Arthritis Care and Research

Physical activity measured by accelerometers requires basic assumptions to translate the output into meaningful measures. We used accelerometer data from the Osteoarthritis Initiative to investigate in the context of knee osteoarthritis (OA) the following data processing assumptions derived from the general US adult population: nonwear (a period the monitor was removed), based on zero activity exceeding 60 minutes; and a valid day of monitoring, based on wear time evidence exceeding 10 hours.

We examined the influence of nonwear thresholds ranging from 20 to 300 minutes of zero activity on mean daily activity minutes (counts >0), mean daily activity counts, and mean daily moderate to vigorous physical activity minutes. The effect of selecting minimums of 8, 10, or 12 wear hours to signify a valid day of monitoring on data retention was examined.

Our sample of 3,536 days of accelerometer data from 519 persons with knee OA showed that mean daily activity minutes increased with the nonwear threshold until stabilizing at 463 minutes per day, corresponding to the 90‐minute nonwear threshold. Similar patterns were observed for mean daily activity counts. Varying the nonwear threshold had no effect on mean daily moderate to vigorous physical activity minutes. Choosing the 90‐minute nonwear threshold and a minimum of 10 wear hours to constitute a valid day provided 94% data retention.

Data supported applying the 90‐minute nonwear threshold to the knee OA population instead of the 60‐minute threshold for the general population, while retaining the 10‐hour valid day threshold.

The impact of increasing utilization of total knee arthroplasty (TKA) on lifetime costs in persons with knee osteoarthritis (OA) is understudied.

We used the Osteoarthritis Policy Model to estimate total lifetime costs and TKA utilization under a range of TKA eligibility criteria among US persons with symptomatic knee OA. Current TKA utilization was estimated from the Multicenter Osteoarthritis Study and calibrated to Health Care Cost and Utilization Project data. OA treatment efficacy and toxicity were drawn from published literature. Costs in 2013 dollars were derived from Medicare reimbursement schedules and Red Book Online. Time costs were derived from published literature and the US Bureau of Labor Statistics.

Estimated average discounted (3% per year) lifetime costs for persons diagnosed with knee OA were $140,300. Direct medical costs were $129,600, with $12,400 (10%) attributable to knee OA over 28 years. OA patients spent a mean ± SD of 13 ± 10 years waiting for TKA after failing nonsurgical regimens. Under current TKA eligibility criteria, 54% of knee OA patients underwent TKA over their lifetimes. Estimated OA‐related discounted lifetime direct medical costs ranged from $12,400 (54% TKA uptake) when TKA eligibility was limited to Kellgren/Lawrence grades 3 or 4 to $16,000 (70% TKA uptake) when eligibility was expanded to include symptomatic OA with a lesser degree of structural damage.

Because of low efficacy of nonsurgical regimens, knee OA treatment–attributable costs are low, representing a small portion of all costs for OA patients. Expanding TKA eligibility increases OA‐related costs substantially for the population, underscoring the need for more effective nonoperative therapies.

To explore physiotherapists’ perceptions before and after delivering exercise advice via telephone to patients with knee osteoarthritis (OA).

We performed a descriptive qualitative study (based on interpretivist methodology) embedded within a randomized controlled trial. Before and after providing exercise therapy to patients with knee OA, all 8 physiotherapists who were involved in the trial participated in semi‐structured interviews via telephone. Interviews were audio recorded, transcribed verbatim, and thematically analyzed.

Prior to delivering the intervention, physiotherapists thought that the telephone should be used only for follow‐up rather than as the primary mode of providing care. They believed that telephone‐delivered care would be convenient and cost‐saving for patients, would provide increased opportunity for patient education, and also increase access to services, but that the lack of visual and physical contact with patients would be problematic. After delivering the intervention, physiotherapists reflected that telephone‐delivered care exceeded their expectations, noting positive patient outcomes including improved pain, function, and confidence. The focus on communication allowed more personal conversations with patients and shifted patient expectations of care away from manual therapies and toward self‐management. Numerous implementation considerations were identified, including the need for clinician training in communication skills, written resources for patients to supplement telephone calls, and careful deliberation of how to schedule telephone consultations during the usual in‐person consultations in the clinic.

Although physiotherapists were initially skeptical about the effectiveness of telephone‐delivered service models to patients with knee OA, perceptions shifted once they experienced delivery of care via this nontraditional method. Our findings suggest that firsthand experience may be necessary for physiotherapists to embrace new models of service delivery.

Physical activity is recommended to mitigate functional limitations associated with knee osteoarthritis (OA). However, it is unclear whether walking on its own protects against the development of functional limitation.

Walking over 7 days was objectively measured as steps/day within a cohort of people with or at risk of knee OA from the Multicenter Osteoarthritis Study. Incident functional limitation over 2 years was defined by performance‐based (gait speed <1.0 meter/second) and self‐report (Western Ontario and McMaster Universities Osteoarthritis Index physical function score >28 of 68) measures. We evaluated the association of steps/day at baseline with developing functional limitation 2 years later by calculating risk ratios adjusted for potential confounders. The number of steps/day that best distinguished risk for developing functional limitation was estimated from the maximum distance from chance on receiver operating characteristic curves.

Among 1,788 participants (mean age 67 years, mean body mass index 31 kg/m², 60% women), each additional 1,000 steps/day was associated with a 16% and 18% reduction in incident functional limitation by performance‐based and self‐report measures, respectively. Walking <6,000 and <5,900 steps/day were the best thresholds to distinguish incident functional limitation by performance‐based (sensitivity 67.3%, specificity 71.8%) and self‐report (sensitivity 58.7%, specificity 68.9%) measures, respectively.

More walking was associated with less risk of functional limitation over 2 years. Walking >6,000 steps/day provides a preliminary estimate of the level of walking activity to protect against developing functional limitation in people with or at risk of knee OA.

To investigate the long‐term outcome and prognostic factors of juvenile dermatomyositis (DM) through a multinational, multicenter study.

Patients consisted of inception cohorts seen between 1980 and 2004 in 27 centers in Europe and Latin America. Predictor variables were sex, continent, ethnicity, onset year, onset age, onset type, onset manifestations, course type, disease duration, and active disease duration. Outcomes were muscle strength/endurance, continued disease activity, cumulative damage, muscle damage, cutaneous damage, calcinosis, lipodystrophy, physical function, and health‐related quality of life (HRQOL).

A total of 490 patients with a mean disease duration of 7.7 years were included. At the cross‐sectional visit, 41.2–52.8% of patients, depending on the instrument used, had reduced muscle strength/endurance, but less than 10% had severe impairment. Persistently active disease was recorded in 41.2–60.5% of the patients, depending on the activity measure used. Sixty‐nine percent of the patients had cumulative damage. The frequency of calcinosis and lipodystrophy was 23.6% and 9.7%, respectively. A total of 40.7% of the patients had decreased functional ability, but only 6.5% had major impairment. Only a small fraction had decreased HRQOL. A chronic course, either polycyclic or continuous, consistently predicted a poorer outcome. Mortality rate was 3.1%.

This study confirms the marked improvement in functional outcome of juvenile DM when compared with earlier literature. However, many patients had continued disease activity and cumulative damage at followup. A chronic course was the strongest predictor of poor prognosis. These findings highlight the need for treatment strategies that enable a better control of disease activity over time and the reduction of nonreversible damage.

To validate manual muscle testing (MMT) for strength assessment in juvenile and adult dermatomyositis (DM) and polymyositis (PM).

Patients with PM/DM (73 children and 45 adults) were assessed at baseline and reevaluated 6–9 months later. We compared Total MMT (a group of 24 proximal, distal, and axial muscles) and Proximal MMT (7 proximal muscle groups) tested bilaterally on a 0–10 scale with 144 subsets of 6 and 96 subsets of 8 muscle groups tested unilaterally. Expert consensus was used to rank the best abbreviated MMT subsets for face validity and ease of assessment.

The Total, Proximal, and best MMT subsets had excellent internal reliability (Total MMT r_s = 0.91–0.98), and consistency (Cronbach's α = 0.78–0.97). Inter‐ and intrarater reliability were acceptable (Kendall's W 0.68–0.76, r_s = 0.84–0.95). MMT subset scores correlated highly with Total and Proximal MMT scores and with the Childhood Myositis Assessment Scale, and correlated moderately with physician global activity, functional disability, magnetic resonance imaging, and axial and distal MMT scores, and, in adults, with creatine kinase level. The standardized response mean for Total MMT was 0.56 in juveniles and 0.75 in adults. Consensus was reached to use a subset of 8 muscles (neck flexors, deltoids, biceps, wrist extensors, gluteus maximus and medius, quadriceps, and ankle dorsiflexors) that performed as well as the Total and Proximal MMT, and had good face validity and ease of assessment.

These findings aid in standardizing the use of MMT for assessing strength as an outcome measure for myositis.

Management of systemic lupus erythematosus (SLE) is complex and variability in practices exists. Guidelines have been developed to help improve the management of SLE patients, but there has been no formal evaluation of these guidelines. This study aims to compare the scope, quality, and consistency of clinical practice guidelines on the diagnosis, monitoring, and treatment of patients with SLE.

Electronic databases were searched up to April 2014. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument and textual synthesis was used to appraise and compare recommendations.

Nine clinical practice guidelines and 5 consensus statements were identified, which covered 7 topics: diagnosis, monitoring, treatment, neuropsychiatric SLE, lupus nephritis, antiphospholipid syndrome, and other manifestations of lupus. The methodological quality of the guidelines was variable, with the overall mean AGREE II scores ranging from 31% to 75%, out of a maximum 100%. Scores were consistently low for applicability, with only 1 guideline scoring above 50%. There was substantial variability in the treatments recommended for class II and V lupus nephritis, the recommended duration of maintenance therapy for class III/IV lupus nephritis (from 1 to 4 years), and timing of ophthalmologic examination for patients taking corticosteroids.

Published guidelines on SLE cover a complex area of clinical care, but the methodological quality, scope, and recommendations varied substantially. Collaborative and multidisciplinary efforts to develop comprehensive, high‐quality evidence‐based guidelines are needed to promote best treatment and health outcomes for patients with SLE.

Low birth weight (LBW) and preterm birth have been associated with adverse adult outcomes, including hypertension, insulin resistance, cardiovascular disease, and reduced bone mass. It is unknown whether LBW and preterm birth affect the risk of osteoarthritis (OA). This study aims to examine whether LBW and preterm birth were associated with the incidence of knee and hip arthroplasty for OA.

A total of 3,604 participants of the Australian Diabetes, Obesity and Lifestyle Study who reported their birth weight and history of preterm birth and were age >40 years at the commencement of arthroplasty data collection comprised the study sample. The incidence of knee and hip replacement for OA during 2002–2011 was determined by linking cohort records to the Australian Orthopaedic Association National Joint Replacement Registry.

One hundred and sixteen participants underwent knee arthroplasty and 75 underwent hip arthroplasty for OA. LBW (yes versus no; hazard ratio [HR] 2.04, 95% confidence interval [95% CI] 1.11–3.75, P = 0.02) and preterm birth (yes versus no; HR 2.50, 95% CI 1.29–4.87, P = 0.007) were associated with increased incidence of hip arthroplasty independent of age, sex, body mass index, education level, hypertension, diabetes mellitus, smoking, and physical activity. No significant association was observed for knee arthroplasty.

Although these findings will need to be confirmed, they suggest that individuals born with LBW or at preterm are at increased risk of hip arthroplasty for OA in adult life. The underlying mechanisms warrant further investigation.

To develop updated guidelines for the pharmacologic management of rheumatoid arthritis.

We developed clinically relevant population, intervention, comparator, and outcomes (PICO) questions. After conducting a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the certainty of evidence. A voting panel comprising clinicians and patients achieved consensus on the direction (for or against) and strength (strong or conditional) of recommendations.

The guideline addresses treatment with disease‐modifying antirheumatic drugs (DMARDs), including conventional synthetic DMARDs, biologic DMARDs, and targeted synthetic DMARDs, use of glucocorticoids, and use of DMARDs in certain high‐risk populations (i.e., those with liver disease, heart failure, lymphoproliferative disorders, previous serious infections, and nontuberculous mycobacterial lung disease). The guideline includes 44 recommendations (7 strong and 37 conditional).

This clinical practice guideline is intended to serve as a tool to support clinician and patient decision‐making. Recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision‐making process based on patients’ values, goals, preferences, and comorbidities.

To assess the feasibility and efficacy of implementing a treat‐to‐target approach versus usual care in a US‐based cohort of rheumatoid arthritis patients.

In this behavioral intervention trial, rheumatology practices were cluster‐randomized to provide treat‐to‐target care or usual care. Eligible patients with moderate/high disease activity (Clinical Disease Activity Index [CDAI] score >10) were followed for 12 months. Both treat‐to‐target and usual care patients were seen every 3 months. Treat‐to‐target providers were to have monthly visits with treatment acceleration at a minimum of every 3 months in patients with CDAI score >10; additional visits and treatment acceleration were at the discretion of usual care providers and patients. Coprimary end points were feasibility, assessed by rate of treatment acceleration conditional on CDAI score >10, and achievement of low disease activity (LDA; CDAI score ≤10) by an intent‐to‐treat analysis.

A total of 14 practice sites per study arm were included (246 patients receiving treat‐to‐target and 286 receiving usual care). The groups had similar baseline demographic and clinical characteristics. Rates of treatment acceleration (treat‐to‐target 47% versus usual care 50%; odds ratio [OR] 0.92 [95% confidence interval (95% CI) 0.64, 1.34]) and achievement of LDA (treat‐to‐target 57% versus usual care 55%; OR 1.05 [95% CI 0.60, 1.84]) were similar between groups. Treat‐to‐target providers reported patient reluctance and medication lag time as common barriers to treatment acceleration.

This study is the first to examine the feasibility and efficacy of a treat‐to‐target approach in typical US rheumatology practice. Treat‐to‐target care was not associated with increased likelihood of treatment acceleration or achievement of LDA, and barriers to treatment acceleration were identified.