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Objective Diet and exercise (D+E) for knee osteoarthritis (OA) is effective and cost‐effective. However, cost‐effectiveness does not imply affordability; the impact of knee OA–specific D+E programs on insurer budgets is unknown. Methods We estimated changes in undiscounted medical expenditures (2016 US dollars) with and without a D+E program. We accounted for both additional program outlays and potential savings from reduced use of other knee OA treatments and from reduced incidence of comorbidities. We adopted the perspective of a representative commercial insurance plan covering 200 000 individuals aged 25 to 64 years and a representative Medicare Advantage plan covering 200 000 Medicare‐eligible individuals aged 65 years and older. We used the Osteoarthritis Policy Model, a validated microsimulation model of knee OA, to model D+E efficacy (measured by pain and weight reduction), adherence, and price based on the Intensive Diet and Exercise for Arthritis (IDEA) trial. In sensitivity analyses, we varied time horizon, D+E efficacy, and D+E price. Results Over 3 years, the D+E program increased spending by $752 200 ($0.10 per member per month [PMPM]) in the commercial plan and by $6.0 million ($0.84 PMPM) in the Medicare plan. Over 3 years, the D+E program reduced opioid use by 6% and 5% and reduced total knee replacements by 5% and 4% in the commercial and Medicare plans, respectively. Expenses were higher in the Medicare plan because it had more patients with knee OA than the commercial plan. Conclusion Although there is no established threshold to define affordability, a D+E program for knee OA would likely produce expenditures comparable with outlays for other health‐promotion interventions.

Objective The Intensive Diet and Exercise for Arthritis (IDEA) trial showed that an intensive diet and exercise (D+E) program led to a mean 10.6-kg weight reduction and 51% pain reduction in patients with knee osteoarthritis (OA). The aim of the current study was to investigate the cost-effectiveness of adding this D+E program to treatment in overweight and obese (body mass index >27 kg/m2 ) patients with knee OA. Methods We used the Osteoarthritis Policy Model to estimate quality-adjusted life-years (QALYs) and lifetime costs for overweight and obese patients with knee OA, with and without the D+E program. We evaluated cost-effectiveness with the incremental cost-effectiveness ratio (ICER), a ratio of the differences in lifetime cost and QALYs between treatment strategies. We considered 3 cost-effectiveness thresholds: $50,000/QALY, $100,000/QALY, and $200,000/QALY. Analyses were conducted from health care sector and societal perspectives and used a lifetime horizon. Costs and QALYs were discounted at 3% per year. D+E characteristics were derived from the IDEA trial. Deterministic and probabilistic sensitivity analyses (PSAs) were used to evaluate parameter uncertainty and the effect of extending the duration of the D+E program. Results In the base case, D+E led to 0.054 QALYs gained per person and cost $1,845 from the health care sector perspective and $1,624 from the societal perspective. This resulted in ICERs of $34,100/QALY and $30,000/QALY. In the health care sector perspective PSA, D+E had 58% and 100% likelihoods of being cost-effective with thresholds of $50,000/QALY and $100,000/QALY, respectively. Conclusion Adding D+E to usual care for overweight and obese patients with knee OA is cost-effective and should be implemented in clinical practice.

OBJECTIVE: We evaluated the cost-effectiveness of telephonic health coaching and financial incentives (THC+FI) to promote physical activity in total knee replacement recipients. DESIGN: We used the Osteoarthritis Policy Model, a computer simulation of knee osteoarthritis, to evaluate the cost-effectiveness of THC+FI compared to usual care. We derived transition probabilities, utilities, and costs from trial data. We conducted lifetime analyses from the healthcare perspective and discounted all cost-effectiveness outcomes by 3% annually. The primary outcome was the incremental cost-effectiveness ratio (ICER), defined as the ratio of the differences in costs and quality-adjusted life years (QALYs) between strategies. We considered ICERs

Objective Type II diabetes mellitus (T2DM) is prevalent in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA) and increases risk for prosthetic joint infection (PJI). We examined the cost-effectiveness of antibiotic prophylaxis (AP) before dental procedures to reduce PJI in TKA recipients with T2DM. Design We used the Osteoarthritis Policy Model, a validated computer simulation of knee OA, to compare two strategies among TKA recipients with T2DM (mean age 68 years, mean BMI 35.4 kg/m2): 1) AP before dental procedures and 2) no AP. Outcomes included quality-adjusted life expectancy (QALE) and lifetime medical costs. We used published efficacy of AP. We report incremental cost-effectiveness ratios (ICERs) and considered strategies with ICERs below well-accepted willingness-to-pay (WTP) thresholds cost-effective. We conducted sensitivity analyses to examine the robustness of findings to uncertainty in model input parameters. We used a lifetime horizon and healthcare sector perspective. Results We found that AP added 1.0 quality-adjusted life-year (QALY) and $66,000 for every 1000 TKA recipients with T2DM, resulting in an ICER of $66,000/QALY. In sensitivity analyses, reduction of the probability of PJI, T2DM-associated risk of infection, or attribution of infections to dental procedures by 50% resulted in ICERs exceeding $100,000/QALY. Probabilistic sensitivity analyses showed that AP was cost-effective in 32% and 58% of scenarios at WTP of $50,000/QALY and $100,000/QALY, respectively. Conclusions AP prior to dental procedures is cost-effective for TKA recipients with T2DM. However, the cost-effectiveness of AP depends on the risk of PJI and efficacy of AP in this population.

Summary Objective The cost-effectiveness of the recently-introduced generic celecoxib in knee OA has not been examined. Method We used the Osteoarthritis Policy (OAPol) Model, a validated computer simulation of knee OA, to evaluate long-term clinical outcomes, costs, and cost-effectiveness of generic celecoxib in persons with knee OA. We examined eight treatment strategies consisting of generic celecoxib, over-the-counter (OTC) naproxen, or prescription naproxen, with or without prescription or OTC proton-pump-inhibitors (PPIs) to reduce gastrointestinal (GI) toxicity. In the base case, we assumed that annual cost was $130 for OTC naproxen, $360 for prescription naproxen, and $880 for generic celecoxib. We considered a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY) and discounted costs and benefits at 3% annually. In sensitivity analyses we varied celecoxib toxicity, discontinuation, cost, and pain level. Results In the base case analysis of the high pain cohort (WOMAC 50), celecoxib had an incremental cost-effectiveness ratio (ICER) of $284,630/QALY compared with OTC naproxen. Only under highly favorable cost, toxicity, and discontinuation assumptions (e.g., annual cost below $360, combined with a reduction in the cardiovascular (CV) event rates below baseline values) was celecoxib likely to be cost-effective. Celecoxib might also be cost-effective at an annual cost of $600 if CV toxicity were eliminated completely. In subjects with moderate pain (WOMAC 30), at the base case CV event rate of 0.2%, generic celecoxib was only cost-effective at the lowest plausible cost ($190). Conclusion In knee OA patients with no comorbidities, generic celecoxib is not cost-effective at its current price.

Objective Total knee replacement (TKR) is an effective treatment for end-stage knee osteoarthritis (OA). American racial minorities undergo fewer TKRs than whites. We estimated quality-adjusted life-years (QALYs) lost for African American knee OA patients due to differences in TKR offer, acceptance, and complication rates. Methods We used the Osteoarthritis Policy Model, a computer simulation of knee OA, to predict QALY outcomes for African American and white knee OA patients with and without TKR. We estimated per-person QALYs gained from TKR as the difference between QALYs with current TKR use and QALYs when no TKR was performed. We estimated average, per-person QALY losses in African Americans as the difference between QALYs gained with white rates of TKR and QALYs gained with African American rates of TKR. We calculated population-level QALY losses by multiplying per-person QALY losses by the number of persons with advanced knee OA. Finally, we estimated QALYs lost specifically due to lower TKR offer and acceptance rates and higher rates of complications among African American knee OA patients. Results African American men and women gain 64,100 QALYs from current TKR use. With white offer and complications rates, they would gain an additional 72,000 QALYs. Because these additional gains are unrealized, we call this a loss of 72,000 QALYs. African Americans lose 67,500 QALYs because of lower offer rates, 15,800 QALYs because of lower acceptance rates, and 2,600 QALYs because of higher complication rates. Conclusion African Americans lose 72,000 QALYs due to disparities in TKR offer and complication rates. Programs to decrease disparities in TKR use are urgently needed.

Inclement weather and home environment can act as barriers to physical activity. However, it is unclear if they reduce the activity of persons participating in activity-promoting programs.Data from a 6-month workplace financial incentives program were used to establish the association between meteorologic (temperature, rain, snow, and wind) and geographic factors (urban/nonurban home location and distance between home and work) and moderate to vigorous physical activity (MVPA). Multivariable models were built to estimate mean weekly minutes of MVPA adjusting for demographic factors, clinical factors, and impulsivity.The 292 participants had a mean age of 38 (SD = 11) years. Eighty-three percent were female and 62% were white. Twenty-nine percent lived within 3 miles of work, and 35% lived in urban areas. Participants who lived more than 3 miles from work averaged 75 [95% confidence interval (CI), 65-84] minutes of weekly MVPA compared with 105 (95% CI, 88-122) minutes for those who lived within 3 miles of work. Urban participants averaged 70 (95% CI, 57-83) minutes of MVPA compared with 91 (95% CI, 80-102) minutes for nonurban participants. Colder temperatures were associated with decreased MVPA, and impulsivity modified the effect.Colder temperatures, greater distance from work, and an urban residence are associated with fewer minutes of MVPA.

Background Although community-based adaptive sports have become a popular means of rehabilitation for individuals with disabilities, little is known regarding the factors that lead to sustained participation. Objective To determine the demographic, environmental, disability-related, and functional factors associated with sustained participation in a community-based adaptive sports program. Design Retrospective cohort study. Setting Community-based adaptive sports program. Participants Adults with mobility-related disabilities. Methods Data were collected from registration forms and participation logs. Participants were described as "sustainers" if they attended ≥2 sessions, or as "nonsustainers" if they attended 0 or 1 session. We examined the associations between sustained participation and demographic, environmental, disability-related, and functional factors in bivariate and multivariable analyses. Main Outcome Measurement Sustained participation in the adaptive sports program. Results Of the 134 participants, 78 (58%) were sustainers and 56 (42%) were nonsustainers. In multivariable analyses, participants who ambulated independently had lower odds of being sustainers (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.11, 0.96), and those who used an ambulatory assistive device had twice the odds of being sustainers (OR = 2.0, 95% CI=0.65, 6.2) compared to those who used a manual wheelchair. Moreover, participants who lived within 5.3 miles of the program site (OR = 3.8, 95% CI=1.1, 13.0) and those who lived between 5.3 and 24.4 miles from the program site (OR = 2.8, 95% CI=1.0, 7.7) had significantly higher odds of sustained participation than those who lived more than 24.4 miles from the program site. Conclusion Sustained participation in community-based adaptive sports is associated with living closer to the program site and the presence of a moderate level of functional impairment. These findings suggest that programs might consider increasing the number of satellite sites and expanding offerings for individuals with mild or more significant mobility-related disabilities to effectively increase program participation. Level of Evidence II

Objective: Young adults, in general, are not aware of their risk of knee osteoarthritis (OA). Understanding risk and risk factors is critical to knee OA prevention. We tested the efficacy of a personalized risk calculator on accuracy of knee OA risk perception and willingness to change behaviors associated with knee OA risk factors. Methods: We conducted a randomized controlled trial of 375 subjects recruited using Amazon Mechanical Turk. Subjects were randomized to either a) use a personalized risk calculator based on demographic and risk factor information (intervention) or b) view general OA risk information (control). At baseline and after the intervention, subjects estimated their 10-year and lifetime risk of knee OA and responded to contemplation ladders measuring willingness to change diet, exercise, or weight-control behaviors. Results: Subjects in both arms had an estimated 3.6% 10-year and 25.3% lifetime chance of developing symptomatic knee OA. Both arms greatly overestimated knee OA risk at baseline, estimating a 10-year risk of 26.1% and a lifetime risk of 47.8%. After the intervention, risk calculator subjects' perceived 10-year risk decreased by 12.9 percentage points to 12.5% and perceived lifetime risk decreased by 19.5 percentage points to 28.1%. Control subjects' perceived risks remained unchanged. Risk calculator subjects were more likely to move to an action stage on the exercise contemplation ladder (RR = 2.1). There was no difference between the groups for diet or weight-control ladders. Conclusions: The risk calculator is a useful intervention for knee OA education and may motivate some exercise-related behavioral change. This article is protected by copyright. All rights reserved.

Bamberger's studies of visual descriptions of rhythmic patterns led to a distinction between two kinds of rhythmic understanding: metric and figural (Bamberger, 1982). Metric understanding describes events in terms of a measured underlying beat, while figural understanding describes events in terms of the events surrounding them. The present study asked whether the ability to produce accurate figural representations is related to the level of metric understanding. Forty-nine children (6-12 years old), and forty-eight adults (17-45 years old), served as subjects. Twenty-four of the adults, but none of the children, were musically trained. Each listener completed four tasks: (1) drawing, (2) clap-back, (3) join-in, and (4) an intelligence test. For the first three tasks, eighteen rhythm sequences were designed so that metric and figural representations did not coincide. The drawing task required listeners to represent each sequence with symbols of their choice, so that someone else could reproduce the sequence from their description. For the clap-back task, listeners were asked to clap back the sequence. For the join-in task, listeners were asked to clap along with what they perceived to be the underlying beat of the sequence. For both children and adults correlations between accuracy on drawing and performance tests were significant for the figural drawers but not for the metric drawers. Accuracy of figural drawing is related, for both children and adults, to the ability to respond to the metric aspects of rhythm. Figural descriptions and metric actions may be complementary aspects of rhythmic understanding.

Twenty melodic tone sequences varying in harmonic structure were first presented once each to listeners selected from three different levels of previous musical training. Listeners rated each sequence on a 6-point scale of "pleasingness". Next, 5 sequences from the original set of 20 were each repeated 10 times in a row and rated after each repetition. The 5 sequences were assigned to listeners so that across listeners the 20 original sequences were equally represented. Finally, all 20 sequences were again each presented once for rating. At all levels of musical training, listeners showed a monotonic relationship between "pleasingness" and level of harmonic structure, with highest ratings of "pleasingness" associated with the highest level of structure. During repeated exposures, judged "pleasingness" increased at all levels of harmonic structure except the highest level, where a decrease of "pleasingness" with exposure was obtained. The effects of repetition did not, however, extend to the final ratings of the original set of 20 sequences. The data are discussed with reference to the optimal- complexity model of aesthetic judgement; specific attention is directed toward the cognitive processes determining sequence complexity.

Japanese women were asked to rank the relative importance they place on the role of wife, mother, woman, and person as well as the relative importance they believe their husbands place on similar male roles. Also asked were questions on the qualities of a good wife, the tone of interpersonal relationships with husbands, and the division of household responsibilities. Findings support the hypothesis that social structural variables related to environmental complexity result in an emphasis on individuality. Furthermore, although the Japanese wife's uncomplaining acceptance of household chores and responsibilities appears to make her fit the stereotype of the selfless domestic desirous of filling her husband's every wish, she seems to be more a disinterested than a willing servant, her husband being nowhere as important a factor in her social and psychological existence as are her children.

Presented are fundamental data on the biological effects of monoenergetic beams of carbon (400 MeV/amu), neon (425 MeV/amu), and argon (570 MeV/amu). Cell survival of human kidney T-1 cells was measured under aerobic and hypoxic conditions over a range of mean LETinfinity from 10 to 600 keV/..mu..m. RBE and OER were measured under hypoxic and aerobic conditions with attention paid to dose, mean LETinfinity, and particle charge effects. (DS)

Combining data gathered in a survey of Japanese women's attitudes toward their various roles with the findings of a comparative study of childrearing and child behavior in Japan and the United States, the present paper examines how social structural and cultural variables affect Japanese women's maternal values and behavior. We find that the maternal role is considered the central one for women, who emphasize it at the expense of their conjugal role, fostering in the process a high degree of interdependence with their children. However, our findings provide evidence of a

CHAPMAN, J. D., BLAKELY, E. A., SMITH, K. C., URTASUN, R. C., LYMAN, J. T., AND TOBIAS, C. A. Radiation Biophysical Studies with Mammalian Cells and a Modulated Carbon Ion Beam. Radiat. Res. 74, 101-111 (1978). Chinese hamster (V-79) and human kidney (T-l) cells were irradiated in stirred suspensions placed at various positions in the plateau and extended Bragg peak of a 400-MeV/amu carbon ion beam. The range of the ions was modulated by a lead (translational) ridge filter and a brass (spiral) ridge filter designed to produce extended peaks of -4 and 10 cm, respectively. Stationary-phase and Gi-phase populations of Chinese hamster cells were found to have different absolute radiosensitivities which, in turn, were different from that of asynchronous human kidney cells. The increase in relative biological effectiveness (RBE) observed as carbon ions were slowed down and stopped in water was similar for the three cell populations at doses greater than 400 rad. At lower doses the RBE was greater for the hamster cell populations than for the human kidney cells. The gain in RBE (at the 50% survival level) between the plateaus and the middle region of the extended peaks was -2.0 and 1.7 for the 4- and 10-cm extended peaks, respectively. Oxygen enhancement ratios (OER) were determined at the 10% survival levels with stationary-phase populations of hamster cells. Values of 2.8, 2.65, and 1.65 were obtained for the OER of 220-kV X rays, plateau carbon, and the middle region of the 4-cm carbon peak, respectively. Across the 10-cm carbon peak the OER was found to vary between values of 2.4 to 1.55 from the proximal to distal positions.

Characteristics of cellular radiation chemistry were studied for mammalian cells saturated with air, nitrous oxide, or nitrogen in the absence or presence of an OH-radical scavenger, for both low- and high-LET radiations. For clarity, the data for low-LET studies are presented separately in this paper, while the results for densely ionizing particle radiations will be discussed in a subsequent manuscript. Cell monolayers were grown in glass vessels and irradiated with 225-kVp X rays. The contribution of OH-radical action was reduced from about 55% in aerobic cells to about 20% in nitrogen-saturated cells. In nitrous oxide-saturated cells, the indirect effect attributable to OH· is about 35%. OH-radical-mediated lesions can therefore result in oxygen-independent as well as oxygen-dependent lesions. Our results show that the hydrated electron does not contribute significantly to radiolethality in anaerobic cells.