Clinical Rheumatology

, Volume 34, Issue 8, pp 1435–1441 | Cite as

The association of comorbid conditions with patient-reported outcomes in Veterans with hip and knee osteoarthritis

  • Leah L. Zullig
  • Hayden B. Bosworth
  • Amy S. Jeffreys
  • Leonor Corsino
  • Cynthia J. Coffman
  • Eugene Z. Oddone
  • William S. YancyJr.
  • Kelli D. AllenEmail author
Original Article


There is limited understanding of how comorbid health conditions affect osteoarthritis (OA)-related outcomes. This study examined associations of different comorbidity measures with baseline OA-related patient-reported outcomes (PROs) among patients with hip and knee OA. Data were from patients (N = 300, 9 % female, mean age = 61.1; SD = 9.2) enrolled in a randomized control trial at the Durham Veterans Affairs Medical Center. Separate multivariable regression models, adjusted for demographic and clinical characteristics, examined the association of each comorbidity measure with baseline PROs: pain, physical function, depressive symptoms, fatigue, and insomnia. Comorbidity measures included the Self-Administered Comorbidity Questionnaire (SACQ), conditions reported as activity-limiting (SACQ-AL), and indicators of depression, diabetes, hypertension, and back pain. Mean (SD) numbers of comorbid conditions and activity-limiting conditions were 3.4 (1.8) and 1.6 (1.4), respectively. Comorbidity scores (SACQ overall and SACQ-AL) and individual comorbidity conditions were each associated with worse OA-related PROs adjusting for demographic and clinical factors. Worse SACQ overall and SACQ-AL scores were associated with worse mean scores for pain, depressive symptoms, fatigue, and insomnia (p values <0.01). Additionally, increasing SACQ-AL scores were associated with worse mean scores for function (p < 0.01). Depression was associated with worse pain (p = 0.03), fatigue, and insomnia (p values <0.01). Diabetes was associated with worse fatigue (p = 0.01), depressive symptoms (p = 0.02), and insomnia (p = 0.03). Back pain was associated with worse pain scores (p = 0.02). Results provide evidence that comorbidity burden, particularly activity-limiting conditions, is associated with worse OA-related PROs. Interventions for patients with OA need to address comorbid conditions and their impact on key outcomes.


Chronic disease Comorbidity Osteoarthritis United States Department of Veterans Affairs 





This project was supported by the National Institute of Arthritis and Musculoskeletal and Skin Disorders (1R01AR059673-01) and the Department of Veterans Affairs, Health Services Research and Development Service (IIR 10–126).


  1. 1.
    Nguyen US, Zhang Y, Zhu Y, Niu J, Zhang B, Felson DT (2011) Increasing prevalence of knee pain and symptomatic knee osteoarthritis: survey and cohort data. Ann Intern Med 155(11):725–732PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Berger A, Hartrick C, Edelsberg J, Sadosky A, Oster G (2011) Direct and indirect economic costs among private-sector employees with osteoarthritis. J Occup Environ Med Am Coll Occup Environ Med 53(11):1228–1235CrossRefGoogle Scholar
  3. 3.
    Losina E, Walensky RP, Reichmann WM, Holt HL, Gerlovin H, Solomon DH, Jordan JM, Hunter DJ, Suter LG, Weinstein AM et al (2011) Impact of obesity and knee osteoarthritis on morbidity and mortality in older Americans. Ann Intern Med 154(4):217–226PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Yelin E, Murphy L, Cisternas MG, Foreman AJ, Pasta DJ, Helmick CG (2007) Medical care expenditures and earnings losses among persons with arthritis and other rheumatic conditions in 2003, and comparisons with 1997. Arthritis Rheum 56(5):1397–1407PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Holla JF, van der Leeden M, Knol DL, Roorda LD, van der Esch M, Voorneman RE, Lems WF, Dekker J (2013) The association of body-mass index and depressed mood with knee pain and activity limitations in knee osteoarthritis: results from the Amsterdam osteoarthritis cohort. BMC Musculoskelet Disord 14(1):296PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Singh JA, Lewallen DG (2013) Time trends in the characteristics of patients undergoing primary total knee arthroplasty. Arthritis Care Res 66(6):897–906CrossRefGoogle Scholar
  7. 7.
    Martin KR, Kuh D, Harris TB, Guralnik JM, Coggon D, Wills AK (2013) Body mass index, occupational activity, and leisure-time physical activity: an exploration of risk factors and modifiers for knee osteoarthritis in the 1946 British birth cohort. BMC Musculoskelet Disord 14:219PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Perruccio AV, Davis AM, Hogg-Johnson S, Badley EM (2011) Importance of self-rated health and mental well-being in predicting health outcomes following total joint replacement surgery for osteoarthritis. Arthritis Care Res 63(7):973–981CrossRefGoogle Scholar
  9. 9.
    Perruccio AV, Katz JN, Losina E (2012) Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone. J Clin Epidemiol 65(1):100–106PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Cleveland RJ, Luong ML, Knight JB, Schoster B, Renner JB, Jordan JM, Callahan LF (2013) Independent associations of socioeconomic factors with disability and pain in adults with knee osteoarthritis. BMC Musculoskelet Disord 14:297PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    McAloney K, Graham H, Law C, Platt L (2013) A scoping review of statistical approaches to the analysis of multiple health-related behaviours. Prev Med 56(6):365–371PubMedCrossRefGoogle Scholar
  12. 12.
    Siemons L, ten Klooster PM, van de Laar MA, van den Ende CH, Hoogeboom TJ (2013) Validity of summing painful joint sites to assess joint-pain comorbidity in hip or knee osteoarthritis. BMC Musculoskelet Disord 14:234PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Allen KD, Bosworth HB, Brock DS, Chapman JG, Chatterjee R, Coffman CJ, Datta SK, Dolor RJ, Jeffreys AS, Juntilla KA et al (2012) Patient and provider interventions for managing osteoarthritis in primary care: protocols for two randomized controlled trials. BMC Musculoskelet Disord 13:60PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, Christy W, Cooke T, Greenwald R, Hochberg M (1986) Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee. Arthritis Rheum 29(8):1039–1049PubMedCrossRefGoogle Scholar
  15. 15.
    U.S. Department of Health and Human Services (2008) physical activity guidelines for Americans. Be active, healthy, and happy 2008Google Scholar
  16. 16.
    Wolfe F (1999) Determinants of WOMAC function, pain and stiffness scores: evidence for the role of low back pain, symptom counts, fatigue and depression in osteoarthritis, rheumatoid arthritis and fibromyalgia. Rheumatology 38(4):355–361PubMedCrossRefGoogle Scholar
  17. 17.
    Bellamy N (2002) WOMAC Osteoarthritis Index user guide, version V. Brisbane, AustraliaGoogle Scholar
  18. 18.
    Alkan BM, Fidan F, Tosun A, Ardicoglu O (2014) Quality of life and self-reported disability in patients with knee osteoarthritis. Mod Rheumatol Jpn Rheum Ass 24(1):166–171CrossRefGoogle Scholar
  19. 19.
    Agarwal P, Pan X, Sambamoorthi U (2013) Depression treatment patterns among individuals with osteoarthritis: a cross sectional study. BMC Psychiatry 13(1):121PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH (2009) The PHQ-8 as a measure of current depression in the general population. J Affect Disord 114(1–3):163–173PubMedCrossRefGoogle Scholar
  21. 21.
    Franssen PM, Bultmann U, Kant I, van Amelsvoort LG (2003) The association between chronic diseases and fatigue in the working population. J Psychosom Res 54(4):339–344PubMedCrossRefGoogle Scholar
  22. 22.
    Sarzi-Puttini P, Cimmino MA, Scarpa R, Caporali R, Parazzini F, Zaninelli A, Atzeni F, Canesi B (2005) Osteoarthritis: an overview of the disease and its treatment strategies. Semin Arthritis Rheum 35(1 Suppl 1):1–10PubMedCrossRefGoogle Scholar
  23. 23.
    Vitiello MV, McCurry SM, Shortreed SM, Balderson BH, Baker LD, Keefe FJ, Rybarczyk BD, Von Korff M (2013) Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: the lifestyles randomized controlled trial. J Am Geriatr Soc 61(6):947–956PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Sangha O, Stucki G, Liang MH, Fossel AH, Katz JN (2003) The Self-Administered Comorbidity Questionnaire: a new method to assess comorbidity for clinical and health services research. Arthritis Rheum 49(2):156–163PubMedCrossRefGoogle Scholar
  25. 25.
    Freund T, Kunz CU, Ose D, Szecsenyi J, Peters-Klimm F (2012) Patterns of multimorbidity in primary care patients at high risk of future hospitalization. Popul Health Manag 15(2):119–124PubMedCrossRefGoogle Scholar
  26. 26.
    Murphy SL, Lyden AK, Phillips K, Clauw DJ, Williams DA (2011) Subgroups of older adults with osteoarthritis based upon differing comorbid symptom presentations and potential underlying pain mechanisms. Arthritis Res Ther 13(4):R135PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Ganz DA, Chang JT, Roth CP, Guan M, Kamberg CJ, Niu F, Reuben DB, Shekelle PG, Wenger NS, MacLean CH (2006) Quality of osteoarthritis care for community-dwelling older adults. Arthritis Rheum 55(2):241–247PubMedCrossRefGoogle Scholar
  28. 28.
    van den Bussche H, Koller D, Kolonko T, Hansen H, Wegscheider K, Glaeske G, von Leitner EC, Schafer I, Schon G (2011) Which chronic diseases and disease combinations are specific to multimorbidity in the elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 11:101PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Agha Z, Lofgren RP, VanRuiswyk JV, Layde PM (2000) Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Arch Intern Med 160(21):3252–3257PubMedCrossRefGoogle Scholar
  30. 30.
    Woolf AD, Pfleger B (2003) Burden of major musculoskeletal conditions. Bull World Health Organ 81(9):646–656PubMedCentralPubMedGoogle Scholar

Copyright information

© Clinical Rheumatology 2014

Authors and Affiliations

  • Leah L. Zullig
    • 1
    • 2
  • Hayden B. Bosworth
    • 1
    • 2
    • 3
    • 4
  • Amy S. Jeffreys
    • 1
  • Leonor Corsino
    • 5
  • Cynthia J. Coffman
    • 1
    • 6
  • Eugene Z. Oddone
    • 1
    • 2
  • William S. YancyJr.
    • 1
    • 2
  • Kelli D. Allen
    • 1
    • 7
    • 8
    Email author
  1. 1.Center for Health Services Research in Primary CareDurham Veterans Affairs Medical CenterDurhamUSA
  2. 2.Division of General Internal Medicine, Department of MedicineDuke UniversityDurhamUSA
  3. 3.School of NursingDuke UniversityDurhamUSA
  4. 4.Department of Psychiatry and Behavioral SciencesDuke UniversityDurhamUSA
  5. 5.Division of Endocrinology, Department of MedicineDuke UniversityDurhamUSA
  6. 6.Biostatistics and BioinformaticsDuke UniversityDurhamUSA
  7. 7.Division of Rheumatology, Department of MedicineUniversity of North CarolinaChapel HillUSA
  8. 8.Thurston Arthritis Research CenterUniversity of North CarolinaChapel HillUSA

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