Bestaande comorbiditeiten bij mensen met artrose: een retrospectieve analyse van een populatiegebaseerd cohort in Alberta, Canada

Bestaande comorbiditeiten bij mensen met artrose: een retrospectieve analyse van een populatiegebaseerd cohort in Alberta, Canada

december 16, 2019 0 Door admin

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Public health

Original research

Existing comorbidities in people with osteoarthritis: a retrospective analysis of a population-based cohort in Alberta, Canada

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  1. Deborah A Marshall1,2,3,4,
  2. Xiaoxiao Liu1,3,4,
  3. Cheryl Barnabe1,2,
  4. Karen Yee5,
  5. Peter D Faris5,
  6. Claire Barber1,2,
  7. Dianne Mosher2,
  8. Thomas Noseworthy1,
  9. Jason Werle6,
  10. Lisa Lix7

  1. 1 Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada

  2. 2 Department of Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada

  3. 3 McCaig Bone and Joint Health Institute, Calgary, Alberta, Canada

  4. 4 O’Brien Institute for Public Health, Calgary, Alberta, Canada

  5. 5 Research Facilitation, Alberta Health Services, Calgary, Alberta, Canada

  6. 6 Department of Surgery, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada

  7. 7 Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
  1. Correspondence to Dr Deborah A Marshall; damarsha{at}ucalgary.ca

Abstract

Objectives The purpose of this study is to estimate the prevalence of comorbidities among people with osteoarthritis (OA) using administrative health data.

Design Retrospective cohort analysis.

Setting All residents in the province of Alberta, Canada registered with the Alberta Health Care Insurance Plan population registry.

Participants 497 362 people with OA as defined by ‘having at least one OA-related hospitalization, or at least two OA-related physician visits or two ambulatory care visits within two years’.

Primary outcome measures We selected eight comorbidities based on literature review, clinical consultation and the availability of validated case definitions to estimate their frequencies at the time of diagnosis of OA. Sex-stratified age-standardised prevalence rates per 1000 population of eight clinically relevant comorbidities were calculated using direct standardisation with 95% CIs. We applied χ2 tests of independence with a Bonferroni correction to compare the percentage of comorbid conditions in each age group.

Results 54.6% (n=2 71 794) of people meeting the OA case definition had at least one of the eight selected comorbidities. Females had a significantly higher rate of comorbidities compared with males (standardised rates ratio=1.26, 95% CI 1.25 to 1.28). Depression, chronic obstructive pulmonary disease (COPD) and hypertension were the most prevalent in both females and males after age-standardisation, with 40% of all cases having any combination of these comorbidities. We observed a significant difference in the percentage of comorbidities among age groups, illustrated by the youngest age group (65 years.

Conclusions Our findings highlight the high frequency of comorbidity in people with OA, with depression having the highest age-standardised prevalence rate. Comorbidities differentially affect females, and vary by age. These factors should inform healthcare programme and delivery.

  • osteoarthritis
  • comorbidity
  • depression
  • hypertension
  • COPD
  • administrative health data

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Strengths and limitations of this study

  • Strong methodological approach to identify cases of osteoarthritis (OA) with a validated case definition using five linked population-based administrative databases.

  • However, case identification based on administrative data may result in underreporting of cases and comorbidities.

  • The age-standardised prevalence of eight comorbidities, selected on their clinical relevance and the availability of validated case definitions for administrative health data, was estimated among people with OA.

  • We limited our analysis to eight comorbidities of clinical relevance.

  • We stratified the analysis by sex and by age cohorts.

Introduction

Osteoarthritis (OA) is the most common form of arthritis, affecting 1 in 8 (13%) Canadians and representing a major cause of pain and disability in society.1 2 OA affects people of all ages, but is more prevalent among females and older age groups.3 4 Due to an ageing population and an increase in obesity, the prevalence of OA is expected to continue to rise, predicted to affect one in four Canadians by 2040.5 6 The high prevalence of OA in Canada has a substantial impact on quality of life and healthcare costs to individuals and healthcare systems. Quality of life was measured to be 10%–25% lower among people with OA relative to the general population7 with an associated economic burden of $C33 billion (direct and indirect costs) in Canada in 2011.3 The annual cost per individual with OA has been estimated to be two to three times higher compared with people without OA,7 and are associated with more physician visits and hospitalisations.8

More recently, the characterisation of comorbidities among people with OA has been explored due to the potential effect of comorbidities on routine clinical practice, clinical practice guidelines, healthcare utilisation and costs.9 10 In people with OA over the age of 50 years in England, the presence of comorbidities resulted in increased physical disability compared with those without OA, with the influence of comorbidities greater than that expected for OA alone or for each comorbidity in isolation.4 Knowledge of the prevalence of comorbidities in people with OA raises important considerations for optimal OA treatment and management, to reduce pain and physical disability, enhance the quality of life and decrease the burden of OA. Comorbidities add complexity to the management of patients with OA to provide patient-centred care, ensure appropriate management recommendations for healthcare programme and delivery.

The purpose of this study is to estimate the prevalence of comorbidities at time of diagnosis among people with OA in the province of Alberta, Canada, using administrative health data. Our study fills the gap in knowledge regarding the patterns and burden of comorbidities in people with OA, particularly with regard to the link between OA and comorbidities associated with age. In addition, our study is unique in that we examine all of the commonly reported comorbidities simultaneously in a single study. This information is useful to consider in clinical practice guidelines and to assess the potential impact of comorbidities for clinical practice.

Materials and methods

Data sources

We used five linked Alberta, Canada provincial administrative databases between 1 April 1994 and 31 March 2013 to identify individuals with OA who accessed healthcare services paid for by the provincial healthcare insurance plan, previously described elsewhere in detail.6 These databases included the Alberta Health Care Insurance Plan (AHCIP) population registry, the Discharge Abstract Database (DAD), the Physician Claims Database (claims), the Ambulatory Care Classification System (ACCS) and the National Ambulatory Care Reporting System (NACRS).

AHCIP population registry captures individual level demographic data on all insured persons as of the last day of each fiscal year (31 March). All Albertans who are included in the AHCIP have a unique, 9-digit personal health number, which is used when accessing healthcare services, and served to link datasets prior to deidentification. Members of the Armed Forces and the Royal Canadian Mounted Police, federal penitentiary inmates and Albertans who have opted out of the AHCIP are excluded.

DAD captures admission and inpatient care data for all hospitalised patients, including diagnostic codes, interventions, patient age and sex, and administrative information. Among 25 DAD diagnostic code fields extracted from the hospital record, OA-related records were identified as those with the first 3 digits 715 or M15 to M19 based on the ninth and tenth revisions of the International Classification of Diseases (ICD) codes, respectively.

Claims captures OA-related physician visits, which were identified based on the aforementioned ICD codes in any of the three diagnostic code fields.

ACCS and NACRS contains data on hospital-based and community-based ambulatory care, including day surgery, outpatient and community-based clinics and emergency departments, and publicly funded hospital support services such as physiotherapy and occupational therapy. OA-related records were identified based on the presence of the aforementioned ICD codes in any of the 10 diagnostic code fields. NACRS was used since April 2010.

Patient and public involvement

No patients were involved in setting the research question, the design and conduct of the study. No patients were involved in the interpretation or writing up of results. There are no plans to disseminate the results of the research to study participants because this was admin health database analysis. We will make the publication available to the relevant patient community.

Case definition of OA

Validated case definitions have been used in previous research related to OA using administrative data.11 12 The sensitivity of algorithms based on both physician claims and hospitalisations records within 2–5 years ranged from 24% to 46%, along with specificity and positive predictive value ranging from 92% to 98%, and 39% to 54%, respectively11. In this study, OA cases were identified as individuals with at least one OA-related hospitalisation (DAD), or at least two OA-related physician visits (claims) within 2 years, or at least two OA-related ambulatory care visits (ACCS/NACRS) within 2 years, assuming none of the physicians or ambulatory care visits had occurred on the same day.11 For our study, the OA cohort refers to those Alberta residents registered with AHCIP who have a specified OA-related diagnostic code in any diagnostic code field position. The cohort inclusion date is the earliest date of the OA-related record identified from either the Claims, DAD or ACCS/NACRS files.

Case definitions of comorbidities

We identified specific comorbidities to explore in this analysis based on three criteria: (1) a high frequency of reported comorbidities in the published literature on OA; (2) the availability of validated case definitions for each comorbid condition; and (3) expert input from our clinical coinvestigators. We first conducted a scoping review of the literature,13 aiming to examine the extent and range of comorbidities research among people with OA. We identified 20 studies from a range of countries (9 in North America, 8 in Europe, 1 in Asia, 1 in South American, 1 in Netherlands), using different study designs (9 cross-sectional, 5 retrospective cohort, 5 prospective cohort and 1 case control study) with a range of sample sizes (91–85 966 369 cases of OA). Based on the results of this review, we derived a list of comorbidities and presented it to our clinical coinvestigators. On this basis, we identified eight comorbidities to include in our analysis: hypertension, depression, COPD, diabetes, congestive heart failure (CHF), peripheral vascular disease (PVD), myocardial infarction (MI) and cerebrovascular disease (CEVD). We applied case definitions for each comorbidity to identify those present within 3 years prior to the OA diagnosis. Detailed ICD 9 and ICD 10 diagnostic codes used to identify each comorbidity are provided in online supplementary appendix 1.14–23

Age-standardised comorbidity prevalence rate

The frequency of each comorbid condition in people meeting the case definition for OA was calculated, as was the frequency of the number of comorbidities present per individual: one comorbidity, two comorbidities and three or more comorbidities. We stratified OA cases by sex, and by age at diagnosis (24 We used the 2016 Canadian population reported publicly by Statistics Canada25 to age-standardise the estimates for females and males with 95% CIs calculated using the binomial approximation method.24 To compare differences between females and males, standardised rate ratios (SRR) were estimated as the female age-standardised rate divided by the male age-standardised rate. We calculated 95% CIs for the SRR based on the SE for each sex, to test for a sex difference.24

We calculated the percentage of females and males in each age group and the percentage of OA cases for each age group by sex. The percentage of comorbidities among OA population was calculated as the number of cases with specific comorbidity divided by the OA population. The percentage of comorbidities among those with comorbidities was calculated using the population with one or more of the eight comorbidities as denominator. We also calculated the frequency of common groupings of these comorbidities in people with OA.

We applied χ2 tests of independence with a Bonferroni correction26 to compare the percentage of specific comorbid conditions among the population with OA in each age group (2 is greater than the critical value for a specific number of df and an altered significance level of 0.005 after Bonferroni correction. All analyses were conducted with R V.3.5.1 and Excel 2013.

Results

We identified 497 362 cases of OA, 57.9% of whom were females (table 1). More than half of the OA cases had at least one of the eight comorbidities (54.6%, n=271 794) (table 2). A total of 161 315 (32.4%) people with OA had only one comorbidity, with 14.6% (n=72 567) having two and 7.6% (n=37 912) having three or more of the comorbidities. Hypertension was the most frequent comorbidity (29%, n=144 453), followed by depression (19.9%, n=99 103), COPD (18.6%, n=92 273), diabetes (9.5%, n=47 102) and CHF (5.6%, n=27 905). PVD (3.0%), CEVD (1.2%) and MI (1.0%) were the least frequent comorbidities.

Table 1

Characteristics of people with OA identified in the population

Table 2

Frequency, percentage and age-standardised rate of comorbidities in people with OA

Comorbidity patterns by sex

A similar pattern was observed regarding the number of comorbidities (with most people with OA having one comorbidity) and the ordering of the frequency of each of the comorbidities among females and males based on age-standardised prevalence rates (table 2). Statistically significant differences among females and males were observed by the number of comorbidities, with females having higher age-standardised rates overall (SRR=1.26, 95% CI 1.25 to 1.28). The number of comorbidities was also higher for females compared with males with SRR ranging from 1.15 (95% CI 1.11 to 1.18) for three or more comorbidities to 1.48 (95% CI 1.44 to 1.52) for two comorbidities (table 2).

Depression, COPD and hypertension remained as the three most prevalent comorbidities in both females and males after age standardisation. However, the prevalence of each of these comorbidities was higher in females compared to males (table 2). Females had significantly higher prevalence rates than males for depression (SRR=1.73, 95% CI 1.69 to 1.77), COPD (SRR=1.28, 95% CI 1.25 to 1.30) and hypertension (SRR=1.11, 95% CI 1.09 to 1.12).

The prevalence of each of these three comorbidities differed significantly in females. For example, the age-standardised prevalence of depression in females was 264 cases per 1000 population, 35% higher and statistically higher than for COPD (196 cases per 1000 population) (SRR=1.35, 95% CI 1.32 to 1.37). In contrast, the prevalence of these three comorbidities among males were not significantly different.

Common groupings of comorbidities in people with OA

As shown in table 3, of the eight comorbidities in people with OA, the most frequent comorbidity was hypertension as a single comorbidity, found in 12.8% of people with OA (n=63 520). The most common grouping of two comorbidities was the coexistence of hypertension and depression (2.9%, n=14 609). The most common grouping with three comorbidities was depression, COPD and hypertension (1.1%, n=5262). People with OA having any combination of the top three comorbidities accounted for ~40% of people with OA.

Table 3

Frequency of top 10 common groupings of comorbidities

Comorbidity patterns by age group

As shown in figure 1, each of the eight comorbidities, with the exception of depression, was most common in people with OA over 65 years old. Hypertension was found in 44.3% of people with OA over 65 years of age (n=91 153 cases) compared with 5.3% (n=4040 cases) in those online supplementary appendix 2.

Figure 1

Percentage of specific comorbid conditions among the population with OA in each age group (

The number of comorbidities in people with OA increased with increasing age. The percentage of people with three or more comorbidities increased significantly from 1.5% in youngest age group (

Discussion

We estimated the prevalence of comorbid conditions in people with OA using provincial administrative health data. Using validated case and comorbidity definitions, we found that 54.6% of people with OA had at least one of the eight comorbidities, and 22.2% had at least two. Depression, COPD and hypertension were the three most prevalent comorbidities in both females and males after age standardisation. However, the prevalence of each of these comorbidities was significantly higher in females compared with males. People with any combination of these three comorbidities represented about 40% of the people with OA. In general, the number of comorbidities in people with OA increased with increasing age. Each of the eight comorbidities, except depression, was most common in people with OA ≥65 years. The largest number of people with OA and depression are in the middle age group (45–64 years), with the youngest age group (

The estimated prevalence of comorbidities varies among studies due to differences in case definitions, the list of included chronic conditions, data sources and study population. We estimated that the prevalence of comorbidity among people with OA was 54.6% for one or more of the eight comorbid chronic conditions and 22.2% for two or more comorbid chronic conditions with OA. Our estimates of the prevalence of comorbidities in people with OA are higher than the prevalence of two or more and three or more chronic conditions among the general Canadian population (26.5% and 10.2%, respectively) as reported by Feely et al,27 and higher than the prevalence of 12.9% (two or more chronic diseases) and 3.9% (three or more chronic diseases) reported by Roberts et al.28 In our study, among 205 978 OA cases in the age group over 65 years old, the prevalence of one or more comorbid chronic conditions was 33.2% (n=68 418) and the prevalence of two or more comorbid chronic conditions with OA was 19.0% (n=39 044). The estimated prevalence of comorbid chronic conditions in people with OA is higher than the estimates reported by Roberts et al, which showed that the prevalence of two or more chronic diseases in the general population over 65 years old was 31.3% and the prevalence of three or more chronic diseases was 11.3%. It has been reported previously that the prevalence of one or more comorbid condition among people with musculoskeletal conditions was more than twice than those without a musculoskeletal condition but with another chronic condition.29

We identified depression, COPD and hypertension as frequent comorbid conditions among the people with OA. This was consistent with findings reported from the Canadian Primary Care Sentinel Surveillance Network showing that the prevalence of OA has significant association with depression, COPD and hypertension.2 Depression is emerging as a significant comorbidity in OA. Previous findings have reported that depression was highly prevalent in people with OA.10 30 A systemic review of depressive symptoms in people with OA, including 49 studies worldwide and representing 15 855 individuals, reported a frequency of depression of 19.9% among people with OA, function gtElInit() { var lib = new google.translate.TranslateService(); lib.setCheckVisibility(false); lib.translatePage(‘en’, ‘nl’, function (progress, done, error) { if (progress == 100 || done || error) { document.getElementById(“gt-dt-spinner”).style.display = “none”; } }); } a href = “# ref-31” id = “xref-ref-31-1″> 31 die vergelijkbaar was met onze schattingen.

Depressieve personen zijn meer kans op chronische of meer ernstige pijn, en meer dan de helft van de patiënten met chronische pijn is depressief. Van mensen met OA is bekend dat ze minder sociale contacten hebben, beperkte fysieke activiteit, verhoogde pijn en handicap, 32 33 erger chirurgische resultaten en verminderde effectiviteit van pijninterventies, 34 die allemaal belangrijke voorspellers van depressie zijn. 35 De huidige klinische richtlijnen voor niet-chirurgische behandeling van artrose bevatten echter geen aanbevelingen met betrekking tot het beheer van de geestelijke gezondheid. 36–39 Dit benadrukt de noodzaak van behandelingen en management voor depressie om de resultaten voor mensen met artrose te verbeteren. 40 Er is gesuggereerd dat artsen informeren over tijdige identificatie van psychologische factoren nuttig kan zijn om de resultaten te verbeteren. Bovendien zou zelfzorgmanagement kunnen worden geïntegreerd in OA-managementstrategieën als een manier om angst en depressie te verminderen, evenals resulterende emotionele en fysieke pijn. Richtlijnen suggereren dat OA-management farmacotherapie ook zorgvuldig moet integreren en voorzichtig moet zijn met de geneesmiddelinteracties en bijwerkingen bij de holistische behandeling van artrose, depressie, angst en pijn. 30 Twee of meer van de comorbiditeiten die we hebben onderzocht, bestaan ​​naast een aanzienlijk deel van de mensen met artrose – ongeveer 22% in totaal. Obesitas, die we niet konden bestuderen met behulp van administratieve gegevens, komt ook veel voor bij mensen met artrose en een risicofactor voor het ontwikkelen van artrose. 41 42 Vanuit klinisch oogpunt moet een arts de implicaties van het voorschrijven van niet-steroïde ontstekingsremmende medicijnen voor pijnbestrijding overwegen, maar dit kan hypertensie verergeren en een geassocieerd verhoogd risico op hart- en vaatziekten hebben. Zonder goed pijnmanagement is het echter moeilijk voor patiënten met artrose om een ​​trainingsprogramma te volgen dat kan helpen hun spieraandoening te verbeteren en mogelijk overgewicht en hypertensie te verminderen. Dit wordt verder bemoeilijkt door de relatie tussen een lagere sociaaleconomische status en een verhoogd risico op het ontwikkelen van artrose, zoals aangetoond in het project voor een Ontario Women’s Health Evidence-based Report. 29

Bovendien hebben onze analyses aangetoond dat depressie niet alleen de meest voorkomende comorbiditeit was na leeftijdsstandaardisatie bij mensen met artrose, maar dat depressiespercentages significant hoger waren voor vrouwen en jongeren ( et al meldde dat mensen jonger dan 65 jaar nog steeds deelnamen aan het personeelsbestand; OA-pijn resulteerde echter in aanzienlijk lagere productiviteit en hogere kosten in vergelijking met mensen zonder OA-pijn. 8 Ze identificeerden een unieke behandeling hiaten voor patiënten jonger dan 60 jaar oud omdat de niet-operatieve behandelingsopties niet effectief waren bij de behandeling van OA-symptomen op lange termijn, maar jonge patiënten waren te jong of misschien niet bereid om definitieve behandeling te ondergaan, zoals totale gewrichtsvervanging. 43 Zelfs voor patiënten die totale gewrichtsvervanging ondergaan, waren ze eerder ontevreden over de behandeling dan oudere patiënten en meldden ze slechtere resultaten inclusief resterende pijn en stijfheid. 44 45 Uit een onderzoek onder orthopedische chirurgen bleek dat 84% de behoefte aan een betere behandeling voor jongere ( 43 Vanwege de verschillende presentaties van comorbiditeiten en behandelingsopties bij jonge en oude leeftijdsgroepen, is het noodzakelijk om de impact van comorbiditeiten op managementstrategieën in een leeftijdsgebonden OA-cohort te onderzoeken.

De meeste richtlijnen voor klinische praktijken zijn gericht op afzonderlijke aandoeningen. 46 Fortin et al concludeerde dat, hoewel de kwaliteit van de Canadese richtlijnen goed was, hun relevantie voor patiënten met twee of meer chronische aandoeningen beperkt was. 47 Boyd et al benadrukte dat het niet in overweging nemen van comorbiditeiten in richtlijnen van de klinische praktijk kan leiden tot een slechte kwaliteit van zorg omdat de gezondheidszorg die sommige patiënten ontvingen niet optimaal was. 48 Sharma et al wees erop dat de huidige literatuur niet volledig ingaat op de managementstrategieën bij het omgaan met comorbiditeiten gezien bij mensen met OA. 30 Patiëntgerichte zorg is aanbevolen in klinische praktijkrichtlijnen met als doel de kwaliteit van zorg te verbeteren door te focussen op de patiënt als geheel in plaats van op een enkele ziekte. . 49 Vanuit een systeemperspectief waren patiënten met verschillende comorbiditeiten ook de belangrijkste gebruikers van hulpmiddelen en diensten in de gezondheidszorg. 50 Patiëntgerichte en gecoördineerde zorg voor deze patiënten kan gerelateerd zorggebruik verminderen. 51 Het werd aanbevolen dat artsen rekening houden met deze comorbiditeiten bij het beheer van mensen met artrose.

Een sterkte van onze studie is het grote populatiegebaseerde aantal mensen met artrose (n = 497 362) en het onderzoek van een groep van acht comorbiditeiten die klinisch relevant zijn voor het management van mensen met artrose. Deze acht comorbiditeiten onder mensen met artrose zijn in eerdere studies gerapporteerd, maar alleen op individuele basis of in groepen van een subset van deze comorbiditeiten. Onze studie is de eerste die al deze comorbiditeiten omvat, wat nodig is om de klinische context voor het beheer van deze patiënten te begrijpen. Bovendien schetst onze analyse ook de patronen van voorkomen en gelijktijdig voorkomen van deze comorbiditeiten met betrekking tot de prevalentie van comorbiditeiten die relevant zijn voor de planning en levering van gezondheidsdiensten voor deze groeiende populatie van mensen met artrose. We hebben casusdefinities toegepast voor administratieve gezondheidsgegevens om gevallen van artrose en elk van de comorbiditeiten bij de diagnose van artrose te identificeren. Een beperking van ons onderzoek is dat gevalidentificatie op basis van administratieve gegevens kan leiden tot onderrapportage van gevallen en comorbiditeiten. De casusdefinities voor OA in administratief gegevensonderzoek, 5 op basis van de claims van artsen en ziekenhuisopnames, zijn toegepast en gevalideerd met een gevoeligheid van 24%, hoge specificiteit van 98% en een positieve voorspellende waarde van 54%. 11 In onze studie hebben we ook ACCS / NACRS opgenomen om het probleem van onderschatting te verminderen. 6 Desalniettemin het geschatte aantal OA gevallen waarbij deze aanpak wordt gebruikt, is vrijwel zeker een onderschatting. Evenzo kunnen de algoritmen voor comorbiditeiten de prevalentie van deze comorbiditeiten onderschatten; de gevoeligheid voor het identificeren van depressie is van 36% tot 51%, 19 voor PVD is 39% 18 en voor COPD is 53% 21 in administratieve gegevens ( online aanvullende bijlage 2 ). Wat nog belangrijker is, de gerapporteerde niveaus van comorbiditeit bij patiënten met artrose werden gemeten ten tijde van de diagnose van artrose. Nieuwe gevallen van comorbiditeit gediagnosticeerd na de OA-diagnose werden niet geïdentificeerd. Verder hebben we onze analyse beperkt tot acht comorbiditeiten van klinische relevantie en waarvoor er case-definities in administratieve gegevens waren.

Conclusies

We vonden dat depressie, COPD en hypertensie de drie meest voorkomende comorbiditeiten waren bij mensen met artrose, met percentages die significant hoger waren bij vrouwen dan bij mannen. Van bijzonder belang is dat het grootste aantal mensen met artrose en depressie in de leeftijdsgroep tussen 45 en 64 jaar oud is, met het hoogste percentage gevallen in de jongere leeftijdsgroepen (

Dankbetuigingen

De auteurs willen graag de volgende teamleden en hun bijdragen aan het onderzoek erkennen: Behnam Sharif.

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