Background Studies determining factors associated with the setting and content of care in patients with hip/knee osteoarthritis (OA) are mainly confined to patient demographics or disease-related factors associated with total joint replacement (TJR). To our knowledge, no studies integrated patient-related factors and factors related to the general practitioner (GP) or general practice to predict TJR, neither took attention to the content of previously utilized care. Moreover, it is unknown which factors are associated with the continuation of non-surgical care in patients once referred to secondary care.
Objectives To identify both socio-demographic, health-related, disease-related and content-of-care-related factors at the level of the patient, as well as socio-demographic factors at the level of the GP and the general practice associated with 1) treatment restricted to primay care, 2) TJR, and 3) continuation of non-surgical treatment after a referral to secondary care in patients with hip/knee OA.
Methods Data were used from a two-year observational prospective cohort study including 313 patients with hip/knee OA visiting their GP with a new episode of complaints1. Logistic multilevel analyses were conducted to identify relevant factors.
Results The referral rate to secondary care amounted 53%. TJR was applied in 34% of this referred subpopulation, representing 18% of the total population. Non-referred patients less often reported knee OA, were faced with less severe complaints and were treated less extensively by non-surgical interventions than referred patients. Identified factors associated with treatment restricted to primary care were less limitations in physical functioning (p≤.01) and non-use of physiotherapy (p=.03), intra-articular injections (p≤.01), and radiological assessments (p≤.01). TJR was associated with the use of radiological assessment (p<.01) and physiotherapy (p<.01). In the subpopulation of referred patients, having a paid job (p=.02), non-use of physiotherapy (p≤.01), and non-use of NSAIDs (p=.05) were associated with continuing non-surgical treatment. Variances were mainly located at the level of the patient (90->99.9%), followed by the general practice (<0.1-5.3%) and the GP (<0.1-4.7%).
Conclusions The present study shows that the setting and content of care in patients with hip/knee OA is mainly associated with the content of previously utilized care. In particular, it could be suggested that patients who did not receive physiotherapy are more likely to stay in primary care or, once referred, to continue non-surgical treatment compared to patients who received physiotherapy. Remarkably, pain severity and limitations in activities are not independently associated with TJR. Since only 34% of the patients referred to secondary care receive a TJR, GPs probably could optimize their referrals to secondary care by first ensuring optimal primary care has been delivered.
Smink AJ, van den Ende CH, Vliet Vlieland TP, et al. “Beating osteoARThritis”: development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis. Clin Rheumatol 2011 Dec;30(12):1623-9.
Acknowledgements Financial support was provided by the Dutch Arthritis Association and the Royal Dutch Society for Physical Therapy
Disclosure of Interest : None declared