Osteoarthritis is the most prevalent chronic joint disease worldwide. The incidence and prevalence are increasing as the population ages and lifestyle risk factors such as obesity increase. There are several evidence-based clinical practice guidelines available to guide clinician decision making, but there is evidence that care provided is suboptimal across all domains of quality: effectiveness, safety, timeliness and appropriateness, patient-centered care, and efficiency. System, clinician, and patient barriers to optimizing care need to be addressed. Innovative models designed to meet patient needs and those that harness social networks must be developed, especially to support those with mild to moderate disease.
Key points
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Key OA hip and knee guideline recommendations are for non-pharmacological interventions such as exercise and weight optimization, and for severe disease, joint replacement surgery.
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There is suboptimal management of OA across a number of quality of care domains, including; effectiveness, safety, access and support for patient self-management.
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There are limitations in current services associated with inadequate information systems, variable team-based care and suboptimal service linkages.
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There is a need for improved delivery of decision support for clinicians and patients to support shared decision-making and uptake of cost-effective interventions.
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There is a need for further research directed at harnessing social networks to support people at risk or with mild to moderate osteoarthritis.
Background
Osteoarthritis (OA) is the most common chronic joint disease. It is highly prevalent and a leading cause of disability worldwide. As such, OA poses a substantial societal burden, predominantly because of growing health care costs and lost productivity. The increasing incidence and prevalence of chronic diseases such as OA are driving health care reform internationally, particularly health care redesign to provide service models that better support the needs of people with these conditions.
In addition, as greater attention is focused toward resolving gaps in implementing evidence into practice and preventing underuse, overuse, and sometimes misuse of effective interventions, a previously narrow focus on clinical outcomes such as mortality has expanded to consider broader measurement of quality of care. The Institute of Medicine in the United States advocates for 6 pillars to improve care: safety, effectiveness, patient-centered care, timeliness, efficiency, and equity ( Table 1 ).
| Quality Outcome Domain | Definitions and Principles of Care Redesign |
|---|---|
| Safety | Patients should be safe from injury caused by the system |
| Effectiveness | Patients should receive care based on the best available scientific knowledge Health care providers and organizations should actively collaborate and communicate to ensure appropriate exchange of information and coordination of care |
| Patient-centered care | Care is customized and based on patients’ needs and values The health system should make available to patients and their families information that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice. This information should include descriptions of the system’s performance on safety, evidence-based practice, and patient satisfaction Patients are given necessary information and the opportunity to exercise the degree of control they choose over the health care decisions that affect them Health care providers and patients should communicate effectively and share information The health system should make available to patients and their families information that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice. This information should include descriptions of the system’s performance on safety, evidence-based practice, and patient satisfaction |
| Timeliness and appropriateness | The system should anticipate patient needs, rather than reacting to events Care should be continuous Health care providers and institutions should actively collaborate and communicate to ensure appropriate exchange of information and coordination of care |
| Efficiency | The health system should not waste resources or patient time |
| Equity | Care should not vary in quality because of gender, ethnicity, geographic location, or socioeconomic status |
There is a useful existing commentary about the ways in which care for people with OA can be improved. This article builds on these sources by exploring system, health care provider, and patient barriers and enablers to improving care for OA in relation to the Institute of Medicine’s 6 pillars for improving chronic care health services.
Background
Osteoarthritis (OA) is the most common chronic joint disease. It is highly prevalent and a leading cause of disability worldwide. As such, OA poses a substantial societal burden, predominantly because of growing health care costs and lost productivity. The increasing incidence and prevalence of chronic diseases such as OA are driving health care reform internationally, particularly health care redesign to provide service models that better support the needs of people with these conditions.
In addition, as greater attention is focused toward resolving gaps in implementing evidence into practice and preventing underuse, overuse, and sometimes misuse of effective interventions, a previously narrow focus on clinical outcomes such as mortality has expanded to consider broader measurement of quality of care. The Institute of Medicine in the United States advocates for 6 pillars to improve care: safety, effectiveness, patient-centered care, timeliness, efficiency, and equity ( Table 1 ).
| Quality Outcome Domain | Definitions and Principles of Care Redesign |
|---|---|
| Safety | Patients should be safe from injury caused by the system |
| Effectiveness | Patients should receive care based on the best available scientific knowledge Health care providers and organizations should actively collaborate and communicate to ensure appropriate exchange of information and coordination of care |
| Patient-centered care | Care is customized and based on patients’ needs and values The health system should make available to patients and their families information that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice. This information should include descriptions of the system’s performance on safety, evidence-based practice, and patient satisfaction Patients are given necessary information and the opportunity to exercise the degree of control they choose over the health care decisions that affect them Health care providers and patients should communicate effectively and share information The health system should make available to patients and their families information that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice. This information should include descriptions of the system’s performance on safety, evidence-based practice, and patient satisfaction |
| Timeliness and appropriateness | The system should anticipate patient needs, rather than reacting to events Care should be continuous Health care providers and institutions should actively collaborate and communicate to ensure appropriate exchange of information and coordination of care |
| Efficiency | The health system should not waste resources or patient time |
| Equity | Care should not vary in quality because of gender, ethnicity, geographic location, or socioeconomic status |
There is a useful existing commentary about the ways in which care for people with OA can be improved. This article builds on these sources by exploring system, health care provider, and patient barriers and enablers to improving care for OA in relation to the Institute of Medicine’s 6 pillars for improving chronic care health services.
Current performance in management of OA
Recommendations for OA care can be found in several jurisdictional evidence-based clinical practice guidelines, the most recent of which are the American College of Rheumatology (ACR) 2012 updated guidelines for conservative management of hand, hip, and knee OA. The degree to which current practice reflects these guidelines is uncertain because it is difficult to access data about longitudinal performance in the management of OA. The exception to this is joint arthroplasty, for which high-quality clinical registries are maintained to monitor joint prosthesis survival outcomes and limited patient outcomes, such as revision rates and mortality.
Data from previous studies indicate that up to one-third of people with chronic conditions in general do not receive recommended care. Suboptimal care may be even higher for those with OA, with 1 study reporting an average indicator pass rate for primary care of only 57%. For OA, there is reported suboptimal use of effective interventions, inequity in access to arthroplasty, inappropriate use of arthroscopy, unmet need for pain assessment and management, and potentially preventable safety issues associated with use of pharmacologic therapies for people with OA. Variation in provision of evidence-based care also occurs. A recent patient survey using questions based on the Arthritis Foundation Quality Indicators for OA found that provision of advice about nonpharmacologic care was not only suboptimal but that this differed according to sex, age, disability, and educational levels.
Unlike previous clinical practice guidelines, the ACR has taken a case-based scenario approach to their recently updated OA recommendations, on the basis that studies to date have not tested sequential management strategies, and case scenarios allow clinicians to better provide an individualized management approach. Thus there are 6 cases and scenarios comprising mild to severe symptomatic OA as well as gastrointestinal and cardiovascular comorbidity scenarios. The guideline summary focuses on the initiation of therapy ( Tables 2 and 3 ), although other case scenarios can be accessed through supplementary material online. Whether this guideline approach will be more effective than others is yet to be tested.
| Treatment | OA Hand | OA Knee | OA Hip |
|---|---|---|---|
| Patient education/self-management programs | √ For joint protection techniques | √ | √ |
| Exercise: aerobic, strengthening, aquatic | No recommendation | √√ | √√ |
| Weight loss if overweight/obese | Not applicable | √√ | √√ |
| Manual therapy | No recommendation | √ With exercise | √ With exercise |
| Acupuncture b | No recommendation | √ | No recommendation |
| Transcutaneous electrical stimulation b | No recommendation | √ | No recommendation |
| Thermal agents | √ | √ | √ |
| Psychosocial interventions | No recommendation | √ | √ |
| Patellar taping | Not applicable | √ For medially directed No recommendation for laterally directed | Not applicable |
| Balance exercises | Not applicable | No recommendation | No recommendation |
| Tai Chi | Not applicable | √ | No recommendation |
| Walking aids or assistive devices | √ | √ | √ |
| Lateral wedge insoles | Not applicable | No recommendation √ If subtalar strapped | Not applicable |
| Medial wedge insoles | Not applicable | √ | Not applicable |
| Braces/splints | √ | No recommendation | Not applicable |
a These recommendations are based on the scenario of an adult with symptomatic knee OA without cardiovascular comorbidities, current or past upper gastrointestinal (GI) problems, or chronic kidney disease presenting to the primary care provider for treatment. The patient complains of mild to severe pain in and/or around the knee(s) and of not having had an adequate response to either intermittent dosing of over-the-counter (OTC) acetaminophen or OTC nonsteroidal antiinflamatory drugs (NSAIDs) or OTC nutritional supplements.
b Only when the patient with knee OA has chronic moderate to severe pain and is a candidate for total joint arthroplasty but is unwilling or unable to have surgery.
| Pharmaceutical Agent | OA Hand | OA Knee | OA Hip |
|---|---|---|---|
| Acetaminophen | No recommendation | √ | √ |
| Oral NSAIDs | √+ | √ | √ |
| Topical NSAIDs | √ | √ | No recommendation |
| Tramadol | √ | √ | √ |
| Intra-articular corticosteroid injections | x | √ | √ |
| Intra-articular hyaluronates | x | No recommendation | No recommendation |
| Opioid analgesia | x | No recommendation | No recommendation |
| Duloxetine | No recommendation | No recommendation | No recommendation |
| Glucosamine | No recommendation | x | x |
| Chrondroitin sulfate | No recommendation | x | x |
a These recommendations are based on the scenario of an adult with symptomatic knee OA without cardiovascular comorbidities, current or past upper GI problems, or chronic kidney disease presenting to the primary care provider for treatment. The patient complains of mild to severe pain in and/or around the knee(s) and of not having had an adequate response to either intermittent dosing of OTC acetaminophen or OTC NSAIDs or OTC nutritional supplements.
Effective, Safe, and Equitable Care for OA
Nonpharmacologic therapy
Clinical guidelines highlight the role of conservative nonpharmacologic treatments as the first-line approach to management of OA and emphasize their important role at all stages of disease. The bulk of research into nonpharmacologic treatments is focused on knee OA. Core nonpharmacologic treatments generally recommended by clinical guidelines for hip and knee OA include patient education, exercise, and, for those who are overweight or obese, weight loss.
In line with OA as a chronic disease, patient education is a key component of treatment and can take many forms in terms of content and mode of delivery. ACR guidelines conditionally recommend that people with hip or knee OA participate in formal self-management programs. However, although OA self-management programs are available in many countries, health practitioners do not necessarily refer patients. A qualitative study found several barriers and enablers to general practitioner (GP) referral of people with OA to self-management programs in Australia. These included GP-related factors (knowledge about availability and types of services on offer, perceptions about patients’ capacity to attend and motivation, beliefs about the benefit of referral), patient-related factors (awareness of the value and availability of services, patient-driven referrals), and program factors (design, content, location, cost, and waiting time). A range of barriers to participation in community-based arthritis self-management programs including travel difficulties and work commitments have also been reported by people with hip or knee OA.
For specific exercise prescription, an individualized approach is required. The ACR guidelines strongly recommend both aquatic and land-based exercises, and conditionally recommend tai chi, with the decision on choice of exercise approach based on patient preferences and functional ability. Strengthening exercises for the lower limb muscles, particularly the quadriceps, and aerobic exercises such as walking are also recommended by several other guidelines. Different exercise delivery modes (individual, group, home based) have all been found to be effective in improving pain and function. However, 12 or more directly supervised exercise sessions seem to be more effective than fewer than 12. Patient adherence is also a key factor in determining long-term outcome from exercise therapy in patients with OA. Given that patient adherence to exercise declines over time, strategies to maximize adherence are needed.
Despite strong evidence from randomized controlled trials (RCTs) showing the beneficial effects of exercise for people with OA and numerous clinical guidelines advocating exercise, international surveys have found that exercise is underused by medical practitioners as a treatment of OA. Furthermore, the attitudes and beliefs of health care professionals regarding exercise may be counterproductive to the patient behavioral changes needed to ensure ongoing exercise participation by the patient. Provision of advice on exercise to patients with OA may also differ across age, sex, disability, and education levels.
Clinical guidelines recommend weight loss for those with lower limb OA who are overweight or obese. For knee OA, a meta-analysis of weight loss trials found that disability could be significantly improved when weight is reduced by more than 5%, or at a rate of greater than 0.24% reduction per week over a 20-week period. Ottawa Panel Guidelines, developed specifically for overweight or obese people with OA, recommend a combination of physical activity (aerobic exercise plus or minus strength training) and diet (caloric restriction). The panel recommends weight loss before implementing weight-bearing exercise to maintain joint integrity. One RCT has shown that rheumatologist adoption of standardized goal-oriented patient visits can positively influence weight loss, exercise, and pain at 4 months follow-up, and improved physical activity, pain, and function at 1 year.
A range of other conservative nonpharmacologic treatments are available for the management of OA, with varying recommendations from clinical guidelines based on limited or low-quality evidence to support their efficacy. Recent ACR recommendations for initial treatment are summarized in Table 2 .
Pharmacologic therapy
Research interest and evidence generated about pharmacologic management of OA has also focused largely on knee OA and, to a lesser extent, hip and hand OA. The pharmacologic armamentarium for OA, unlike that for rheumatoid arthritis (RA), remains directed primarily toward symptom management rather than structural modification and prevention of disease progression.
Overall, the recent ACR recommendations are largely in keeping with previous guidelines, with some interesting differences. For instance, there is inclusion of a new psychoactive agent, duloxetine, a balanced serotonin and norepinephrine reuptake inhibitor (SNRI), for which there is RCT evidence of a benefit in reduction of pain and improvement of function over a 13-week trial period compared with placebo. Although there was no statistical difference noted in harms, a greater proportion of the treated group experienced adverse events compared with placebo, and these results require testing in other settings and older OA populations.
In contrast with nonpharmacologic management, in which there is strong support for exercise, aquatic therapy, and weight loss for those who are overweight, all pharmacologic recommendations about initiation of therapy for hand, hip, and knee OA were of lower grade; that is, conditional recommendations (see Table 3 ). Recommendations for use of simple analgesia and nonsteroidal antiinflamatory drugs (NSAIDs) remain similar to those in the European League Against Rheumatism (EULAR) and Osteoarthritis Research Society International (OARSI) guidelines; however, there is now a recommendation that glucosamine and chondroitin sulfate should not be given, based on evidence from a meta-analysis and a systematic review. This is a contentious area because another recent meta-analysis supports use of chondroitin sulfate, based on a small but significant effect on cartilage loss for OA knee.
In 2001 it was suggested that guidelines should be reviewed every 3 years ; however, given the rapidly changing evidence, a more responsive knowledge synthesis and dissemination process is required. For instance, the EULAR and OARSI guidelines supported use of hyaluronic acid, and the ACR guidelines provide no recommendation; however, a new systematic review reported only small and clinically irrelevant benefit from use of intra-articular hyaluronate therapy, suggesting that a stronger negative recommendation may now be appropriate.
Safety of pharmacologic therapy
Understanding of safety in relation to OA care is largely based on information gathered in individual therapeutic intervention trials or meta-analyses and joint registry reported outcomes. NSAID gastrointestinal and cardiovascular risks and preventive strategies are well described, and prescribing practices, associated with reduction in prescription of NSAIDs, have changed over the past 10 years. However, an area of increasing interest is use of opioid medications. The ACR data indicate that, although there is strong evidence to support a benefit for pain (number needed to treat [NNT] = 5) and functional outcomes (NNT = 7), the number needed to harm with nausea (NNT = 5) and constipation (NNT = 4) is similar. The rapid increase in use of opioids for management of nononcological chronic pain, including OA, in the last 10 years, particularly in developed countries, is of significant concern. Data from Australia suggest that the peak age for prescribing opioids is 45 to 64 years, with high levels also noted for older people and 60% of prescriptions being for musculoskeletal problems. A further study reported that in 2007 to 2008 the rate of hospital separations for poisoning associated with use of morphine, oxycodone, and codeine had increased from 0.05/1000 population to 0.11/1000. There is therefore an imperative to develop drug surveillance systems for monitoring long-term outcomes to inform guideline recommendations and clinical practice management of OA.
Surgery
Access and equity for hip and knee arthroplasty in OA
There is good evidence that knee and hip arthroplasty are cost-effective interventions for the management of end-stage OA. Although equitable access to arthroplasty for those who require it is a key goal in the management of severe OA, access to surgery is not always dictated by clinical need. Access can be limited by a range of health professional–related and health system–related factors such as delayed referral to an orthopedic surgeon, protracted waiting times for orthopedic consultation and surgery, inconsistent methods for prioritizing surgical waiting lists, and the availability of hospital resources. International studies have revealed great variation between settings in the severity of OA before surgery, and this is likely to reflect the lack of concrete indications for arthroplasty and the lack of consensus regarding the appropriate timing of surgery. There is also substantial evidence of disparities in access to hip and knee arthroplasty in many countries, including those that have universal health care or parallel public and private health care systems. Disparities exist across demographic factors including race or ethnicity and gender, and socioeconomic factors such as level of education, income, and health care cover. For example, a Canadian population-based study found that people with less education or lower income had the greatest unmet need for hip and knee arthroplasty, and the likelihood of undergoing surgery has been shown to increase significantly with higher socioeconomic status in England and Canada. In the United States, significantly lower rates of hip and knee arthroplasty have been reported for African American and Hispanic individuals. Studies from Australia and the United Kingdom have found that people from lower socioeconomic backgrounds had greater symptom severity before arthroplasty and poorer preoperative well-being, suggesting delayed access to care.
Facilitating equitable access to arthroplasty is a complex task that requires an improved understanding of the barriers faced by people with OA. Frameworks that adopt a holistic approach to determining need for surgery could also be valuable. Dieppe and colleagues described a capacity to benefit algorithm. Incorporating both disease-related and treatment-related aspects, this algorithm brings together a range of factors for consideration by health professionals, including the personal impact of the condition, the likely benefit of arthroplasty, and individual preferences for treatment. This type of framework could assist in prioritizing access to arthroplasty for people with the greatest need and potential for improvement, given their individual circumstances. However, the conceptual framework for capacity to benefit could be expanded to incorporate system factors ( Fig. 1 ). Although arthroplasty is cost-effective, there is evidence that total knee arthroplasty is more costly and less effective in low-volume centers compared with high-volume centers, and a recent systematic review reports a clear and consistent relationship between higher provider (surgeon) or hospital volumes and improved patient outcomes. At the clinical interface, use of patient decision aids, which been shown to improve knowledge, improves treatment expectation and reduces decisional conflict, and could assist patients with decision making about arthroplasty.
Related posts:
Epidemiology of Osteoarthritis
The Measurement of Joint Mechanics and Their Role in Osteoarthritis Genesis and Progression
Diagnosis and Clinical Presentation of Osteoarthritis
Update on the Role of Muscle in the Genesis and Management of Knee Osteoarthritis
Targeting Care
Nonarthroplasty Hip Surgery for Early Osteoarthritis
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