Clinical practitioners not adhering to evidence-based guidelines for osteoarthritis

A 2002 report by the World Health Organization (WHO) estimated OA to be the fourth leading cause of years lost due to disease (YLD) worldwide. OA disability is quickly becoming a major public health concern with experts suggesting that by 2020 the number of people with OA will have doubled due to growing obesity prevalence and the aging of the "baby boomer" generation. According to the Centers for Disease Control and Prevention (CDC), arthritis and other rheumatic conditions cost the U.S. $128 billion in 2003—a 24% increase since 1997. Much of the cost burden in arthritis care can be attributed to OA which accounts for a large volume of surgical procedures including total joint replacements.

Dr. David Hunter from the University of Sydney in Australia and New England Baptist Hospital in Boston, Massachusetts and colleagues reviewed how standard clinical practice diverges from evidence-based recommendations in the management of OA. "We present a potential roadmap for optimizing the quality of OA healthcare for those developing and enforcing policy decisions, and for clinicians on the frontlines of OA management to enact practice change," commented Dr. Hunter.

Current clinical practice does not reflect recommendations based upon medical evidence. The authors report that therapeutic interventions are primarily aimed at reducing pain and improving joint function by using therapies that target symptoms, but do not facilitate improvement in joint structure or long-term betterment of the disease. Frequently, physicians do not recommend conservative non-pharmacologic management therapies which leads to unnecessary diagnostic imaging and inappropriate referrals to orthopedic surgeons.

Many individuals with OA are overweight or obese. The authors support medical evidence which recommend a conservative non-pharmacologic management for OA patients. "Weight management and exercise programs tend to be overlooked by clinicians," said Dr. Hunter. "These conservative approaches are beneficial to patients who adhere to weight-loss and exercise programs."

Researchers further suggest that surgery be resisted when symptoms can be well managed by other treatment methods. The typical indications for a surgical approach in treating OA are debilitating pain and major limitation of functions such as walking, working, or sleeping. However, prior studies have shown that up to 30% of some surgical procedures are inappropriate and recent recommendations suggest routine arthroscopy for knee OA management should be avoided—something not reflected in clinical practice.

The study team also noted an overuse of inappropriate diagnostic imaging instead of clinical diagnosis based on history and physical examination. Based on current guidelines imaging should be reserved for instances where a diagnosis is unclear and radiography could rule out other diseases that may produce similar symptoms. Research studies estimate there are 95 million high-tech scans (CT, MRI, PET) done annually in the U.S—representing a $100 billion industry, of which $14 billion has been shouldered by Medicare—and 20% to 50% of these scans were unnecessary as the results failed to help treat or diagnose the patient's symptoms.

"Eliminating unproven procedures and reducing needless costs is necessary to improve the quality and lower the cost of healthcare in the U.S.," concluded Dr. Hunter. "The management of OA should focus on a patient-centered and provider integrated approach that improves quality and reduces cost by following evidence-based recommendations."

More information: "Quality of Osteoarthritis Management and the Need for Reform in the US." David J. Hunter, Tuhina Neogi, and Marc C. Hochberg. Arthritis Care and Research; Published Online: June 25, 2010 (DOI: 10.1002/acr.20278); Print Issue Date: January 2011. http://onlinelibrary.wiley.com/doi/10.1002/acr.20278/abstract

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