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MOORE, Administrator v. ATLANTA TRANSIT SYSTEM, INC.
(105 Ga. App. 70)
(123 SE2d 693)
Action for damages. Summary judgment. Hearsay evidence rule. Fulton Superior Court. Before Judge Alverson.
EBERHARDT, Judge.
1. The purpose of the Summary Judgment Act of 1959 (Ga. L. 1959, pp. 234-236; Code Ann. 110-1201 to 110-1209, is to eliminate a jury trial where such a trial would be unnecessary. Therefore, if the only proof offered by a party in support of his allegations would be incompetent, there would be no necessity for a jury trial and a motion for summary judgment should be granted.
2. The declarations of a decedent to whomsoever made are admissible in evidence if there are no other witnesses to the alleged occurrence, it being for the jury, under appropriate instructions, to determine their weight and credibility.
Both sides filed certain interrogatories, which were subsequently answered. In response to plaintiff's interrogatories, the defendant answered that it knew of no one who saw the event complained of or who arrived on the scene "immediately or shortly thereafter." The plaintiff's response to similar interrogatories by the defendant was also that he knew of no eyewitnesses or other persons who arrived "immediately or shortly thereafter."
The defendant Transit System then moved for summary judgment under the provisions of the act of 1959 (Ga. L. 1959, pp. 234-236; Code Ann. 110-1201 to 110-1209) on the grounds that there were no eyewitnesses to the event; there were no persons who came upon the scene "immediately or shortly thereafter"; and that the original plaintiff, Elsie J. Moore, was now deceased. The plaintiff offered certain evidence which will be more fully discussed in the opinion. The trial judge excluded the evidence and entered an order granting the defendant's motion for summary judgment. This order is brought there by the plaintiff for review.
At the hearing held on the defendant's motion for summary judgment, the plaintiff sought to introduce a letter from one Dr. Weinstein, a physician employed by the defendant to examine plaintiff's decedent, and particularly that part of the letter in which the doctor related the decedent's history of her complaint given to him, as follows: "In July, 1956, I was boarding an Atlanta Transit bus on Moreland Avenue, S.E. The bus driver closed the door of the bus as I was entering. I was struck on the right chest and back. This caused me to fall on steps of bus. It knocked me out temporarily. On the same day of the accident, I saw Dr. Huie, Glenwood Avenue. He X-rayed my ribs and back, and I saw Dr. Huie twice after the accident. He put a brace on me. I stayed in bed most of the time for 4 weeks. I could not get up or down without much pain. I did and still have a thumping pain in my back." The defendant objected to the introduction of the letter as being "hearsay and irrelevant, immaterial and has no connection with any allegation of negligence set out in the petition and that it was a self-serving declaration." The trial judge sustained the objection. The plaintiff indicated that all of his evidence as to how the decedent had been injured was of this type, consisting of what the plaintiff's decedent told various doctors and other persons.
The grounds of plaintiff's appeal are two-fold. First, he contends that a motion for summary judgment is not the proper method for deciding questions relative to the admissibility of evidence; and second, that the type of evidence adduced by plaintiff was admissible.
1. There is no merit in the plaintiff's first contention. The purpose of the Summary Judgment Act of 1959 was to eliminate the necessity for a jury trial where there is no genuine issue as to any material fact in the case. Scales v. Peevy, 103 Ga. App. 42, 46 (118 SE2d 193); Dillard v. Brannan, 217 Ga. 179 (121 SE2d 768). The "genuine issue" test is not met unless the evidence offered is competent and admissible. Dyer v. McDougal, 201 F2d 265 (2d Cir.); 6 Moore, Federal Practice, 2d Ed. 1953, 56.02[9], p. 2019; 3 Barron & Holtzoff, Federal Practice & Procedure, 1958 Rev., 1235, pp. 148-149 and 1237, p. 164. Appolonio v. Baxter, 217 F2d 267 (6th Cir.), is directly in point. There the defendant's motion for summary judgment was held properly granted where plaintiff's case was not provable by competent evidence because of the Tennessee "Dead Man's Statute." Resort to Federal cases is appropriate because the act of 1959 is substantially identical with Rule 56 of the Federal Rules of Civil Procedure. McCallum v. Twiggs County Bank, 172 Ga. 591 (1) (158 SE 302, 74 ALR 932).
2. However, the problem of the admissibility of the evidence in this case still remains. Unless such evidence is admissible, we would be constrained under the first division of this opinion to hold that the defendant's motion for summary judgment was properly granted, for in that event it would appear from plaintiff's admissions that all of his evidence as to the alleged occurrence is of the same character; and from the admissions of both plaintiff and defendant that there is no known witness who saw it. Hence there would be no competent evidence to raise any material issue.
It is clear that the evidence offered here was hearsay within the definition set forth in Code 38-301 as "that which does not derive its value solely from the credit of the witness, but rests mainly on the veracity and competency of other persons." The Code recognizes exceptions to the hearsay rule in the remainder of 38-301, but concludes with the assertion that "The very nature of the evidence shows its weakness, and it is admitted only in specified cases from necessity."
Before proceeding further, perhaps an inquiry into the history and background of the hearsay rule and its exceptions would be helpful. In the words of Morgan, "There was a time when all relevant hearsay was admissible, and there never has been a time when Anglo-American courts have rejected all hearsay." 2 Morgan, Basic Problems of Evidence (1954), p. 221. And professor Wheaton in "What Is Hearsay?", 46 Iowa L. Rev. 210, citing Holdsworth, Morgan and Wigmore, says that "It seems clear that in the very early days of the jury trial there was no objection to the use of hearsay, for the jury reached its decision from information that it gained outside the courtroom. During the sixteenth century the jury began to get information from testimony in court and by the early seventeenth century it received most of its information from that source. During the first three-quarters of the seventeenth century hearsay was constantly received as corroborative evidence. It was in the last quarter of that century that the rule against hearsay came into existence. By the middle of the eighteenth century the exclusionary doctrine was definitely settled." The reason for the rule, as he then points out, is basically the absence of opportunity to cross-examine and a fear that the admission of hearsay would afford too many opportunities for inaccuracy, mistake, fraud, and untrustworthiness. Various theories to support the numerous exceptions to the hearsay rule have been advanced. Professor Wigmore, for instance, relies on the principles of "a Circumstantial Probability of Trustworthiness, and a Necessity," as the guides. 5 Wigmore, Evidence (3d Ed., 1940) 1420. Morgan states that no theory will explain all of the exceptions, and proposes the dual test as "(a) whether the hearsay is such that the trier can put a reasonably accurate value upon it as evidence of the matter it is offered to prove, and (b) whether direct testimony of the declarant is unavailable, or if available, is likely to be less reliable." 2 Morgan, Basic Problems of Evidence (1954), p. 222. The American Law Institute has suggested the following: "Evidence of a hearsay declaration is admissible if the judge finds that the declarant (a) is unavailable as a witness, or (b) is present and subject to cross-examination." Model Code of Evidence, American Law Institute (1642), Rule 503.
The multitudinous exceptions spawned by the hearsay rule have caused vexatious problems for courts operating under common-law principles. For example, there are now from ten to twenty exceptions recognized in the various jurisdictions. McCormick, Evidence (1954), 300, p. 626. We have seen that even the authorities are unable to agree on the exceptions and the theoretical basis for them. Professor Green says that the exceptions are "best explained by history rather than logic." Green, Georgia Law of Evidence (1957), 225, p. 503. McCormick agrees with the statement saying that "The Exceptions were struck off in the heat of trial as improvisations intended to be played by ear, but they fail of that purpose because the classes are grown so many and the boundaries so meandering that no one can carry any large part of this hearsay-exception-learning in his head." McCormick, Evidence (1954), 300, p. 626. Wigmore indicates his lack of sympathy in the following passage: "The needless obstruction to investigation of truth caused by the Hearsay rule is due mainly to the inflexibility of its exceptions, to the rigidly technical construction of those exceptions by the Courts, and to the enforcement of the rule when its contravention would do no harm, but would assist in obtaining a complete understanding of the transaction." 5 Wigmore, Evidence (3d Ed., 1940), 1427, p. 209.
The above attempt to delineate the broader picture of the hearsay rule and its exceptions with generous brush strokes from the learned authorities will not, of course, control the immediate question before us. Resort must be had to Georgia authorities.
The plaintiff cites as supporting the admissibility of his evidence here the cases of Mutual Life Ins. Co. v. Davis, 48 Ga. App. 742 (173 SE 471); Lathem v. Hartford Acc. &c. Co., 60 Ga. App. 523 (3 SE2d 916); City of Atlanta v. Crouch, 91 Ga. App. 38 (84 SE2d 475); Fleming v. St. Paul-Mercury Indem. Co., 91 Ga. App. 582 (86 SE2d 637); and Orkin Exterminating Co. v. Wright, 92 Ga. App. 224 (88 SE2d 205). The defendant cites Smith v. U. S. Fidelity &c. Co., 94 Ga. App. 507 (95 SE2d 35), as also supporting the proposition but requests that this court distinguish Smith and all the other cases cited above, excepting Mutual Life Ins. Co. v. Davis, 48 Ga. App. 742, supra, on the basis that different, more liberal rules of evidence apply to workmen's compensation cases, and asks that Davis be overruled.
We can find no support for this contention in the Workmen's Compensation Act and, on the contrary, find implied rejection in Code 114-710. In that section, dealing with appeals to the superior court, one of the grounds on which the order or decree of the board may be set aside is that "(4) There is not sufficient competent evidence in the record to warrant the members in making the order or decree complained of . . ." Code 114-710 (Emphasis added). How can it be determined whether there is "sufficient competent evidence" without applying the rules of evidence? While we find no Georgia case in which it is held that compensation cases are to be accorded treatment different from others in this respect, we do note that the appellate courts of this State have applied the common-law rules of evidence in numerous cases, e. g., Alexander v. Brennen, 53 Ga. App. 676 (3) (187 SE 141) (hearsay rule); U. S. Fidelity &c. Co. v. Bohannan, 36 Ga. App. 34 (135 SE 319) (res gestae). And, without the effect of a liberalizing statute, the idea that there is a distinction in the rules of evidence to be applied to workmen's compensation cases has been specifically refused elsewhere (Hamilton v. Huebner, 146 Neb. 320, 19 NW2d 552, 559, 163 ALR 1), even where a liberalizing statute has been enacted. Williams v. Jahncke Service, Inc., 217 La. 1078 (48 S2d 93). We may say parenthetically, however, that in Johnston v. Payne-Yost Const. Co., 292 Pa. 509 (141 A 481) and Jacobs v. Village of Buhl, 199 Minn. 572 (273 NW 245), a different view is expressed. There may be others. But we think that the liberal construction referred to in such cases as Wilson v. Maryland Cas. Co., 71 Ga. App. 184, 188 (30 SE2d 420) quite obviously pertains to the provisions of the Workmen's Compensation Act and not to the rules of evidence to be applied in determining whether there was competent evidence upon which to base the award.
Turning then to a consideration of the cases we find that Mutual Life Ins. Co. v. Davis, 48 Ga. App. 742, supra, involved an action on the double indemnity portion of a life insurance policy. The plaintiff's decedent, a traveling salesman, had stated to a physician operating on him that he had "had a shake-up in a Ford car." The alleged accident had happened while the plaintiff's decedent was on a sales trip and, except for the statement above, the only evidence of the accident adduced on the trial was circumstantial. The court held that the verdict was authorized by the evidence. In discussing the admissibility of the decedent's statement to his physician, the court, after discussing the necessity of admitting evidence in certain cases, went on to say, at page 746: "It would seem that where death has sealed the mouth of a witness, the same necessity would make admissible his representations to his physician as to his injury an':l its cause, it being contended that such injury was the cause of his death, and there being no other witness thereto except the deceased." Chief Judge Broyles dissented on the basis that the physician's testimony of what the decedent had told him, being hearsay, was inadmissible.
Lathem v. Hartford Acc. & Indem. Co., 60 Ga. App. 523, supra, is the next Georgia case in which this factual pattern appears. In that workmen's compensation case, there were no witnesses to the alleged injury suffered by claimant's decedent. The court reversed the superior court judge's ruling that there was not sufficient competent evidence to support the award made by the board. The only evidence offered by the claimant as to the where and how of the injury was that of the decedent's physician, wife, and relatives which consisted of what the decedent told them had happened. Judge MacIntyre, with Chief Judge Broyles and Judge Guerry concurring, held that "When death has sealed the mouth of a witness, and there is no other witness as to such deceased witness's injury and its cause, it being contended that the injury was the cause of his death, 'the declarations of a party himself, to whomsoever made, are competent evidence, when confined strictly to such complaints, expressions, and exclamations as furnish evidence of a present-existing pain or malady, to prove his condition, ills, pains, and symptoms, whether arising from sickness or from an injury by accident or violence. If made to a medical attendant, they are of more weight than if made to another person.' "
In City of Atlanta v. Crouch, 91 Ga. App. 38, supra, the issue was the admissibility of what the decedent had told his wife and son-in-law. The court stated in the headnote, "The declarations and complaints made by the deceased were admissible and competent where there were no other witnesses to the alleged injury and the cause thereof." It is to be noted that in Crouch there was no statement to a physician or other medical attendant and that the defendant produced witnesses who saw the decedent during the day who said they heard no complaint from him.
Thus we see the evolution in the application of the rule of necessity admitting the statements of deceased persons where there is no other evidence available from statements to physicians only (Davis, supra), to statements to physician, wife and relatives (Lathem, supra), to statements to the wife and son-in-law (Crouch, supra), to statements to the wife only (Flemming and Wright, supra). The circumscription is completed where the defendant's utilization of such evidence is a primary factor in a ruling in his favor. (Smith, supra).
While we realize that the Georgia rule as set out above may represent a bench mark in what Professor McCormick has called "The Borderland of Hearsay" (McCormick, The Borderland of Hearsay, 39 Yale L. J. (1930), p. 489), it is not without support in other jurisdictions. In Dabbert v. Travelers Ins. Co., 2 Cin. Super. 98 (1870), (Bigelow's Life & Acc. Ins. Reps. 366 (1875)), the court (Judge Alonzo Taft) held that the deceased declarant's statement to his physician was "competent evidence to prove what was the actual cause of his illness and death . . . to avoid a failure of justice." Here the necessity existed because there were no witnesses to the alleged accident. Foulkrod v. Standard Acc. Ins. Co., 343 Pa. 505 (23 A2d 430) involved an action on an accident policy where it was alleged that the deceased had fallen off a stool while alone in a room. His statements to his wife and physician, unobjected to, were admissible and were substantive proof of the accident. A Wisconsin case held admissible the treating physician's testimony relating the statements of a deceased woman on whom an abortion had been allegedly performed as to the facts of the abortion. Kraut v. State, 228 Wis. 386 (280 NW 327). In another abortion case, an attending nurse was permitted to testify what the deceased had said. Gilchrist v. Mystic Workers of the World, 188 Mich. 466 (154 NW 575, AC 1918C 757).
In Kentucky, statements of a deceased declarant to a physician that "A mosquito bit him," Omberg v. United States Mut. Assn., 101 Ky. 303, 40 SW 909, 72 ASR 413), and that he slipped and fell carrying watermelons (Massachusetts Bonding &c. Co. v. Duncan, 166 Ky. 515, 179 SW 472), were held admissible as showing when and how the accident happened but not where. And see Valentine v. Weaver, 191 Ky. 37 (228 SW 1036); Hills Admx. v. North American Acc. Ins. Co., 186 Ky. 273 (215 SW 428). On the other hand, in a personal injury action the physician's testimony as to plaintiff's statement of where (on a street car) the incident occurred was held properly admitted. Alabama Power Co. v. Edwards, 219 Ala. 162 (121 S 543). And, in an F.E.L.A. case, the decedent's declarations to his physician of the place and circumstances of the injury were said to have been properly received. Stewart v. Baltimore & O. R. Co., 137 F2d 527 (2d Cir.).
Other cases allowing the admission of hearsay testimony based on necessity are Lee Pong Tai v. Acheson, 104 F. Supp. 503 (E. D. Pa.) and Dallas County v. Commercial Union Assur. Co., 286 F2d 388 (5th Cir.). The Lee Pong Tai case concerned a deportation proceeding. There, the affidavit of one since deceased was held admissible to prove the birthplace of a person approximately 70 years of age. It was said there that ". . . the evidence must be weighed in the light of the defendant's ability to produce evidence . . ." In the Dallas County case, Circuit Judge Wisdom upheld the admission of a newspaper account of a fire alleged to have happened some 58 years before with the comment, "There is no procedural canon against the exercise of common sense in deciding the admissibility of hearsay evidence."
There are a number of cases which present factual situations similar to that found in Flemming v. St. Paul-Mercury Indemn. Co., 91 Ga. App. 582, supra, in which testimony as to the decedent's statements was held admissible. Wilhelmi v. American Ry. Express Co., 6 N. J. Mis. R 674 (142 A 555) (physician); Greenfarb v. Arre, 62 N. J. Super. 420 (163 A2d 173) (physician, wife and others); Hillman v. Utah Power &c Co., 56 Idaho 67 (51 P2d 703) (physician and nurse); Youngblood v. Colfax Motor Co., 12 La. App. 415 (125 S 883) (physician); Columbia Steel Co. v. Industrial Comm'n, 92 Utah 72 (66 P2d 124) (Wife); Valentine v. Weaver, 191 Ky. 37 (228 SW 1036) (physician); F. Eggers Veneer Seating Co. v. Industrial Comm'n, 168 Wis. 377 (170 NW 280) (physician); Bohan v. Lord & Keenan, Inc., 98 N. H. 144 (95 A2d 786) (physician and wife); Wright v. Kerrigan, [1911] 2 Ir. R. 303 (7 Irish Law Rep. 360) (physician, wife and others); Lloyd v. Powell Duffryn Steam Coal Co., [1914] A. C. 733 (semble), reversing [1913] K. B. 1309 (admissible as admission against interest). In the following cases, the legislature had adopted a statute liberalizing the evidence rules in workmen's compensation cases but the court did not rely primarily on the statute. Baker v. Industrial Comm'n, 44 Ohio App. 539 (186 NE 10); Standard Oil Co. v. Mealey, 147 Md. 249 (127 A 850). Additional cases may be cited where the hearsay was admitted but without a showing of necessity. Bober v. Independent Plating Corp., 28 N. J. 160 (145 A2d 463); Shell Oil Co. v. Industrial Comm'n, 2 Ill. 2d 590 (119 NE2d 224). In many instances, hospital records have been held admissible to prove the truth of their contents. Annot. 44 ALR2d 535. But see Heard v. Heard, 99 Ga. App. 864 (110 SE2d 76); and Whitener v. Baly Tire Co., 98 Ga. App. 257, 260 (105 SE2d 775).
The common nexus of these cases is the necessity of the situation. The ex necessitate principle was recognized in another situation involving the admission of hearsay evidence over one hundred years ago in Georgia. In Feagin v. Beasley, 23 Ga. 17, and Tilman v. Stringer, 26 Ga. 171, Justice Lumpkin held that testimony as to the representations of a slave were admissible. (Similar cases may be found in Annot. 67 ALR 10, 21). At that time slaves were not competent to testify against a free white person. See Grady v. State, 11 Ga. 253 (2). The necessity in the slave cases was recognized specifically in Atlanta, K. & N. Ry. Co. v. Gardner, 122 Ga. 82, 97 (49 SE 818). The court in Gardner also pointed out another instance of necessity which existed prior to the time when parties were made competent to testify in their own behalf by adoption of the act of 1866 (Ga. L. 1866, p. 138, now Code 38-1603). And see Graves v. Harris, 117 Ga. 817, 818 (45 SE 239). Even the admissibility of expressions of present pain is predicated on the necessity rule. See Lassiter v. Poss, 85 Ga. App. 785 (3) (70 SE2d 411), where it is said at p. 790 that the condition "might be impossible to show by other testimony." Similar situations of necessity arise in the case of infants of tender years who would be too lacking in understanding to give direct testimony (Grant v. State, 124 Ga. 757, 759 (4), 53 SE 334; Louisville & N. R. Co. v. Studdard, 34 Ga. App. 570 (5), 130 SE 532; see Welter v. Bowman Dairy Co., 318 Ill. App. 305, 47 NE2d 739); or where one competent at the time of an event has later become insane (Code 38-1607), or loses his power of speech (Conner v. State, 25 Ga. 515 (4), 71 AD 184). Cf. Ward v. City of Pittsburgh, 353 Pa. 156 (44 A2d 553). A Georgia commentator has said that the use of the necessity principle is common. Green, Georgia Law of Evidence, 1957, 225. Code 38-301 recognized the exceptions as "admitted only in specified cases from necessity. " (Emphasis added). The cases from other jurisdictions specifically recognizing the rule of necessity are numerous. E.g., Eby v. Travelers Ins. Co., 258 Pa. 525 (102 A 209); Tromblee v. North Amer. Acc. Ins. Co., 158 NYS 1014; Boyd v. Industrial Comm'n, 88 Utah 173 (48 P2d 498); Dabbert v. Travelers Ins. Co., 2 Cin. Super. 98, supra; Baker v. Industrial Comm'n, 44 Ohio App. 539, supra; Foulkrod v. Standard Acc. Ins. Co., 343 Pa. 505, supra.
The theory that the rule of necessity is valid where the declarations of a decedent are the only method of proof available finds at least partial support in McCormick's work. He states, "Some courts have accepted the view that these statements as to external cause when relevant to treatment and made to a doctor employed for that purpose are admitted as evidence of the fact stated. This conclusion, particularly in actions for death where there were no eyewitnesses other than the victim, seems the view most consonant with the demands of justice." McCormick, Evidence (1954) p. 564, 266. (Emphasis added). Another commentator has said that "Hardship in a particular case does not warrant an exception to the hearsay rule, but the existence of a class of cases in which hearsay is the only possible proof necessitates an exception." 3 Jones, Evidence, p. 2191 (Henderson Rev. 1926) (Emphasis added). And, as Judge Learned Hand said, "It would of course be undesirable to open the doors to hearsay evidence when better was available, but I ask you whether Baron Gilbert was not right in saying that men should use in their disputes the best means they can get to reach the truth?" 3 N.Y. City Bar Ass'n Lectures on Legal Topics, 1921-22, at p. 99 (as quoted 5 Wigmore, Evidence (3rd Ed. 1940) p. 436, 1576).
These quotations are in accord with Jasper County v. Butts County, 147 Ga. 672 (95 SE 254) where it is said (p. 673), "The modern tendency is to relax rather than to restrict the rules for the admission of evidence, to the end that the discovery of truth may be aided, rather than obstructed." Accord: Dade County v. State of Georgia, 77 Ga. App. 139, 145 (48 SE2d 144); Manners v. State, 77 Ga. App. 843 (3), 849 (50 SE2d 158); Rogers v. State, 80 Ga. App. 585, 590 (56 SE2d 633); Maxwell v. State, 94 Ga. App. 625, 626 (95 SE2d 767). And, as Justice Lumpkin said, "Truth, common sense, and enlightened reason, alike demand the abolition of all those artificial rules which shut out any fact from the jury, however remotely relevant, or from whatever source derived, which would assist them in coming to a satisfactory verdict." Johnson v. State, 14 Ga. 55, 62.
Our holding then, following the previous rulings cited above, is that the declarations of a decedent, or where there is equivalent unavailability of the declarant, to whomsoever made are admissible in evidence if there are no other witnesses to the alleged occurrence. "Other witnesses" within the meaning of this rule would include eyewitnesses, whether favorable or unfavorable to the party offering the evidence, but would exclude those who merely testify that they did not see the alleged occurrence, as in Crouch v. City of Atlanta, 91 Ga. App. 38, supra; Orkin Exterminating Co. v. Wright, 92 Ga. App. 224, supra; and Smith v. U.S. Fidelity &c. Co., 94 Ga. App. 507, supra. In this situation, the evidence may be offered by either the plaintiff or the defendant. Smith v. U. S. Fidelity &c. Co., 94 Ga. App. 507, supra. Most, if not all, jurisdictions in which this rule is recognized hold, as in Lathem, supra, that when the statement or declaration is made to a physician with a view of obtaining treatment it is entitled to greater weight than if made to others or under other circumstances. The statement here offered, though made to a doctor, was not made with a view of obtaining treatment by him, but was made to one who was to examine the declarant and evaluate her condition for the Transit System, against whom she had made a claim for damages. Such a statement, like a confession in a criminal case, should be received with caution and scanned with care, for, as Chief Justice Bleckley reminds us in Atlanta St. R. Co. v. Walker, 93 Ga. 462, 465 (21 SE 48), there is "scarcely anything less reliable than a sick plaintiff's opinion of his own case when he is in pursuit of damages." Indeed, if the statement had been made after her suit was filed it would require even more careful scrutiny, and might be held inadmissible. See Atlanta Ry. Co. v. Gardner, 122 Ga. 82, 95 (11), supra. Uniform Rules of Evidence 63 (4) (c), if in force here, would admit the statement only "if made in good faith prior to the commencement of the action." However, it is to be noted that the accident is alleged to have occurred July 24, 1956, and the statement was made to the doctor December 4, 1957, while the action was filed July 13, 1958. Moreover, it appears from the answers to requests for admissions that there were other similar statements by the decedent to others and at other times. Thus, we hold that the statement was admissible, since that "which tends to establish the issue in controversy is admissible, even if it is not of itself sufficient for that purpose." Carter v. Marble Products, Inc., 179 Ga. 122, 127 (175 SE 480), and it is for the jury, under appropriate instructions, to determine its weight and credibility.
We do not bottom this ruling on the res gestae principle. While the utilization of this principle is often proper, its mere intonation has no magical effect and cannot be used as a catch-all for difficult cases. See comments and quotations in 6 Wigmore, Evidence (3rd Ed. 1940) 1767; 2 Morgan, Basic Problems of Evidence, p. 248 n. 1; McCormick, Evidence (1954) 274; and Annot. 163 ALR 15 (passim). See also Cox v. State, 64 Ga. 374, 410 (37 AR 76). Professor Slough has a very informative article on the matter of spontaneous statements in 46 Iowa L. Rev. 224, and at page 253 deals with the situation where the declarant is unavailable. But the res gestae rule, in our judgment, has no application here. Rather, we specifically base our ruling on the well-recognized rule of necessity.
In the light of what has been said, the evidence offered by the plaintiff should have been admitted, and it must follow that the trial judge improperly granted the defendant's motion for summary judgment.
ON MOTION FOR REHEARING.
Able counsel for defendant in error, in a motion evidencing exhaustive study of the authorities, particularly those from our Georgia courts, urge that the many cases cited in their motion require a different result. We have read with care all of them, but we do not agree. The cases relied upon fall generally into distinguishable categories of instances where the deceased declarant's statement was offered as a part of the res gestae but was held, under the circumstances of the case, not to be (W. & A. R. Co. v. Beason, 112 Ga. 553, 37 SE 863; Hunter v. State, 147 Ga. 823, 95 SE 668; Davis v. Metropolitan Life Ins. Co., 48 Ga. App. 179, 172 SE 467; East Tenn. &c. R. Co. v. Maloy, 77 Ga. 237, 2 SE 941; White v. Southern Ry. Co., 123 Ga. 353, 51 SE 411; Fulton v. Metropolitan Cas. Ins. Co., 19 Ga. App. 127, 91 SE 228; Higgins v. Trentham, 186 Ga. 264, 197 SE 862), or as a dying declaration which was held not admissible in a civil case under the rule concerning such (Davis v. Metropolitan Life Ins. Co., 48 Ga. App. 179, supra; Wooten v. Wilkins, 39 Ga. 223, 99 AD 456), to show an intent or a state of mind (Miller v. Everett, 192 Ga. 26, 14 SE2d 449; Paris v. Paris, 207 Ga. 341, 61 SE2d 491; Gullatt v. Thompson, 61 Ga. App. 253, 6 SE2d 447; Wooten v. Wilkins, supra), to show delivery of a deed or lack thereof (thus affecting title to land) (Blalock v. Miland, 87 Ga. 573, 13 SE 551; Smith v. Smith, 206 Ga. 461, 57 SE2d 611; Miller v. Everett, 192 Ga. 26, supra; Dollar v. Thompson, 212 Ga. 831, 96 SE2d 493; Fuller v. Fuller, 213 Ga. 103, 97 SE2d 306), declarations against interest (or in his own interest), as affecting title (Whitaker v. Smith, 33 Ga. 237; Massee-Felton Lbr. Co. v. Sirmans, 122 Ga. 297, 50 SE 92; Miller v. Everett, 192 Ga. 26, supra; Blalock v. Miland, 87 Ga. 573, supra; Freeman v. Brewster, 93 Ga. 648, 21 SE 165; Hollis v. Sales, 103 Ga. 75, 29 SE 482; Groover v. Wilkes, 145 Ga. 714, 89 SE 761; Hill v. McLendon, 147 Ga. 733, 95 SE 232; State Banking Co. v. Miller, 185 Ga. 653, 196 SE 47; Higgins v. Trentham, 186 Ga. 264, supra; Smith v. Smith, 206 Ga. 461, supra), cases in which there was other evidence or there were other witnesses (whether favorable or unfavorable) available (Drawdy v. Hesters, 130 Ga. 161, 60 SE 451, 15 LRA (NS) 190; Hunter v. State, 147 Ga. 823, supra; East Tenn. &c. R. Co. v. Maloy, 77 Ga. 237, supra; White v. Southern Ry. Co., 123 Ga. 353, supra; Davis v. Metropolitan Life Ins. Co., 48 Ga. App. 179, supra; Lanier v. Huguley, 91 Ga. 791, 18 SE 39; Freeman v. Brewster, 93 Ga. 648, supra; Hollis v. Sales, 103 Ga. 75, supra; Groover v. Wilkes, 145 Ga. 714, supra; Hill v. McLendon, 147 Ga. 733, supra; State Banking Co. v. Miller, 185 Ga. 653, supra; Higgins v. Trentham, 186 Ga. 264, supra; Hobbs v. Houston, 190 Ga. 505, 9 SE2d 749; Smith v. Smith, 206 Ga. 461, supra; Paris v. Paris, 207 Ga. 341, supra; Rabun v. Wynn, 209 Ga. 80, 70 SE2d 745; Fuller v. Fuller, 213 Ga. 103, supra; Gullatt v. Thompson, 61 Ga. App. 253, supra).
Two cases are cited which, on their facts, closely parallel the case here. Bolton v. Columbia Cas. Co., 34 Ga. App. 658 (130 SE 535), and Poole v. East Tenn. &c. Ry. Co., 92 Ga. 337 (17 SE 267). These, however, are distinguishable. In each of them the ruling was altogether on the basis of the rule of res gestae, and in neither was the rule of necessity dealt with. Moreover, in Poole the case turned upon the physical condition of a railroad crossing, a matter about which there should have been ample other evidence available.
Counsel urge that since the statement here was in the interest of the deceased declarant it is necessarily excluded by the terms of Code 38-309. We do not agree. The provisions of the Code sections dealing with hearsay are not exhaustive of those in which hearsay is admissible and do not pre-empt the area. Rea v. Pursley, 170 Ga. 788, 793 (154 SE 325); Ellis v. O'Neal, 175 Ga. 652, 657 (165 SE 751). And see, on the matter of such declarations when they are "self-serving," McCormick, Evidence, 275 (1954).
The doctrine of stare decisis has been invoked. "This is an action for negligence; and while even as applicable to such cases an erroneous decision, if thoroughly established, might be followed as a matter of judicial policy; yet the rule of stare decisis is usually considered as one more appropriately applied to vested property rights." Rogers v. Carmichael, 184 Ga. 496, 511 (192 SE 39). Dean Roscoe Pound has stated that stare decisis is ". . . primarily useful as a principle where rules of property and rules of commercial transactions [are] involved." Pound, Law Finding Through Experience and Reason, 39-40 (1960). Other jurisdictions have followed this rule and the rule of Rogers, 184 Ga. 496, supra, e.g., Smith v. Glen Alden Coal Co., 347 Pa. 290 (32 A2d 227, 234); Fuller v. Virginia Trust Co., 183 Va. 704 (33 SE2d 201, 205). And, if the cases upon which there is reliance in the invoking of the doctrine were in all respects applicable and on no basis distinguishable, we should feel obliged, under that rule, to follow the principle of the older cases of Feagin v. Beasley, 23 Ga. 17, and Tilman v. Stringer, 26 Ga. 171.
Further effort to make clear our view, as outlined in the opinion, would be a work of supererogation or a rechauffe of what we have already said.
Motion denied. Carlisle, P. J., and Custer, J., concur.
Crenshaw, Hansel, Ware, Brandon & Dorsey, Hugh M. Dorsey, Jr., Jule W. Felton, Jr., Charles R. Adams, Jr., contra.
J. E. B. Stewart, James O. Goggins, for plaintiff in error.
DECIDED NOVEMBER 9, 1961 -- REHEARING DENIED DECEMBER 12, 1961.
LEE v. PEACOCK et al. (199 Ga. App. 192) (404 SE2d 473) (1991)
ATLANTA GAS LIGHT COMPANY v. GRESHAM et al. (260 Ga. 391) (394 SE2d 345) (1990)
HODGES et al. v. EFFINGHAM COUNTY HOSPITAL AUTHORITY. (182 Ga. App. 173) (355 SE2d 104) (1987)
TRANSAMERICA INSURANCE COMPANY v. THRIFT-MART, INC. et al. (159 Ga. App. 874) (285 SE2d 566) (1981)
IRBY et al. v. BROOKS et al. (246 Ga. 794) (273 SE2d 183) (1980)
JAAKKOLA et al. v. DOREN. (244 Ga. 530) (261 SE2d 701) (1979)
FOUNTAIN v. CABE. (242 Ga. 787) (251 SE2d 529) (1979)
GREEN v. THE STATE. (242 Ga. 261) (249 SE2d 1) (1978)
CROSBY v. JONES. (241 Ga. 558) (246 SE2d 677) (1978)
FEDERAL INSURANCE COMPANY v. OAKWOOD STEEL COMPANY et al. (126 Ga. App. 479) (191 SE2d 298) (1972)
CHRYSLER MOTORS CORPORATION v. DAVIS.; GLYNN PLYMOUTH, INC. v. DAVIS. (173 SE2d 691) (226 Ga. 221) (1970)
(120 Ga. App. 475) (170 SE2d 848) (1969)
IRELAND v. MATTHEWS, Administratrix. (120 Ga. App. 510) (171 SE2d 387) (1969)
HORTON et al. v. NICHOLS, Administrator. (117 Ga. App. 748) (162 SE2d 208) (1968)
GENERAL INSURANCE COMPANY OF AMERICA v. CAMDEN CONSTRUCTION COMPANY et al. (115 Ga. App. 189) (154 SE2d 26) (1967)
PAULK v. THOMAS. (115 Ga. App. 436) (154 SE2d 872) (1967)
CRAFTON v. LIVINGSTON. (114 Ga. App. 161) (150 SE2d 371) (1966)
MILLHOLLAND v. OGLESBY. (114 Ga. App. 745) (152 SE2d 761) (1966)
PARROTT v. EDWARDS et al. (113 Ga. App. 422) (148 SE2d 175) (1966)
SORRELLS v. COLE. (111 Ga. App. 136) (141 SE2d 193) (1965)
COCHRAN, by Next Friend v. SOUTHERN BUSINESS UNIVERSITY, INC. (110 Ga. App. 666) (139 SE2d 400) (1964)
COMMISSIONERS OF ROADS & REVENUES OF FULTON COUNTY v. DOWIS. (107 Ga. App. 647) (131 SE2d 144) (1963)
HOLLAND v. CENTER.; HOLLAND v. SANDLER.; HOLLAND v. SANFAX CORPORATION. (106 Ga. App. 1) (126 SE2d 442) (1962)
MEEKS v. LUNSFORD. (106 Ga. App. 154) (126 SE2d 531) (1962)
ROBINSON et al. v. COLONIAL DISCOUNT COMPANY, INC. (106 Ga. App. 274) (126 SE2d 824) (1962)
Friday May 22 23:39 EDT


Elvis Presley - What Now, What Next, Where To?
Elvis Presley - Who Needs Money?
Elvis Costello - Crawling To The U.S.A.
Elvis Costello - What Do I Do Now?
Elvis Costello - Why Don't You Love Me (Like You Used To Do)?
Emerson Drive - What If?


text:
The Long Island Literary Journal May 2018
"We did this to ourselves," Jonesy said sliding bullets into a tarnished old .38. Besides an aluminum baseball bat and a barn full of rusted farm implements, it was their primary means of defense, one they had yet to use, but the expectation was that things were to only get worse. It had been eighteen months since the ban went into effect, fourteen since the MOAB was dropped on a so tagged hot-spot in the Middle-east and five weeks since the dirty bombs went off in Boston and New York.
Stan watched Jonesy cautiously in the rearview as he guided the dinged-up Dodge Charger along the roadway marred by frost heaves and years of neglect. He knew little about his passenger other than he was elusive when it came to questions but seemed to know much about the western hills of Massachusetts and Connecticut and how to get the most from the woods. Just five days earlier he had drifted out from the tree line under the weight of a large backpack. Stan was prompt in his effort to dismiss the intruder, and felt he had matters in hand until Echo appeared on the back porch with a bottle of pop in hand.
"Maybe he can help with the generator?" she interjected casually, "We might need that hunk of junk after all."
Stan wished to protest but knew his wife was probably right just like his mother was when she had the massive crate delivered to the farmhouse in the tense months following 9/11. "If anything like that ever happens again," the matriarch chortled while drinking a saucer full of cheap scotch when she could easily afford better, "you kids just jump in the car and head to Weathervane Farm. I'll have everything there for you." Stan found the notion of buying a farm in Western Massachusetts when his parents lived in Connecticut a complete waste of money, though Church View did turn out to be a good central place for Worthington holiday gatherings. His sister lived in Chicago and made the dutiful trek east twice a year with her ever growing brood. It was perfect while it lasted and now, his mother's paranoid ramblings about the future of mankind boomeranged back from the beyond as shards of prophetic wisdom. Stan's only regret being that he wished he had set up the generator back then when she had wished it.
The car hit a pothole and a bullet slipped from Jonesy's hand. "Steady mate," he said cooly as he retrieved the projectile, "Be a shame if Bulla put a hole in your seat."
That coy air of amiable aloofness bothered Stan. He knew he was alone in that regard. The others taking refuge in the place his mother had so affectionately rebranded 'Manure Manor,' didn't share his scrutiny. Little Jade was delighted by the coins pulled from her ears at dinner that first night, and afterwards Jonesy toiled under Echo's direction in the kitchen, sharing wine and laughs late into the evening. Even crabby old Rosemary appeared susceptible to his charms granting Jonesy great deference before launching in with her bristly opines and demeaning insistences. Each morning, Stan expected the man hidden behind aviator sunglasses and a fine beard, to disappear back into the woods, but at night, when dinner was served, he was there at the table as if he has always been. The tenor of the manor had shifted. There was less control, more spontaneity and things got done. Jonesy was fit and able, a rising commodity as networks fell and the availability of shrink wrapped sustenance waned.
"How much we got?" Stan asked.
"Sixty, maybe seventy last I looked," Jonesy replied. "But who knows if we'll need it."
The sky blue reimagining of the American muscle classic that Stan's father had insisted on buying over a decade ago, but hardly ever drove, drifted down and out from the cedar cover. The engine still purred with masculine intensity but there was that intermittent ping that concerned Stan. In the fore laid a stretch of furrowed fields and molted pastures, each side of the road dotted by a huddle of weather-worn barns and a lone white farmhouse. Near the vanishing point, at the base of the cascading green hills, loomed the object of their mission, the telltale yellow ovoid of a Sunoco sign rising up from a copse of trees.
Jonesy laid the gun on the seat and began to sort through a thick stack of small bills and loose change. "Seventy-six, four-five," he declared and slid the money back into the frayed envelope.
Off to the left, two mangy cows grazed nonchalantly while a third laid near the road, its belly ripped open and entrails strewn down the grassy slope of a drainage gulch. A swarm of flies buzzed in through the open windows. Stan swatted haplessly at the air and cursed. Amid the unkempt furrows to the right, a withered old man struggled to glean ears of corn from broken stalks. On the stoop of one of the farmhouses, an observant yellow dog sat nearly motionless, its ears up and alert as its nose slowly drew in the scent of demise.
Stan eased off the gas as the Charger sailed through the thicket of trees. The sweet, cloying smell of birch and elm trickling in atop the dank humidity. The parking lot was empty except a mud splattered Mercedes with New York plates and Old Mac's stoic John Deere that had been running flawlessly since Watergate broke. Of the three broad glass panes that formed the storefront, one had been replaced by an expanse of plywood and a second, cracked outward from an ostensible projectile strike, was held firm by a web of gray duct tape. The intensity of the mid-day sun flashed off the sport coupe's hubcaps and caused Stan to squint as he pulled in. One of the two fuel pumps was entwined in yellow caution tape.
Stan killed the engine. "Gas, oil and anything in cans, right?"
"Smokes too," Jonesy said passing forward the grimy envelope.
The younger man exited the car, the butt of the gun protruding from his waistband and pulled two red containers from the trunk. Stan slipped between the pumps and headed towards the mirrored glass door that separated the bay of garage doors from the minimart.
Bells along the back of the door announced his entrance. It had been more than two weeks since Stan had last paid a visit, and while he wasn't surprised by the depleted shelves, he did take notice of the store's overall poor state. Wrapper shards, crushed chips and spots of dried soda dotted the aisles. In the bread section, a few of the bags were torn open, one unfortunate loaf was flattened and smeared across the speckled linoleum.
Stan pulled a plastic shopping basket from the stack. A smattering of pistachio shells swirled aimlessly across the latticed bottom. Through the reflective glass he could see Jonsey filling up the containers, then there was a faint flush from the rear of the store. Stan froze and listened. A door slammed and a tall gaunt man in a flannel shirt and tattered Bowling Green baseball cap appeared. Stan had never seen the man before but was struck by how much he looked like a reliever who hurled sparingly for the Red Sox over four seasons, including that miraculous 2004 World Series run. The player's name eluded Stan.
"Not much left, but have at it," the man said in a twangy drawl further muddled by a wad of something set deep inside the crease of his cheek.
"I can see Old Mac's been slacking off," Stan said with a head gesture and a weak smile. The man made no reaction and Stan set off down an aisle to fill the orders of those waiting for him back at Weathervane Farm. Small juice boxes and Oreos for Jade. Cheetos and veggie sticks for Echo, though he briefly reconsidered the puffy bags of hydrogenated snacks knowing well his wife would spend time agonizing over the health risks of all the artificial ingredients listed in fine print on the back, and then, as an informed result, would only eat a small meted amount and curse the junk food for its rich addictive flavor. Stan loaded up on Campbell's Soup cans and Spaghetti-Os, and grabbed the last two bottles of cooking oil, which had proved useful beyond its kitchen-wise intent.
At the register, Stan added three Heath bars to the basket for Rosemary. He knew Mac's wouldn't have the old English styled toffee his downstairs neighbor from 45 Cranwell Street had requested, but did what he always had when the woman caught him in the Victorian styled foyer and lectured him about the affairs and rules of the stately brownstone they each owned a share of, which was to nod and smile and move on. When they moved into the desirable Cambridge neighborhood in the wake of the shocking election result, paying well over market for the privilege of an 02138 address, Echo was initially drawn to the statuesque senior who she described as 'fiercely independent" and encouraged Stan to remain civil even after he scoured the condo docs and other legal documents and couldn't find many of the official orders that Rosemary had proclaimed and reiterated in email, shaming him to the other residents of the building. When Stan confronted her about such absences during a condo meeting, Rosemary dismissed him with patronizing efficiency. "I don't know Stan," she said in her languorous Blanche DuBois intonation that Echo often mimicked over a glass of Pinot Gris, "it's how we've always done things here. We're a harmonious anomaly, why tinker with perfection?" The other residents just shrugged and acquiesced.
Such minor indignities became a way of life at 45 Cranwell Street, and throughout it all, Rosemary continued to ask Stan do little things for her; the clogged drain, a heavy bag of groceries and that hard-to-get-at piece of tin foil blown back behind a rose bush in the garden. He did them all reluctantly, spurred on by Echo's encouragement and the promise that sustained good will would eventually pay returns. For his effort, Stan was routinely subjected to long boastful tales of a son and daughter who prospered on the West Coast, though Stan found it odd he never had seen either of them visit. One night when Stan was coming home with Styrofoam containers full of sushi he found Echo pulling the normally dormant bottle of Tito's Vodka from the freezer and pouring a shot. "Read your email," she said knocking back the glass emblazoned with the insignia of their alma mater. "Rosemary Pegram's a two-faced bitch," she added and slammed down the glass. Stan poked around on his iPhone and found the long missive from the woman downstairs requesting "the residents of Unit 6 to respect the building's quiet time policy and cease their unruly offspring from running about the place like a herd of wild buffalo."
"Just yesterday," Echo said, "she patted Jade on the head and told her she'd dig up her children's books in the basement for her. Woman's arrogant, entitled and crazy. Batshit crazy."
Stan kept scrolling through accusations and admonishments. Echo handed him a cold shot. "Clearly, the residents of Unit 6," Rosemary concluded, "do not know how to abide civilly." She never mentioned any of them by name specifically and CCed the rest of the building.
In the inglorious aftermath, tensions abated slowly. Stan used the back entrance to come and go. No more inflammatory emails were slung as the tenor at 45 Cranwell Street returned to its natural awkward calm. Then the bomb went off in the Seaport.
"She's got no one," Echo said emphatically when Stan made a face.
"She's got kids our age," he protested.
"You know as well as I, she's probably pissed them off and they don't talk, and probably haven't in years. Maybe they don't even exist?" She shrugged. "Besides, they're all over there and the airport's totally fucked, right?"
Stan nodded. "What about the Thorntons, she has dinner with them all the time, or Suzie down in 1?"
Echo rolled her eyes and it was done.
Stan tossed in a few Almond Joys for himself. "Could I get a carton of Winstons too?"
The man was preoccupied with his cellphone. "Can't get shit no more," he said and spit some juice of whatever it was in his mouth into a Styrofoam cup. "The whole world's going to hell," he added before poking around lazily down under the counter. "Ain't got no Winstons."
Stan took a quick look over his shoulder as the man seemed to be staring at something behind him, but there was nothing there. "How about Lucky Strike?"
"Nope, all I got are these," the man said as he dumped five packs of Marlboro on the counter.
Okay," Stan said and waited for the man to begin punching away at the register, but he never did. "Uhmm, how much?" Stan, finally asked. "We've got twenty gallons of gas too."
The man spit again. "How about we call it a hundred?"
"Shouldn't we ring it up?"
Stan took another glance over his shoulder and then, studying the man's coarse face, realized the man had a lazy eye, the glaring asymmetry between the ever-wide and probing dominant eye and its inert and feeble counterpart being the cause of his sudden distraction. "Uhmmm because Old Mac's a stickler?"
"Aw, he don't care. Nobody much cares anymore."
"Anal Old Mac? I don't believe it. Where's the old coot anyhow?"
"He's not feeling so good."
"I hope it's nothing too serious."
"He didn't much say, just that he wasn't in a right state. How much you got there?"
"And Sweet Ellie's not around either?"
"Hmmm," Stan pondered for a second. "All I've got is seventy-six and change," he announced and wished he had pulled one of the tightly sealed plastic packages from behind the loose cinder block in the basement, but Jonesy had been too close and he didn't want him to know too much, too soon, not until he knew more about his new house guest.
"That'll do," the man said and pointed to leather pouch on Stan's belt, "I'll take that too."
Stan didn't want to surrender the Swiss Army knife but knew he had to sweeten the deal somehow and dug down into his front pocket. "How about these?" he said producing a pair of demure diamond earrings. "And we'll fill up the car and take some bread and a few jugs of water too." The earrings weren't worth much Stan figured, they were just some of the random evening accoutrements his mother had accrued over the years that made their way into the safe at the farm. He paused for a moment and thought about putting them back in his pocket. "Don't be foolish Stanley," he could hear his mother say, "this is why I bought Manure Manor, now be a good boy and do as I wish."
"And the cash too," the man said.
"Just the earrings."
"They're purdy, but I ain't got no use for them."
"They're diamonds. You could sell them. Got to be worth a grand or so," Stan said cheerily as a flush of red raced across his face.
"Who knows what anything's worth anymore?" the man said placing his palms on the countertop and leaning in toward Stan. The tang of wintergreen tickled Stan's nostrils as the looming eye probed behind him. The culmination of sensations had a disorienting effect. Stan's inclination was to cough or retract but he held his posture. Then the man, without so much moving anything but his lips, let a long viscous dollop of brown saliva descend delicately into the cup. Stan dropped the envelope on the counter and left.
Outside Jonesy squeegeed off the windshield while Stan loaded the water jugs onto the floorboard of the front passenger side. "Something's not quite right," Stan said in a low voice. "Store looks like shit and Old Mac's not there, just some random guy."
"Nobody works twenty-four, seven, right?"
"Old Mac runs a tight ship, has a conniption if a bit of dander sits around too long. Plus I asked him about Sweet Ellie and he seemed to know her but didn't."
"You're speaking in riddles mate. Back up and begin again."
"Sweet Ellie's Old Mac's wife who died three years ago. He didn't seem to know that."
"Hmmm," Jonesy purred and glanced back at the mini-mart.
"We've got the gun."
"Bulla," Jonesy corrected and placed a hand on the butt of the pistol. "He might have one too. You have to consider the possibilities."
"That may be…" Stan began, his next thought knocked aside by the distant growl of a Diesel engine that punched the air. The two men straightened. From the patch of firs at the base of the foothills, a military personnel vehicle emerged. Jonesy shifted the gun from the front of his waistband to the back. Stan went to take a step towards the road, but Jonesy caught him by the elbow and pulled him back gently. The two exchanged a quick sideways glance as the surging power of the engine rattled up through their knees and fill their chests. The vehicle roared by without a concern and left the men in a choking swirl of dust. Through splayed fingers, Stan could make out a huddled mass of boyish faces looming out form the rear canopied compartment, all uniformly stoic and blindly dutiful.
After the vehicle disappeared beyond the fields and the humid still returned, Stan turned to Jonesy and gestured with his chin toward the mirrored door.
"Sometimes," Jonesy said, "not knowing is best. Don't let what you can't make sense of consume you."
Tags: Apocalypse, drama, political, post apocalyptic, Trump
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The purpose was to quantify the decrement in health utility (referred as disutility) associated with knee osteoarthritis (OA) and different symptomatic and radiographic uni- and bilateral definitions of knee OA in a repeated measures design of persons with knee OA or at increased risk of developing knee OA.
Data were obtained from the Osteoarthritis Initiative database. SF-12 health-related quality of life was converted into SF-6D utilities, and were then handled as the health utility loss by subtracting 1.000 from the utility score, yielding a negative value (disutility). Symptomatic OA was defined by radiographic findings (Kellgren-Lawrence, K-L, grade ≥ 2) and frequent knee pain in the same knee. Radiographic OA was defined by five different definitions (K-L ≥ 2 unilaterally / bilaterally, or the highest / mean / combination of K-L grades of both knees). Repeated measures generalized estimating equation (GEE) models were used to investigate disutility in relation to these different definitions.
Utility decreased with worsening of symptomatic or radiographic status of knee OA. The participants with bilateral and unilateral symptomatic knee OA had 0.03 (p < 0.001) and 0.02 (p < 0.001) points lower utility scores, respectively, compared with the reference group. The radiographic K-L grade 4 defined as the mean or the highest grade of both knees was related to a decrease of 0.04 (p < 0.001) and 0.03 (p < 0.001) points in utility scores, respectively, compared to the reference group.
Knee OA is associated with diminished health-related quality of life. Health utility can be quantified in relation to both symptomatic and radiographic uni- and bilateral definitions of knee OA, and these definitions are associated with differing disutilities. The performance of symptomatic definition was better, indicating that pain experience is an important factor in knee OA related quality of life.
Osteoarthritis (OA) is a chronic and degenerative joint disease. It is the most common type of arthritis, and it affects most frequently hips, knees, and hands . Knee OA is a major cause of disability and loss of function among older adults, and it causes a major burden both to individuals and health care systems [2, 3]. Older age and obesity are significant risk factors of knee OA [4, 5], and with the continuously aging population and increasing prevalence of obesity, the burden of knee OA is anticipated to increase.
While knee OA manifests pain, stiffness, and daily activity deficits, it causes deterioration in patient-reported health-related quality of life (HRQoL). OA is associated with strong negative effect on HRQoL [6, 7], and bilateral knee pain, other joint pain comorbidity, and inadequate pain relief in conjunction with knee OA have been shown to be associated with even poorer quality of life [8–10]. Correspondingly, total knee replacement has been reported to improve patients' quality of life .
In chronic conditions such as knee OA, HRQoL is one of the most commonly used patient-reported outcome metrics. In knee OA research literature, several disease specific instruments have been used under the label of HRQoL. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)  and The Knee injury and Osteoarthritis Outcome Score (KOOS) , and their subscales, are widely used questionnaires to assess patient-reported outcomes related to knee OA in clinical trials. WOMAC questionnaire assesses pain, stiffness, and functional limitation , while KOOS includes separate subscales for pain, symptoms, function in daily living, function in sport and recreation, and knee-related quality of life . The benefit of these disease-spesific instruments is that they cover dimensions relevant to knee OA . However, disease-spesific HRQoL measures do not provide preference-based utility values needed in health economic analyses. Instead, single, general, and calibrated preference-based health utility scores are needed to incorporate the quantity of life (years) and quality of life into quality-adjusted life years (QALYs) . QALY is commonly used as an outcome measure in health economic analyses and health care decision-making.
In health economic analyses, information on how health utility values response to the disease-spesific health states is essential. However, in the case of knee OA, the gold standard of knee OA definition is currently unavailable, and variety of criteria and definitions have been used in previous research studies . Previously, EQ-5D (EuroQol-5 dimensions questionnaire) health utility values in relation to different knee OA definitions have been assessed in two separate studies [17, 18]. Both of the studies used an unilateral knee OA definition. Consequently, the information on health utility in relation to different definitions of knee OA is scarce, and particularly information on health utility in relation to bilateral definition of knee OA is lacking. Therefore, the objective of the present study was to quantify the preference-based health utility values associated with different symptomatic and radiographic uni- and bilateral definitions of knee OA in a repeated measures design of persons with symptomatic knee OA or at increased risk of developing knee OA.
Data used in the preparation of this article were obtained from the open access Osteoarthritis Initiative (OAI) study (http://www.oai.ucsf.edu/), which is a multi-center, longitudinal cohort study on knee OA . The study incorporates a progression, an incidence, and a reference sub-cohort. Subjects in the progression sub-cohort have symptomatic knee OA at baseline, while subjects in the incidence sub-cohort are at increased risk of developing it. Reference sub-cohort subjects have neither symptomatic knee OA nor eligibility risk factors at baseline. The specific eligibility risk factors and ethical issues are described in detail in Osteoarthritis Initiative Study Protocol . Ethical approval for collecting all subject information was provided by the OAI. Informed consent was obtained from all individual participants included in the study. Applied OAI datasets are listed in additional file (see Additional file 1). Data from baseline and follow-up visits at 12, 24, 36 and 48 months were applied in the study.
A mapping algorithm (https://www.sheffield.ac.uk/) was used to convert 12-item Short Form Health Survey (SF-12) data from the OAI study into SF-6D utility scores . SF-12 is a measure of general health covering eight health domains. The SF-6D estimates a preference-based single index utility measure from SF-12 using general population values and standard gamble valuation technique. SF-6D scores fall on the scale from 0 (death) to 1 (perfect health). The worst SF-6D score, excluding death, is 0.291 ('floor effect'). We handled SF-6D utilities as decrement in health utility by subtracting 1.000 from the SF-6D utility score, yielding a negative value (referred as disutility).
Kellgren-Lawrence (K-L) radiographic system classifies knee OA into five grades based on the severity of radiographic findings of joint space narrowing, osteophytes, sclerosis, and bone deformity . K-L grade 0 indicates intact joint without any features of OA, and K-L grade 2 is considered the cut-off point of definite OA, while K-L grade 4 indicates severe OA. However, persons with K-L grade ≥ 2 may be asymptomatic and vice versa. Therefore, symptomatic definition of knee OA is considered more relevant. In prevalence studies, symptomatic knee OA is usually defined as the concurrent presence of radiographic findings (usually K-L grade ≥ 2) and frequent knee pain in the same knee [1, 22, 23].
In order to estimate the effect of different definitions on the HRQoL associated with knee OA, seven definitions of knee OA were studied. Two definitions were based on the symptomatic definition of knee OA (K-L grade ≥ 2 and knee pain, aching or stiffness on more than half the days during past month in the same knee): (a) 2-scale: no/yes (OA present either uni- or bilaterally), or (b) 3-scale: no/unilateral/bilateral knee OA. The remaining five definitions were based solely on the radiographic definition of knee OA: (c) 2-scale: no/yes (K-L grade ≥ 2 either uni- or bilaterally), (d) 3-scale: no/unilateral/bilateral K-L grade ≥ 2, (e) 5-scale unilateral definition: the highest K-L grade of both knees, (f) 9-scale bilateral definition: mean K-L grade of both knees, or (g) 15-scale bilateral definition: combination of K-L grades of both knees ((0;0), (1;0), (1;1) … (4;2), (4;3), (4;4)). Missing data regarding K-L grades was not imputed.
We used 11 covariates as adjusting variables. Demographics (age, gender, education, living status), clinical status (injuries, surgical history, body mass index (BMI), comorbid conditions, smoking status), and physical activity were selected as a standard set of adjusting variables according to Rolfson and co-authors . We also included race into adjusting variables because of its association with pain level and health status [25, 26].
Injury status and surgical history were both dichotomized and based on the OAI query on ever (baseline) or since last visit (follow-up) injuring either knee badly enough to limit ability to walk for at least 2 days, and ever having knee surgery or arthroscopy (answers regarding left and right knee pooled). Self-reported race was dichotomized (White or Caucasian/Other than White) because the frequency in original groups 'Black or African American', 'Asian' and 'other Non-White' was low.
Age, living status, BMI, physical activity and comorbid conditions were categorized because the distribution of the covariates was skewed and in order to allow for nonlinear associations. Age was categorized into three groups (45–54, 55–64, and 65–79 years). Education based on the OAI query refers to the highest grade of school completed, and had three categories: primary/none (less than college), secondary (college graduate or some graduate school), and tertiary level (graduate degree).
Living status based on the OAI query was dichotomized as living alone or living with someone else. BMI based on physical examination was categorized into four groups (< 25, 25 to < 30, 30 to < 35, ≥35 kg/m2). Physical activity was based on the Physical Activity Scale for the Elderly (PASE) score, where higher scores indicate greater physical activity , and was divided into quintiles (0–90, 91–134, 135–175, 176–237, 238–526). Smoking status was categorized into three groups (never/former/current smoker) based on OAI questions on smoking pipe, cigars or cigarillos and smoking cigarettes. Comorbid conditions based on Charlson comorbidity index score  was dichotomized (none/> 0 comorbid conditions).
OAI data covered living status at baseline and year 3 follow-up visit, comorbid conditions at baseline, year 2 and 4 follow-up visits, and smoking status at baseline and year 4 follow-up visit. Missing data regarding living status, comorbid conditions and smoking status were imputed with the information available from the baseline visit or with the previous follow-up visit (i.e., last observation carried forward).
Descriptive statistics were used to summarize characteristics of OAI study participants. Repeated measures generalized estimating equation (GEE) models  were used to evaluate the population average  disutility in relation to the symptomatic and radiographic definitions of knee OA in the longitudinal data in order to take into account the repeated measurements of the same individual as observations of a same study subject are correlated. GEE modeling was used because it allows the inclusion of all baseline participants in the analyses rather than only those participants who remained in the study and had data available at all follow-up visits. By utilizing a GEE model, we were able to include data for participants who dropped out of the study, or who did not have radiographic knee examination in all visits. All GEE-models were specified using a normal (Gaussian) distribution, an identity link function and an unstructured correlation matrix. The assumption of normal distribution is justified by the large number of observations, and because by that means we avoided transformation of explanatory variable values equal to zero or one, which is required for example in gamma and beta regressions. The inspection of disutility distributions is presented in the additional file (see Additional file 2). The repeated within-subject time-variable was the visit number (0, 1, 2, 3 or 4). All GEE models were adjusted for the 11 covariates mentioned earlier. The dependent variable was the SF-6D disutility score and the independent variable was a symptomatic or radiographic definition of knee OA. Quasi Likelihood under Independence Model Criterion was used to study models' goodness of fit. Estimated marginal means and 95% Wald confidence intervals of disutility scores were compared between different subgroups of knee OA definitions. Participants with no knee OA on the basis of different definitions were regarded as the reference group. Results are presented also as minimally important difference (MID) values using a score difference of ≥0.027 as a cut-point for MID . In all statistical analyses, conducted with IBM SPSS for Windows, version 23.0, the level of statistical significance was considered as p < 0.05.
The flowchart of the cohort definition and number of observations eligible for the adjusted GEE analyses is presented in Fig. 1. In order to be eligible for analyses, participants had to have knee radiograph assessment available for both knees and to have answered the SF-12 questionnaire in full at the same study visit at least once. In addition, participants with partial or total knee replacement (KR) were excluded at baseline. Altogether, 4278 participants were eligible at baseline and had data on all adjusting variables. Participants having a partial or total KR at least for one knee during the follow-up were censored once after the replacement. There were 14,161 observations eligible for analyses according to the radiographic definition of knee OA during the 4-year follow-up. In order to be eligible for analyses according to the symptomatic definition of knee OA, participants had to have answered the knee pain query also (14,074 observations eligible for analyses). The main reason for missing data in the present analyses was the missing data on K-L grades for 42, 43 and 44% of participants at study visits 1, 2 and 3, respectively (see Fig. 1 and Additional file 3). Fifty-three percent of participants eligible for the analyses had three or more observations (see Additional file 3).
The baseline characteristics of participants are presented in Table 1. At baseline, the mean age was 61.1 years (standard deviation (SD) 9.2), and 58% of participants were female. The mean BMI was 28.5 (SD 4.8), and 76% of participants had no comorbid conditions at baseline. Fifty-seven and 78% of participants reported no knee injuries and no knee surgical history, respectively, at baseline. The characteristics of participants during follow-up are presented in additional file (see Additional file 3).
The prevalence of knee OA according to different definitions among participants at baseline and among all observations are presented in Table 2. At baseline, 57% of participants had K-L grade ≥ 2 in at least one knee, and 26% had knee OA according to the symptomatic definition of knee OA. At baseline, when using the definition of the highest K-L grade for knee OA, the most prevalent grades were 2 (30%) and 0 (28%), while the most prevalent mean K-L grades were 0.0 (28%) and 2.0 (17%). The most prevalent K-L grade combinations at baseline were (0;0) and (2;2) accounting for 28 and 13% of participants, respectively. The prevalence of knee OA according to different definitions during follow-up are presented in additional file (see Additional file 3).
At baseline, the mean (SD) unadjusted SF-6D utility score of all study participants was 0.801 (0.120) indicating utility loss (disutility) equal to − 0.199 (see Table 1). The mean adjusted disutility scores in relation to different symptomatic and radiological definitions of knee OA are presented in Figs. 2, 3 and 4 and in more detail in additional file (see Additional file 4). The parameter estimates from GEE analyses are presented in additional file (see Additional file 4). Pairwise comparisons are presented in additional file (see Additional file 5).
The estimated disutility score increased with worsening of symptomatic or radiographic status of knee OA. Symptomatic and radiographic knee OA in at least one knee was associated with an increase of 0.026 and 0.006 (corresponding to 1.0 MID and 0.2 MID), respectively, in disutility scores compared with the reference group (Fig. 2a and b). Bilateral or unilateral symptomatic knee OA was associated with 0.030 (1.1 MID) or 0.024 (0.9 MID) higher disutility scores, respectively, compared with the reference group (Fig. 2c). The estimated increase in disutility was 0.013 points (0.5 MID) with bilateral radiographic knee OA compared with the reference group (Fig. 2d).
The estimated disutility scores increased by 0.027 and 0.040 points (1.0 MID and 1.5 MID) from the best to the worst among the highest and mean of K-L grades (Fig. 3a and b), respectively. Compared to a mean K-L grade value of 0.0, the estimated increase in disutility score was statistically significant with mean values of 2.0, 3.0, 3.5, and 4.0 (Fig. 3b). An additional file shows this in more detail (see Additional file 5).
Increase in estimated disutility scores from the best combination of K-L grades (0;0) to the worst (4;4) was the same (0.040 points, corresponding to 1.5 MID) as with mean K-L grade classification due to arithmetical reasons (Fig. 4). The disutility scores in health states (2;2), (3;3), (4;0), (4;2), (4;3), and (4;4) differed significantly from the reference health state (0;0) (Fig. 4). An additional file shows this in more detail (see Additional file 5).
The difference in disutility scores between the worst and best health state according to different definitions of knee OA was the greatest when using combinations or mean values of K-L grades. The differences in the remaining definitions can be ranked as follows: symptomatic OA (3-scale) > highest K-L grade > symptomatic OA (2-scale) > radiographic OA (3-scale) > radiographic OA (2-scale).
In the present study, we estimated health disutilities associated with knee OA and its different symptomatic and radiographic uni- and bilateral definitions. Our results show that the emergence of symptomatic knee OA and increasing radiographic K-L grade are in relation to statistically and clinically significant worsening of health utility measured by the SF-6D instrument. The worsening was particulary strong when the subject had symptomatic bilateral knee OA or a high mean value of K-L grades. Health disutility in bilateral knee OA differed from disutility associated with unilateral knee OA when using the radiographic definition. Based on our results, pain experience is an important factor in OA-related quality of life as the disutility score associated with knee OA was greater when taking pain experience into account (i.e., symptomatic definition) than when using only radiographic definition (K-L grade ≥ 2).
The results indicate that symptomatic knee OA worsens SF-6D health utility score significantly by 0.025 points (0.9 MID) on average. The association of unilateral and bilateral symptomatic knee OA with health utility were similar. Previously, it has been shown that symptomatic knee OA is associated with a decrease of 0.003–0.19 points in EQ-5D utility scores [17, 18]. However, the precise comparability of the results is challenging because of different preference-based health utility measures  and knee OA definitions utilized in previous studies: Muraki and co-authors  based their definition on the highest K-L grade of both knees, similarly to one of our definitions. They used K-L grade 3 as a cut-off point of radiographic knee OA, and symptomatic knee OA was defined as knee pain lasting at least 1 month within the current or previous year in the knee with K-L grade ≥ 3. Kiadaliri and co-authors  used clinical ACR (American College of Rheumatology) criteria based on frequent knee pain, crepitus, morning stiffness, age, and/or bony enlargements and a radiographic definition that approximates K-L grade 2 or higher. Both of the studies utilized unilateral knee OA definition (i.e., the OA status of the other knee was omitted).
We considered unilateral symptomatic and radiographic definitions (2-scale measures and the highest K-L grade) to be overly broad definition of health states in a sense of health economics analyses. That is why we wanted to examine, if we can differentiate the changes in disutility scores between bilateral definitions and the five (0–4) K-L grades. Because health utility is tied to a person's general experience on quality of life but knee OA may emergence only in one or both knees, we used bilateral definitions of OA and the mean and combination of K-L grades as an attempt to take the effect of both knees on disutility into account, yet these are not validated and generally accepted outcome measures. Our results indicate that as symptomatic definition was applied, the unilateral and bilateral definitions yielded similar outcomes. On the other hand, according to our findings, we consider bilateral definition important when plain radiographic definition is applied.
Our findings indicate that the bilateral radiographic definition of knee OA and the mean and combination classifications of K-L grades were able to differentiate disutility scores between the health states although pain experience was not included in the OA definition. Mean K-L grade definition was able to differentiate more groups than the highest K-L grade. This may be result of the fact that K-L grades of both knees were included, even though rather heterogeneous K-L pairs result in the same mean value. The advantage of combination K-L grades is that it does neither omit nor summarize the K-L grades of the knees, but it resulted in smaller group sizes, which enlarged the reported confidence intervals.
The capability of K-L grade alone to differentiate the disutility between sequential health states was limited, although the difference between the extreme K-L grades was explicit in all definitions. For example, the definition based on the highest K-L grade was able to differentiate all pairwise disutility comparisons only with K-L grade 4. The reason for inadequate differentiation of disutility between the consecutive K-L grades may be that the radiographic classification has its shortcomings, and K-L is more likely an ordinal, not an interval scale. Firstly, the original K-L grades are verbally described, and the interpretation of them and radiographs is inconsistent and varies between observers . Secondly, radiographic findings of knee OA does not absolutely result in pain experience or disability , which are the obvious factors deteriorating the patient-reported HRQoL. On the other hand, radiographic findings have some prognostic strength in relation to the symptomatology [35, 36].
Results of the present study confirm that the bilateral definition of knee OA was related to higher disutility scores if the definition was symptomatic, incorporating patient-reported frequent pain experience, rather than simple radiographic definition [17, 18]. Interestingly, our results are also consistent with previous findings that there is a relationship between self-reported knee pain and radiological OA defined by the highest K-L grade of both knees based on a previous study showing that knee pain experience differed by K-L grades and was explicit at least with the worst K-L grade .
Results of the present study may also be interpreted in the perspective of a health economic evaluation. If an intervention would prevent the progression of joint damage in both knees from the mean K-L grade 0 to 2 or from 2 to 4 the raw QALY gain would be 0.012, or 0.028 per year, respectively. In the treatment of OA, long-term objectives should focus on prevention of joint damage and on the improvement of quality of life .
If there was a more consistent diagnostic test for knee OA, defining the health states would be more straightforward. At present, the comparability of clinical and cost-effectiveness studies is challenging due to different definitions of knee OA. The comparability between studies is also challenging because of different applied health utility instruments. The present study applied the SF-12 questionnaire, and the results were converted to SF-6D-utilities by a mapping algorithm . SF-6D takes into account six dimensions of the original SF-12 questionnaire. An advantage of the SF-6D measure is that it provides a single index score for the estimation of QALYs in cost-effectiveness analyses. We used the value of 0.027  as a cut-point for MID as a smallest change in health utility that is important to a subject. However, estimates for SF-6D MID-values vary from 0.010 to 0.048 .
To our knowledge, the present study is the first to quantify the health disutility related to knee OA using the generic, preference-based SF-6D instrument in relation to different symptomatic and radiographic uni- and bilateral definitions of knee OA. Although the impact of knee OA on quality of life has been studied widely, there has been lack of information on preference-based quality of life in relation to different definitions of knee OA, and particularly in relation to uni- and bilateral definitions. Previously, it has been shown that bilateral knee pain is associated with poorer quality of life . However, we found that bilateral knee OA definition is uncommon in HRQoL research, even though both knees naturally affect patients' quality of life. This is probably a result of the fact that the generally used definitions of knee OA do not differentiate between uni- or bilateral knee OA. In the previous knee OA related quality of life, functional decline, and pain studies, the use of unilateral knee OA definition is usually implicitly expressed, and the selection of the analyzed knee has been variable (e.g., the worse knee or symptomatic definition with knee OA in at least one knee or knee randomly selected or both knees analyzed separately) (e.g., [17, 18, 25, 35, 39]). However, in our study we explicitly quantified the health disutility in relation to symptomatic and radiographic uni- and bilateral knee OA definitions.
The strength of this study is that we quantified the SF-6D scores in a repeated measures design with a substantial number of OAI study subjects. OAI is a large open access database with relatively low rate of drop-outs and high response rate to the validated SF-12 questionnaire. Earlier studies have quantified health utility in relation to knee OA using EQ-5D instrument in cross-sectional study design [17, 18]. There is no gold standard for generic preference-based HRQoL measure. National health technology assessment organizations such as NICE (National Institute for Health and Care Excellence) recommend EQ-5D as a generic health utility measure. However, a working group for standard set of outcome measures recently recommended both SF-12 and EQ-5D as standard patient reported outcome measure tools for persons with hip or knee OA for HRQoL evaluation . Variety of disease-spesific instruments (KOOS, WOMAC, knee pain) may also be used to measure knee OA related quality of life. The OAI dataset includes KOOS, WOMAC and SF-12 questionnaires. Although the disease-spesific instruments have advantages, and they cover the dimensions relevant to knee OA, they are not suitable for calculating QALYs for health economic analyses unlike generic, preference-based health utility instruments. However, there are mapping algorithms available to estimate the preference-based utility from the disease-spesific instrument scores but they should be applied cautiously .
The results of the present study should be interpreted in light of some limitations. Firstly, while we have reported the health disutilities of OAI study participants, the findings of this study are, however, based on UK population-based preferences. There is evidence that health state valuing may differ between countries [41, 42]. SF-6D valuation surveys have been completed also in China , Japan , Portugal , Spain  and Brazil . Secondly, as we took patient reported comorbid conditions into account we did not specifically focus on comorbidities of musculoskeletal system as adjusting variables. However, problems in musculoskeletal system, joint pain comorbidity, coexisting back pain, and hip OA have been reported to have impact on the quality of life and experience of knee pain in patients with knee OA [8, 47–50]. Thirdly, we used symptomatic definition only in 2- and 3-scale definitions. It would have been interesting to combine pain status also with the different radiographic definitions, but this would have resulted in too small group sizes. Fourthly, there was a substantial number of missing K-L grades at year 1, 2 and 3 follow-up visits. The GEE model utilized has a straightforward assumption of missing completely at random (MCAR). The missing K-L grades could have been 'safely' imputed with the technique of 'last observation carried forward' as the degeneration in knee joint (K-L grade) is not assumed to recover. However, 94 and 85% of participants had K-L grade available at baseline and at year 4 follow-up visit, respectively. Fifthly, the OAI study participants may be healthier and more educated than general population, which may limit the generalizability of the findings.
The results of the present study confirm that knee OA is associated with diminished HRQoL. Our study expands upon the previous research by quantifying the health disutility values associated with different symptomatic and radiographic definitions of knee OA, as the gold standard of knee OA definition is currently unavailable. As previous research, we found different definitions of knee OA to be associated with different health disutilities, which can have an effect on the results of health economic analyses. Health disutility in relation to bilateral knee OA is less studied, and we found it to differ from disutility associated with unilateral knee OA when using radiographic definition of knee OA. The radiographic definition was, however, a crude measure to differentiate the disutility by sequential K-L grades. The performance of symptomatic definition was better, indicating that pain experience is an important factor in knee OA related quality of life.
The authors wish to thank the patients and staff of all the hospitals who have contributed data to the Osteoarthritis Initiative. The OAI is a public-private partnership comprised of five contracts (N01-AR-2-2258; N01-AR-2-2259; N01-AR-2-2260; N01-AR-2-2261; N01-AR-2-2262) funded by the National Institutes of Health, a branch of the Department of Health and Human Services, and conducted by the OAI Study Investigators. Private funding partners include Merck Research Laboratories; Novartis Pharmaceuticals Corporation, GlaxoSmithKline; and Pfizer, Inc. Private sector funding for the OAI is managed by the Foundation for the National Institutes of Health. This manuscript was prepared using an OAI public use data set and does not reflect the opinions or views of the OAI investigators, the NIH, or the private funding partners. The authors wish to thank biostatistician Tuomas Selander, MSc, and statistician Piia Lavikainen, PhD, for their guidance in statistical analyses.
The research leading to these results has received funding from the Academy of Finland (grant 305138) and the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation programme (grant agreement No 755037). The institution had no role in the design of the study or collection, analysis and interpretation of data, or in writing the manuscript, or in the decision to submit the manuscript for publication.
The data that support the findings of this study are available from the Osteoarthritis Initiative (OAI), http://www.oai.ucsf.edu/.
All authors were involved in conception and designing the study. ST undertook the analyses, interpretation of the data, and drafting the manuscript. All authors contributed to revising the manuscript critically for important intellectual content, and have approved the final version to be submitted.
This article was prepared using an Osteoarthritis Initiative (OAI) public-use data set (http://www.oai.ucsf.edu/). Ethical approval for collecting all subject information was provided by the OAI, and informed consent was obtained from all individual participants included in the study. This article does not contain any studies with human participants performed by any of the authors. Access, download and analyses of the OAI data were performed under the OAI Data Use Agreement.
ST has been a paid employee of Medfiles Ltd., and is the founder of MediSoili Oy. JM is a founding partner of ESiOR Oy. These companies were not involved in carrying out this research. All other authors declare that they have no competing interests.
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