January 2014

Update from USBJI President Steve Gnatz, MD, MHA

Dear Friends,

It is a very ambitious goal--to minimize the burden of musculoskeletal disorders in the United States by 2025. Very ambitious to be sure, and perhaps unrealistic at least until "minimize" is more precisely defined, but it is one of the proposed goals for the USBJI discussed by USBJI Board members at their December meeting.

Musculoskeletal disorders remain the most common cause of disability among adults in the US and around the world. Minimizing the burden of musculoskeletal disorders will have a tremendous impact on the health, happiness, and productivity of all people everywhere. How can USBJI do it? Well we certainly can't do it alone, and maybe this will have to be redefined in more realistic incremental steps. However, USBJI is not alone.

We are a unique organization that provides an interdisciplinary forum for more than 100 organizations representing health professionals, schools, industry, government, and (most importantly) people with musculoskeletal conditions. We come together with the task of finding common ground and areas to collaborate in the quest of our goal. During 2014, we will publish the final strategic plan with all the goals set for the next few years, and in aggregate they will cover a narrowly focused set of areas on which we believe the broader musculoskeletal community feels is in the interests of all and able to raise the priority of bone and joint disorders. Some of the ways that USBJI has been able to be effective in recent years, in 2013, and its plans for the coming year are listed here:

Participants in the USBJI's Young Investigators Initiative have reached nearly $200 million in approved grants as a result of their participation in the program, representing nearly 500 grants;
USBJI will publish in 2014 an updated edition of The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and Economic Cost (BMUS) an important data resource for researchers, health policy experts, and anyone drafting advocacy communications;
The Chronic Osteoarthritis Management Initiative will issue recommendations on actions to create a Model of Care for the Management of Osteoarthritis, and groups will begin work on those areas;
Recommendations from the recent USBJI Summit on Best Practices in Patient-centered Musculoskeletal Care will shortly be issued, and incorporated into the strategic plan;
USBJI held a record number of 118 public education sessions in 2013 (including our 500th session of Fit to a T);
From less than half of medical schools offering no required instruction in musculoskeletal to undergraduate medical students, now more than 83% offer some form of required instruction in this area.
Our work is not finished yet, we have a lot more to do, and an optimal outcome cannot be achieved without the involvement of the whole musculoskeletal community. Please join me in welcoming another year of interdisciplinary collaboration through the USBJI. Together we will minimize the burden of musculoskeletal disorders.

Yours truly,

Steve Gnatz, MD, MHA
President

Federal Investments in Bone and Joint Research

By Stephen I. Katz, MD, PhD

Director, National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National

Institutes of Health (NIH), U.S. Department of Health and Human Services

A component of the National Institutes of Health (NIH), the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) supports a wide range of research, training, and information dissemination activities related to bone, joint, muscle, and skin diseases. Our work is funded by the American taxpayers and serves a key role in our Nation's research and development pipeline through supporting basic, clinical, and epidemiological studies that would not otherwise be conducted. It should be noted that we, the NIAMS, often team with other NIH Institutes and Centers in supporting this research.

One of the privileges of my job is explaining the benefits of NIAMS-funded research. I appreciate the U.S. Bone and Joint Initiative for allowing me to highlight a few of the ways that the research we've supported has improved Americans' health and healthcare today, and to underscore our commitment to continuing to foster innovative science in these fields.

NIAMS supported research has shown us that:

Bone mineral density (BMD) relates closely to fracture risk. This finding from decades of research provided a foundation for Medicare's decision to pay for many adults to get their BMD measured. The increased rate of diagnosed osteoporosis contributed to a rise in the number of people who began taking bone-preserving drugs, which in turn led to a dramatic decrease in the rate of hip fractures among female beneficiaries (25% between 1995 and 2005).
Lifestyle changes can prevent osteoporosis and related fractures. Research has shown that a balanced diet and modest exercise can enhance bone strength. Adding more lights, removing clutter in a person's home, working with a healthcare provider to find medications that do not cause dizziness or confusion, and correcting vision problems can help prevent the falls that precede many osteoporotic fractures.
Exercise reduces joint pain and stiffness due to osteoarthritis. Now, instead of rest, moderate physical activity is suggested as a component of therapy for patients who have osteoarthritis.
Surgery is more effective than other treatments for many with back problems. Otherwise healthy people who have surgery for one of the three most common causes of severe low back pain--intervertebral disk herniation, lumbar spinal stenosis, or degenerative spondylolisthesis--are likely to fare better than those who receive non-operative care. However, people whose conditions are not progressing and whose pain is tolerable also may recover without surgery. And, importantly, delaying or avoiding surgery does not cause additional damage in most cases.
People with knee injuries may not need surgery. Many people with knee osteoarthritis and a meniscal tear may be able to avoid surgery and achieve comparable relief, albeit less quickly, from physical therapy alone. For patients considering surgical repair of a torn anterior cruciate ligament, surgeons now have a rigorous body of data on which to base advice about the likelihood of subsequent injuries and the need for additional surgeries.

NIAMS-supported research also touches the lives of people who have less common bone and joint conditions. Results from a clinical trial published earlier this year showed that bracing reduces the likelihood that adolescents who have idiopathic scoliosis will require surgery. And, studies into the inflammatory mechanisms that cause autoimmune diseases, such as rheumatoid arthritis, paved the way for several joint-preserving biologic therapies that are now widely used.

Research that NIAMS funds leads to hundreds of new findings every year. Some, like the discoveries described above, directly relate to improvements in health and health care. Many others are incremental advances in our understanding of basic biology and technological developments-building blocks that ultimately lead to better health. As we look to the future, we will continue to invest in the best and most promising science within the NIAMS mission. I encourage everyone to visit the NIAMS website (www.niams.nih.gov) to learn more about the work we do.

2013 MSK Summit Seeks to Advance Best Practices in Patient-Centered Musculoskeletal Care

How do we define and implement best practices in musculoskeletal care?

What does patient-centered care look like--and how can it be measured?

What is known about current best practices for musculoskeletal conditions?

How can best practices in patient-centered musculoskeletal care be advanced in the near future?

These questions framed presentations and discussions at the 2013 Musculoskeletal Summit, convened in November 2013 by the U.S. Bone and Joint Initiative. In four related sessions, participants--representing patients, providers, industry, payers, and other stakeholders--heard from a distinguished roster of speakers on current ideas about best practices and patient-centered musculoskeletal care.

Several cross cutting themes emerged from the Summit presentations and discussions. For example, the idea of multi-disciplinary teams--to reflect the inherently multi-disciplinary field of musculoskeletal care--was evoked by many speakers. Yet the configuration of actual teams across settings, how team members work together and share information, and--crucially--who is in charge of these teams remains unclear in many systems. This uncertainty can contribute to excessively fragmented care (especially for some conditions) that undermines the goals of providing patient-centered, cost-effective care and makes the outcomes sought by patients, care teams, and health systems more elusive.

Throughout the Summit and in small group sessions, participants combined their own perspectives and expertise with information from speakers to develop recommendations and action steps. These included:

Using research and data more effectively to build an evidence base for best practices and for establishing, disseminating, and implementing guidelines.
Summit participants called for more systematic reviews of existing evidence, moving guidelines and associated quality measures beyond their current focus on the process of care to test methods for improving the quality of care, empowering teams to create and promote systems that support best practices (e.g., through Plan-Do-Study-Act cycles), exploring how evolving information technology (IT) systems could generate more useful data for quality improvement (beyond billing), determining the best parameters for measuring and applying Patient Reported Outcomes (PROs), incorporating routine outcomes measures in rehabilitation practice, and identifying--and using--the most relevant cost metrics to document value (e.g., the American Academy of Orthopaedic Surgeons "A Nation in Motion" campaign), assessing and addressing barriers to more comprehensive patient registries for musculoskeletal conditions, and prioritizing research on patient engagement and implementable interventions (especially to close persistent health disparities gaps).
Identifying and delivering patient-centered care.
Patient-centered care should include families as well as patients and should aim to achieve individual care and population health goals simultaneously. USBJI could play a role by creating tools that help patients and families learn to become better advocates for themselves and by vetting Web-based information and advice.
Developing and promoting current best practice models to spark broader implementation.
Summit participants shared several models and examples of team-based musculoskeletal care and common features associated with their success (e.g., identifying and cultivating internal champions, empowering front-line care managers, robust data collection and monitoring, taking advantage of "teachable moments" with patients, communicating across teams and settings, and following up). Developing clinical practice guidelines based on settings where these are already successful could accelerate the adoption of these practices. In addition, professional education should incorporate team-based approaches; specific roles (such as fracture liaison coordinators) could be certified to reflect the specialized training for health professionals who manage patients presenting with fractures.

Each of the many professions and settings involved in effective musculoskeletal care has a role to play in advancing these recommendations, so that best practices in patient-centered musculoskeletal care can become far more common--and more effective--in the future.

If you or your professional or patient organization identifies specific area(s) of interest or pursuit from the recommendations listed above (e.g., for a specific population group, setting, area of musculoskeletal care), please inform the USBJI (usbji@usbji.org).

CDC Figures Show Slight Increase in Arthritis Prevalence

The Centers for Disease Control and Prevention (CDC) released new national estimates on the prevalence of arthritis in the U.S. population in November, published in the Morbidity and Mortality Weekly Report (MMWR). Estimates went slightly up to 22.7% of the population or 52.5 million.

During 2010-2012, an estimated 52.5 million (22.7%) of adults in the United States reported doctor-diagnosed arthritis, and 22.7 million (9.8%) reported arthritis-attributable activity limitation (AAAL) (43.2% of those with arthritis). These estimates represent net increases of 0.87 million adults with arthritis per year and 0.53 million adults with AAAL per year since the 2007-2009 estimates of 49.9 million with arthritis and 21.1 million with AAAL. These increases can be attributed, in part, to the aging of the U.S. population. The arthritis estimate is consistent with an earlier projection and suggests that projections of 55.7 million adults with arthritis by 2015 and 67 million by 2030 are reasonable. For AAAL, the estimate exceeds the earlier projection of 22 million adults with AAAL by 2020 and, therefore, might exceed the 25 million projected for 2030.

Arthritis and AAAL create a substantial personal and societal burden in the United States. Arthritis and AAAL prevalence were greater in the same age, sex, race/ethnicity, and education subgroups as seen previously, and exceptionally high among those who were unable to work or were disabled and those with fair or poor health, even when adjusted for age. About half of all adults with heart disease or diabetes had arthritis, and more than a quarter of adults with either condition and arthritis had AAAL; almost one third of adults who were obese also had arthritis, and more than 15% of these adults had AAAL. The high prevalence of arthritis among adults with these conditions in the general population is consistent with the results of a previous study on co-occurrence of chronic diseases among adults aged 25 years who participated in National Health Interview Survey (NHIS), in which arthritis was among the most common comorbidities. The negative effects of combinations of arthritis and other chronic conditions are suggested by the AAAL findings in this analysis, along with studies identifying arthritis as associated with greater physical inactivity for adults with multiple chronic conditions.

The findings in this report are subject to at least four limitations. First, doctor-diagnosed arthritis was self-reported and not confirmed by a health-care professional; however, this case definition has been shown to be sufficiently sensitive for public health surveillance. Second, because NHIS is a cross-sectional survey, a causal relationship between risk factors (i.e., obesity or physical activity) and arthritis and AAAL could not be established. Nonetheless, obesity is a factor that increases risk for osteoarthritis; a prospective study with 10 years of follow-up found that obese adults were more than twice as likely to develop knee and hand osteoarthritis. Third, social desirability bias might play a role in some self-report characteristics, with underreporting of weight, over-reporting of height, and over-reporting of leisure-time physical activity. Finally, because response rates ranged from 60.8% to 66.3% the findings might be subject to selection bias, although the application of sampling weights is expected to considerably reduce nonresponse bias.

To view the full report and references: Morbidity and Mortality Weekly Report (MMWR), November 8, 2013 / 62(44);869-873 www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a1.htm

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