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Achieving Important Improvement in Womac Pain and Function Impacts Satisfaction 1 Year Following Total Knee Replacement
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Abstracts / Osteoarthritis and Cartilage 25 (2017) S76eS444
346 ACHIEVING IMPORTANT IMPROVEMENT IN WOMAC PAIN AND FUNCTION IMPACTS SATISFACTION 1 YEAR FOLLOWING TOTAL KNEE REPLACEMENT A. Davis y, S. Ibrahim z, S. Hogg-Johnson z, R. Wong y, D. Beaton z, B. Chesworth x, R. Gandhi k, N. Mahomed k, A. Perruccio y, V. Rajgopal ¶, J. Waddell #. y Krembil Res. Inst., Toronto, ON, Canada; z Inst. for Work and Hlth., Toronto, ON, Canada; x Western Univ., London, ON, Canada; k Univ. Hlth.Network, Toronto, ON, Canada; ¶ Middlesex Hosp. Alliance, Strathroy, ON, Canada; # St. Michael's Hosp., Toronto, ON, Canada Purpose: Patients need to be supported in their decision about when and if to have total knee replacement (TKR) based on understanding how their pain and function will be impacted, and satisfaction with outcome. While some research has quantified important improvement (II) in pain and function, the degree to which achievement of II in pain, function and higher demand activities are associated with satisfaction has received little attention. We hypothesized that the association of pre-surgery pain, function, higher demand activities and outcome expectations with 1-year satisfaction were mediated by achievement of II in pain, function and higher demand activities, taking into account factors that are associated with satisfaction following primary TKR. Methods: We followed 354 patients from pre- to 1-year post-TKR. Presurgery, participants completed demographic and health questionnaires, the WOMAC pain and function and Late Life Disability Index (LLDI) limitation subscales, a measure of higher demand activities, and identified outcome expectations for pain, other symptoms, mobility/activities of daily living (ADL), and participation in social roles/instrumental activities of daily living (IADL). The WOMAC, LLDI and a satisfaction questionnaire also were completed 1-year post surgery. All were scored 0e100 with higher scores indicating better outcome. Using II values for WOMAC pain, function and high demand activities generated from a separate cohort recruited from similar centres, we derived a variable indicating if an individual achieved II (no/yes) for each outcome. Based on sensitivity analysis, we categorized those who had baseline scores precluding achievement of II who reached the measure ceiling as achieving the II. We used a Bayesian approach with non-informative priors to evaluate our hypothesized mediation model, adjusting for age, sex, education, obesity, depression (Hospital Anxiety and Depression Scale), comorbidity count and self-rated health. As the tetrachoric correlations among the expectations ranged from 0.11e0.60, they were modeled as individual predictors. Results: The sample mean age was 65 years; 65% were female; and, 66% had >high school education. The mean comorbidity count was 1.6 (sd¼1.3) and depression was 5.3 (sd¼3.5). 40% rated their overall health as very good/excellent. The mean pre-surgery pain, function and high demand activities scores were 47.8 (sd¼17.8), 50.3 (sd¼18.5) and 59.2 (sd¼11.0) respectively. The mean satisfaction score was 80.7 (sd¼21.9). 57, 47, 57 and 15% expected improvement in pain, other symptoms, mobility/ADL and social roles/IADL respectively. 77.3, 77.4 and 78.8% achieved II for pain, function and high demand activities respectively. In the final adjusted model (Figure 1), achieving II in function (estimate 0.668) was directly associated with higher satisfaction and higher expectation for mobility/ADL improvements (0.606) was significantly
directly associated with lower satisfaction. Achieving II in function was associated with higher demand II achievement (0.467). All other significant effects were indirect with a path of baseline pain to achieving pain II (0.147) to achieving function II (0.802) to satisfaction (0.668). Additionally, higher expectation of mobility/ADL improvements was associated with achieving II in higher demand activities through achievement of II in function (indirect path coefficients 0.439 and 0.467). There were no significant direct associations from II in pain or higher demand activities to satisfaction. Conclusions: People who achieve important improvement in function are more likely to be satisfied with the outcome of their TKR surgery. Strategies that target achieving important improvement in function as well as pain post-surgery could be critical to further enhancing outcome satisfaction. 347 DISEASE BURDEN IN RHEUMATOID ARTHRITIS (RA) PATIENTS WHO HAVE SECONDARY OSTEOARTHRITIS (OA) IS LOWER THAN IN PRIMARY OA BUT HIGHER THAN IN RA WITH NO SECONDARY OA I. Castrejon, J.R. Chua, A.M. Malfait, J.A. Block, T. Pincus. RUSH Univ. Med. Ctr., Chicago, IL, USA Purpose: To compare disease burden in patients' in 3 groups: a) primary OA, b) primary RA, or c) patients with RA who are recognized to have secondary (2 ) OA, according to scores on a multi-dimensional health assessment questionnaire (MDHAQ) and physician RheuMetric checklist. Methods: At one academic rheumatology center, all patients with all diagnoses complete an MDHAQ. The MDHAQ includes 0e10 scores for physical function (FN), pain (PN), and patient global estimate (PATGL), compiled into a 0e30 composite routine assessment of patient index data (RAPID3), and a 0e48 RA disease activity index (RADAI) self-report joint count. Rheumatologists complete a RheuMetric checklist, which includes four 0e10 visual analog scales (VAS) for overall physician global estimate (DOCGL), inflammation or reversible findings (DOCINF), damage or irreversible findings (DOCDAM), and patient distress unexplained by DOCINF or DOCDAM (e.g. fibromyalgia, depression) (DOCSTR). Patients were classified as RA, RA with 2 OA, or primary OA, according to medical record diagnoses. Measures were compared in the 3 groups by MANOVA, adjusted for age. Results: 669 patients seen in routine care between September 2014 and June 2015 were studied, including 248 with RA, 47 with RA and 2 OA (16% of all RA), and 374 with primary OA. Patients with primary OA were significantly older, but no differences were seen in formal education level or gender (Table). MDHAQ scores indicated substantial disease burden in all 3 diagnosis groups, although least in RA patients with no 2 OA, intermediate in RA patients with 2 OA, and greatest in patients with primary OA, e.g., RAPID3 was 11.0±7.7, 12.3±6.7, and 15.1±6.3 in the 3 groups, respectively (Table) (p<0.001 adjusted for age). Among RheuMetric checklist scores, DOCGL did not differ significantly in the 3 groups; DOCDAM was higher than DOCINF in all 3 groups, but differed by 0.7 /10 units in RA vs 1.6 units in RA with secondary OA and 3.2 units in patients with primary OA (Table).
RA N¼ 248
Demographic measures Age, mean, years 56.8 Education level, mean, years 13.7 Female, % 85.8% MDHAQ: Mean Patient self-report scores MDHAQ-Function 2.4 MDHAQ-Pain 4.7 MDHAQ-PATGL 4.2 RAPID3 (0e30) 11.0 RADAI (0e48) 10.7 RheuMetric: Mean Physician Estimates DOCGL 3.7 DOCDAM 2.9 DOCINF 2.2 DOCSTR 1.1
RA with secondary OA N¼ 47
OA N¼374
P
62.4 14.1 80.6%
66.3 13.5 88.1%
<0.001 0.48 0.20
2.8 5.0 4.5 12.3 10.5
2.8 6.3 5.6 15.1 12.1
0.12 <0.001 <0.001 <0.001 0.32
3.9 3.4 1.8 0.5
4.0 4.1 0.9 1.6
0.28 <0.001 <0.001 0.03
Abstracts / Osteoarthritis and Cartilage 25 (2017) S76eS444
346 ACHIEVING IMPORTANT IMPROVEMENT IN WOMAC PAIN AND FUNCTION IMPACTS SATISFACTION 1 YEAR FOLLOWING TOTAL KNEE REPLACEMENT A. Davis y, S. Ibrahim z, S. Hogg-Johnson z, R. Wong y, D. Beaton z, B. Chesworth x, R. Gandhi k, N. Mahomed k, A. Perruccio y, V. Rajgopal ¶, J. Waddell #. y Krembil Res. Inst., Toronto, ON, Canada; z Inst. for Work and Hlth., Toronto, ON, Canada; x Western Univ., London, ON, Canada; k Univ. Hlth.Network, Toronto, ON, Canada; ¶ Middlesex Hosp. Alliance, Strathroy, ON, Canada; # St. Michael's Hosp., Toronto, ON, Canada Purpose: Patients need to be supported in their decision about when and if to have total knee replacement (TKR) based on understanding how their pain and function will be impacted, and satisfaction with outcome. While some research has quantified important improvement (II) in pain and function, the degree to which achievement of II in pain, function and higher demand activities are associated with satisfaction has received little attention. We hypothesized that the association of pre-surgery pain, function, higher demand activities and outcome expectations with 1-year satisfaction were mediated by achievement of II in pain, function and higher demand activities, taking into account factors that are associated with satisfaction following primary TKR. Methods: We followed 354 patients from pre- to 1-year post-TKR. Presurgery, participants completed demographic and health questionnaires, the WOMAC pain and function and Late Life Disability Index (LLDI) limitation subscales, a measure of higher demand activities, and identified outcome expectations for pain, other symptoms, mobility/activities of daily living (ADL), and participation in social roles/instrumental activities of daily living (IADL). The WOMAC, LLDI and a satisfaction questionnaire also were completed 1-year post surgery. All were scored 0e100 with higher scores indicating better outcome. Using II values for WOMAC pain, function and high demand activities generated from a separate cohort recruited from similar centres, we derived a variable indicating if an individual achieved II (no/yes) for each outcome. Based on sensitivity analysis, we categorized those who had baseline scores precluding achievement of II who reached the measure ceiling as achieving the II. We used a Bayesian approach with non-informative priors to evaluate our hypothesized mediation model, adjusting for age, sex, education, obesity, depression (Hospital Anxiety and Depression Scale), comorbidity count and self-rated health. As the tetrachoric correlations among the expectations ranged from 0.11e0.60, they were modeled as individual predictors. Results: The sample mean age was 65 years; 65% were female; and, 66% had >high school education. The mean comorbidity count was 1.6 (sd¼1.3) and depression was 5.3 (sd¼3.5). 40% rated their overall health as very good/excellent. The mean pre-surgery pain, function and high demand activities scores were 47.8 (sd¼17.8), 50.3 (sd¼18.5) and 59.2 (sd¼11.0) respectively. The mean satisfaction score was 80.7 (sd¼21.9). 57, 47, 57 and 15% expected improvement in pain, other symptoms, mobility/ADL and social roles/IADL respectively. 77.3, 77.4 and 78.8% achieved II for pain, function and high demand activities respectively. In the final adjusted model (Figure 1), achieving II in function (estimate 0.668) was directly associated with higher satisfaction and higher expectation for mobility/ADL improvements (0.606) was significantly
directly associated with lower satisfaction. Achieving II in function was associated with higher demand II achievement (0.467). All other significant effects were indirect with a path of baseline pain to achieving pain II (0.147) to achieving function II (0.802) to satisfaction (0.668). Additionally, higher expectation of mobility/ADL improvements was associated with achieving II in higher demand activities through achievement of II in function (indirect path coefficients 0.439 and 0.467). There were no significant direct associations from II in pain or higher demand activities to satisfaction. Conclusions: People who achieve important improvement in function are more likely to be satisfied with the outcome of their TKR surgery. Strategies that target achieving important improvement in function as well as pain post-surgery could be critical to further enhancing outcome satisfaction. 347 DISEASE BURDEN IN RHEUMATOID ARTHRITIS (RA) PATIENTS WHO HAVE SECONDARY OSTEOARTHRITIS (OA) IS LOWER THAN IN PRIMARY OA BUT HIGHER THAN IN RA WITH NO SECONDARY OA I. Castrejon, J.R. Chua, A.M. Malfait, J.A. Block, T. Pincus. RUSH Univ. Med. Ctr., Chicago, IL, USA Purpose: To compare disease burden in patients' in 3 groups: a) primary OA, b) primary RA, or c) patients with RA who are recognized to have secondary (2 ) OA, according to scores on a multi-dimensional health assessment questionnaire (MDHAQ) and physician RheuMetric checklist. Methods: At one academic rheumatology center, all patients with all diagnoses complete an MDHAQ. The MDHAQ includes 0e10 scores for physical function (FN), pain (PN), and patient global estimate (PATGL), compiled into a 0e30 composite routine assessment of patient index data (RAPID3), and a 0e48 RA disease activity index (RADAI) self-report joint count. Rheumatologists complete a RheuMetric checklist, which includes four 0e10 visual analog scales (VAS) for overall physician global estimate (DOCGL), inflammation or reversible findings (DOCINF), damage or irreversible findings (DOCDAM), and patient distress unexplained by DOCINF or DOCDAM (e.g. fibromyalgia, depression) (DOCSTR). Patients were classified as RA, RA with 2 OA, or primary OA, according to medical record diagnoses. Measures were compared in the 3 groups by MANOVA, adjusted for age. Results: 669 patients seen in routine care between September 2014 and June 2015 were studied, including 248 with RA, 47 with RA and 2 OA (16% of all RA), and 374 with primary OA. Patients with primary OA were significantly older, but no differences were seen in formal education level or gender (Table). MDHAQ scores indicated substantial disease burden in all 3 diagnosis groups, although least in RA patients with no 2 OA, intermediate in RA patients with 2 OA, and greatest in patients with primary OA, e.g., RAPID3 was 11.0±7.7, 12.3±6.7, and 15.1±6.3 in the 3 groups, respectively (Table) (p<0.001 adjusted for age). Among RheuMetric checklist scores, DOCGL did not differ significantly in the 3 groups; DOCDAM was higher than DOCINF in all 3 groups, but differed by 0.7 /10 units in RA vs 1.6 units in RA with secondary OA and 3.2 units in patients with primary OA (Table).
RA N¼ 248
Demographic measures Age, mean, years 56.8 Education level, mean, years 13.7 Female, % 85.8% MDHAQ: Mean Patient self-report scores MDHAQ-Function 2.4 MDHAQ-Pain 4.7 MDHAQ-PATGL 4.2 RAPID3 (0e30) 11.0 RADAI (0e48) 10.7 RheuMetric: Mean Physician Estimates DOCGL 3.7 DOCDAM 2.9 DOCINF 2.2 DOCSTR 1.1
RA with secondary OA N¼ 47
OA N¼374
P
62.4 14.1 80.6%
66.3 13.5 88.1%
<0.001 0.48 0.20
2.8 5.0 4.5 12.3 10.5
2.8 6.3 5.6 15.1 12.1
0.12 <0.001 <0.001 <0.001 0.32
3.9 3.4 1.8 0.5
4.0 4.1 0.9 1.6
0.28 <0.001 <0.001 0.03