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Costs incurred were mainly for time lost from employment and leisure, and for unpaid informal caregivers. Failure to value such indirect costs significantly underestimates the true burden of OA. Costs increased with worsening health status and greater OA severity. After adjustment, men were less likely to incur costs, possibly due to greater social resources.

Objective. To examine prospectively the predictors of time to total joint arthroplasty (TJA).Methods. This was a prospective cohort study with a median followup time of 6.1 years. We included participants from an existing population-based cohort of 2,128 individuals, ages 55 years and older with disabling hip and/or knee arthritis and no prior TJA, from 2 regions of Ontario, Canada, 1 urban with low TJA rates and 1 rural with high rates. The main outcome measure was the occurrence of a TJA based on procedure codes in the hospital discharge abstract database.Results. At baseline, the mean age of the patients was 71.5 years, 67.9% had a high school education or higher, 73.4% were women, the mean arthritis severity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) score was 41.1 (maximum possible score 100), and 20.0% were willing to consider TJA. Greater probability of undergoing TJA was associated with higher (worse) baseline WOMAC scores (hazard ratio [HR] 1.22 per 10-unit increase, P < 0.001), age (compared with age <62 years, the HR increased to 1.57 for 63-68 years, 1.46 for 69-74 years, and 1.51 for 75-81 years, and fell to 0.44 for >82 years; P < 0.05 for all), better health (HR 1.14 per 10-unit increase in Short Form 36 general health survey score, P < 0.001), and willingness to consider TJA (HR 4.92, P < 0.001). When willingness was excluded from the model, education level, but not sex or income, became a significant predictor of TJA receipt.Conclusion. Willingness to consider TJA was the strongest predictor of the time to first TJA. Given that previous research indicates that willingness is largely explained by perceptions of the indications for and risks associated with TJA and not disease severity, this finding supports the need for population education about arthritis treatments, including TJA.Osteoarthritis (OA) is a major cause of disability worldwide (1). Total joint arthroplasty (TJA) is a highly cost-effective procedure for the management of hip and knee OA (2,3). Despite this, variations in the rates of TJA by region, sex, race, and socioeconomic status (SES) have been shown (4-9). These studies, however, have been based largely on cross-sectional analyses of administrative data that tell us about who is undergoing surgery, but provide little information about determinants of access to care. No studies have prospectively examined predictors of receipt of TJA in community cohorts or considered the impact of subjects' preferences in determining access to care. The Andersen behavioral model (10) posits that health services use is influenced by 3 groups of factors: 1) predisposing factors, including sociodemographics and health beliefs (11-13); 2) enabling factors, including health insurance, living circumstances, and social support (14-17); and 3) need factors, including the health condition that warrants treatment. Determining whether and how these factors predict use of TJA is essential as a first step toward guiding the development of interven-

ObjectiveThis study defined negative outcomes of solid organ transplantation, proposed a new classification of complications by severity, and applied the classification to evaluate the results of orthotopic liver transplantation (OLT). Summary and Background DataThe lack of uniform reporting of negative outcomes has made reports of transplantation procedures difficult to interpret and compare. In fact, only mortality is well reported; morbidity rates and severity of complications have been poorly described. MethodsBased on previous definition and classification of complications for general surgery, a new classification for transplantation in four grades is proposed. Results including risk factors of the first 215 OLTs performed at the University of Toronto have been evaluated using the classification. ResultsAll but two patients (99%) had at least one complication of any kind, 92% of patients surviving more than 3 months had grade 1 (minor) complications, 74% had grade 2 (life-threatening) complications, and 30% had grade 3 (residual disability or cancer) complications. Twenty-nine per cent of patients had grade 4 complications (retransplantation or death). The most common grade 1 complications were steroid responsive rejection (69% of patients) and infection that did not require antibiotics or invasive procedures (23%). Grade 2 complications primarily were infection requiring antibiotics or invasive procedures (64%), postoperative bleeding requiring >3 units of packed red cells (35%), primary dysfunction (26%), and biliary disease treated with antibiotics or requiring invasive procedures (18%). The most frequent grade 3 complication was renal failure, which is defined as a permanent rise in serum creatinine levels 2 twice the pretransplantation values (1 1%). Grade 4 complications (retransplantation or death) mainly were infection (14%) and primary dysfunction (11%). Comparison between the first and last 50 OLTs of the series indicates a significant decrease in the mean number of grade 1 and 2 complications. This was partially a result of better medical status of patients at the time of transplantation. Using univariate and multivariate analyses of risk factors, the best predictor of grade 1 complications was donor 109

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Objective. To evaluate patient predictors of good outcome following total joint arthroplasty (TJA).Methods. A population cohort with hip/knee arthritis (osteoarthritis [OA] or inflammatory arthritis) ages >55 years was recruited between 1996 and 1998 (baseline) and assessed annually for demographics, troublesome joints, health status, and overall hip/knee arthritis severity using the Western Ontario and McMaster Universities OA Index (WOMAC). Survey data were linked with administrative databases to identify primary TJAs. Good outcome was defined as an improvement in WOMAC summary score greater than or equal to the minimal important difference (MID; 0.5 SD of the mean change). Logistic regression and Akaike's information criterion were used to determine the optimal number of predictors and the best model of that size. Log Poisson regression was used to determine the relative risk (RR) for a good outcome.Results. Primary TJA was performed in 202 patients (mean age 71.0 years; 79.7% female; 82.7% with >1 troublesome hip/knee; 65.8% knee replacements). Mean improvement in WOMAC summary score was 10.2 points (SD 18.05; MID 9 points). Of these patients, 53.5% experienced a good outcome. Four predictors were optimal. The best 4-variable model included pre-TJA WOMAC, comorbidity, number of troublesome hips/knees, and arthritis type (C statistic 0.80). The probability of a good outcome was greater with worse (higher) pre-TJA WOMAC summary scores (adjusted RR 1.32 per 10-point increase; P < 0.0001), fewer troublesome hips/knees (adjusted RR 0.82 per joint; P ‫؍‬ 0.002), OA (adjusted RR for rheumatoid arthritis versus OA 0.33; P ‫؍‬ 0.009), and fewer comorbidities (adjusted RR per condition 0.88; P ‫؍‬ 0.01).Conclusion. In an OA cohort with a high prevalence of multiple troublesome joints and comorbidity, only half achieved a good TJA outcome, defined as improved pain and disability. A more comprehensive assessment of the benefits and risks of TJA is warranted.

Objectives To identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified.Design Propensity score matched cohort study. Setting Ontario, CanadaParticipants 37 881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery.Main outcome measure The rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery.Results Multivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done ≤35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v 1.3%, P=0.006; NNH 172) and revision (1.5% v 1.0%, P=0.03; NNH 204).Conclusions In a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery.

Our data provide evidence that the MTHFR C677T polymorphism affects the concentration and intracellular distribution of folates and changes the growth and chemosensitivity of colon and breast cancer cells. The MTHFR C677T polymorphism may be a useful pharmacogenetic determinant for providing rational and effective tailored chemotherapy.