Susan Williams

All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study

Objective To examine all cause and disease specific mortality in patients with osteoarthritis of the knee or hip. Design Population based cohort study. Setting General practices in the southwest of England. Participants 1163 patients aged 35 years or over with symptoms and radiological confirmation of osteoarthritis of the knee or hip. Main outcome measures Age and sex standardised mortality ratios and multivariable hazard ratios of death after a median of 14 years’ follow-up. Results Patients with osteoarthritis had excess all cause mortality compared with the general population (standardised mortality ratio 1.55, 95% confidence interval 1.41 to 1.70). Excess mortality was observed for all disease specific causes of death but was particularly pronounced for cardiovascular (standardised mortality ratio 1.71, 1.49 to 1.98) and dementia associated mortality (1.99, 1.22 to 3.25). Mortality increased with increasing age (P for trend <0.001), male sex (adjusted hazard ratio 1.59, 1.30 to 1.96), self reported history of diabetes (1.95, 1.31 to 2.90), cancer (2.28, 1.50 to 3.47), cardiovascular disease (1.38, 1.12 to 1.71), and walking disability (1.48, 1.17 to 1.86). However, little evidence existed for increased mortality associated with previous joint replacement, obesity, depression, chronic inflammatory disease, eye disease, or presence of pain at baseline. The more severe the walking disability, the higher was the risk of death (P for trend <0.001). Conclusion Patients with osteoarthritis are at higher risk of death compared with the general population. History of diabetes, cancer, or cardiovascular disease and the presence of walking disability are major risk factors. Management of patients with osteoarthritis and walking disability should focus on effective treatment of cardiovascular risk factors and comorbidities, as well as on increasing physical activity.

Variations in the pre-operative status of patients coming to primary hip replacement for osteoarthritis in European orthopaedic centres

BackgroundTotal hip joint replacement (THR) is a high volume, effective intervention for hip osteoarthritis (OA). However, indications and determinants of outcome remain unclear. The EUROHIP consortium has undertaken a cohort study to investigate these questions. This paper describes the variations in disease severity in this cohort and the relationships between clinical and radiographic severity, and explores some of the determinants of variation.MethodsA minimum of 50 consecutive, consenting patients coming to primary THR for primary hip OA in each of the 20 participating orthopaedic centres entered the study. Pre-operative data included demographics, employment and educational attainment, drug utilisation, and involvement of other joints. Each subject completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC – Likert version 3.1). Other data collected at the time of surgery included the prosthesis used and American Society of Anaesthesiologists (ASA) status. Pre-operative radiographs were read by the same three readers for Kellgren and Lawrence (K&L) grading and Osteoarthritis Research Society International (OARSI) atlas features. Regression analyses were carried out.ResultsData from 1327 subjects has been analysed. The mean age of the group was 65.7 years, and there were more women (53.4%) than men. Most (79%) were ASA status 1 or 2. Reported disease duration was 5 years or less in 69.2%. Disease in other joint sites was common.Radiographs were available in 1051 subjects and the K&L grade was 3 or 4 in 95.8%. There was much more variation in clinical severity (WOMAC score); the mean total WOMAC score was 59.2 (SD 16.1). The radiographic severity showed no correlation with WOMAC scores.Significantly higher WOMAC scores (worse disease) were seen in older people, women, those with obesity, those with worse general health, and those with lower educational attainment.Conclusion1. Clinical disease severity varies widely at the time of THR for OA.2. In advanced hip OA clinical severity shows no correlation with radiographic severity.3. Simple scores of pain and disability do not reflect the complexity of decision-making about who should have a THR.

Help-seeking behaviour among people living with chronic hip or knee pain in the community

BackgroundA large proportion of people living with hip or knee pain do not consult health care professionals. Pain severity is often believed to be the main reason for help seeking in this population; however the evidence for this is contradictory. This study explores the importance of several potential risk factors on help seeking across different practitioner groups, among adults living with chronic hip or knee pain in a large community sample.MethodsHealth care utilization, defined as having seen a family doctor (GP) during the past 12 months; or an allied health professional (AHP) or alternative therapist during the past 3 months, was assessed in a community based sample aged 35 or over and reporting pain in hip or knee. Adjusted odds ratios were determined for social deprivation, rurality, pain severity, mobility, anxiety/depression, co-morbidities, and body mass index.ResultsOf 1119 persons reporting hip or knee pain, 52% had pain in both sites.Twenty-five percent of them had seen a doctor only, 3% an AHP only, and 4% an alternative therapist only. Thirteen percent had seen more than one category of health care professionals, and 55% had not seen any health care professional. In the multivariate model, factors associated with consulting a GP were mobility problems (OR 2.62 (1.64-4.17)), urban living (OR 2.40 (1.14-5.04) and pain severity (1.28 (1.13-1.44)). There was also some evidence that obesity was associated with increased consultation (OR 1.72 (1.00-2.93)). Factors were similar for consultation with a combination of several health care professionals. In contrast, seeing an alternative therapist was negatively associated with pain severity, anxiety and mobility problems (adjusting for age and sex).ConclusionDisability appears to be a more important determinant of help-seeking than pain severity or anxiety and depression, for adults with chronic pain in hip or knee. The determinants of seeking help from alternative practitioners are different from determinants of consulting GPs, AHPs or a combination of different health care providers.

Routes to total joint replacement surgery: Patients and clinicians' perceptions of need

To explore patients perspectives of need for total joint replacement associated with decision making in orthopaedic consultations for hip or knee osteoarthritis.

Unstated factors in orthopaedic decision-making: a qualitative study

BackgroundTotal joint replacement (TJR) of the hip or knee for osteoarthritis is among the most common elective surgical procedures. There is some inequity in provision of TJR. How decisions are made about who will have surgery may contribute to disparities in provision. The model of shared decision-making between patients and clinicians is advocated as an ideal by national bodies and guidelines. However, we do not know what happens within orthopaedic practice and whether this reflects the shared model. Our study examined how decisions are made about TJR in orthopaedic consultations.MethodsThe study used a qualitative research design comprising semi-structured interviews and observations. Participants were recruited from three hospital sites and provided their time free of charge. Seven clinicians involved in decision-making about TJR were approached to take part in the study, and six agreed to do so. Seventy-seven patients due to see these clinicians about TJR were approached to take part and 26 agreed to do so. The patients outpatient appointments (consultations) were observed and audio-recorded. Subsequent interviews with patients and clinicians examined decisions that were made at the appointments. Data were analysed using thematic analysis.ResultsClinical and lifestyle factors were central components of the decision-making process. In addition, the roles that patients assigned to clinicians were key, as were communication styles. Patients saw clinicians as occupying expert roles and they deferred to clinicians expertise. There was evidence that patients modified their behaviour within consultations to complement that of clinicians. Clinicians acknowledged the complexity of decision-making and provided descriptions of their own decision-making and communication styles. Patients and clinicians were aware of the use of clinical and lifestyle factors in decision-making and agreed in their description of clinicians styles. Decisions were usually reached during consultations, but patients and clinicians sometimes said that treatment decisions had been made beforehand. Some patients expressed surprise about the decisions made in their consultations, but this did not necessarily imply dissatisfaction.ConclusionsThe way in which roles and communication are played out in decision-making for TJR may affect the opportunity for shared decisions. This may contribute to variation in the provision of TJR. Making the importance of these factors explicit and highlighting the existence of patients surprise about consultation outcomes could empower patients within the decision-making process and enhance communication in orthopaedic consultations.

Professional experience guides opioid prescribing for chronic joint pain in primary care.

BACKGROUNDnChronic joint pain is common and is a leading cause of disability. Most chronic joint pain is managed in primary care. Opioid pain medication is one option for pain management, but research suggests that its use by general practitioners (GPs) may be suboptimal. There is a widespread perception that doctors concerns about misuse and addiction limit use of opioids.nnnOBJECTIVESnTo explore GPs opinions about opioids and decision-making processes when prescribing strong opioids for chronic joint pain.nnnMETHODSnQualitative semi-structured interviews were conducted with 27 GPs. Using thematic analysis methods, the data were coded and grouped into themes.nnnRESULTSnGPs described a variety of prescribing habits for chronic joint pain. Opioids engendered strong opinions. GPs said that decisions about prescribing were based on careful assessment of patients needs and their personal views about the management of adverse effects. Although addiction and misuse were discussed, there was limited concern about these issues. The overarching influence on prescribing decisions was GPs previous experience, including previous outcomes and exposure to palliative care settings.nnnCONCLUSIONSnGPs prescribing decisions are primarily influenced by previous professional experience of opioids. Much existing literature stresses that opioids are not prescribed due to concerns about addiction or misuse, but our study indicates otherwise. Augmenting GPs exposure to and experience of opioids may be key to providing better pain management for patients.

Association of bone attrition with knee pain, stiffness and disability: a cross-sectional study

Objectives Bone pathologies as detected on MRI are associated with the presence of pain in knee osteoarthritis (OA). The authors examined whether bone attrition assessed on x-rays was associated with pain, stiffness and disability. Methods The authors analysed x-rays of 1326 knees with OA from 783 individuals participating in the cross-sectional population-based Somerset and Avon Survey of Health. The diagnosis of OA was defined by the presence of osteophytes in anteroposterior (AP) or lateral views. Bone attrition was graded from 0 (no attrition) to 3 (severe attrition >10 mm) and Kellgren and Lawrence (K/L) scores were assigned on AP views. Logistic regression models adjusted for gender, age, body mass index, effusion and K/L scores were used to determine whether bone attrition was associated with pain, stiffness and disability. Results Pain was reported in 84 knees (74%) with radiographic bone attrition compared with 505 (42%) without bone attrition (adjusted OR 2.22, 95% CI 1.29 to 3.80). The adjusted OR was increased for day pain but not for night pain (p for interaction <0.001). Stiffness was reported for 85 knees with bone attrition (75%) and 437 knees without (36%) (adjusted OR 3.23, 95% CI 1.85 to 5.64). Disability was reported by 40 individuals with bone attrition (50%) and 140 individuals without (24%) (adjusted OR 2.09, 95% CI 1.19 to 3.68). Conclusions Bone attrition detected on conventional x-rays using a simple cheap technique is strongly associated with the presence of day pain, stiffness and disability in knee OA.

Encountering “Gerald”: Experiments With Meandering Methodologies and Experiences Beyond Our “Selves” in a Collaborative Writing Group

This article describes a process of moving in and out of a place of “ordinary, transient and sustainable community” within a collaborative writing group. The group meets together both on- and offline. Over the last 5 years, the authors have developed an every day, meandering, and nomadic practice of being, talking, and writing. This enables frequent encounters with a very precious, precarious, and particular sense of collective energy. The group came to describe this experience of moving beyond, in, out of, and through their individual and collective selves as “Gerald.” This article comprises a narrating text in which quotations from the authors’ writing archives are embedded.

Friend and Foe? Technology in a Collaborative Writing Group

This is a partial account of the journey undertaken by a group of academic nomads in search of collaborative writing space. Never intending to permanently settle anywhere, we chose to explore writing technologies that supported collaborative forms of engagement with our task and with each other. Along the way we took up with, and discarded, a variety of writing technologies. Reflecting teamwork and collective biography practices sustained our work and our commitments towards collaboration. Although we have not found any electronic technologies helpful in creating or maintaining our sense of community, they enabled collective ways of re-presenting our work to ourselves and, later, to others. Twenty of us set out and twelve* remain on this journey. The current text includes three voices, each woven from writings and silences of many members of our group, thereby including traces of us all. The text explores our relationship with electronic technology and its role in our collaborative writing venture.