Abstract
Osteoarthritis (OA) is a leading cause of disability worldwide. Clinical practice guidelines (CPGs) have been developed to facilitate improved OA management. Scientific communities worldwide have proposed CPGs for OA treatment. Despite the number of highly prominent guidelines available and their remarkable consistency, their uptake has been suboptimal. Possibly because of the multitude of barriers related to the implementation of CPGs. For example, different guidelines show contradictions, some lack evidence, and they lack a hierarchy or tools to facilitate their translation and application. Also, the guidelines do not acknowledge the effect of comorbidities on choosing the treatments. Finally, poor integration of multidisciplinary services within and across healthcare settings is a major barrier to the effective implementation of management guidelines. Here we describe the main problems related to the OA guidelines and some solutions so as to offer some guidance on the elaboration of future CPGs and their implementation in primary care.
1
Introduction
Several international or domestic scientific groups have focused on the need to improve the management of osteoarthritis (OA) because OA is a leading cause of disability worldwide , it has a high and increasing prevalence and it is a chronic and incurable disease . Consequently, OA is associated with an extremely high economic burden and is considered a priority problem for public health internationally .
Clinical practice guidelines (CPGs) have been published to improve OA management. CPGs are defined as a structured set of recommendations informed by a systematic review of the most relevant evidence available. The guidelines aim to guide clinicians in selecting the best care, taking into account the benefits and harms of therapies and the strength of the recommendations appraised . According to Lim and Doherty the 3 main types of evidence to guide clinical decision-making are research evidence, expert opinion or experience, and patient opinion or acceptability. The authors affirmed that best practice occurs with agreement of the 3 types.
Scientific communities around the world have proposed CPGs for OA treatment. The leading groups are the American Academy of Orthopaedic Surgeons (AAOS) , European League Against Rheumatism (EULAR) , US National Institute for Health and Care Excellence (NICE) , OA Research Society International (OARSI) and American College of Rheumatology (ACR) . The guidelines differ in the joints considered (knee, hip and/or hand) and the types of treatments proposed (pharmacological, nonpharmacological, nonsurgical and general). Despite the multitude of available robust guidelines, their uptake has been suboptimal .
To offer some guidance on the elaboration of future CPGs, we need to examine the main limitations of OA guidelines and their solutions. Thus, the aim of this article is to provide a critical analysis of OA CPGs, barriers to implementation and possible solutions.
2
Background
Efforts have been made to identify the reasons for the continual gap between the CPG recommendations and clinical practice. A systematic review of recommendations and guidelines for the management of OA found no lack of quality but rather a failure of dissemination and implementation . The knowledge about the specific issues is essential for developing solutions. Thus, we organised this paper by these issues. Table 1 summarises the main problems and solutions, which were based on the referenced articles and the authors’ knowledge.
| Problems | Solutions |
|---|---|
| Literature limitation Poor evidence of RCTs specific for hip OA Poor evidence of therapies for patients with comorbidities Contradictory information about some therapies that lead to contradictory recommendations among guidelines | Literature limitation RCTs specific for hip OA Systematic review and meta-analysis of controversy therapies Inclusion of patients with comorbidities in RCTs to better represent clinical scenarios Studies to test cost-effectiveness of CPG recommendations in different models of care |
| External limitation Lack of time of GP to see patients Resistance of patients to lifestyle changes Lack of skills of some physicians Limited access of patients to other health professionals Patients beliefs Inefficient referral process Inadequate model of care to implement CPGs Poor integration of multidisciplinary settings | External limitation More time for GPs to see patients Effective multidisciplinary teams Accredited training courses for GPs Development of an efficacious model of care that allows CPGs implementation |
| CPGs limitations Absence of standardized methodology Poor recommendation description Illogical format for presentation of recommendations Poor information about management of OA with comorbidities Disease driven guidelines Absence of economic aspects of recommendations | CPGs limitations Guide future research in order to increase research value and decrease waste with redundant work Development of tools to aid communication with patient Flowchart, algorithm or single page check-list to translate CPGs Standardise CPG development to allow trustworthy and transparent guidelines Develop patient driven CPGs rather than disease driven Include cost-conscious aspects of each recommendation Structured and logical presentation of recommendations Detailed description of recommendations including, prescription, dosage and clinical scenario |
2
Background
Efforts have been made to identify the reasons for the continual gap between the CPG recommendations and clinical practice. A systematic review of recommendations and guidelines for the management of OA found no lack of quality but rather a failure of dissemination and implementation . The knowledge about the specific issues is essential for developing solutions. Thus, we organised this paper by these issues. Table 1 summarises the main problems and solutions, which were based on the referenced articles and the authors’ knowledge.
| Problems | Solutions |
|---|---|
| Literature limitation Poor evidence of RCTs specific for hip OA Poor evidence of therapies for patients with comorbidities Contradictory information about some therapies that lead to contradictory recommendations among guidelines | Literature limitation RCTs specific for hip OA Systematic review and meta-analysis of controversy therapies Inclusion of patients with comorbidities in RCTs to better represent clinical scenarios Studies to test cost-effectiveness of CPG recommendations in different models of care |
| External limitation Lack of time of GP to see patients Resistance of patients to lifestyle changes Lack of skills of some physicians Limited access of patients to other health professionals Patients beliefs Inefficient referral process Inadequate model of care to implement CPGs Poor integration of multidisciplinary settings | External limitation More time for GPs to see patients Effective multidisciplinary teams Accredited training courses for GPs Development of an efficacious model of care that allows CPGs implementation |
| CPGs limitations Absence of standardized methodology Poor recommendation description Illogical format for presentation of recommendations Poor information about management of OA with comorbidities Disease driven guidelines Absence of economic aspects of recommendations | CPGs limitations Guide future research in order to increase research value and decrease waste with redundant work Development of tools to aid communication with patient Flowchart, algorithm or single page check-list to translate CPGs Standardise CPG development to allow trustworthy and transparent guidelines Develop patient driven CPGs rather than disease driven Include cost-conscious aspects of each recommendation Structured and logical presentation of recommendations Detailed description of recommendations including, prescription, dosage and clinical scenario |
3
Target joint
Most CPGs are directed toward knee and hip OA; however, some recommendations are often specific to knee OA and extrapolated to hip OA. As noted by Bennell and Hinman , some findings cannot be directly translated to hip OA because of differences in biomechanics, impairments, rapidity of OA progression and risk factors. Therefore, the extrapolated recommendations are mainly based on expert opinion. This fact indicates limited evidence for the management of hip OA.
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