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1.  Surgery or Consultation: A Population-Based Cohort Study of Use of Orthopaedic Surgeon Services 
PLoS ONE  2013;8(6):e65560.
Background
This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon.
Methods
Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1st, 2004 and September 30th, 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months.
Results
Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0–24 and 25–44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0–24: OR 3.45 95%CI 3.33–3.57; age 25–44: OR 1.30 95%CI 1.27–1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions.
Conclusion
A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum.
doi:10.1371/journal.pone.0065560
PMCID: PMC3672140  PMID: 23750266
2.  Chronic back problems and labor force participation in a national population survey: impact of comorbid arthritis 
BMC Public Health  2013;13:326.
Background
Back problems and arthritis are common chronic conditions, while having back problems is a frequent reason for lost work time. The objective of this study was to investigate employment status amongst individuals who report having both back problems and arthritis, compared to having either condition alone.
Methods
We analyzed data from the 2007/2008 Canadian Community Health Survey (ages 25–64, n = 79,719). Respondents who reported neither having worked in the past 12 months nor the past week were coded as not currently employed. Those reported being permanently unable to work were considered to be out of the labor force. Log-Poisson regressions, adjusting for socio-demographic and lifestyle factors, were used to estimate risks for being not currently employed or being out of the labor force for 5 mutually exclusive groups of chronic conditions: arthritis and back problems, back problems, arthritis, any other chronic conditions, and no chronic conditions.
Results
12.7% of respondents reported being not currently employed and 2.9% being out of the labor force. 5.8% of respondents reported both arthritis and back problems, while 16.1% reported back problems and 7.3% arthritis. The back problems and arthritis group had the highest risk of not being currently employed. The risk was higher for men (PR = 1.90; 95% CI = 1.58, 2.29) than for women (PR = 1.31; 95% CI = 1.18, 1.46). Risks of being permanently unable to work were also the greatest for those with comorbid back problems and arthritis.
Conclusions
There is a need for a reappraisal of back problems as a cause of work disability to account for the possibility of co-occurring arthritis.
doi:10.1186/1471-2458-13-326
PMCID: PMC3626871  PMID: 23575216
Arthritis; Back problems; Employment; Comorbidity
3.  The relative impact of 13 chronic conditions across three different outcomes 
Study objective
Previous estimates of individual and population attributable risks for adverse outcomes due to chronic conditions have considered only a limited number of conditions and outcomes, with some studies using inappropriate formulae or methods of estimation. This study re‐examines the magnitude of individual and population attributable risks for a wide range of conditions and various health outcomes.
Design
Log‐Poisson regression was used to calculate prevalence ratios as an indicator of individual risk and population‐associated fractions of 13 chronic conditions, examining activity limitations, self‐rated health and physician visits. The effect of multimorbidity on prevalence ratios was examined.
Setting
Canada, 2000–01.
Participants
Nationally representative sample of Canadians aged 12+ years (n = 130 880).
Main results
At the individual level, fibromyalgia/chronic fatigue syndrome and cancer, and to a lesser extent stroke and heart disease, were associated with an increased risk of both activity limitations and a self‐rated health status of fair or poor; high blood pressure was associated with four or more physician visits in the previous 12 months. In contrast, population attributable fractions were substantial for arthritis/rheumatism, heart disease, back problems and high blood pressure across all outcomes. Adjustment for multimorbidity resulted in a marked decreases in prevalence ratios.
Conclusions
Differences in the ranking of individual risks and population attributable fractions for different diseases and outcomes are substantial. This needs to be taken into account when setting priorities, as interventions may need to be targeted to different conditions depending on which aspects of health are being considered, and whether the focus is on individuals, such as in clinical care, or improving the health of the population.
doi:10.1136/jech.2006.047308
PMCID: PMC2465660  PMID: 18000127
chronic disease; health survey; population; cross‐sectional analysis; health priorities
4.  A single group follow-up study of non-surgical patients seen by physiotherapists working in expanded roles in orthopaedic departments: recall of recommendations, change in exercise and self-efficacy 
BMC Research Notes  2012;5:669.
Background
Specially trained physiotherapists (advanced practice physiotherapists (APP)) are working in orthopaedic clinics to improve access to orthopaedic services and support chronic disease management. Little attention has been paid to the impact APPs may have on non-surgical patients. In non-surgical patients with hip or knee arthritis consulting an APP in an orthopaedic clinic, the objectives were to: 1) describe patients’ recall of APP recommendations, use of self-management strategies, and barriers to management six weeks following consultation; and, 2) compare exercise behaviour and self-efficacy at baseline and six weeks.
Findings
This was a single group pre-and post-intervention study of patients who saw an APP when consulting the orthopaedic departments of two hospitals. At baseline and six weeks participants completed the adapted Stanford Exercise Behaviour Scale (response options: none, < 60 minutes/week, 1–3 hours/week or > 3 hours/week), and the Chronic Disease Self-efficacy Scale (range 1–10; higher scores indicate higher self-efficacy). At follow-up participants completed questions on recall of APP recommendations, use of self-management strategies and barriers to management. Seventy three non-surgical patients with hip or knee arthritis participated, a response rate of 89% at follow-up. Seventy one percent of patients reported that the APP recommended exercise, of whom 83% reported exercising to manage their arthritis since the visit. Almost 50% reported an increase in time spent stretching; over 40% reported an increase in time spent walking or doing strengthening exercises at follow-up. Common barriers to arthritis management were time, cost and other health problems. Mean chronic disease self-efficacy scores significantly improved from 6.3 to 7.2 (p < 0.001). The mean difference was 0.95 (95% CI 0.43, 1.62); the effect size was 0.51.
Conclusions
This pilot study of an APP intervention for non-surgical patients referred for orthopaedic consultation showed promising results, particularly for enhancing use of conservative management strategies such as exercise.
doi:10.1186/1756-0500-5-669
PMCID: PMC3538671  PMID: 23206311
Arthritis; Physiotherapists; Advanced practice; Non-surgical; Self-management behaviours; Orthopaedics
5.  Magnitude of impact and healthcare use for musculoskeletal disorders in the paediaric: a population-based study 
Background
Although musculoskeletal disorders (MSD) are among the most prevalent chronic conditions, minimal attention has been paid to the paediatric population. The aim of this study is to describe the annual prevalence of healthcare contacts for MSD by children and youth age 0-19 years, including type of MSD, care delivery setting and the specialty of the physician consulted.
Methods
Analysis of data on all children with healthcare contacts for MSD in Ontario, Canada using data from universal health insurance databases on ambulatory physician and emergency department (ED) visits, same-day outpatient surgery, and in-patient admissions for the fiscal year 2006/07. The proportion of children and youth seeing different physician specialties was calculated for each physician and condition grouping. Census data for the 2006 Ontario population was used to calculate person visit rates.
Results
122.1 per 1,000 children and youth made visits for MSD. The majority visited for injury and related conditions (63.2 per 1,000), followed by unspecified MSD complaints (33.0 per 1,000), arthritis and related conditions (27.7 per 1,000), bone and spinal conditions (14.2 per 1,000), and congenital anomalies (3 per 1,000). Injury was the most common reason for ED visits and in-patient admissions, and arthritis and related conditions for day-surgery. The majority of children presented to primary care physicians (74.4%), surgeons (22.3%), and paediatricians (10.1%). Paediatricians were more likely to see younger children and those with congenital anomalies or arthritis and related conditions.
Conclusion
One in eight children and youth make physician visits for MSD in a year, suggesting that the prevalence of MSD in children may have been previously underestimated. Although most children may have self-limiting conditions, it is unknown to what extent these may deter involvement in physical activity, or be indicators of serious and potentially life-threatening conditions. Given deficiencies in medical education, particularly of primary care physicians and paediatricians, it is important that training programs devote an appropriate amount of time to paediatric MSD.
doi:10.1186/1471-2474-13-98
PMCID: PMC3493363  PMID: 22691633
6.  Tension at the borders: perceptions of role overload, conflict, strain and facilitation in work, family and health roles among employed individuals with arthritis 
Rheumatology (Oxford, England)  2011;51(2):324-332.
Objective. To examine inter-relationships among arthritis (A), work (W) and personal life (P) roles and their reciprocal influences, especially experiences of role balance/imbalance among individuals with inflammatory arthritis (IA) and OA.
Methods. Eight focus groups were conducted with 24 women and 16 men (aged 29–72 years). A purposive sample was recruited from community advertising. Eligibility included current employment or having been employed within the previous year. Participants were asked about ways arthritis, work and personal life roles intersected and their impact. A standardized questionnaire collected demographic, symptom and employment data for descriptive purposes.
Results. Participants noted that having arthritis affected their identity and intersected with work and personal roles, creating role overload, role conflict, role strain and role facilitation. Role overload highlighted that arthritis both affected and was impacted by work and personal life (A → W; A → P; W → A; P → A). Role conflict focused on A → W and A → P difficulties, whereas role facilitation emphasized the positive impact of work and personal life roles on arthritis (W → A; P → A). Role strain was pervasive and arose from numerous sources. Personal strategies (e.g. positive framing) and contextual factors (e.g. support) were important in contributing to or ameliorating role balance/imbalance.
Conclusions. By comprehensively examining multiple types of role balance/imbalance and the context within which it occurs, this study identifies gaps in patient-oriented measurement of the impact of arthritis and areas of need in the development of arthritis intervention.
doi:10.1093/rheumatology/ker317
PMCID: PMC3262164  PMID: 22039223
arthritis; employment; participation; work–family conflict; role overload; role conflict; role strain; role facilitation
7.  Musculoskeletal comorbidities in cardiovascular disease, diabetes and respiratory disease: the impact on activity limitations; a representative population-based study 
BMC Public Health  2011;11:77.
Background
The purpose of this study was to quantify the contribution of comorbidity to activity limitations in populations with chronic cardiovascular disease, diabetes or respiratory disease (index conditions), with emphasis on musculoskeletal comorbidity (arthritis or back problems).
Methods
Analysis of the 2005 Canadian Community Health Survey 3.1 (age 20+ years, n = 115,915). Prevalence ratios for activity limitations in people with the index conditions and co-occurring musculoskeletal disease, adjusted for age, gender, and socioeconomic factors, were used to estimate population associated fractions (PAF).
Results
Comorbid arthritis and back problems significantly increased the risk of activity limitations across all index conditions with prevalence ratios of 1.60 and 1.46 for cardiovascular disease, 1.51 and 1.36 for diabetes, and 1.38 and 1.44 for respiratory disease for arthritis and back problems respectively. Arthritis and back problems accounted for at least 13% and 9% of activity limitations in the index populations.
Conclusions
While chronic musculoskeletal conditions are not always considered priorities in chronic disease prevention, they account for a substantial proportion of activity restrictions seen in people with cardiovascular disease, diabetes and respiratory disease, with implications for prevention and control strategies.
doi:10.1186/1471-2458-11-77
PMCID: PMC3040146  PMID: 21291555
8.  A population-based study of ambulatory and surgical services provided by orthopaedic surgeons for musculoskeletal conditions 
Background
The ongoing process of population aging is associated with an increase in prevalence of musculoskeletal conditions with a concomitant increase in the demand of orthopaedic services. Shortages of orthopaedic services have been documented in Canada and elsewhere. This population-based study describes the number of patients seen by orthopaedic surgeons in office and hospital settings to set the scene for the development of strategies that could maximize the availability of orthopaedic resources.
Methods
Administrative data from the Ontario Health Insurance Plan and Canadian Institute for Health Information hospital separation databases for the 2005/06 fiscal year were used to identify individuals accessing orthopaedic services in Ontario, Canada. The number of patients with encounters with orthopaedic surgeons, the number of encounters and the number of surgeries carried out by orthopaedic surgeons were estimated according to condition groups, service location, patient's age and sex.
Results
In 2005/06, over 520,000 Ontarians (41 per 1,000 population) had over 1.3 million encounters with orthopaedic surgeons. Of those 86% were ambulatory encounters and 14% were in hospital encounters. The majority of ambulatory encounters were for an injury or related condition (44%) followed by arthritis and related conditions (37%). Osteoarthritis accounted for 16% of all ambulatory encounters. Orthopaedic surgeons carried out over 140,000 surgeries in 2005/06: joint replacement accounted for 25% of all orthopaedic surgeries, whereas closed repair accounted for 16% and reductions accounted for 21%. Half of the orthopaedic surgeries were for arthritis and related conditions.
Conclusion
The large volume of ambulatory care points to the significant contribution of orthopaedic surgeons to the medical management of chronic musculoskeletal conditions including arthritis and injuries. The findings highlight that surgery is only one component of the work of orthopaedic surgeons in the management of these conditions. Policy makers and orthopaedic surgeons need to be creative in developing strategies to accommodate the growing workload of orthopaedic surgeons without sacrificing quality of care of patients with musculoskeletal conditions.
doi:10.1186/1472-6963-9-56
PMCID: PMC2682488  PMID: 19335904
9.  Characteristics of evolving models of care for arthritis: A key informant study 
Background
The burden of arthritis is increasing in the face of diminishing health human resources to deliver care. In response, innovative models of care delivery are developing to facilitate access to quality care. Most models have developed in response to local needs with limited evaluation. The primary objective of this study is to a) examine the range of models of care that deliver specialist services using a medical/surgical specialist and at least one other health care provider and b) document the strengths and challenges of the identified models. A secondary objective is to identify key elements of best practice models of care for arthritis.
Methods
Semi-structured interviews were conducted with a sample of key informants with expertise in arthritis from jurisdictions with primarily publicly-funded health care systems. Qualitative data were analyzed using a constant comparative approach to identify common types of models of care, strengths and challenges of models, and key components of arthritis care.
Results
Seventy-four key informants were interviewed from six countries. Five main types of models of care emerged. 1) Specialized arthritis programs deliver comprehensive, multidisciplinary team care for arthritis. Two models were identified using health care providers (e.g. nurses or physiotherapists) in expanded clinical roles: 2) triage of patients with musculoskeletal conditions to the appropriate services including specialists; and 3) ongoing management in collaboration with a specialist. Two models promoting rural access were 4) rural consultation support and 5) telemedicine. Key informants described important components of models of care including knowledgeable health professionals and patients.
Conclusion
A range of models of care for arthritis have been developed. This classification can be used as a framework for discussing care delivery. Areas for development include integration of care across the continuum, including primary care.
doi:10.1186/1472-6963-8-147
PMCID: PMC2491608  PMID: 18625070
10.  Fatigue in osteoarthritis: a qualitative study 
Background
Fatigue is recognized as a disabling symptom in many chronic conditions including rheumatic disorders such as rheumatoid arthritis (RA) and lupus. Fatigue in osteoarthritis (OA) is not routinely evaluated and has only been considered in a very limited number of studies. To date, these studies have focused primarily on patients with OA under rheumatological care, which represent the minority of people living with OA. The purpose of this study was to increase our understanding of the fatigue experience in community dwelling people with OA.
Methods
In 2004, 8 focus groups were conducted with 28 men and 18 women (mean age 72.3) with symptomatic hip or knee OA recruited from a population-based cohort. Participants completed a self-administered questionnaire, which included demographics, measures of OA severity (WOMAC), depression (CES-D) and fatigue (FACIT). Sessions were audio taped and transcribed verbatim. Two researchers independently reviewed the transcripts to identify themes. Findings were compared and consensus reached.
Results
Mean pain, disability, depression and fatigue scores were 8.7/20, 27.8/68, 15.4/60, and 30.9/52, respectively. Participants described their fatigue as exhaustion, being tired and "coming up against a brick wall". Participants generally perceived fatigue as different from sleepiness and distinguished physical from mental fatigue. Factors believed to increase fatigue included OA pain and pain medications, aging, various types of weather and poor sleep. Mental health was identified as both affecting fatigue and being affected by fatigue. Participants described fatigue as impacting physical function, and their ability to participate in social activities and to do household chores. Rest, exercise, and avoiding or getting assistance with activities were cited as ways of coping. Participants generally did not discuss their fatigue with anyone except their spouses.
Conclusion
Participants with OA described experiencing notable amounts of fatigue and indicated that it had a substantial impact on their lives. Further research is required to better understand the role of fatigue in OA in order to identify strategies to reduce its impact.
doi:10.1186/1471-2474-9-63
PMCID: PMC2386135  PMID: 18452607
11.  Assessment of health-related quality of life in arthritis: conceptualization and development of five item banks using item response theory 
Background
Modern psychometric methods based on item response theory (IRT) can be used to develop adaptive measures of health-related quality of life (HRQL). Adaptive assessment requires an item bank for each domain of HRQL. The purpose of this study was to develop item banks for five domains of HRQL relevant to arthritis.
Methods
About 1,400 items were drawn from published questionnaires or developed from focus groups and individual interviews and classified into 19 domains of HRQL. We selected the following 5 domains relevant to arthritis and related conditions: Daily Activities, Walking, Handling Objects, Pain or Discomfort, and Feelings. Based on conceptual criteria and pilot testing, 219 items were selected for further testing. A questionnaire was mailed to patients from two hospital-based clinics and a stratified random community sample. Dimensionality of the domains was assessed through factor analysis. Items were analyzed with the Generalized Partial Credit Model as implemented in Parscale. We used graphical methods and a chi-square test to assess item fit. Differential item functioning was investigated using logistic regression.
Results
Data were obtained from 888 individuals with arthritis. The five domains were sufficiently unidimensional for an IRT-based analysis. Thirty-one items were deleted due to lack of fit or differential item functioning. Daily Activities had the narrowest range for the item location parameter (-2.24 to 0.55) and Handling Objects had the widest range (-1.70 to 2.27). The mean (median) slope parameter for the items ranged from 1.15 (1.07) in Feelings to 1.73 (1.75) in Walking. The final item banks are comprised of 31–45 items each.
Conclusion
We have developed IRT-based item banks to measure HRQL in 5 domains relevant to arthritis. The items in the final item banks provide adequate psychometric information for a wide range of functional levels in each domain.
doi:10.1186/1477-7525-4-33
PMCID: PMC1550394  PMID: 16749932
12.  The Impact of Arthritis on Canadian Women 
BMC Women's Health  2004;4(Suppl 1):S18.
Health Issue
Arthritis is one of the most prevalent chronic conditions in Canada and a leading cause of long-term disability, pain, and increased health care utilization. It is also a far more prevalent condition among women than men. Information was obtained primarily from the 1998–99 National Population Health Survey and the Canadian Joint Replacement Registry.
Key Findings
In 1998, the overall prevalence of self-reported arthritis or rheumatism in Canadian women was 20.0%. This rate increased to 55.6% among women over 75 years of age. Compared to women with chronic conditions, women with arthritis were more likely to experience long-term disability; report worse health; experience more pain; be dependent upon others and consult general practitioners, specialists, and physiotherapists more frequently. While men and women with arthritis under-utilize total joint replacement surgery, the degree of under-use was over three times greater for women.
Data Gaps and Recommendations
There is a lack of detailed information on the use of health care services by women with arthritis. There are also no systematic data available on the prescribing of medications, access to services such as assistive devices or exercise programs, or use of community support, self-management strategies, or rehabilitation services. The burden of arthritis both on women and on society is expected to increase as the population ages. A comprehensive health strategy to reduce the impact of arthritis is required to ensure that health and support services are available in a timely manner and provided in such a way to meet the needs of Canadian women.
doi:10.1186/1472-6874-4-S1-S18
PMCID: PMC2096689  PMID: 15345081
13.  Improving Primary Health Care in Chronic Musculoskeletal Conditions through Digital Media: The PEOPLE Meeting 
JMIR Research Protocols  2013;2(1):e13.
Background
Musculoskeletal (MSK) conditions are the most common cause of severe chronic pain and disability worldwide. Despite the impact of these conditions, disparity exists in accessing high quality basic care. As a result, effective treatments do not always reach people who need services. The situation is further hampered by the current models of care that target resources to a limited area of health services (eg, joint replacement surgery), rather than the entire continuum of MSK health, which includes services provided by primary care physicians and health professionals. The use of digital media offers promising solutions to improve access to services. However, our knowledge in this field is limited. To advance the use of digital media in improving MSK care, we held a research planning meeting entitled “PEOPLE: Partnership to Enable Optimal Primary Health Care by Leveraging Digital Media in Musculoskeletal Health”. This paper reports the discussion during the meeting.
Objective
The objective of this study was to: (1) identify research priorities relevant to using digital media in primary health care for enhancing MSK health, and (2) develop research collaboration among researchers, clinicians, and patient/consumer communities.
Methods
The PEOPLE meeting included 26 participants from health research, computer science/digital media, clinical communities, and patient/consumer groups. Based on consultations with each participant prior to the meeting, we chose to focus on 3 topics: (1) gaps and issues in primary health care for MSK health, (2) current application of digital media in health care, and (3) challenges to using digital media to improve MSK health in underserviced populations.
Results
The 2-day discussion led to emergence of 1 overarching question and 4 research priorities. A main research priority was to understand the characteristics of those who are not able to access preventive measures and treatment for early MSK diseases. Participants indicated that this information is necessary for tailoring digital media interventions. Other priorities included: (1) studying barriers and ethical issues associated with the use of digital media to optimize MSK health and self-management, (2) improving the design of digital media tools for providing “just-in-time” health information to patients and health professionals, and (3) advancing knowledge on the effectiveness of new and existing digital media interventions.
Conclusions
We anticipate that the results of this meeting will be a catalyst for future research projects and new cross-sector research partnerships. Our next step will be to seek feedback on the research priorities from our collaborators and other potential partners in primary health care.
doi:10.2196/resprot.2267
PMCID: PMC3628154  PMID: 23612113
primary health care; Internet; digital media; health service delivery

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