical group and 18.5 (95% CI, 15.6 to 21.5) in the physical-therapy group (mean difference, 2.4 points; 95% CI, -1.8 to 6.5). At 6 months, 51 active participants in the study who were assigned to physical therapy alone (30%) had undergone surgery, and 9 patients assigned to surgery (6%) had not undergone surgery. The results at 12 months were similar to those at 6 months. The frequency of adverse events did not differ significantly between the groups. CONCLUSIONS In the intention-to-treat analysis, we did not find significant differences between the study groups in functional improvement 6 months after randomization; however, 30% of the patients who were assigned to physical therapy alone underwent surgery within 6 months. (Funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases; METEOR ClinicalTrials.gov number, NCT00597012.).

Cumulative incidence of ACL reconstruction after ACL injury in adults: Role of age, sex and race

Background: Anterior cruciate ligament (ACL) injuries are common and potentially disabling and frequently prompt surgical reconstruction. The utilization of ACL reconstruction among ACL-injured patients has not been examined rigorously. Purpose: This study reports the 3-year cumulative incidence of ACL reconstruction among adults with ACL injury and compares demographic and clinical characteristics of ACL-injured patients who do and do not go on to undergo ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A tertiary health care system patient data repository was used to identify patients diagnosed with an ACL injury between January 1, 2001, and December 31, 2007. Follow-up data were obtained to determine how many patients with ACL injury underwent ACL reconstruction within 3 years of ACL injury diagnosis. Stratified analyses were used to examine incidence rates separately by sex, age, race, primary language, socioeconomic status (SES), and health insurance status. Multivariable logistic regression models were built to examine the association of patient characteristics with utilization of ACL reconstruction. Results: There were 2304 patients, with a mean age of 47 years, diagnosed with an ACL injury between 2001 and 2007. The 3-year cumulative incidence of ACL reconstruction after ACL injury diagnosis was 22.6% (95% CI, 20.9%-24.3%). Eighty-six percent of patients undergoing reconstruction did so within 6 months of injury diagnosis, while 94% underwent reconstruction within 1 year. In multivariable models, several patient features were independently associated with a higher adjusted odds of undergoing ACL reconstruction, including male sex (adjusted odds ratio [aOR], 1.4; 95% CI, 1.1-1.7), younger age (aOR per decade, 1.8; 95% CI, 1.7-2.0), white race (aOR, 1.4; 95% CI, 0.94-1.9), higher SES (aOR, 1.4; 95% CI, 1.04-1.8 for high vs low SES; aOR, 1.3; 95% CI, 1.02-1.8 for medium vs low SES), and private health insurance versus self-pay (aOR, 1.9; 95% CI, 1.04-3.5). Conclusion: Less than a quarter of patients with a diagnosed ACL injury underwent ACL reconstruction in the 3 years after diagnosis. The odds of having surgery were higher for men, whites, younger patients, patients with higher SES, and patients with private health insurance.

Factors Associated with Refusal of Rapid HIV Testing in an Emergency Department

HIV screening studies in the emergency department (ED) have demonstrated rates of HIV test refusal ranging from 40–67%. This study aimed to determine the factors associated with refusal to undergo routine rapid HIV testing in an academic ED in Boston. HIV counselors offered routine testing to 1,959 patients; almost one-third of patients (29%) refused. Data from a self-administered survey were used to determine independent correlates of HIV testing refusal. In multivariate analysis, women and patients with annual household incomes of

Effectiveness of Knee Injury and Anterior Cruciate Ligament Tear Prevention Programs: A Meta-Analysis

50,000 or more were more likely to refuse testing, as were those who reported not engaging in HIV risk behaviors, those previously HIV tested and those who did not perceive a need for testing. Enrollment during morning hours was also associated with an increased risk of refusal. Increased educational efforts to convey the rationale and benefits of universal screening may improve testing uptake among these groups.

Association between socioeconomic status and pain, function and pain catastrophizing at presentation for total knee arthroplasty

Objective Individuals frequently involved in jumping, pivoting or cutting are at increased risk of knee injury, including anterior cruciate ligament (ACL) tears. We sought to use meta-analytic techniques to establish whether neuromuscular and proprioceptive training is efficacious in preventing knee and ACL injury and to identify factors related to greater efficacy of such programs. Methods We performed a systematic literature search of studies published in English between 1996 and 2014. Intervention efficacy was ascertained from incidence rate ratios (IRRs) weighted by their precision (1/variance) using a random effects model. Separate analyses were performed for knee and ACL injury. We examined whether year of publication, study quality, or specific components of the intervention were associated with efficacy of the intervention in a meta-regression analysis. Results Twenty-four studies met the inclusion criteria and were used in the meta-analysis. The mean study sample was 1,093 subjects. Twenty studies reported data on knee injury in general terms and 16 on ACL injury. Maximum Jadad score was 3 (on a 0–5 scale). The summary incidence rate ratio was estimated at 0.731 (95% CI: 0.614, 0.871) for knee injury and 0.493 (95% CI: 0.285, 0.854) for ACL injury, indicating a protective effect of intervention. Meta-regression analysis did not identify specific intervention components associated with greater efficacy but established that later year of publication was associated with more conservative estimates of intervention efficacy. Conclusion The current meta-analysis provides evidence that neuromuscular and proprioceptive training reduces knee injury in general and ACL injury in particular. Later publication date was associated with higher quality studies and more conservative efficacy estimates. As study quality was generally low, these data suggest that higher quality studies should be implemented to confirm the preventive efficacy of such programs.

Patient Satisfaction With Rapid HIV Testing in the Emergency Department

BackgroundPatients with higher socioeconomic status (SES) are shown to have better total knee arthroplasty (TKA) outcomes compared to those with lower SES. The relationship between SES and factors that influence TKA use is understudied. We examined the association between SES and pain, function and pain catastrophizing at presentation for TKA.MethodsIn patients undergoing TKA at an academic center, we obtained preoperative pain and functional status (WOMAC Index 0–100, 100 worst), pain catastrophizing (PCS, ≥16 high), and mental health (MHI-5, <68 poor). We described individual-level SES using education as a proxy, and area-level SES using a validated composite index linking geocoded addresses to U.S. Census data. We measured associations between these indicators and pain, function and pain catastrophizing, adjusting for age, sex and BMI.ResultsAmong 316 patients, mean age was 65.9 (SD 8.7), 59% were female, and 88% were Caucasian; 17% achieved less than college education and 62% were college graduates. The median area SES index score was 59 (U.S. median 51). Bivariable analyses demonstrated associations between higher individual- and area-level SES and lower pain, higher function and less pain catastrophizing (all p<0.05). Adjusted analyses demonstrated statistically significant associations between higher individual- and area-level SES and better function and less pain.ConclusionIn this cohort, patients with higher individual- and area-level SES had lower pain and higher function at the time of TKA than lower SES patients. Further research is needed to assess what constitutes appropriate levels of pain and function to undergo TKA in these higher SES groups.

Resource Utilization and Cost-Effectiveness of Counselor- vs. Provider-Based Rapid Point-of-Care HIV Screening in the Emergency Department

OBJECTIVE Patient satisfaction with HIV screening is crucial for sustainable implementation of the Centers for Disease Control and Prevention (CDC) HIV testing recommendations. This investigation assesses patient satisfaction with rapid HIV testing in the emergency department (ED) of an urban tertiary academic medical center. METHODS After receiving HIV test results, participants in the Universal Screening for HIV Infection in the Emergency Room (USHER) randomized controlled trial were offered a patient satisfaction survey. Questions concerned overall satisfaction with ED visit, time spent on primary medical problem, time spent on HIV testing, and test providers ability to answer HIV-related questions. Responses were reported on a 4-point Likert scale, ranging from very dissatisfied to very satisfied (defined as optimal satisfaction). RESULTS Of 4,860 USHER participants, 2,025 completed testing and were offered the survey: 1,616 (79.8%) completed the survey. Overall, 1,478 (91.5%) were very satisfied. Satisfaction was less than optimal for 34.5% (10 of 29) of participants with reactive results and for 7.5% (115 of 1,542) with nonreactive results. The independent factors associated with less than optimal satisfaction were reactive test result, aged 60 years or older, black race, Hispanic/Latino ethnicity, and testing by ED provider instead of HIV counselor. CONCLUSION Most participants were very satisfied with the ED-based rapid HIV testing program. Identification of independent factors that correlate with patient satisfaction will help guide best practices as EDs implement CDC recommendations. It is critical to better understand whether patients with reactive results were negatively affected by their results or truly had concerns about the testing process.

The Value of History, Physical Examination, and Radiographic Findings in the Diagnosis of Symptomatic Meniscal Tear among Middle-Age Subjects with Knee Pain.

Background Routine HIV screening in emergency department (ED) settings may require dedicated personnel. We evaluated the outcomes, costs and cost-effectiveness of HIV screening when offered by either a member of the ED staff or by an HIV counselor. Methods We employed a mathematical model to extend data obtained from a randomized clinical trial of provider- vs. counselor-based HIV screening in the ED. We compared the downstream survival, costs, and cost-effectiveness of three HIV screening modalities: 1) no screening program; 2) an ED provider-based program; and 3) an HIV counselor-based program. Trial arm-specific data were used for test offer and acceptance rates (provider offer 36%, acceptance 75%; counselor offer 80%, acceptance 71%). Undiagnosed HIV prevalence (0.4%) and linkage to care rates (80%) were assumed to be equal between the screening modalities. Personnel costs were derived from trial-based resource utilization data. We examined the generalizability of results by conducting sensitivity analyses on offer and acceptance rates, undetected HIV prevalence, and costs. Results Estimated HIV screening costs in the provider and counselor arms averaged

The AViKA (Adding Value in Knee Arthroplasty) postoperative care navigation trial: rationale and design features

8.10 and

Postoperative Care Navigation for Total Knee Arthroplasty Patients: A Randomized Controlled Trial.

31.00 per result received. The Provider strategy (compared to no screening) had an incremental cost-effectiveness ratio of