https://acpinternist.org/weekly/archives/2015/12/22/1.htm

Patient-clinician intervention associated with modest improvement in knee osteoarthritis

The patient intervention was telephone-based, while clinicians received patient-specific recommendations on osteoarthritis treatment via the electronic medical record.


An intervention involving both patients and clinicians resulted in modest improvement in knee osteoarthritis, a new study has found.

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Researchers performed a cluster randomized clinical trial to determine whether a combined intervention would help improve osteoarthritis outcomes in a population of U.S. veterans. Patients and clinicians were assigned to intervention and usual care groups. The patient intervention was telephone-based and involved weight management, physical activity, and cognitive-behavioral pain management. Clinicians, meanwhile, received patient-specific recommendations on osteoarthritis treatment via the electronic medical record as progress notes that required an electronic signature. The study's primary outcome was total score at 12 months on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); lower scores were better. Secondary outcomes were pain and function WOMAC subscale scores, physical performance as measured by the Short Physical Performance Battery, and depressive symptoms as measured by the Patient Health Questionnaire-8. The study results were published Dec. 22 by Annals of Internal Medicine.

Thirty primary care clinicians and 300 patients were enrolled in the study. One hundred fifty-one patients were assigned to the intervention group, and 149 were assigned to the usual care group. Of the enrolled participants, 88% completed the 6-month measures and 91% completed the 12-month measures. Total WOMAC scores at 12 months were 4.1 points lower in the intervention group versus the usual care group (P=0.009). Improvements were seen in total WOMAC score in both groups at 6 months, but the mean score in the usual care group reverted to baseline by 12 months. WOMAC function subscale scores were 3.3 points lower in the intervention group than in the usual care group at 12 months (P=0.005). No between-group differences were seen in WOMAC subscale scores for pain, in physical performance, or in depressive symptoms. More patients in the intervention group than in the usual care group were referred by clinicians for recommended osteoarthritis treatments, such as physical therapy (12% vs. 7%) and knee braces (19% vs. 11%), but the numbers of patients who received these treatments was low in both groups.

The authors noted that their study was conducted in a single Veterans Affairs Medical Center, that patient and clinician interventions could not be examined separately, and that data on physical activity were self-reported, among other limitations. However, they concluded that the combined intervention tested in their study yielded modest improvements in self-reported physical function and physical activity in this population. “The provider-based intervention seemed particularly useful for increasing referrals for behavioral and rehabilitative programs,” the authors wrote. “However, changes in study outcomes were modest, which may indicate that higher-intensity interventions are needed to yield clinically meaningful changes in osteoarthritis-related outcomes.”

Also this month, the American Academy of Orthopaedic Surgeons published extensive recommendations on surgical management of osteoarthritis of the knee. Some of these recommendations are relevant to primary care, including those on risk factors for worse surgical outcomes, preoperative physical therapy, and postoperative mobilization. The full report is available free of charge online.