Friday, January 7, 2011

Practitioners Ignore Osteoarthritis Guidelines

Arthritis A new report in the January 2011 issue of the journal Arthritis Care & Research observes that clinicians who care for patients with osteoarthritis (OA) often do not follow standard care guidelines based on current medical evidence. For example, practitioners are prescribing medications for pain and inflammation, or opting for surgical interventions, rather than recommending weight loss plans or exercise programs to patients with OA.

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 aging of the “baby boomer” generation. David Hunter, MBBS, PhD, from the University of Sydney in Australia and New England Baptist Hospital in Boston, Mass., and colleagues reviewed how standard clinical practice diverges from evidence-based recommendations in the management of OA [Hunter et al. 2011].

The authors observe 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. Many individuals with OA are overweight or obese, and the authors support medical evidence recommending conservative nonpharmacologic management for OA patients. “Weight management and exercise programs tend to be overlooked by clinicians,” Hunter believes. “These conservative approaches are beneficial to patients who adhere to weight-loss and exercise programs.”

Hunter et al. further suggest that surgery should be resisted when symptoms can be well-managed by other treatment modalities. 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 suggesting routine arthroscopy for knee OA management should be avoided — something not reflected in clinical practice, the authors note.

The study team also criticized 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. From 20% to 50% of these scans were unnecessary, the authors note, since the results failed to help treat or diagnose the patient’s symptoms.

COMMENTARY: Hunter and coauthors conclude that, “Eliminating unproven procedures and reducing needless costs is necessary to improve the quality and lower the cost of healthcare in the U.S. 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.”

While their proposal makes rhetorical sense and seems reasonable, its application in everyday practice may be another matter. Most patients with pain expect “treatment,” rather than education and advice to lose weight and exercise; even though those measures are often appropriate and helpful. Conservative approaches are sometimes viewed by patients as nontreatment, which places the burden back on healthcare providers.

Pain Treatment Topics provides open access to published guidelines for the treatment of arthritis [here], and there are many to chose among. There appears to be an assumption in the paper by Hunter et al. that the guidelines are of high quality, with strong recommendations based on unequivocal evidence, and this is not always the case. Many of the guidelines are complex, and some contain inconsistencies or contradictions. Therefore, at the present time, it is difficult to blame practitioners for not always strictly following published guidelines and, indeed, such nonadherence in some cases may represent a practitioner focus on individualized, “patient-centered care” that is advocated by Hunter and colleagues.

REFERENCE: Hunter DJ, Neogi T, Hochberg MC. Quality of Osteoarthritis Management and the Need for Reform in the US. Arth Care Res. 2011(Jan);63(1):31-38 [abstract here].