Osteoarthritis

Bandolier has published an article on this subject. They make the point that patient perspectives of osteoarthritis are not always captured by clinical trials, which use outcomes like the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scales, or pain in the rather contrived setting of walking on a flat surface.

A UK survey of 3,127 patients whose diagnosis of osteoarthritis had been confirmed by a GP, contained results on 18 quality of life indicators. Sleeping, walking, and such everyday activities as bathing and dressing often affected people.

If quality of life is low with arthritis, what happens to quality of life after joint replacement?

An Australian study reported on part of an ongoing prospective trial. Patients with a diagnosis of osteoarthritis or rheumatoid arthritis were eligible, though here only results for osteoarthritis were reported. Patients were mailed monthly self-administered WOMAC and SF-36 questionnaires. WOMAC  measures dimensions of pain, stiffness and physical function. SF-36 is a generic quality of life questionnaire.

There was a 67% response rate in 252 patients recruited. The 194 participants had an average age of 74 years; 86 had osteoarthritis of the hip and 108 of the knee. The overall follow up averaged 11 months. Disease duration averaged 10 years, and half were women.

There were significant improvements for all three areas of the WOMAC scale of physical function. There were also significant improvements in the SF-36 quality of life questionnaire for most of the eight domains for both hip and knee replacement. Exceptions were emotional role function for both hip and knee, and general health and mental health for knee replacements, though both scores were high initially

For most patients having hip or knee replacement large quality of life gains will occur. With the modest cost of the operations, this will mean the cost per quality-adjusted life year will be low. These results also underscore the quality of life losses by people with osteoarthritis who have not had a joint replacement. Yet these most cost-effective operations consistently have the longest waiting lists, presumably because patients suffer, but are less likely to die of the disease than for cardiac disease or cancer

Ref: Web Bandolier 122

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Occupational Therapy for stroke

Trials of occupational therapy for stroke patients living in the community have varied in their findings. It is unclear why these discrepancies have occurred. In this study trials were identified from searches of the Cochrane Library and other sources.

The primary outcome measure was the Nottingham Extended Activities of Daily Living (NEADL) score at the end of intervention. Secondary outcome measures included the Barthel Index or the Rivermead ADL (Personal ADL), General Health Questionnaire (GHQ), Nottingham Leisure Questionnaire (NLQ), and death.

The study included 8 single-blind randomized controlled trials incorporating 1143 patients. Occupational therapy was associated with higher NEADL scores at the end of intervention and higher leisure scores at the end of intervention. Occupational therapy emphasizing activities of daily living (ADL) was associated with improved end of intervention NEADL and personal activities of daily living but not NLQ. Leisure-based occupational therapy improved end of intervention NLQ but not NEADL or PADL. The authors conclude that community occupational therapy significantly improved personal and extended activities of daily living and leisure activity in patients with stroke. Better outcomes were found with targeted interventions.

Ref: Web Stroke July 22 2004

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Acute medicine

This is a new report of a Working Party of the Royal College of Physicians

They say that good delivery of acute medical care can mean the difference between life and death. Yet such care has traditionally been 'fitted in' by specialists working in other areas of medicine. Changes to this unsatisfactory system have already begun, as evidenced by the recognition of acute medicine with its own training programme.

The report aims to strengthen the specialty by setting out new conditions for practice;

1.               assessing how many specialists are and will be needed

2.               how much time should be allocated to patient care

3.               how care can be organised across departments and disciplines

It also details training requirements at both undergraduate and postgraduate level, together with plans to establish a firm teaching base for the future.

The recommendations are addressed to medical directors and chief executives of trusts, chief executives of primary care trusts, undergraduate and postgraduate deans, members of the PMETB and the Department of Health.

The vision for the future of this vital area of medical care will, it says, be required reading for all those involved in planning, providing and educating for care for people who are suddenly and acutely ill.

Ref: RCP Report May 2004

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Smoking interventions by nurses

Health care professionals, including nurses, frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions. This Cochrane Review was set up to determine the effectiveness of nursing-delivered smoking cessation interventions.

Twenty-nine studies met the inclusion criteria. Twenty studies comparing a nursing intervention to a control or to usual care found the intervention to significantly increase the odds of quitting: Peto Odds Ratio 1.47.

There was limited evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized patients also showed evidence of benefit. Five studies of nurse counselling on smoking cessation during a screening health check, found the intervention to have less effect under these conditions.

The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice.

Ref: Cochrane Systematic Review 2004

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