Patterns of knee osteoarthritis management in general practice:a retrospective cohort study using electronic health records

Objective: This study determined patterns of knee osteoarthritis (OA) management by general practitioners (GPs) using routine healthcare data from Dutch general practices from 2011 to 2019. Design: A retrospective cohort study was conducted using the Integrated Primary Care Information database between 2011 and 2019. Electronic health records (EHRs) of n = 750 randomly selected knee OA patients (with either codified or narrative diagnosis) were reviewed against eligibility criteria and n = 503 patients were included. Recorded information was extracted on GPs’ management from six months before to three years after diagnosis and patterns of management were analysed.Results: An X-ray referral was the most widely recorded management modality (63.2%). The next most widely recorded management modalities were a referral to secondary care (56.1%) and medication prescription or advice (48.3%). Records of recommendation of/referral to other primary care practitioners (e.g. physiotherapists) were found in only one third of the patients. Advice to lose weight was least common (1.2%). Records of medication prescriptions or recommendation of/referral to other primary care practitioners were found more frequently in patients with an X-ray referral compared to patients without, while records of secondary care referrals were found less frequently. Records of an X-ray referral were often found in narratively diagnosed knee OA patients before GPs recorded a code for knee OA in their EHR. Conclusion: These findings emphasize the importance of better implementing non-surgical management of knee OA in general practice and on initiatives for reducing the overuse of X-rays for diagnosing knee OA in general practice.</p

Nonexercise Interventions for Prevention of Musculoskeletal Injuries in Armed Forces: A Systematic Review and Meta-Analysis

Context: This study evaluates the effect of nonexercise interventions on the reduction of risk for musculoskeletal injuries in armed forces. Evidence acquisition: A database search was conducted in PubMed/MEDLINE, Embase, Cochrane Library, CINAHL, SPORTdiscus, Greylit, Open Grey, the WHO trial registry, and the reference lists of included articles up to July 2019. RCTs and cluster RCTs evaluating nonexercise interventions for the prevention of musculoskeletal injuries in armed forces compared with any other intervention(s) or no intervention were eligible for inclusion. Data extraction and risk of bias assessment were done by 2 authors independently, followed by meta-analysis and Grading of Recommendations Assessment, Development,

Nonexercise Interventions for Prevention of Musculoskeletal Injuries in Armed Forces: A Systematic Review and Meta-Analysis

Context: This study evaluates the effect of nonexercise interventions on the reduction of risk for musculoskeletal injuries in armed forces. Evidence acquisition: A database search was conducted in PubMed/MEDLINE, Embase, Cochrane Library, CINAHL, SPORTdiscus, Greylit, Open Grey, the WHO trial registry, and the reference lists of included articles up to July 2019. RCTs and cluster RCTs evaluating nonexercise interventions for the prevention of musculoskeletal injuries in armed forces compared with any other intervention(s) or no intervention were eligible for inclusion. Data extraction and risk of bias assessment were done by 2 authors independently, followed by meta-analysis and Grading of Recommendations Assessment, Development, and Evaluation assessment, if appropriate. Evidence synthesis: This study included 27 articles with a total number of 25,593 participants, examining nutritional supplementation, prophylactic medication, and equipment modifications with mostly high or unclear risk of bias. Meta-analysis and Grading of Recommendations Assessment, Development, and Evaluation assessment could be performed for 3 comparisons: custom-made insoles versus no insoles, tropical/hot-weather boots versus leather boots, and shock-absorbing insoles versus nonshock-absorbing insoles interventions, all showing the very low quality of evidence. Some evidence was found to support the preventive effect of shock-absorbing insoles, basketball shoes, padded polyester socks, calcium with vitamin D supplementation, only calcium supplementation, protein supplementation, and dynamic patellofemoral braces. Conclusions: Although an evidence base for the efficacy of preventive interventions for musculoskeletal injuries in armed forces is weak, there are some indications for the preventive effect of shock-absorbing insoles, basketball shoes, padded polyester socks, supplementation of calcium alone or combined with vitamin D, protein supplementation, and dynamic patellofemoral braces on the incidence of musculoskeletal injuries

Exercise Programs to Reduce the Risk of Musculoskeletal Injuries in Military Personnel: A Systematic Review and Meta-Analysis

Objective: To evaluate the effect of exercise programs on reduction of musculoskeletal injury (MSI) risk in military populations. Design: Systematic review and meta-analysis. Literature Survey: A database search was conducted in PubMed/MEDLINE, EMBASE, Cochrane Library, CINAHL, SPORTdiscus, WHO International Clinical Trials Registry Platform Search Portal, Open Gray, National Technical Reports Library, and reference lists of included articles up to July 2019. Randomized and cluster-randomized controlled trials evaluating exercise programs as preventive interventions for MSIs in armed forces compared to other exercise programs or to usual practice were eligible for inclusion. Methodology: Two authors independently assessed risk of bias and extracted data. Data were adjusted for clustering if necessary and pooled using the random-effects model when appropriate. Synthesis: We included 15 trials in this review, with a total number of 14 370 participants. None of the included trials appeared to be free of any risk of bias. Meta-analysis and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment could be performed for static stretching compared to no stretching (3532 participants), showing low quality of evidence indicating no favorable effect of stretching. Gait retraining, an anterior knee-pain targeted program, and resistance exercises showed cautious favorable effects on reducing injury risk in military personnel. Conclusion: The current evidence base for exercise-based MSI prevention strategies in the military is of low quality. Areas worthy of further exploration include the effects of gait retraining, anterior knee-pain targeted programs, agility training, and resistance training programs, on medial tibial stress syndrome incidence, anterior knee pain incidence, attrition due to injuries and any type of MSI, respectively

Incidence and prevalence of knee osteoarthritis using codified and narrative data from electronic health records: a population-based study

OBJECTIVE: This study aimed to determine the incidence and prevalence of knee osteoarthritis (OA) using codified and narrative data from general practices throughout the Netherlands. METHODS: A retrospective cohort study was conducted using the Integrated Primary Care Information database. Patients with codified knee OA were selected and an algorithm was developed to identify patients with narratively diagnosed knee OA only. Point prevalence proportions and incidence rates among people aged ≥30 were assessed from 2008 to 2019. The association of comorbidities with codified knee OA was analysed using multivariable logistic regression. RESULTS: The positive predicted value of narratively diagnosed knee OA only was 94.0% (95%CI 87.4%-100%) and for codified knee OA 96.0% (95%CI 90.6%-100%). Including narrative data in addition to codified data resulted in a prevalence of 1.83 to 2.01 times higher (over the study years); prevalence increased from 5.8% to 11.8% between 2008 and 2019. The incidence rate was on 1.93 to 2.28 times higher and increased from 9.98 per 1000 person-years to 13.8 per 1000 person-years between 2008 and 2019. Among patients with codified knee OA, 39.4% were previously diagnosed narratively with knee OA, on average approximately three years earlier. Comorbidities influenced the likelihood of being recorded with codified knee OA. CONCLUSION: Our study of a Dutch primary care database showed that current incidence and prevalence estimates based on codified data alone from electronic health records are underestimated. Narrative data can be incorporated in addition to codified data to identify knee OA patients more accurately

Estimating incidence and prevalence of hip osteoarthritis using electronic health records: a population-based cohort study

Objective: To determine the incidence and prevalence of hip osteoarthritis (OA) in electronic health records (EHRs) of Dutch general practices by using narrative and codified data. Method: A retrospective cohort study was conducted using the Integrated Primary Care Information database. An algorithm was developed to identify patients with narratively diagnosed hip OA in addition to patients with codified hip OA. Incidence and prevalence estimates among people aged ≥30 were assessed from 2008 to 2019. The association of comorbidities with codified hip OA diagnosis was analysed using multivariable logistic regression. Results: Using the hip OA narrative data algorithm (positive predicted value = 72%) in addition to codified hip OA showed a prevalence of 1.76–1.95 times higher and increased from 4.03% in 2008 to 7.34% in 2019. The incidence was 1.83–2.41 times higher and increased from 6.83 to 7.78 per 1000 person-years from 2008 to 2019. Among codified hip OA patients, 39.4% had a previous record of narratively diagnosed hip OA, on average approximately 1.93 years earlier. Hip OA patients with a previous record of spinal OA, knee OA, hypertension, and hyperlipidaemia were more likely to be recorded with a hip OA code. Conclusion: This study using Dutch EHRs showed that epidemiological estimates of hip OA are likely to be an underestimation. Using our algorithm, narrative data can be added to codified data for more realistic epidemiological estimates based on routine healthcare data. However, developing a valid algorithm remains a challenge, possibly due to the diagnostic complexity of hip pain in general practice

Evaluation of intermediate care for knee and hip osteoarthritis: a mixed-methods study

Background: To evaluate intermediate care for knee and hip osteoarthritis (KHOA) in the general practice that incorporate specialist services into general practice to prevent unnecessary referrals to hospitals. Methods: We used a mixed methods approach including semi-structured interviews, patient experience questionnaires and data from medical records from three intermediate care projects. Semi-structured interviews were conducted with patients, general practitioners (GPs), orthopaedists and a healthcare manager in intermediate care. Satisfaction of patients who received intermediate care (n = 100) was collected using questionnaires. Referral data and healthcare consumption from medical records were collected retrospectively from KHOA patients before (n = 96) and after (n = 208) the implementation of intermediate care. Results: GPs and orthopaedists in intermediate care experienced more intensive collaboration compared to regular care. This led to a perceived increase in GPs’ knowledge enabling better selection of referrals to orthopaedics and less healthcare consumption. Orthopaedists felt a higher workload and limited access to diagnostic facilities. Patients were satisfied and experienced better access to specialists’ knowledge in a trusted environment compared to regular care. Referrals to physiotherapy increased significantly after the implementation of intermediate care (absolute difference = 15%; 95% CI = 7.19 to 22.8), but not significantly to orthopaedics (absolute difference = 5.9%; 95% CI = -6.18 to 17.9). Conclusions: Orthopaedists and GPs perceived the benefits of an intensified collaboration in intermediate care. Intermediate care may contribute to high quality of care through more physiotherapy referrals. Further research with longer follow-up is needed to confirm these findings and give more insight in referrals and healthcare consumption

Quality indicators for knee and hip osteoarthritis care: a systematic review

To provide an overview of quality indicators (QIs) for knee and hip osteoarthritis (KHOA) care and to highlight differences in healthcare settings. A database search was conducted in MEDLINE (PubMed), EMBASE, CINAHL, Web of Science, Cochrane CENTRAL and Google Scholar, OpenGrey and Prospective Trial Register, up to March 2020. Studies developing or adapting existing QI(s) for patients with osteoarthritis were eligible for inclusion. Included studies were categorised into healthcare settings. QIs from included studies were categorised into structure, process and outcome of care. Within these categories, QIs were grouped into themes (eg, physical therapy). A narrative synthesis was used to describe differences and similarities between healthcare settings. We included 20 studies with a total of 196 QIs mostly related to the process of care in different healthcare settings. Few studies included patients’ perspectives. Rigorous methods for evidence synthesis to develop QIs were rarely used. Narrative analysis showed differences in QIs between healthcare settings with regard to exercise therapy, weight counselling, referral to laboratory tests and ‘do not do’ QIs. Differences within the same healthcare setting were identified on radiographic assessment. The heterogeneity in QIs emphasise the necessity to carefully select QIs for KHOA depending on the healthcare setting. This review provides an overview of QIs outlined to their healthcare settings to support healthcare providers and policy makers in selecting the contextually appropriate QIs to validly monitor the quality of KHOA care. We strongly recommend to review QIs against the most recent guidelines before implementing them into practice

Fatty acid metabolism in European sea bass (Dicentrarchus labrax) : effects of n-6 PUFA and MUFA in fish oil replaced diets

Monounsaturated fatty acids (MUFA)-rich and n-6 polyunsaturated fatty acid (n-6 PUFA)-rich vegetable oils are increasingly used as fish oil replacers for aquafeed formulation. The present study investigated the fatty acid metabolism in juvenile European sea bass (Dicentrarchus labrax, 38.4&nbsp;g) fed diets containing fish oil (FO, as the control treatment) or two different vegetable oils (the MUFA-rich canola/rapeseed oil, CO, and the n-6 PUFA-rich cottonseed oil, CSO) tested individually or as a 50/50 blend (CO/CSO). The whole-body fatty acid balance method was used to deduce the apparent in vivo fatty acid metabolism. No effect on growth performance and feed utilization was recorded. However, it should be noted that the fish meal content of the experimental diets was relatively high, and thus the requirement for n-3 long-chain polyunsaturated fatty acid (n-3 LC-PUFA) may have likely been fulfilled even if dietary fish oil was fully replaced by vegetable oils. Overall, relatively little apparent in vivo fatty acid bioconversion was recorded, whilst the apparent in vivo ?-oxidation of dietary fatty acid was largely affected by the dietary lipid source, with higher rate of ?-oxidation for those fatty acids which were provided in dietary surplus. The deposition of 20:5n-3 and 22:6n-3, as % of the dietary intake, was greatest for the fish fed on the CSO diet. It has been shown that European sea bass seems to be able to efficiently use n-6 PUFA for energy substrate, and this may help in minimizing the ?-oxidation of the health benefiting n-3 LC-PUFA and thus increase their deposition into fish tissues