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Patients report only 38% of GPs adhere to quality indicators for OA
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A survey of patients with nonsurgical knee osteoarthritis found that just 38% of general practitioners adhere to process indicators, particularly informing patients of the importance of weight loss and referring them to physical therapy, according to data published in Arthritis Care & Research.
“Quality indicators (QIs) are measurable tools in assessing and monitoring the quality of care,” David Spitaels, MD, of the Academic Center for General Practice, in Leuven, Belgium, and colleagues wrote. “The classification of QIs is most commonly related to structure, process, or outcome of health care. ‘Structure’ denotes the attributes of the settings in which care occurs, while ‘process’ denotes what is actually done in giving and receiving care, and while ‘outcome’ measures describe the effects of care on the health status of patients (eg, mortality, quality of life).”
“Even though OA is one of the most prevalent conditions in general practice, evidence-based and valid QIs for assessing quality of primary care for knee OA are scarce,” they added. “Moreover, although insight into the relation between process and outcome measures in real-world settings is crucial to improve quality of care, it remains poorly understood.”
To characterize the quality of OA care in general practice from the point of view of the patient, and to evaluate the links between process quality indicators and patient-reported outcomes, Spitaels and colleagues recruited 235 participants with knee OA from 64 practices in Flanders, Belgium. Participants completed a 54-question survey based on both process and outcome indicators, including four subheads — personal data and background, care provided by the physician, care provided by the physical therapist and quality of life with knee OA.
The researchers extracted process indicators from international guidelines. These indicators included diagnosis, self-management, treatment and followup. Spitaels and colleagues used the Western Ontario McMaster Universities Osteoarthritis Index and RAND 36Item Health Survey to analyze patient-reported outcomes. Experience with care was assessed using the EUROPEP instrument. The researchers used multilevel regression analyses to evaluate the patient-level factors and associations between process and outcome indicators.
According to the researchers, overall adherence to process indicators was low, at 38%. Adherence to individual indicators ranged from 97% (95% CI, 93.6-98.6) for “patients should not receive strong opioids,” to 22.6% (95% CI, 16.8-29.5) for “patients should be given information, access and education about the importance of measure to unload the damaged joint.” In addition, informing patients on the importance of weight loss had a patient-reported adherence of 24.3% (95% CI, 18.9-30.6), and adherence to referring symptomatic patients for physical therapy was 40.7% (95% CI, 33.3-48.5).
Participants rated their quality of life with knee OA as “moderate,” the researchers wrote, with an overall RAND score or 63% and a WOMAC survey score of 35%. Patients with higher education levels were better informed on lifestyle and management strategies (OR = 3.4; P = .0003). Links between process and outcome indicators were scarce, save for patient satisfaction with care and NSAID use (OR=2.9; P = .0014).
“The data indicate there is vast room for improvement in care of knee OA, and that investing in quality of care is appropriate to improve guideline adherence,” Spitaels and colleagues wrote. “In the future, patienttailored strategies to improve patients' knowledge and self management could be helpful to improve guideline adherence.” – by Jason Laday
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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David A. McLain, MD, FACP, FACR
Osteoarthritis is the most common joint disorder and knee osteoarthritis accounts for 83% of the burden. The economic impact of osteoarthritis is substantial with an estimated cost comparable to coronary artery disease; additionally, it is the fourth leading cause of disability worldwide.
The results of this study indicate that overall, there is low adherence to process indicators, with just 38% of general practitioners. Only 24% of patients in this study were told that they should lose weight (as reported by the patient), whereas only 41% of the patients reported being referred to physical therapy. As has been seen in other studies, patients with a higher educational level were better informed. The process indicators and outcome indicators had little correlation with each other with the exception of patient satisfaction and the use of NSAIDs.
The authors felt that patients with osteoarthritis receive suboptimal conservative care. There are several problems with the treatment of osteoarthritis. Patients with osteoarthritis express satisfaction with the taking of NSAIDs as shown in this study. However, there are problems with NSAIDs in older individuals — namely, renal insufficiency, gastrointestinal bleeding, heart attack, stroke, thrombotic events, decompensation of CHF and hypertension.
In addition, nephrologists, gastroenterologists, and cardiologists are frequently discontinuing NSAIDs in our patients. With the checking of [estimated glomerular filtration rates] on a regular basis, we are often stopping NSAIDs in the rheumatology clinic ourselves. I have often thought that low-dose narcotics were safer than NSAIDs in the older individual; with the exception of constipation, patients often tolerate low-dose narcotics better than NSAIDs.
With the loss of propoxyphene, the narcotic option now requires a schedule II narcotic like hydrocodone for those patients who cannot tolerate tramadol; however, this is a big jump and with the ongoing opioid crisis, many physicians are no longer writing narcotics. Another option has been low-dose naltrexone, which I have been using for 8 years. The use of low-dose naltrexone as treatment for chronic pain has been previously reported by Younger and colleagues in Clinical Rheumatology, and appears to be a safe and well-tolerated alternative to NSAIDs and narcotics.
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