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2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and KneeObjective: To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. Methods: We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. Results: Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. Conclusion: This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients’ values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.
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Utilization and Cost of the Biologic Disease Modifying Anti-rheumatic Drugs among Medicare Beneficiaries with Rheumatoid ArthritisBackground: Disease modifying anti-rheumatic drugs (DMARDs) are essential for symptom control among rheumatoid arthritis (RA) patients. Biologic DMARDs are expensive and typically used among moderate to severe RA patients. The prevalence of RA is higher among Medicare beneficiaries compared to the rest of the population in the U.S (2% vs. 0.6%). The coverage rules of Medicare, in addition to access factors and patient preferences, may influence the use of facility-administered, infusible biologics (Part B covered) and home-administered self-injectable/oral biologics (Part D covered). However, there is limited information about utilization patterns of biologic DMARDs by route of administration and their impact on Medicare spending overall. The goals of this dissertation were to identify patient factors and healthcare expenditure associated with biologic DMARD use by route of administration among Medicare beneficiaries with RA. Methods: The study population consisted of Medicare beneficiaries with RA from the 5% random sample of the Chronic Conditions Warehouse database from 2006-2015. First, the study analyzed patient-level factors associated with biologic DMARD use by route of administration using generalized estimating equations. Second, adherence (PDC>80%), discontinuation, and switching patterns for biologic DMARDs were measured, accounting for patient level-factors , using logistic regression, Cox proportional hazards models, and chi-square analyses, respectively. Third, the study compared annualized average healthcare costs of patients who were adherent to versus non-adherent to biologic DMARDs. Results: Among Medicare beneficiaries diagnosed with RA who received DMARD treatment (n=46,002), 71.8% (n=33,028) used traditional DMARDs, and among biologic DMARD users (n=12,931), twice as many used infusible biologics (18.3%, n=8,436) compared to self-injectable/oral (9.9%, n=4,538). Beneficiaries who were low-income subsidy (LIS) recipients i.e. who had lower out-of-pocket costs for using biologics, (compared to non-LIS) had 4.54 times higher odds of using self-injectable/oral biologics (95% CI: 4.2 - 5.0) and 5% lower odds of discontinuing biologic DMARDs (OR=0.94, 95% CI: 0.91-0.97). The total healthcare cost was lower among adherent compared to non-adherent infusible biologic DMARD users ($33,797 vs. $90,181; p<0.001) and among adherent vs. non-adherent self-injectable/oral biologic DMARD users ($64,977 vs. $80.908; p<0.05). Conclusions: Adherence and cost savings generated, as a result, varied by the biologic DMARD route of administration. Additionally, beneficiaries' LIS status was associated with the route of administration used and the discontinuation rates, indicating an association with their out-of-pocket costs. These findings are relevant to the discussion about the proposed transition of Part B covered infusible medications under the Part D which is projected to increase the beneficiary out-of-pocket cost. The evidence on adherence can also be used for value-based insurance design involving RA biologics. Future research could leverage the findings from this study to additionally explore how biosimilar products may impact overall biologic utilization and RA treatment spending.
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Race and socioeconomic status as predictors of utilization and need for total knee arthroplasty for knee osteoarthritis: Data from the OsteoArthritis Initiative studyObjective: Previous studies consistently report reduced rates of utilization of total knee arthroplasty (TKA) among black U.S. adults as compared with whites. This study assessed whether differences in TKA utilization rates between blacks and whites persist after including estimates of socioeconomic status and theoretical candidacy for joint replacement surgery. This study also examined whether blacks and whites differ in rate of reaching candidacy for TKA, and whether socioeconomic factors are related to reaching VTKA. Methods: This study employed data from the OsteoArthritis Initiative study. Study participants were black and white adults enrolled in the OAI study between the ages of 49 and 79 at baseline. Study aims were achieved using a discrete survival approach. Cox-analogue proportional hazards models were employed using a log minus log link to produce hazard ratios specific to respective intervals between time points. Models were fit using General Estimating Equations. Results: Results showed that blacks were significantly less likely to undergo total knee arthroplasty than whites, even after including estimates of baseline differences in BMI and number of comorbidities, baseline need for TKA, and socioeconomic status (education and income) (e^(β)=0.50, p=0.0016). Individuals who met need for TKA criteria at baseline were significantly more likely to undergoing TKA than those who did not (e^(β)=8.25, p<0.0001). Results also revealed race not to be a significant predictor of reaching need for TKA after including estimates of baseline differences in BMI and number of comorbidities. These findings persisted even with the inclusion of socioeconomic variables. Conclusions: Findings confirmed that substantial racial differences in utilization of TKA exist. The inclusion of socioeconomic status measures accounted for only a small proportion of the difference between blacks and whites in terms of TKA utilization (e^(β)=0.41 versus e^(β)=0.50). Racial differences in progression of knee OA to virtual TKA were also found, although race became non-significant after accounting for baseline differences in BMI categories (overweight and obese). Results suggest that other factors not captured in this study differentially influence the rate of TKA utilization among black and white U.S. adults.
