Can We Predict Those With Osteoarthritis Who Will Worsen Following a Chronic Disease Management Program?

Implementing an osteoarthritis management program to deliver guideline-driven care for knee and hip osteoarthritis in a U.S. academic health system

Objective

Assess implementation feasibility and outcomes for an Osteoarthritis Management Program (OAMP) at an academic center.

Design

This open study assessed an OAMP designed to deliver care in 1-5 individual or group visits across ≤12 months. Eligibility included adults with knee or hip osteoarthritis with ≥1 visit from 7/1/2017-1/15/2021. A multidisciplinary care team provided: education on osteoarthritis, self-management, exercise, weight loss; pharmacologic management; assessments of mood, sleep, quality of life, and diet. Clinic utilization and growth are reported through 2022. Patient outcomes of body mass index (BMI), pain, and function were analyzed using multivariable general linear models. OAMP outcomes were feasibility and sustainability.

Results

Most patients were locally referred by primary care. 953 patients attended 2531 visits (average visits 2.16, treatment duration 187.9 days). Most were female (72.6%), older (62.1), white (91.1%), and had medical insurance (95.4%). Obesity was prevalent (84.7% BMI ≥30, average BMI 40.9), mean Charlson Comorbidity Index was 1.89, and functional testing was below average. Longitudinal modeling revealed statistically but not clinically significant pain reduction (4.4-3.9 on 0-10 scale, p ​= ​0.002). BMI did not significantly change (p ​= ​0.87). Higher baseline pain and BMI correlated with greater reductions in each posttreatment. Uninsured patients had shorter treatment duration. Increasing clinic hours (4-24 ​h weekly) and serving 953 patients over four years demonstrated OAMP sustainability.

Conclusions

OAMP implementation was feasible and sustainable. Patients with high baseline pain and BMI were more likely to improve. Noninsurance was a barrier. These results contribute to understanding OAMP outcomes in U.S. healthcare.

Discordance Between Self-Reported and Performance-Based Physical Function in Patients Who Have Knee Osteoarthritis: Associations With Pain Intensity and Negative Affect

BACKGROUND

Although self-reported measures of physical disability are strong indication criterion for total knee arthroplasty (TKA) in painful knee osteoarthritis (OA), some patients may report greater-than-observed disability. Contributing factors to this discordance are relatively unexplored. We aimed to examine whether pain and negative affect, including anxiety and depression, were associated with the discordance of self-reported measures with performance-based measures (PPM) of physical function.

METHODS

We used cross-sectional data (n = 212) from two randomized rehabilitation trials in knee OA. All patients were assessed for knee pain intensity and symptoms of anxiety and depression. Self-reported function was assessed by the Western Ontario and McMaster Universities Arthritis Index (WOMAC) physical-function subscale. Objective performance-based measures (PPMs) of physical function were assessed by timed gait and stair tests. Continuous discordance scores were quantified by the difference in percentiles between WOMAC and PPMs (WOMAC-PPM), where a positive discordance, WOMAC-PPM >0, implied greater perceived than observed disability.

RESULTS

Around 1 in 4 patients had >20 percentile units in WOMAC-PPM discordance. In Bayesian regression analyses, knee pain intensity had >99% posterior probability of positive associations with WOMAC-PPM discordance. Among patients awaiting TKA, anxiety intensity had approximately 99% probability of positive associations with discordance, and these associations had >65% probability of exceeding 10 percentile units. In contrast, depression had low (79% to 88%) probability of any association with discordance.

CONCLUSION

In patients who have knee OA, a sizable proportion reported substantially greater physical disability than actually observed. Pain and anxiety intensity, but not depression, were meaningful predictors of this discordance. If validated, our findings may help in refining patient selection criteria for TKA.

Evaluating Osteoarthritis Management Programs: outcome domain recommendations from the OARSI Joint Effort Initiative

OBJECTIVE

To develop sets of core and optional recommended domains for describing and evaluating Osteoarthritis Management Programs (OAMPs), with a focus on hip and knee Osteoarthritis (OA).

DESIGN

We conducted a 3-round modified Delphi survey involving an international group of researchers, health professionals, health administrators and people with OA. In Round 1, participants ranked the importance of 75 outcome and descriptive domains in five categories: patient impacts, implementation outcomes, and characteristics of the OAMP and its participants and clinicians. Domains ranked as "important" or "essential" by ≥80% of participants were retained, and participants could suggest additional domains. In Round 2, participants rated their level of agreement that each domain was essential for evaluating OAMPs: 0 = strongly disagree to 10 = strongly agree. A domain was retained if ≥80% rated it ≥6. In Round 3, participants rated remaining domains using same scale as in Round 2; a domain was recommended as "core" if ≥80% of participants rated it ≥9 and as "optional" if ≥80% rated it ≥7.

RESULTS

A total of 178 individuals from 26 countries participated; 85 completed all survey rounds. Only one domain, "ability to participate in daily activities", met criteria for a core domain; 25 domains met criteria for an optional recommendation: 8 Patient Impacts, 5 Implementation Outcomes, 5 Participant Characteristics, 3 OAMP Characteristics and 4 Clinician Characteristics.

CONCLUSION

The ability of patients with OA to participate in daily activities should be evaluated in all OAMPs. Teams evaluating OAMPs should consider including domains from the optional recommended set, with representation from all five categories and based on stakeholder priorities in their local context.

Evaluation of the strategy for implementing the GLA:D programme in Switzerland: protocol for an implementation-effectiveness hybrid type 3 design study with a mixed-method approach

INTRODUCTION

International guidelines recommend the use of exercise, education and weight reduction, when appropriate, as first-line treatment for the conservative management of knee osteoarthritis (OA). These guidelines have not been applied systematically in Switzerland, resulting in an evidence-performance gap. After an analysis of available programmes, the Good Life with osteoArthritis Denmark (GLA:D) programme was determined as the most applicable exercise and education programme for its implementation in Switzerland. The implementation of GLA:D Switzerland OA was initiated to encourage the wider implementation of the clinical guideline recommendations and to improve conservative management of knee OA. The aim of this study protocol is to describe the evaluation of the implementation strategy and its impact on implementation, service and clinical outcomes; as well as to identify contributing barriers and facilitators.

METHODS AND ANALYSIS

The Implementation Research Logic Model will be used to evaluate the strategy and analyse its impact on the implementation outcomes by means of a mixed methods approach. This protocol outlines the proposed measures, data sources and strategies for the evaluation. Predefined implementation outcomes will help to identify the implementation impact and analyse barriers and facilitators systematically. The study population will be the healthcare professionals who are involved in the conservative management of knee OA in Switzerland, that is, physiotherapists and medical doctors, and their patients.

ETHICS AND DISSEMINATION

The use of the registry data containing data of patients participating in the GLA:D Switzerland OA programme does not fall within the scope of the Swiss Human Research Act (BASEC-Nr. Req-2019-00274). However, all participants involved in the evaluation will be asked to give informed written consent and all measures are taken to protect data and privacy of participants. Research findings will be submitted to journals relevant for the topic.

TRIAL REGISTRATION NUMBER

Not applicable.

Factors Influencing Pain Response Following Patient Education and Supervised Exercise in Male and Female Subjects With Hip Osteoarthritis

OBJECTIVE

To understand factors associated with pain intensity responder status following nonsurgical hip osteoarthritis (OA) intervention, according to sex.

METHODS

Data were from individuals with hip OA participating in the Danish Good Life With Osteoarthritis in Denmark 8-week education and exercise program. The following factors were recorded at program entry: age; education; mental well-being; comorbidities; body mass index; symptoms in hip, knee, and low back; and program-specific factors including education sessions, former participant lectures, and supervised exercise sessions. Pain intensity was recorded at baseline and at month 3 (post-program) on a 0-100-mm visual analog scale. Response was defined as pain intensity improvement of ≥30% from baseline to post-program. Logistic regression was used and conducted separately in male and female subjects.

RESULTS

The sample included 791 men and 2,253 women. Female subjects had a mean baseline pain score of 47.2 of 100 (95% confidence interval [95% CI] 46.4-48.1) and male subjects had a score of 41.7 (95% CI 40.3-43.1). By post-program, the proportion of pain responders was 50.4% among women and 45.8% among men (difference P = 0.025). Among women, program-specific factors (attending former participant lectures and more supervised exercise sessions) were positively associated with pain response, as were better mental well-being and fewer comorbidities, while symptoms in other joints/sites were associated with a decreased likelihood of response. Among men, program-specific factors were not associated with response, while better mental well-being and fewer comorbidities were associated with being a responder.

CONCLUSION

Findings suggest that the influence of some factors on pain response differ for male and female subjects and point to a potential need for targeted approaches for men and women who may require different key messages/approaches from health care providers.

Applicability of Exercise and Education Programmes for Knee Osteoarthritis Management to Switzerland

Objectives: The aim of this study was to assess the applicability of six OARSI (Osteoarthritis Research Society International) approved exercise and education programmes for the conservative management of knee osteoarthritis to the Swiss health care system. Methods: The RE-AIM framework was used in this cross-sectional survey study to analyse the characteristics of the six exercise and education programmes. A survey was developed based on the RE-AIM dimensions, "Reach, Effectiveness, Adoption, Implementation, and Maintenance," for rating the applicability of the programmes (on a scale of 1 = "least applicable" to 10 = "most applicable"). Programme scores of ≥7 indicated applicability to the Swiss health care system. Nine selected physiotherapy experts for knee OA management in Switzerland were invited for the rating. Results: The six programmes were rated by six of the nine invited research experts with mean scores of between 5.9 and 9.45. Four programmes scored 7 or more. These four programmes all included supervised exercise sessions and education with the goal that the participants understand the diagnosis and the management of OA. The two lower rated programmes focused on exercise counselling or weight reduction. Conclusion: The programme with the highest scores consists of exercise and education and scored higher than 7 in all RE-AIM dimensions. Therefore, this programme is most applicable to the Swiss health care system as only a few adaptations would be needed for its successful implementation.

The Inverse OARSI-OMERACT Criteria Is a Valid Indicator of the Clinical Worsening of Knee Osteoarthritis: Data From the Osteoarthritis Initiative

OBJECTIVE

We assessed if the inverse Osteoarthritis Research Society International (OARSI) and Outcome Measures in Rheumatology (OMERACT) criteria relate to concurrent radiographic knee osteoarthritis (KOA) progression and decline in walking speed, as well as future knee replacement.

METHODS

We conducted knee-based analyses of data from the Osteoarthritis Initiative. All knees had symptomatic OA: at least doubtful radiographic KOA (Kellgren-Lawrence grade ≥ 1) and knee pain ≥ 10/100 (Western Ontario and McMaster Universities Osteoarthritis Index pain) at the 12-month visit. The inverse of the OARSI-OMERACT responder criteria depended on knee pain and function, and global assessment of knee impact. We used generalized linear mixed models to assess the relationship of the inverse OARSI-OMERACT criteria over 2 years (i.e., 12-month and 36-month visits) with worsening radiographic severity (any increase in Kellgren-Lawrence grade from 12 months to 36 months) and decline in self-selected 20-m walking speed of ≥ 0.1m/s (from 12 months to 36 months). We used a Cox model to assess time to knee replacement during the 6 years after the 36-month visit as an outcome.

RESULTS

Among the 1746 analyzed, 19% met the inverse OARSI-OMERACT criteria. Meeting the inverse OARSI-OMERACT criteria was associated with almost double the odds of experiencing concurrent worsening in radiographic KOA severity (OR 1.89, 95% CI 1.32-2.70) or decline in walking speed (OR 1.82, 95% CI 1.37-2.40). A knee meeting the inverse OARSI-OMERACT criteria was more likely to receive a knee replacement after the 36-month visit (23%) compared with a nonresponder (10%; HR 2.54, 95% CI 1.89-3.41).

CONCLUSION

The inverse OARSI-OMERACT criteria for worsening among people with KOA had good construct validity in relation to clinically relevant outcomes.

Stakeholder engagement in methodological research: Development of a clinical decision support tool

Introduction

Shared patient-clinician decision-making is central to choosing between medical treatments. Decision support tools can have an important role to play in these decisions. We developed a decision support tool for deciding between nonsurgical treatment and surgical total knee replacement for patients with severe knee osteoarthritis. The tool aims to provide likely outcomes of alternative treatments based on predictive models using patient-specific characteristics. To make those models relevant to patients with knee osteoarthritis and their clinicians, we involved patients, family members, patient advocates, clinicians, and researchers as stakeholders in creating the models.

Methods

Stakeholders were recruited through local arthritis research, advocacy, and clinical organizations. After being provided with brief methodological education sessions, stakeholder views were solicited through quarterly patient or clinician stakeholder panel meetings and incorporated into all aspects of the project.

Results

Participating in each aspect of the research from determining the outcomes of interest to providing input on the design of the user interface displaying outcome predications, 86% (12/14) of stakeholders remained engaged throughout the project. Stakeholder engagement ensured that the prediction models that form the basis of the Knee Osteoarthritis Mathematical Equipoise Tool and its user interface were relevant for patient-clinician shared decision-making.

Conclusions

Methodological research has the opportunity to benefit from stakeholder engagement by ensuring that the perspectives of those most impacted by the results are involved in study design and conduct. While additional planning and investments in maintaining stakeholder knowledge and trust may be needed, they are offset by the valuable insights gained.

Low back pain and radiographic severity as predictors in hip osteoarthritis patients receiving steroid injection therapy

INTRODUCTION

We investigated the effects of lower back pain (LBP) on measures of pain, disability, and function in highly symptomatic hip OA patients receiving intra-articular steroid injection (IASI) therapy. We also investigated the effect of radiographic severity of hip OA for comparison to LBP.

METHODS

97 consenting subjects with symptomatic hip OA presenting for IASI were evaluated at baseline, assessed over an 8-week period, and followed at least 1 year later for new arthroplasty. At baseline and 8 weeks follow-up patient demographics, presence/absence of back pain, physical function tests, a single anteroposterior pelvis x-ray, and subjective scores of pain, stiffness and function (VAS and WOMAC) were collected. We also followed which subjects proceeded to obtain total hip arthroplasty in the examined hip.

RESULTS

Cohorts with LBP reported significantly worse scores for all of VAS pain and WOMAC questionnaires but showed no difference in ROM and were not more likely to proceed to arthroplasty. Cohorts with severe radiographic OA had significantly worsened scores for stiffness (χ² = 6.74, p = 0.009), decreased ROM (p < 0.01), and were more likely to proceed to arthroplasty (χ² = 9.79, p = 0.044).

DISCUSSION

Back pain has a substantial effect on clinical parameters relevant to assessment of severity of hip OA, especially self-reported pain and function. This finding highlights LBP as a significant confounding factor in hip OA patient assessments and will inform future studies to determine the most effective treatment strategies for hip OA patients.

Depression negatively affects patient-reported knee functional outcome after intraarticular hyaluronic acid injection among geriatric patients with knee osteoarthritis

PURPOSE

Intraarticular hyaluronic acid injection (IAHA) is a popular treatment for knee osteoarthritis (OA). This study investigates whether depression, anxiety, and pain affect self-reported knee function in geriatric OA people who have received IAHA.

METHODS

Through convenience sampling, 102 geriatric patients (mean age = 70.91 ± 7.19; 28 males) with knee OA who had undergone IAHA participated in this study. All participants self-reported depression using the Geriatric Depression Scale (GDS), anxiety using the State-Trait Anxiety Inventory (STAI), knee function using the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the International Knee Documentation Committee subjective knee evaluation form (IKDC), and pain severity using the Visual Analogue Scale (VAS). They completed the aforementioned questionnaires at baseline before injection and then again at 2-, 4-, and 6-month follow-ups.

RESULTS

Depression was significantly associated with IKDC, WOMAC physical function subscale, and total WOMAC scores. Anxiety was only significantly associated with the WOMAC pain subscale score. Pain severity was significantly associated with IKDC, WOMAC stiffness subscale, WOMAC physical function subscale, and total WOMAC scores.

CONCLUSION

Given that depression negatively affected patient-reported knee function among geriatric OA patients who had undergone IAHA, further attention should be paid to the depressive status of this population.

The use of patient-specific equipoise to support shared decision-making for clinical care and enrollment into clinical trials

Background:

To enhance enrollment into randomized clinical trials (RCTs), we proposed electronic health record-based clinical decision support for patient–clinician shared decision-making about care and RCT enrollment, based on “mathematical equipoise.”

Objectives:

As an example, we created the Knee Osteoarthritis Mathematical Equipoise Tool (KOMET) to determine the presence of patient-specific equipoise between treatments for the choice between total knee replacement (TKR) and nonsurgical treatment of advanced knee osteoarthritis.

Methods:

With input from patients and clinicians about important pain and physical function treatment outcomes, we created a database from non-RCT sources of knee osteoarthritis outcomes. We then developed multivariable linear regression models that predict 1-year individual-patient knee pain and physical function outcomes for TKR and for nonsurgical treatment. These predictions allowed detecting mathematical equipoise between these two options for patients eligible for TKR. Decision support software was developed to graphically illustrate, for a given patient, the degree of overlap of pain and functional outcomes between the treatments and was pilot tested for usability, responsiveness, and as support for shared decision-making.

Results:

The KOMET predictive regression model for knee pain had four patient-specific variables, and an r² value of 0.32, and the model for physical functioning included six patient-specific variables, and an r² of 0.34. These models were incorporated into prototype KOMET decision support software and pilot tested in clinics, and were generally well received.

Conclusions:

Use of predictive models and mathematical equipoise may help discern patient-specific equipoise to support shared decision-making for selecting between alternative treatments and considering enrollment into an RCT.

Can effusion-synovitis measured on ultrasound or MRI predict response to intra-articular steroid injection in hip osteoarthritis?

OBJECTIVES

Intra-articular steroid injection (IASI) is an effective therapy for hip osteoarthritis (OA), but carries risks and provides significant pain relief to only two thirds of patients. We attempted to predict response to IASI in hip OA patients using baseline clinical, ultrasound, and MRI data.

METHODS

Observational study of 97 subjects with symptomatic hip OA presenting for IASI. At baseline and 8 weeks we obtained hip MRI, grayscale and Doppler ultrasound, clinical range of motion (ROM), timed-up and go test (TUG) scores, and self-reported Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain, stiffness, and function scores. Bone-capsule distance (BCD) measurements of inflammation on hip ultrasound and MRI were measured at three locations: the proximal-most uncovered portion of the femoral head, the superficial-most (apex) portion of the femoral head, and the largest fluid pocket at the femoral neck.

RESULTS

Ultrasound and MRI BCD correlated with each other significantly and strongly at the apex and neck. Power Doppler findings did not correlate significantly with any other imaging indices. Eight weeks post-injection, WOMAC pain, function, and stiffness scores significantly improved and TUG time improved nearly to the level of significance, but there were no significant changes in ultrasound, MRI, or Doppler indices. Baseline variables were not significantly different between responder and nonresponder WOMAC pain or TUG time cohorts.

CONCLUSION

Basic measures of inflammation on ultrasound and MRI are highly related to each other, but provide little insight into patient function and pain after IASI. Other mechanisms to explain improvement in patient status after IASI are likely at work.

Outcomes and Factors Influencing Response to an Individualized Multidisciplinary Chronic Disease Management Program for Hip and Knee Osteoarthritis

BACKGROUND

The objective of the study was to investigate the effectiveness of, and factors associated with, response to a chronic disease management program for patients with hip and knee osteoarthritis (OA).

METHODS

Over a 2-year period (2012-2014), 218 patients (97 hip OA; 121 knee OA) were managed with an individualized program of interventions that could include education, physiotherapy, orthotics, occupational therapy, or dietitian referral. Changes in Oxford Hip Score or Oxford Knee Score and Short Form-12 (SF-12) Physical and Mental Component Summary Score (PCS, MCS) were analyzed by joint affected, both unadjusted, and gender and age adjusted. A further analysis also adjusted for body mass index.

RESULTS

At mean 12-month follow-up, patients with knee OA had a statistically significant improvement in Oxford Knee Score and PCS, while patients with hip OA had a statistically significant deterioration in all 3 scores. There was evidence that these changes differed between joints for Oxford and PCS scores. Older age was associated with worse outcomes for Oxford scores. Higher body mass index was associated with worse outcomes for Oxford and PCS scores. Patients with hip OA (35%) were more likely to deteriorate to a clinically significant extent (5 points) for Oxford scores than those with knee OA. Gender was not associated with outcomes. Patients with hip OA (54%) were more likely than those with knee OA (24%) to have subsequently had surgery (P < .001).

CONCLUSIONS

Patients with knee OA were more likely to improve with a chronic disease management plan than patients with hip OA and efforts should be directed to them.

Challenges and controversies of complex interventions in osteoarthritis management: recognizing inappropriate and discordant care

A number of controversies and challenges exist for the management of OA in health care. This paper describes the challenges and gaps in OA care, particularly in relation to population health management, complex interventions and outcomes. It sets this in the context of competing health priorities and multimorbidity, access to high quality conservative care, non-pharmacological therapies, resource limitations and models of care. The overuse of some therapies and neglect of others are discussed, as well as the potential for self-management. The roles of patient and public involvement and the healthcare team are highlighted in enhancing best care for OA and providing solutions for closing the evidence-to-practice gap. Implementation of models of care offer one solution to the challenges and progress of such implementation is described. Areas for further research are highlighted.

Osteoarthritis: Models for appropriate care across the disease continuum

Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Despite the existence of evidence-based treatments and guidelines, substantial gaps remain in the quality of OA management. There is underutilization of behavioral and rehabilitative strategies to prevent and treat OA as well as a lack of processes to tailor treatment selection according to patient characteristics and preferences. There are emerging efforts in multiple countries to implement models of OA care, particularly focused on improving nonsurgical management. Although these programs vary in content and setting, key lessons learned include the importance of support from all stakeholders, consistent program delivery and tools, a coherent team to run the program, and a defined plan for outcome assessment. Efforts are still needed to develop, deliver, and evaluate models of care across the spectrum of OA, from prevention through end-stage disease, in order to improve care for this highly prevalent global condition.