Standard clinical practice diverges from evidence-based recommendations for patients with osteoarthritis (OA), according to research published in the January 2011 issue of Arthritis Care & Research.1
According to the study, physicians are prescribing medications for pain and inflammation, suggesting cautious waiting, or opting for surgical interventions, rather than recommending weight-loss or exercise programs. In a narrative review of literature, lead author David J. Hunter, MD, and colleagues also noted an overuse of inappropriate diagnostic imaging instead of clinical diagnosis based on history and physical examination.
“In an era where ‘healthcare reform’ is appropriately receiving due attention, it is vital that clinicians be engaged in considering the best means of healthcare delivery for chronic diseases such as osteoarthritis,” Dr. Hunter, a rheumatologist with the University of Sydney in Australia and the New England Baptist Hospital in Boston, told The Rheumatologist. He added that “the results were not surprising, but were enlightening, and serve to highlight the shortcomings of acute episodic care of this chronic disease.”
While numerous evidence-based recommendations for OA management have been developed in recent years by scientific societies and healthcare organizations, and despite what the authors called “remarkable consistency between recommendations,” clinical practice does not reflect these guidelines, the authors wrote. Noting that the majority of persons with OA are either overweight or obese, the authors recognized that there are often difficulties in the implementation of weight-loss and exercise programs “related to patient motivation and adherence and the inability of clinicians to effectively provide such interventions within their practices, and more broadly, within the current healthcare system.”
“It is easier to write a prescription for an analgesic than it is to appropriately counsel patients about exercise and weight loss,” Dr. Hunter says. “Similarly, the counseling itself is not sufficient to change behavior, and engagement of health professionals to facilitate exercise and weight loss is needed. There is resistance and/or barriers to these changes from both patients and clinicians.”
The authors of the study suggested avoidance of surgery when symptoms can be managed by other treatment modalities, but noted the lack of a metric to monitor conservative management. They pointed to other studies suggesting that up to 30% of some surgical procedures are inappropriate, including recent recommendations against the use of routine arthroscopy for knee OA management.
Regarding imaging, the authors said “there is no rationale for obtaining serial radiographs if the clinical state remains unchanged … magnetic resonance imaging should only be used in infrequent circumstances to facilitate the diagnosis of other causes of joint pain that can be confused with OA.”
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Roy D. Altman, MD, professor of medicine at UCLA, who is not affiliated with this study, calls it a “well written summary of quality indicators of care in osteoarthritis of the knee, although the title suggests it applies to all forms of osteoarthritis.”
Dr. Altman feels that the authors do a good job of pointing out the use of unproven remedies, inadequate use of nonpharmacologic methods, excessive use of imaging, the cost of surgery, and the excessive use of arthroscopy. However, he notes a problem that the article does not address: “None of our therapies, short of joint replacement, is very effective in reducing pain and improving function. In addition, none is uniformly accepted that they can alter the course of osteoarthritis. If there was a therapeutic program that was really effective, the literature would be more definitive, resulting in guidelines that would be more specific and helpful. Adherence would then be less of a problem.”
Hunter et al point out the need for a financial incentive to improve quality indicators of care. “Indeed,” agrees Dr. Altman, “at the present time there is a financial disincentive, as there is a financial penalty for spending time educating the patient.”
Dr. Hunter sees opportunity in the current state of OA care. “The increasing prevalence of osteoarthritis and the focus on health reform provide an opportunity for us to focus attention on redressing health service delivery for this chronic disease,” he says. “If we don’t, the patients themselves and the health care system will only suffer further.”
Sue Pondrom is a medical journalist based in San Diego.
Reference
- Hunter DJ, Neogi T, Hochberg MC. Quality of osteoarthritis management and the need for reform in the US. Arthritis Care Res. 2011;63:31-38.
