Recommendation Rates for Physical Therapy, Lifestyle Counseling, and Pain Medications for Managing Knee Osteoarthritis in Ambulatory Care Settings: A Cross-Sectional Analysis of the National Ambulatory Care Survey (2007-2015).
门诊护理机构中管理膝骨关节炎的物理治疗、生活方式咨询和疼痛药物的推荐率: 全国门诊护理调查 (2007-2015) 的横断面分析。
- 作者列表："Khoja SS","Almeida GJ","Freburger JK
OBJECTIVE:To describe and compare triennial rates of physicians' recommendations for physical therapy (PT), lifestyle counseling, and pain medication for knee osteoarthritis (OA) and to identify patient, physician, and practice factors associated with each treatment recommendation. METHODS:We conducted a cross-sectional analysis examining data between 2007 and 2015 from the National Ambulatory Medical Care Survey. Visits to orthopedists and primary care physicians for knee OA were identified and assessed for the following: PT referral, lifestyle counseling, nonsteroidal antiinflammatory drug (NSAID) prescriptions, and narcotics prescriptions. Triennial rates for each treatment were calculated. We examined associations between patient (e.g., race, insurance), physician, and practice factors (e.g., ownership, location) and treatments prescribed using multivariate logistic regression that accounted for complex sampling design. RESULTS:A total of 2,297 physician visits related to knee OA (~67 [±4] million weighted visits) were identified. For visits to orthopedists, PT and lifestyle recommendation rates declined (158 to 88 of 1,000 visits and 184 to 86 of 1,000 visits, respectively), while NSAID and narcotics prescriptions increased (132 to 278 of 1,000 visits and 77 to 236 of 1,000 visits, respectively) over time (P < 0.05). For visits to primary care physicians, there were no significant changes in rates of PT, lifestyle counseling, and narcotics prescriptions over time, while NSAIDs prescriptions increased (221 to 498 of 1,000 visits; P < 0.05). Treatment recommendations were associated with nonclinical factors, including practice type, location, and type of provider. CONCLUSION:In patients with knee OA, PT and lifestyle counseling seem underutilized, while pain medication prescriptions increased during the investigated timeframe. Variation in treatment choices were associated with nonclinical factors. Future research is necessary to examine ways to improve PT and lifestyle utilization and reduce variation in care for knee OA.
目的: 描述和比较医生对膝关节骨关节炎 (OA) 的物理治疗 (PT) 、生活方式咨询和疼痛药物建议的三年率，并确定患者、医生、和与每个治疗建议相关的实践因素。 方法: 我们进行了一项横断面分析，检查了 2007 年至 2015 年全国门诊医疗调查的数据。确定并评估膝关节OA的骨科医生和初级保健医生的访视情况: PT转诊、生活方式咨询、非甾体抗炎药 (NSAID) 处方和麻醉剂处方。计算每次治疗的三年率。我们检查了患者之间的关联 (e。g.，种族、保险) 、医生和实践因素 (e。g.，所有权、位置) 和使用多变量逻辑回归规定的治疗，解释了复杂的抽样设计。 结果: 共确定了 2,297 次与膝关节OA相关的医生访视 (~ 67 [± 4] 百万次加权访视)。对于骨科医生的访视，PT和生活方式推荐率下降 (158 次访视中的 1,000 至 88 次，184 次访视中的 1,000 至 86 次)，而NSAID和麻醉剂处方随着时间的推移而增加 (132 次访视中的 278 至 1,000 次和 236 次访视中的 77 至 1,000 次) (P <0.05)。对于初级保健医生的访视，PT、生活方式咨询和麻醉药物处方的发生率随着时间的推移没有显著变化，而NSAIDs处方增加 (221 次访视中的 498 至 1,000; P <0.05)。治疗建议与非临床因素相关，包括实践类型、地点和提供者类型。 结论: 在膝关节OA患者中，PT和生活方式咨询似乎未得到充分利用，而疼痛药物处方在调查时间段内增加。治疗选择的变异与非临床因素相关。未来的研究有必要探讨改善PT和生活方式利用的方法，减少膝关节OA护理的差异。
METHODS:OBJECTIVE:Patients with immune-mediated inflammatory diseases such as rheumatoid arthritis or systemic lupus erythematosus are at increased risk of cardiovascular disease. However, the cardiovascular risk of patients with primary Sjögren's syndrome (SS) remains poorly studied. We aimed to investigate the association between primary SS and cardiovascular morbidity and mortality. METHODS:We performed a systematic review of articles in Medline and the Cochrane Library and recent abstracts from US and European meetings, searching for reports of randomized controlled studies of cardiovascular morbidity and cardiovascular mortality in primary SS. The relative risk (RR) values for cardiovascular morbidity and mortality associated with primary SS were collected and pooled in a meta-analysis with a random-effects model by using Review Manager (Cochrane collaboration). RESULTS:The literature search revealed 484 articles and abstracts of interest; 14 studies (67,124 patients with primary SS) were included in the meta-analysis. With primary SS versus control populations, the risk was significantly increased for coronary morbidity (RR 1.34 [95% confidence interval (95% CI) 1.06-1.38]; P = 0.01), cerebrovascular morbidity (RR 1.46 [95% CI 1.43-1.49]; P < 0.00001), heart failure rate (odds ratio 2.54 [95% CI 1.30-4.97]; P < 0.007), and thromboembolic morbidity (RR 1.78 [95% CI 1.41-2.25]; P < 0.00001), with no statistically significant increased risk of cardiovascular mortality (RR 1.48 [95% CI 0.77-2.85]; P = 0.24). CONCLUSION:This meta-analysis demonstrates that primary SS is associated with increased cardiovascular morbidity, which suggests that these patients should be screened for cardiovascular comorbidities and considered for preventive interventions, in a multidisciplinary approach with cardiologists.
METHODS:OBJECTIVE:We aimed to evaluate the comparative risk of hospitalized infection among patients with rheumatoid arthritis (RA) who initiated abatacept versus a tumor necrosis factor inhibitor (TNFi). METHODS:Using claims data from Truven MarketScan database (2006-2015), we identified patients with RA ages ≥18 years with ≥2 RA diagnoses who initiated treatment with abatacept or a TNFi. The primary outcome was a composite end point of any hospitalized infection. Secondary outcomes included bacterial infection, herpes zoster, and infections affecting different organ systems. We performed 1:1 propensity score (PS) matching between the groups in order to control for baseline confounders. We estimated incidence rates (IRs) and hazard ratios (HRs) with 95% confidence intervals (95% CIs) for hospitalized infection. RESULTS:We identified 11,248 PS-matched pairs of patients who initiated treatment with abatacept and TNFi with a median age of 56 years (83% were women). The IR per 1,000 person-years for any hospitalized infection was 37 among patients who initiated treatment with abatacept and 47 in those who initiated treatment with TNFi. The HR for the risk of any hospitalized infection associated with abatacept versus TNFi was 0.78 (95% CI 0.64-0.95) and remained lower when compared to infliximab (HR 0.63 [95% CI 0.47-0.85]), while no significant difference was seen when compared to adalimumab and etanercept. The risk of secondary outcomes was lower for abatacept for pulmonary infections, and similar to TNFi for the remaining outcomes. CONCLUSION:In this large cohort of patients with RA who initiated treatment with abatacept or TNFi as a first- or second-line biologic agent, we found a lower risk of hospitalized infection after initiating abatacept versus TNFi, which was driven mostly by infliximab.
METHODS:OBJECTIVE:Reducing pain is one of the main health priorities for children and young people with juvenile idiopathic arthritis (JIA); however, some studies indicate that pain is not routinely assessed in this patient group. The aim of this study was to explore health care professionals' (HCPs) beliefs about the role of pain and the prioritization of its assessment in children and young people with JIA. METHODS:Semi-structured interviews were conducted with HCPs who manage children and young people with JIA in the UK (including consultant and trainee pediatric rheumatologists, nurses, physical therapists, and occupational therapists). Data were analyzed qualitatively following a framework analysis approach. RESULTS:Twenty-one HCPs participated. Analyses of the data identified 6 themes, including lack of training and low confidence in pain assessment, reluctance to engage in pain discussions, low prioritization of pain assessment, specific beliefs about the nature of pain in JIA, treatment of pain in JIA, and undervaluing pain reports. Assessment of pain symptoms was regarded as a low priority and some HCPs actively avoided conversations about pain. CONCLUSION:These findings indicate that the assessment of pain in children and young people with JIA may be limited by knowledge, skills, and attitudinal factors. HCPs' accounts of their beliefs about pain in JIA and their low prioritization of pain in clinical practice suggest that a shift in perceptions about pain management may be helpful for professionals managing children and young people with this condition.