Up to one-third of patients experience limited benefit following surgical intervention for LS-OA. Thus, identifying contributing factors to this is important. People with OA often have multijoint involvement, yet this has received limited attention in this population. We documented the occurrence and evaluated the influence of multijoint symptoms on outcome following surgery for LS-OA.

141 patients undergoing decompression surgery+/−fusion for LS-OA completed the Oswestry Disability Index (ODI) pre- and 12-months post-surgery. Also captured pre-surgery: age, sex, education, BMI, smoking, depressive symptoms and comorbidities. Any joints with “pain/stiffness/swelling most days of the month” were indicated on a homunculus. A symptomatic joint site count (e.g. one/both knees= one site), excluding the back, was derived (range zero to nine) and considered as a predictor of magnitude of ODI change, and likelihood of achieving minimally clinically important improvement in ODI (MCID=12.8) using multivariable adjusted linear and log-Poisson regression analyses.

Mean age: 66 years (range:42–90), 46% female. 76% reported one+ joint site other than the back, 43% reported three+, and nearly 10% reported six+. (< MCID) for those with three sites, and four units for those with six+ sites. Associated with a greater likelihood of not achieving MCID were increasing joint count (11% increase per site (p=0.012)), higher BMI, current/former smoker, and worse baseline ODI tertile.

Results suggest there is more than just the back to consider to understand patient-reported back outcomes. Multijoint symptoms directly contribute to disability, but there is potential they may contribute to systemic, largely inflammatory, effects in OA as well.

The objective of this study was to quantify the burden of musculoskeletal disorders (MSDs) on the Ontario health care system. Specifically, we examined the magnitude and costs of MSD-associated ambulatory physician care and hospital service use, considering different physician types (e.g. primary care, rheumatologists, orthopaedic surgeons) and hospital settings (e.g. emergency department (ED), day surgery, inpatient hospitalizations).

Administrative health data were analyzed for fiscal year 2013/14 for adults aged 18+ years (N=10,841,302). Data sources included: Ontario Health Insurance Plan Claims History Database, which captures data on in- and out-patient physician services, Canadian Institute for Health Information (CIHI) Discharge Abstract Database, which records diagnoses and procedures associated with all inpatient hospitalizations, and CIHI National Ambulatory Care Reporting System, which captures data on all emergency department (ED) and day surgery encounters. Services associated with MSDs were identified using the single three digit International Classification of Diseases (ICD) version 9 diagnosis code provided on each physician service claim for outpatient physician visits and the “most responsible” ICD-10 diagnosis code recorded for hospitalizations, ED visits and day surgeries. Patient visit rates and numbers of patients and visits were tabulated according to care setting, patient age and sex, and physician specialty. Direct medical costs were estimated by care setting. Data were examined for all MSDs combined as well as specific diagnostic groupings, including a comprehensive list of both trauma and non-trauma related conditions.

Overall, 3.1 million adult Ontarians (28.5%) made 8 million outpatient physician visits associated with MSDs in 2013/14. These included 5.6 million primary care visits, nearly 15% of all adult primary care visits in the province. MSDs accounted for 560,000, 12.3%, of all adult ED visits. Patient visit rates to the ED for non-trauma spinal conditions were the highest of all MSDs at 1032 per 100,000 population, accounting for 23% of all MSD-related ED visits. Osteoarthritis had the highest rate of inpatient hospitalization of all MSDs at 340 per 100,000 population, accounting for 42% of all MSD-related admissions. Total costs for MSD-related care were $1.6 billion, with 12.6% of costs attributed to primary care, 9.2% to specialist care, 8.6% to ED care, and 61.2% of total costs associated with inpatient hospitalizations. Costs due to ‘arthritis and related conditions’ as a group accounted for 40.1% of total MSD costs ($966 million). Costs due to non-trauma related spinal conditions accounted for 10.5% ($168 million) of total MSD costs. All trauma-related conditions (spine and non-spine combined) were responsible for 39.4% ($627 million) of total MSD costs. MSD-related imaging costs for patients who made physician visits for MSDs were $169 million. Including these costs yields a total of $1.8 billion.

MSDs place a significant and costly burden on the health care system. As the population ages, it will be essential that health system planning takes into account the large and escalating demand for MSD care, both in terms of health human resources planning and the implementation of more clinically and cost effective models of care, to reduce both the individual and population burden.

Spine surgery is common and costly. Researchers and policy makers believe that utilization of spine surgery in the US is significantly higher than in other industrialized countries. Although within-country variation in spine surgery utilization is well studied, there has been little exploration of variation in spine surgery between countries.

We used population level administrative data from Ontario (years 2011–2015) and New York (2011–2014) to identify all adults who underwent inpatient spinal decompression or fusion surgery. We compared Ontario and New York with respect to patient demographics and the percentage of hospitals performing spine surgery. We compared rates of decompression and fusion surgery (procedures per-10,000 population per-year) in Ontario and New York for all procedures, emergent procedures alone, and elective procedures and after stratifying by patient age.

Patients in Ontario were older than patients in New York for decompression (mean age 58.8 vs. 51.3 years, P<.001) and fusion (58.1 vs. 54.9, P<.001). A smaller percentage of hospitals in Ontario performed decompression or fusion compared to New York (decompression, 26.1% in Ontario vs 54.9% in New York: fusion 15.2% vs 56.7%, both P<.001). Overall, utilization of spine surgery in Ontario was 6.6 procedures per-10,000 population per-year and in New York was 18 per-10,000 per-year (P<.001). Ontario-New York differences in utilization were small for emergent cases (2 per-10,000 in Ontario vs. 2.8 in New York, P<.001), but large for elective cases (4.6 vs 15.2, P<.001). In analyses stratified by surgical subtype, differences in utilization of decompression in New York and Ontario were relatively modest (2.4 vs 3.1, P<.001), while utilization of fusion was approximately 400% higher in New York than Ontario (15.7 vs 3.5, P<.001). Further analysis demonstrated that the New York-Ontario difference in utilization was substantially larger among younger patients and smaller for older patients. For example, utilization of spine procedures in New York was 340% greater than Ontario for patients less-than 50 years of age (11.7 vs 3.4), but only 25% greater in patients age 80 and above (10 vs 12.6).

After adjusting for patient demographics, hospital LOS and surgical urgency, differences in mortality in Ontario and New York were not significant for either decompression or fusion. In adjusted analyses differences in hospital LOS were slightly greater for decompression in Ontario, but similar for fusion and readmission rates in Ontario were significantly lower than in New York.

In conclusion, we found significantly lower utilization of spine surgery in Ontario when compared to New York. The difference in utilization was attributable to less elective fusion surgery, primarily in younger (i.e. non-Medicare) patients. These findings can serve inform broader spine surgery policy reforms in both jurisdictions.

Patient satisfaction is an important measure of patient-centered outcomes and physician performance. Given the continued growth of the population undergoing surgical intervention for osteoarthritis (OA), and the concomitant growth in the associated direct costs, understanding what factors drive satisfaction in this population is critical. A potentially important driver not previously considered is satisfaction with pre-surgical consultation. We investigated the influence of pre-surgical consultation satisfaction on overall satisfaction following surgery for OA.

Study data are from 1263 patients who underwent surgery for hip (n=480), knee (n=597), and spine (n=186) OA at a large teaching hospital in Toronto, Canada. Before surgery, patient-reported satisfaction with information received and degree of input in decision-making during the pre-surgical consultation was assessed, along with expectations of surgery (regarding pain, activity limitation, expected time to full recovery and likelihood of complete success). Pre- and post-surgery (6 weeks, and 3, 6, and 12 months) patients reported their average pain level in the past week (0–10, 10 is worst). At each follow-up time-point, two pain variables were defined, pain improvement (minimal clinically important difference from baseline ≥2 points) and ‘acceptable’ pain (pain score ≤ 3). Patients also completed a question on satisfaction with the results of the surgery (very dissatisfied/dissatisfied/somewhat satisfied/very satisfied) at each follow-up time point. We used multilevel ordinal logistic regression to examine the influence of pre-surgery satisfaction with consultation on the trajectory of satisfaction over the year of recovery controlling for expectations of surgery, pain improvement, acceptable pain, socio-demographic factors (age, sex, and education), body mass index, comorbidity, and depressive symptoms (Hospital Anxiety and Depression Scale).

Mean age of the sample was 65.5 years, and over half (54.3%) were women. Overall, 74% and 78.9% of patients were satisfied with the information received and with the decision-making in the pre-surgical consultation, respectively, no significant differences were found by surgical joint (p=0.22). Post-surgery, levels of satisfaction varied very little over time (6 weeks: 92.5% were satisfied and 66.4% were very satisfied, 1 year: 91.1% were satisfied and 65.6% were very satisfied). Results from a model including time, surgical joint, satisfaction with consultation and control factors indicated that being satisfied with the information received in the pre-surgical consultation was associated with higher odds of being more satisfied after surgery (OR: 1.2, 95% CI: 1–1.4). Additionally, spine and knee patients were more likely to be dissatisfied than hip patients (OR: 3.2, 95% CI: 2.1–4.9 and OR: 2.5, 95% CI: 1.8–3.4 for spine and knee patients respectively). Achieving pain improvement (OR: 1.7, 95% CI: 1.3–2.4) and acceptable pain (OR: 2.5, 95% CI: 1.6–3.9) were both significantly associated with greater satisfaction. Pre-operative expectations were not significantly associated with post-surgery satisfaction.

Findings highlight the important role of pre-surgery physician-patient communication and information on post-surgery satisfaction. This points to the need to ensure organizational provisions that foster supportive and interactive relationships between surgeons and their patients to improve patients' satisfaction. Findings also highlight that early post-recovery period (i.e. <= 3 months) as a key driver of longer-term satisfaction.

In addition to mechanical stresses, an inflammatory mediated association between obesity and knee osteoarthritis (OA) is increasingly being recognised. Adipokines, such as adiponectin and leptin, have been postulated as likely mediators. Clinical and epidemiological differences in OA by race have been reported. What contributes to these differences is not well understood. In this study, we examined the profile of adipokines in knee synovial fluid (SF) and the gene expression profile of the infra-patellar fat pad (IFP) by race among patients with end-stage knee OA scheduled for knee arthroplasty.

Age, sex, weight and height (used to derive body mass index (BMI)) and race (White, Asian and Black) were elicited through self-report questionnaire prior to surgery. SF and IFP samples were collected at the time of surgery. Adipokines (adiponectin and leptin) were examined in the SF using MAGPIX Multiplex platform. IFP was profiled using Human Adipogenesis PCRArray and genes of interest were further validated via quantitative relative RT-PCR using Student's t-test. Overall differences in adiponectin and leptin concentrations were tested across race. Linear regression modeling was used to investigate the association between adiponectin and leptin concentrations (outcomes) and race (predictor; referent group: White), adjusting for age, sex and BMI.

67 patients (18 White, 33 Asian, 16 Black) were included. Mean SF adiponectin concentration was greatest in Whites (1175.05 ng/mL), followed by Blacks (868.53 ng/mL) and Asians (702.23 ng/mL) (p=0.034). The mean SF leptin concentration was highest in Blacks (44.88 ng/mL), followed by Whites (29.86 ng/mL) and Asians (20.18 ng/mL) (p=0.021). Regression analysis showed Asians had significantly lower adiponectin concentrations compared to Whites (p<0.05). However, leptin concentrations did not differ significantly by race after adjusting for covariates. Testing of the IFP, using the Adipogenesis PCRArray, showed significant higher expression of LEP gene (leptin, p=0.03) in Asians (n=4) compared to Whites (n=4).

There appears to be important racial differences in the SF adiponectin profile among individuals with end-stage knee OA. Differential gene expression in the IFP across racial groups could be a potential contributory source for the noted SF variations. Further work to determine the source and function of adipokines in knee OA pathophysiology across racial groups is warranted.