METHODS/DESIGN: This randomized clinical trial (RCT) will test the efficacy of a theory-based telephone-delivered Patient Self-Management Support intervention that seeks to enhance adherence to independent exercise and activity among post- TKR patients. The intervention consists of 12 sessions, which begin prior to surgery and continue for approximately 9 weeks post-TKR. The intervention condition will be compared to a usual care control condition using a randomized design and a probabilistic sample of men and women. Assessments are conducted at baseline, eight weeks, and six- and twelve- months. The project is being conducted at a large healthcare system in Massachusetts. The study was designed to provide greater than 80% power for detecting a difference of 4 points in physical function (SF36/Physical Component Score) between conditions (standard deviation of 10) at six months with secondary outcomes collected at one year, assuming a loss to follow up rate of no more than 15%.

DISCUSSION: As TKR use expands, it is important to develop methods to identify patients at risk for sub-optimal functional outcome and to effectively intervene with the goal of optimizing functional outcomes. If shown efficacious, this peri-TKR intervention has the potential to change the paradigm for successful post-TKR care. We hypothesize that Patient Self-Management Support to enhance adherence to independent activity and exercise will enhance uniform, optimal improvement in post-TKR function and patient autonomy, the ultimate goals of TKR.

For knee and hip arthritis patients, self-assessed pain and physical function are central to treatment decisions as well as to clinical and outcomes research.

Both paper and electronic health records capture the clinician’s summary of the patient symptoms.

Brief patient-reported arthritis symptom assessments have been broadly tested and validated in clinical research, yet have not been integrated into routine office practice.

The introduction of electronic health records offers an opportunity for patient direct-entry and real-time scores of standardized symptom assessments to be included in the routine health record.

Purpose

To both support patient-centered health care in arthritis care and to track aggregate outcomes for longitudinal research, a comprehensive arthritis care record system was designed and implemented with the goal of integrating standardized symptom assessments and clinical metrics in an individual patient health record.

• Trend pain and function metrics over time,

• Provide real-time data to patients and clinicians to inform treatment decisions, and,

• Track aggregate outcomes for quality assessment and research.

Study Design

The data collection and management system was implemented in the Arthritis and Total Joint Center (TJC) ambulatory clinic at UMass Medical Center.

The host system allows development and delivery of custom web-based surveys and serves as a database archive system with interfaces to hospital information services (HIS) and a data storage location.

The survey data are divided into 21 tables representing clinical categories (e.g., pain, function, clinical diagnoses) with 259 measures, and 66 among them are used for QA reports.

The patient-entered survey data are merged with the clinical data in a structured format, providing comprehensive longitudinal records for individual patients. In addition, real-time symptom trend reports are produced using query, search and analysis functions.

System Use

The core system was established in 2007, fully operational in 2008, and by June 2010, over 1,000,000 clinical measures had been collected from over 30,000 patients visiting the Arthritis and Total Joint Center (TJC). Among patient measures, around 400,000 measures (28,500 surveys) are related to patient self-assessed symptoms.

Conclusions

The system implemented in our clinic is a successful model for collecting and integrating patient symptom data with clinical data as part of a patient health record.

This template is the foundation for a newly funded national research registry for comparative effectiveness in total joint replacement surgery (FORCE-TJR).

Total knee replacement (TKR) is an effective procedure to eliminate knee pain due to osteoarthritis. However variation in functional outcome persists. Patient attributes, including age, gender, body mass index (BMI), and emotional health, influence degree of functional gain. The level of daily physical activity (PA) is important to weight management, knee OA care, and overall health. As the arthritis population becomes more overweight and inactive, it is important to understand the physical activity benefits accrued following TKR.

Health promotion programs, conducted in community dwelling adults, have called attention to the use of accelerometers (step activity monitor devices) as a measure of general activity. The device, worn around the leg, gives an accurate number of daily steps (mean steps/ day), as well as, walking rate (mean steps/ minute). Unfortunately, there are limited data on the use of accelerometers in patients with knee OA.

It is unknown if self-reported physical function correlates with objectively measured physical activity (e.g., steps/day) or if patient attributes influence the level of physical activity in patients with osteoarthritis before and after TKR.

We hypothesized that patient physical activity at 6 months post-TKR varies with the two patients attributes, gender and body mass index (BMI).

Materials and Methods

A consecutive series of 89 TKR patients wore a small ankle accelerometer (StepWatch Activity Monitor/SAM; CYMA, Inc.) above the ankle of the operative leg before TKR and again at 6 months after surgery.

Demographic attributes, self-reported function measured with SF36 and WOMAC, and physical activity as measured by accelerometer as quantity of steps/day and % of day inactive were recorded. Descriptive statistics and mean differences were calculated.

Results

Patients had a mean age of 67 years, mean BMI of 30, and 71% were women.

• Overall, physical activity significantly improved from a mean of 6600 steps/day before TKR to 7690 steps/day at 6 months.

• Women walked fewer steps/day than men before and after TKR (6,218 before, 7,150 after; a 15% increase).

• Non-obese patients improved steps/day, obese did not.

• While male reduced their inactive time after TKR, women did not.

• After adjusting for BMI and age, gender differences persisted in objectively measured physical activity.

• The number of steps/day was moderately but significant correlated with PCS and WOMAC function (r=0.28 – 0.4).

Conclusions

• Physical activity as measured by accelerometer improved after TKR, varied with patient attributes, including gender and BMI, and was moderately correlated with self-reported function.

• A 15% increase in pre to post TKR patient steps/day is highly significant and contributes to the health status improvement of patients with advanced arthritis.

• Women‘s lower physical activity levels before surgery persists after TKR, despite significant pain relief.

• Physical activity differences should be considered when designing TKR patient pathways and rehabilitation programs.

OBJECTIVES: To document the prevalence of midline vertebral artery (VA) migration in a subgroup of patients presenting with neck pain, radiculopathy, or myelopathy and to identify the course of the VA through the TFs.

SUMMARY OF BACKGROUND DATA: Knowledge of VA anomalies and their respective prevalence may help surgeons decrease the incidence of iatrogenic injury to this artery. METHODS: In this retrospective review of 281 consecutive patients, who had an magnetic resonance imaging for axial neck pain, radiculopathy, or myelopathy, anatomic measurements were obtained from C2 to C7.

RESULTS: The observed VA anomalies can be classified into following 3 main groups: (1) intraforaminal anomalies-midline migration, (2) extraforaminal anomalies, and (3) arterial anomalies. Midline migration of the VA was identified in 7.6% (19/250) of patients. The etiology can be degenerative or traumatic. It is important to note that the pattern of medial migration was clockwise rotation from caudal to cephalad and was present in all of our patients with anomalous arteries. Additionally, at C6, only 92% (460/500) of VAs were located within their respective transverse foramens and hypoplastic VAs were identified in 10% (25/250) of patients.

CONCLUSION: Anomalies that must be considered before surgery include interforamenal anomalies, extraforamenal anomalies, and arterial anomalies. The intraforaminal anomalies involve midline migration, which places the VA at direct risk during corpectomy. Extraforaminal anomalies are related to VAs entering the transverse foramen at a level other than C6, which can increase the risk of injury during the anterior approach to the cervical spine. Arterial anomalies can be fenestrated, hypoplastic, or absent. These raise concern with the ability to maintain cerebral perfusion in the setting of damage to one of the VAs with the presence of contralateral arterial abnormality.

OBJECTIVE: This study quantified the effectiveness of injection treatment on pain relief among adults 60 years and over who were diagnosed with degenerative lumbar spinal stenosis, a common cause of lower back pain in older adults. The variations of the effectiveness were examined by selected patient attributes.

STUDY DESIGN: Prospective, non-randomized, observational human study.

SETTING: Single institution spine clinic.

METHODS: Patients scheduled for lumbar injection treatment between January 1 and July 1, 2008 were prospectively selected from the study spine clinic. Selection criteria included patients age 60 and over, diagnosed with degenerative lumbar spinal stenosis and no previous lumbar injection within 6 months or lumbar surgery within 2 years. The pain sub-score of the SF-36 questionnaire was used to measure pain at baseline and at one and 3 months post injection. Variations in longitudinal changes in pain scores by patient characteristics were analyzed in both unadjusted (univariate) analyses using one-way analysis of variance (ANOVA), and adjusted (multiple regression) analyses using linear mixed effects models.

LIMITATIONS: This study is limited by its sample size and observational design.

RESULTS: Of 62 patients receiving epidural steroid injections, the mean Pain score at baseline was 27.4 (SD =13.6), 41.7 (SD = 22.0) at one month and 35.8 (SD = 19.0) at 3 months. Mean Pain scores improved significantly from baseline to one month (14.1 points), and from baseline to 3 months (8.3 points). Post injection changes in pain scores varied by body mass index (BMI) and baseline emotional health. Based on a linear mixed effects model analysis, higher baseline emotional health, as measured by the SF-36 Mental Component Score (MCS>/=50), was associated with greater reduction in pain over 3 months when compared to lower emotional health (MCS), was associated with greater reduction in pain over 3 months when compared to lower emotional health (MCS <50). In patients with higher emotional health, pain scores improved by 14.1 (P < .05: 95% CI 6.9, 21.3). Patients who were obese also showed significant improvement in pain scores over 3 months compared to non-obese patients. In obese patients, pain scores increased by 7.9 (P <.05; 95% CI:1.0, 14.8) points.

CONCLUSION: Lower back pain in older adults with degenerative lumbar spinal stenosis might be clinically significantly alleviated after injection treatment. Pain relief varies by a patients personal and clinical characteristics. Healthier emotional status and obesity appears to be associated with more pain relief experienced over 3 months following injection.

Methodology (including study design, analysis, and evaluation): The UMass Medical School Women’s Faculty Committee (WFC) initiated a partnership with the medical library to compete successfully to host the traveling exhibition “Changing the Face of Medicine: Celebrating America’s Women Physicians.” Concurrent with the 6-week exhibition, fifteen events brought local and nationally prominent women together for mentoring activities, an original dramatic production, and an awards luncheon for women faculty. Women featured in the exhibit as well as its Visiting Curator spoke at UMMS about their research and career challenges, read from their published works, and were featured at graduation and a regional medical society event.

Results: Application-writing and event planning sessions forged robust working relationships among top-ranking administrators, senior and junior faculty, and staff. The exhibition increased opportunities for administration, faculty, and students to understand the impact of women in medicine, their leadership potential, and historical contributions. It also generated new mentor/mentee relationships and grant-writing collaborations. The exhibition’s national recognition helped draw a larger, more diverse and gender-balanced audience (575+ people) to the events enhancing the visibility of the WFC, as evidenced by institutional funding for women faculty to attend the AAMC WIM professional development workshops and ELAM for the first time.

Conclusion(s): Creative partnerships, motivated by the opportunity to host “Changing the Face of Medicine,” produced greater than expected gains for women faculty, generating new awareness and understanding of women’s accomplishments and leadership potential. This partnership allowed for a wide range of multi-disciplinary efforts, strengthening networking across silos, and advancing the goals of women in an academic medical center.

Presented October 29, 2006 at AAMC 2006 Annaul Meeting, Seattle, WA.

METHODS: A retrospective review of all orthopedic cases from the operating room scheduling system at a level-one trauma center was undertaken from October 2003 to September 2005. Before October 2004, unscheduled cases were placed on a shared add-on list, and no special priority was given to orthopedic cases. Additionally, a subset of adult patients with isolated femoral shaft fractures was identified to evaluate time from admission to surgery, operative time, frequency of transfer of care between surgeons, and total length of hospital stay.

RESULTS: The number of orthopedic cases was 1799 in fiscal year 2004 (FY04) and 2046 in FY05, an increase of 14%. Overall, the hospital experienced an increase in level-one trauma activations from 1450 in FY04 to 1580 in FY05 (8.2%), and an increase in the number operative trauma cases from 447 to 494 (9.5%). Cases after 7:00 pm declined from 197 in FY04 to 165 in FY05, a decrease of 16%. Cases between midnight and 7:00 am declined from 63 in FY04 to 35 in FY05, a decrease of 44%. For the subset of femur fracture patients, transfer of care to another operating surgeon occurred 4.5 times more frequently. The median delay between admission and surgery increased from 5.7 hours to 10.9 hours. Median case duration increased from 106 to 127 minutes.

CONCLUSIONS: It is possible to dramatically decrease the occurrence of after-hours orthopedic surgery in a level-one trauma center through the use of a dedicated room for unscheduled orthopedic trauma cases. Benefits include less frequent activation of after-hours operating room resources, fewer disruptions to the OR schedule and office hours, and more frequent fracture care by orthopedic traumatologists. The impact of a longer delay between admission and surgical treatment and more frequent transfer of care between surgeons deserves further evaluation.

METHODS: Thirty consecutive patients who met inclusion and exclusion criteria underwent arthroscopic debridement by a single surgeon and concomitant delivery of 6 ml/90 mg HA (Orthovisc(R)). These patients were evaluated preoperatively, at 6 weeks, 3 and 6 months post-operatively. Evaluations consisted of WOMAC pain score, SF-36 Physical Component Summary (PCS) score and complications.

RESULTS: No complications occurred during this study. Pre-op average WOMAC pain score was 6.8 +/- 3.5 (n = 30) with a reduction to 3.4 +/- 3.1 at 6 weeks (n = 27). Final average WOMAC pain score improved to 3.2 +/- 3.8 at six months (n = 23). No patients had deterioration of the WOMAC pain score. Mean pre-operative SF-36 PCS score was 39.0 +/- 10.4 with SF-36 PCS score of the bottom 25th percentile at 29.9 (n = 30). Post procedure and HA delivery, mean PCS score at 6 weeks improved to 43.7 +/- 8.0 with the bottom 25th percentile at 37.5 (n = 27). At 6 months, mean PCS score was 48.0 +/- 9.8 with the bottom 25th percentile improved to 45.8 (n = 23).

CONCLUSION: The results show that concomitant delivery of high molecular weight hyaluronan (Orthovisc(R) - 6 ml/90 mg) is safe when given at the time of arthroscopic debridement of the osteoarthritic knee. By delivering HA (Orthovisc(R)) at the time of the arthroscopic debridement, there may be a decreased risk of joint infection and/or injection site pain. Furthermore, the combination of both procedures show efficacy in reducing WOMAC pain scores and improving SF-36 PCS scores over a six month period.

MATERIALS AND METHODS: Charts and radiographs were reviewed for 25 patients over age 65 and 46 patients under age 65 who underwent operative treatment of an ankle fracture during a 2-year period. Postoperative complications and need for placement in a skilled nursing facility following discharge were noted. The SF-36 and the Olerud and Molander Ankle Score were completed. Mean duration of followup in patients greater than 65 was 27 months and 24 months for patients less than or equal to 65 years.

RESULTS: Patients over 65 had a higher number of postoperative complications (40% vs. 11%, p < 0.007), and required nursing home placement more frequently than patients under 65 (p < 0.0001). At long-term followup, the data showed no significant difference in patient reported physical outcomes.

CONCLUSION: Early postoperative outcomes after operative fixation of ankle fractures suggest significantly worse outcomes for patients over age 65. However, long-term function in the elderly was comparable to patients under age 65 in this sample. The elderly population had a significantly better mental composite score than the non-elderly.

Methodology (including study design, analysis, and evaluation): The UMass Medical School Women’s Faculty Committee (WFC) initiated a partnership with the medical library to compete successfully to host the traveling exhibition “Changing the Face of Medicine: Celebrating America’s Women Physicians.” Concurrent with the 6-week exhibition, fifteen events brought local and nationally prominent women together for mentoring activities, an original dramatic production, and an awards luncheon for women faculty. Women featured in the exhibit as well as its Visiting Curator spoke at UMMS about their research and career challenges, read from their published works, and were featured at graduation and a regional medical society event.

Results: Application-writing and event planning sessions forged robust working relationships among top-ranking administrators, senior and junior faculty, and staff. The exhibition increased opportunities for administration, faculty, and students to understand the impact of women in medicine, their leadership potential, and historical contributions. It also generated new mentor/mentee relationships and grant-writing collaborations. The exhibition’s national recognition helped draw a larger, more diverse and gender-balanced audience (575+ people) to the events enhancing the visibility of the WFC, as evidenced by institutional funding for women faculty to attend the AAMC WIM professional development workshops and ELAM for the first time.

Conclusion(s): Creative partnerships, motivated by the opportunity to host “Changing the Face of Medicine,” produced greater than expected gains for women faculty, generating new awareness and understanding of women’s accomplishments and leadership potential. This partnership allowed for a wide range of multi-disciplinary efforts, strengthening networking across silos, and advancing the goals of women in an academic medical center.

Presented October 29, 2006 at AAMC 2006 Annual Meeting, Seattle, WA.