Quality of knee osteoarthritis care in the Netherlands: a survey on the perspective of people with osteoarthritis

Background

Quality indicators (QIs) are used to monitor quality of care and adherence to osteoarthritis (OA) standards of care. Patient reported QIs can identify the most important gaps in quality of care and the most vulnerable patient groups. The aim of this study was to capture the perspective of people with knee OA (KOA) in the Netherlands on the quality of care received, and explore determinants related to lower achievement rates.

Methods

We sent an online survey to all members of The Dutch Knee Panel (n = 622) of the Sint Maartenskliniek Nijmegen, the Netherlands between September and October 2019. The survey consisted of a slightly adapted version of the “OsteoArthritis Quality Indicator” (OA-QI) questionnaire (18 items; yes, no, N/A); a rating of quality of KOA care on a 10-point scale; a question on whether or not one wanted to see change in the care for KOA; and an open-ended question asking recommendations for improvement of OA care. Furthermore, sociodemographic and disease related characteristics were collected. Pass rates for separate QIs and pass rates on patient level were calculated by dividing the number of times the indicator was achieved by the number of eligible persons for that particular indicator.

Results

A total of 434 participants (70%) completed the survey. The mean (SD) pass rate (those answering “Yes”) for separate QIs was 49% (20%); ranging from 15% for receiving referral for weight reduction to 75% for patient education on how to manage knee OA. The mean (SD) pass rate on patient level was 52% (23%). Presence of OA in other joints, comorbidities, and having a knee replacement were associated with higher pass rates. On average, a score of 6.5 (1.6) was given for the quality of care received, and the majority of respondents (59%) wanted change in the care for KOA. Of 231 recommendations made, most often mentioned were the need for tailoring of care (14%), more education (13%), and more empathy and support from healthcare providers (12%).

Conclusion

This study found patients are only moderately satisfied with the OA care received, and showed substantial gaps between perceived quality of care for OA and internationally accepted standards. Future research should focus on the underlying reasons and provide strategies to bridge these gaps.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08014-1.

Responsiveness of four patient-reported outcome measures to assess physical function in patients with knee osteoarthritis

OBJECTIVES

The aim of this study was to evaluate the responsiveness of four patient-reported outcome measures (PROMs) to measure change in physical function simultaneously in patients with knee osteoarthritis (OA) following currently recommended COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) standards.

METHOD

Patients with knee OA receiving conservative treatment following a stepped care approach were invited to complete a set of questionnaires at baseline and 3 months. Questionnaires included four widely used measures of physical function: the Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), the Lequesne algofunctional index (LAI), the Lower Extremity Functional Scale (LEFS), and the Western Ontario and McMaster University Osteoarthritis Index Physical Function subscale (WOMAC-PF). Responsiveness of physical function was investigated according to the COSMIN standards by testing 15 a priori defined hypotheses. Responsiveness was considered positive if > 75% of the hypotheses could be confirmed.

RESULTS

A total of 161 patients participated [61% female, mean (sd) age 59 (9) years and body mass index 29.7 (5.0) kg/m²]. Baseline values of the four PROMs were, mean (sd): KOOS-PS 53.6 (16.8), LAI 11.0 (4.0), LEFS 40.6 (14.1), and WOMAC-PF 51.8 (19.4). We could confirm 12 out of 15 predefined hypotheses (80%) about expected correlations for the WOMAC-PF whereas for the KOOS-PS, LAI, and LEFS < 75% hypotheses could be confirmed (73, 67, and 73%. respectively).

CONCLUSIONS

Our results suggest that the WOMAC-PF is able to detect changes over time in physical function and therefore should be the measure of first choice in clinical trials evaluating the effectiveness of an intervention on physical function in knee OA patients.

The relationship between impairments in joint function and disabilities in independent function in children with systemic juvenile idiopathic arthritis

OBJECTIVE

Knowledge about the impact of joint impairment on functional ability is needed in planning care and setting treatment goals in children with juvenile idiopathic arthritis (JIA). We investigated the relationship between joint impairments and upper and lower limb function.

METHODS

Twenty-one children with systemic JIA with an average age of 9.2 years and a mean disease duration of 4.8 years participated in this study. Joint impairments were assessed by the following variables: joint counts on swollen (JCS) and tender (JCT) joints and the loss of joint motion as determined by the Joint Alignment and Motion scale (JAM). Functional performance and functional ability were determined by the Juvenile Arthritis Functional Assessment Scale (JAFAS) and Childhood Health Assessment Questionnaire (CHAQ), respectively. The relationship between impairments and functional disabilities was studied at the level of (1) the complete instruments, (2) upper and lower limb function separately, and (3) the individual joints and items.

RESULTS

Regarding complete instruments, the Spearman rank correlation between functional disabilities and loss of joint motion was moderate to good (JAM/CHAQ rs = 0.66, JAM/JAFAS rs = 0.77). A fair correlation was found between functional disabilities and the joint count on swollen joints (JCS/CHAQ rs = 0.45, JCS/JAFAS rs = 0.52), but no significant relationship was found with the number of tender joints (JCT/CHAQ rs = 0.02, p > 0.05, and JCT/JAFAS rs = 0.14, p > 0.05). At the extremity level (upper and lower limb function), the relationship between functional disabilities and the loss of joint motion appeared to be stronger in the leg than in the arm. At the level of the individual joints and questionnaire items, loss of joint motion in hip or shoulder joint appeared to be the most important factor in predicting limitation in leg or arm function.

CONCLUSION

Our study shows that with respect to joint impairments, loss of joint motion is the strongest indicator of functional disability in children with systemic JIA. Loss of joint motion has a greater effect on lower limb function.

Effect of intensive exercise on patients with active rheumatoid arthritis: a randomised clinical trial

OBJECTIVE

To investigate the effects of a dynamic, intensive exercise regimen on pain, disease activity, and physical functioning in active rheumatoid arthritis (RA).

METHODS

64 patients with RA with a mean age of 60 (13) years and mean disease duration of 8 (8) years, admitted to hospital because of active disease, were randomly assigned to an intensive exercise programme or to a conservative exercise programme during their period in hospital with a mean length of 30 (14) days. The intensive exercise programme consisted of knee and shoulder dynamic and isometric muscle strengthening exercises against resistance five times a week and conditioning bicycle training three times a week and was supplemental to the conservative exercise programme of range of motion and isometric exercises. Indices of disease activity, pain, muscle strength, and functional ability were assessed at 0, 3, 6, 12, and 24 weeks by a blinded observer.

RESULTS

The medical treatment during the study was the same in both groups. Both groups improved in measures of disease activity, differences between groups were not statistically significant. The mean improvement in disease activity score at 24 weeks in the intensive and conservative exercise group was -1.4 (1. 5) and -0.7 (1.4), respectively. Measures of physical functioning improved significantly for patients in the intensive exercise group, and differences between groups were statistically significant for measures of muscle strength.

CONCLUSION

A short term intensive exercise programme in active RA is more effective in improving muscle strength than a conservative exercise programme and does not have deleterious effects on disease activity.

Clinical reliability and validity of elbow functional assessment in rheumatoid arthritis

OBJECTIVES

(1) To investigate the measurement characteristics of the Hospital for Special Surgery (HSS) and Mayo Clinic elbow assessment instruments, utilizing methodological criteria including feasibility, reliability, validity, and discriminative ability; and (2) to develop an efficient and disease-specific rating system for elbow function assessment (EFA) in adult patients with RA, using a combination of self-reported subjective items and objective measures, and comparing its characteristics with the HSS and Mayo Clinic scales.

METHODS

(1) Selection of elbow-specific items. (2) Investigation of reliability and validity of all separate items, as well as the total HSS and Mayo Clinic scores, in 42 patients with RA (mean age 60 yrs). Direct observation of functional elbow performance was defined as the gold standard against which criterion validity was compared. (3) Reaching agreement within a team of professionals on the different scale dimensions and the assigned weight. (4) Item reduction by eliminating unreliable, inaccurate, unfeasible, and ambiguous items. Finally, the EFA scale was constructed by selecting the most reliable and accurate items.

RESULTS

The EFA scale showed a superior or equal degree of reliability as reflected in intraclass correlation coefficients of more than 0.88, and also superior validity, compared with the HSS and Mayo Clinic measures.

CONCLUSION

Although the elbow scoring systems currently available provide a reliable measure, they seem restricted in evaluating elbow-specific functional ability. The EFA scale was found to be most suitable to measure elbow functional ability in RA, and was also shown to be highly reliable and practical in clinical practice.

The limited value of the Health Assessment Questionnaire as an outcome measure in short term exercise trials

OBJECTIVE

To examine the value of the Health Assessment Questionnaire (HAQ) as an outcome measure in short term exercise trials. We studied the association of the objectives of exercise, namely joint mobility, muscle strength, and physical condition, with the HAQ.

METHODS

Data for 100 patients with rheumatoid arthritis (RA) included in a study to examine the effect of exercise therapy were used for secondary analysis. Disease activity was determined by the disease activity score (DAS3), pain was scored on a visual analog scale (VAS), and depression was measured by the Dutch Arthritis Impact Measurement Scale. Aerobic capacity (VO2max) estimated from a submaximal ergometer test, grip strength (kPa), isokinetic muscle strength of the knee (Nm/kg), and the Escola Paulista de Medicina range of motion (EPM-ROM) score, a measure of general flexibility, were used as indicators for physical impairments. All variables were entered in a forward multiple regression analysis with the HAQ as dependent variable.

RESULTS

The HAQ was significantly correlated with the DAS3 score (r = 0.53), pain (r = 0.51), depression (r = 0.40), joint mobility (r = 0.27), quadriceps strength (r = -0.35), and grip strength (r = -0.50), but not with physical condition. The DAS3 score was first entered in the multiple regression analysis model, followed by pain, quadriceps strength, and grip strength (R2 = 0.45). After 12 weeks of exercise therapy changes in the HAQ were significantly correlated with changes in pain (r = 0.41), in depression (r = 0.33), and in quadriceps strength (r = -0.25), but not with changes in joint mobility or physical condition.

CONCLUSION

Physical impairments are weakly associated with the HAQ. The HAQ is not an appropriate instrument to detect changes in physical impairments due to short term exercise therapy.

Comparison of high and low intensity training in well controlled rheumatoid arthritis. Results of a randomised clinical trial

OBJECTIVE

To investigate the benefit of intensive dynamic exercises in comparison to range of motion (ROM) and isometric exercises in rheumatoid arthritis.

METHODS

100 consecutive rheumatoid arthritis patients on stable medication were randomly assigned to (1) intensive dynamic group exercises which included full weight bearing exercises and conditioning exercises on a stationary bicycle while the heart rate was maintained at 70-85% of the age predicted maximum heart rate, (2) range of motion (ROM) exercises and isometric exercises in a group, (3) individual isometric and ROM exercises, and (4) home instructions for isometric and ROM exercises. Variables of physical condition, muscle strength, joint mobility, daily functioning (HAQ), and disease activity were assessed before and after the 12 week exercise course, and 12 weeks thereafter. An intention to treat analysis was performed.

RESULTS

Increases in aerobic capacity (n = 77), muscle strength, and joint mobility in the high intensity exercise programme were respectively 17%, 17% and 16% and differed significantly from the changes in aerobic capacity, muscle strength, and joint mobility in the other exercise groups. No deterioration of disease activity was observed. Twelve weeks after discontinuation of the exercise course the gain in physical capacity had disappeared.

CONCLUSIONS

Intensive dynamic training is more effective in increasing aerobic capacity, joint mobility, and muscle strength than ROM exercises and isometric training in rheumatoid arthritis patients with well controlled disease.

Discordance between objective and subjective assessment of functional ability of patients with rheumatoid arthritis

The objectives were to investigate whether there is a discordance between observed and reported functional ability in patients with rheumatoid arthritis (RA) as measured by the Health Assessment Questionnaire (HAQ) and, if so, which demographic, clinical and psychological factors contribute to that discordance. Fifty-one consecutive RA patients of the out-patient clinic were included. Self-reported functional ability was compared with the observed performance of tasks as described by the HAQ. The amount of discordance was computed by subtracting reported scores from observed scores. A positive sign stands for overestimation of functional ability by the patient. The average amount of discordance was low, 0.09 (S.D. 0.39), but showed a large range: -0.88 to 1.00. Multiple regression analysis showed that male patients overestimate their functional ability by 0.21 HAQ units compared with female patients. RA patients overestimate their functional ability with increasing disease duration and severity, while RA patients in the early stage of the disease tend to underestimate their functional ability.

Evaluation of joint mobility in rheumatoid arthritis trials: the value of the EPM-range of motion scale

OBJECTIVE

Evaluation of joint range of motion (ROM) is important in the therapeutic approach to patients with rheumatoid arthritis (RA). The reliability, construct validity and sensitivity to change of the Escola Paulista de Medicina (EPM)--range of motion scale that measures 10 distinct movements of small and large joints were examined.

METHODS

Fifty patients with active RA who were participating in an inpatient multidisciplinary treatment program were examined by 2 investigators. Twenty-five of the patients were examined both at admission and at discharge from the hospital.

RESULTS

The mean EPM-ROM score at study entry was 11.52 (SD +/- 3.80). The intra and inter-observer reliability of the EPM-ROM scale was high, with correlations of r = 0.91 and r = 0.85, respectively. There was a good correlation between the EPM-ROM scale and measures of functional ability. Correlations with measures of disease activity were poor. After a mean duration of the treatment program of 4.2 weeks, patients generally improved in variables of functional status and disease activity. The improvement of the EPM-ROM score (mean difference 1.58, 95% CI 0.84-2.32) was generally larger than improvement in other variables of functional status.

CONCLUSION

The EPM-ROM scale is a reliable instrument, and according to its correlation with measures of functional status, relevant to the performance of activities of daily living. It showed a good response to improvement of functional status and disease activity and was more sensitive to changes than other variables of functional status.