Osteoarthritis In General Practice Research Articles

Patterns of knee osteoarthritis management in general practice: a retrospective cohort study using electronic health records

ObjectiveThis study determined patterns of knee osteoarthritis (OA) management by general practitioners (GPs) using routine healthcare data from Dutch general practices from 2011 to 2019.DesignA retrospective cohort study was conducted using the Integrated Primary Care Information database between 2011 and 2019. Electronic health records (EHRs) of n = 750 randomly selected knee OA patients (with either codified or narrative diagnosis) were reviewed against eligibility criteria and n = 503 patients were included. Recorded information was extracted on GPs’ management from six months before to three years after diagnosis and patterns of management were analysed.ResultsAn X-ray referral was the most widely recorded management modality (63.2%). The next most widely recorded management modalities were a referral to secondary care (56.1%) and medication prescription or advice (48.3%). Records of recommendation of/referral to other primary care practitioners (e.g. physiotherapists) were found in only one third of the patients. Advice to lose weight was least common (1.2%). Records of medication prescriptions or recommendation of/referral to other primary care practitioners were found more frequently in patients with an X-ray referral compared to patients without, while records of secondary care referrals were found less frequently. Records of an X-ray referral were often found in narratively diagnosed knee OA patients before GPs recorded a code for knee OA in their EHR.ConclusionThese findings emphasize the importance of better implementing non-surgical management of knee OA in general practice and on initiatives for reducing the overuse of X-rays for diagnosing knee OA in general practice.

Real-world data: how is paracetamol prescribed in low back pain and osteoarthritis in general practice in France?

Common low back pain (LBP) and osteoarthritis (OA) can significantly impact patients’ quality of life and thus require an adequate pain management. In France, paracetamol remains the first-line analgesic according to the national recommendations, but it is challenged by the international guidelines. Prescription patterns in 27 559 patients presenting with OA- or LBP- and receiving paracetamol during the GP visit were retrieved from the IQVIA French database. Paracetamol was prescribed first line and alone in 57% of LBP and 78% of OA patients and remains the pivotal analgesic in both indications in France.

Patient-Reported Quality of Care for Osteoarthritis in General Practice in South Tyrol, Italy: Protocol for Translation, Validation and Assessment of the OsteoArthritis Quality Indicator Questionnaire (OA-QI)

Evidence-based recommendations for the treatment of knee and hip osteoarthritis are similar internationally. Nevertheless, clinical practice varies across countries. Instruments for measuring quality have been developed to improve health care through targeted interventions. Studies on health service quality must consider the structural and cultural characteristics of countries, because each of their strengths and weaknesses differ. However, such instruments for health-related patient-reported outcomes for osteoarthritis have not yet been validated in German and Italian languages. In order to be able to set targeted measures for the improvement of prevention and non-surgical treatment of osteoarthritis in South Tyrol, Italy, the quality of care must be recorded. Therefore, the aim of the project is to update, translate, and validate the OsteoArthritis Quality Indicator (OA-QI) questionnaire version 2, an established and validated questionnaire in Norwegian and English, for Germany and Italy. The second aim is to determine the quality of care for osteoarthritis of the hip and knee in a sample of patients who consult general practice in South Tyrol, and for comparison with patients who are admitted to rehabilitative spa-treatments for osteoarthritis in the state of Salzburg, Austria. The results of this study will enable the identification and closure of gaps in osteoarthritis care. Although it is expected that body weight and exercise will play special roles, other areas of nonsurgical care might also be involved.

Trends in management of hip and knee osteoarthritis in general practice in Australia over an 11-year window: a nationwide cross-sectional survey

BackgroundWe aimed to describe trends in knee and hip OA management by general medical practitioners (GPs) in Australia. MethodsWe analysed cross-sectional survey data from the Bettering the Evaluation and Care of Health (BEACH) program (1,000 randomly-selected GPs annually recording 100 consecutive patient encounters) over two periods: Period one April 1, 2005-March 31, 2010 and period two April 1, 2010-March 31, 2016. This included data from 10,738 GPs and 1,073,800 patient encounters with 6,565 GPs and 9,196 patient encounters for hip/knee OA. Data were summarized using descriptive statistics and 95% confidence intervals around point estimates. FindingsRate of knee OA problems managed by GPs increased in period two (7•1 (6•9-7•4) vs 6•2 (95% CI 6•0-6•5) per 1,000 all encounters), with a similar trend for hip OA. Encounter rates rose for some subgroups but remained stable for vulnerable subgroups. Although use of Medicare chronic disease management items, referral to allied health professionals and advice/education and lifestyle management (knee OA) increased, rates remained low. Use of MRI imaging rose. Overall medication rates were stable but substantially higher than non-pharmacological treatments. Declining reliance on non-steroidal anti-inflammatory drugs and glucosamine and increased reliance on paracetamol (knee OA) and opioids were demonstrated. InterpretationGPs in Australia are more frequently managing knee and hip OA. While small changes in GP management actions occured, rates of recommended first-line non-pharmacological treatments remained low and imaging, medications, and surgical referral rates high. Strategies are needed to optimise lifestyle management and reduce low-value care, with attention to healthcare disparities. FundingFunding was provided for this report by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Translational Research in Musculoskeletal Pain (#1079078).

Association between received treatment elements and satisfaction with care for patients with knee osteoarthritis seen in general practice in Denmark

Objective While education, exercise, and weight reduction when indicated, are recommended first-line treatments for knee osteoarthritis patients, they remain poorly implemented in favour of pain killer treatment, imaging and referral to surgery. A reason could be that patients are more satisfied with receiving these adjunctive treatment elements. This study aimed to investigate the associations between the received elements of care and the patient’s satisfaction with the care for knee osteoarthritis in general practice. Design Cross-sectional study. Setting A Danish general practice. Subjects All consecutive patients ≥30 years of age who consulted the general practitioner (GP) with chronic knee complaints during 18 months and who replied to a mailed questionnaire (n = 136). Main outcome measures The questionnaire addressed patient’s knee-related quality of life, and overall satisfaction with care, as well as reception of seven types of information, which are known quality indicators. Information on reception of adjunctive treatment elements was obtained from electronic medical records. Results Patient satisfaction (versus neutrality/dissatisfaction) was positively associated with reception of information on: physical activity and exercise (relative risks [RR] 1.38, 95% bootstrap percentile interval [BPI] 1.02–4.33), and the relationship between weight and osteoarthritis (1.38, 1.01–4.41). No significant associations were found for the five remaining types of information and all the adjunctive treatment elements. Conclusion Providing information as education to patients with knee osteoarthritis as part of the treatment is positively associated with satisfaction with care. KEY POINTS General practitioners worry about the doctor–patient relationship when addressing recommended lifestyle changes. However, this study revealed: •Patients in general practice with knee osteoarthritis are satisfied with care after having received information on lifestyle changes, such as exercise and the relationship between weight and osteoarthritis. •Patient satisfaction was not associated with the reception of adjunctive treatment elements for osteoarthritis.

Could it be osteoarthritis? How dog owners and veterinary surgeons describe identifying canine osteoarthritis in a general practice setting

Canine osteoarthritis is a common, painful condition that is typically managed in a general practice setting. Osteoarthritis may have significant negative impacts on the welfare of both dogs and their owners. Anticipated early clinical signs of canine osteoarthritis and the preferred route to its diagnosis are well described by veterinary subject experts in published literature. However, little is known about changes owners first recognise in a dog ultimately diagnosed with osteoarthritis, how they make decisions about when to present that dog to a general practitioner, or whether the described diagnostic pathways are followed by general practitioners. The aim of this research was to investigate how dog owners and veterinary surgeons describe identifying and diagnosing canine osteoarthritis.Owners of osteoarthritic dogs were recruited for semi-structured interview, and veterinary surgeons working in general practice were invited to take part in practice-based focus groups. Transcripts from both datasets were thematically analysed using a contextualist epistemology with an ontology based on critical realism to construct convergent themes from latent and semantic codes. Thirty-two interviews were completed with 40 owners from 32 households who discussed 35 dogs with osteoarthritis, and 26 veterinary surgeons engaged in four practice-based focus groups.Owners described identifying a wide range of acute and chronic, typically subtle and intermittent, behavioural and demeanour changes prior to their dogs’ osteoarthritis diagnosis. Few attributed these changes to canine osteoarthritis, and some waited many months before presenting their dog to a veterinary practice. Veterinary surgeons described a consistent ‘typical osteoarthritis’ presentation that they recognised through history taking and clinical examination. Their diagnostic work-up rarely followed that advocated by subject experts for reasons including lack of time and perceptions that it would not change the outcome. Many veterinary surgeons described frustration that some owners did not accept their recommendations to provide analgesia for affected dogs. Short consultation lengths, poor awareness of owner knowledge levels, and lack of recognition of the importance of owners’ prior knowledge, beliefs and assumptions may contribute to these consultations being perceived as challenging by some veterinary surgeons and owners.This research demonstrates that veterinary surgeons and owners want dogs with clinical signs of osteoarthritis to be happy and comfortable, but that ineffective communication and lack of trust in the consulting room may be a barrier. Our data identifies many new avenues for future research and improved communication strategies that could facilitate earlier identification and treatment of canine osteoarthritis in general practice.

Epidemiology of knee osteoarthritis in general practice: a registry-based study

ObjectivesThe present study investigated (1) trends in the prevalence and incidence of knee osteoarthritis over a 20-year period (1996–2015); (2) trends in multimorbidity and (3) trends in drug prescriptions.DesignRegistry-based study.SettingPrimary...

Management of hip and knee osteoarthritis in general practice: a systematic review

Purpose: Osteoarthritis (OA) management by general practitioners (GPs) is aimed at improving quality of life, self-management and preventing further progression of the disease. Understanding GP reported clinical practice is key when trying to improve adherence to the well-established management guidelines. The aim of this study was to summarise GP reported management of hip and knee OA, including pharmacological and non-pharmacological management, referrals, diagnostic tools and assessment patterns. Methods: Databases (Embase, MEDLINE, CINHAL and Cochrane Central Register for Controlled Trial) were searched using the keywords “general practice”, “treatment” and “osteoarthritis” from inception to June 2018. Published studies that comprised GP reported management for people with hip and knee OA were identified. Risk of bias was assessed based on predetermined measures of informativeness and internal validity. Results: Out of a total of 13,930 records identified through the databases search, 14 original articles were included in this review, all of which used a prospective cross-sectional design. Results were collected from ∼19,446 GPs; response rates ranged from 17% to 90%. Of the included studies, seven studies reported respondents’ male percentage (mean (SD) 72% (18)), six reported respondents’ practice location (urban 60% (18) versus rural 40% (14)) and five reported respondents’ time since graduation (20 years (8)). Overall, studies scored high in most internal validity measures including reproducibility of results and standardising GP management definitions across cohorts. However, eight of the included studies did not adjust analyses for confounding factors such as patients and GPs’ characteristics. Informativeness rated low as seven included studies lacked data on respondents’ baseline characteristics. Pharmacological management: Twelve of the 14 studies included data on GP reported management with non-steroidal anti-inflammatory drugs (NSAIDs) with prescription rates ranging from 15% to 84%. NSAID prescription rates differed by stages of disease severity (stage 1: 43%, stage 2 and 3 >70%) and before and after treatment (19% before, 9.3% after). Paracetamol prescription rates ranged from 7% to 91%, as reported in 10 out of the 14 studies. One Australian study showed that for every 100 patients treated for hip and knee OA, 23 were prescribed paracetamol. Prescription of NSAIDs combined with paracetamol was reported in one study, while prescription of NSAIDs combined with analgesics was reported in three out of the 14 included studies. The rates ranged from 1.4% to 42.8%. Non-pharmacological management: GP reported non-pharmacological management of OA using exercise prescription and/or weight reduction advice was reported in 10 of the 14 studies. The percentages of GPs recommending general exercise ranged from 15% to 87%. Four of the 10 studies which included data on exercise prescription showed that types of recommended exercise included walking, swimming, cycling and hydrotherapy. Weight reduction advice rates ranged from 32% to 68%, as reported in nine of the 14 studies. Five of the 14 included studies reported on management using intra-articular steroid injections and rates were low ranging from 4% to 25%. There was a low percentage of GPs recommending the use of walking sticks in early-stage OA (25% as reported in two studies) and this percentage increased to 45% in the case of acute exacerbation. Referrals: Referral rates to allied health professionals (physiotherapists, exercise physiologists and/or nutritionists) ranged from 0.1% to 62.7%, as reported in seven of the 14 included studies. Referral to orthopaedic surgeons ranged from 7% to 75%, as reported in three studies. GPs also referred to other health care practitioners (6% to 18%), secondary care (13%), rheumatologists (5%) and clinical specialists (46%). Diagnostic tools and assessment patterns Five of the 14 studies reported data on GPs’ use of diagnostic tools when assessing patients with knee or hip OA. Across these studies, 35% to 85% of GPs reported requesting plain radiography (X-ray). One study reported that 28% of GPs would request additional imaging even if patients had previously undergone radiography within the past six months. Two studies reported that >50% of GPs request blood tests to investigate erythrocyte sedimentation rate and blood count. Conclusions: Pharmacological management largely concentrated on NSAIDs and paracetamol, with similar prescription rates for both. Non-pharmacological management using exercise and/or weight reduction and referral to allied health professionals varies widely but appears to be underutilised. Diagnostic imaging use appears high, given OA can be diagnosed clinically, suggesting that GPs over investigate the diagnosis. More work needs to be done to support GPs’ implementation of evidence-based management of hip and knee OA.

A new decision tree for diagnosis of osteoarthritis in primary care: international consensus of experts

Background and aimsAlthough osteoarthritis (OA) is managed mainly in primary care, general practitioners (GPs) are not always trained in its diagnosis, which leads to diagnostic delays, unnecessary resource utilization, and suboptimal patient outcomes.MethodsTo address this situation, an International Rheumatologic Board (IRB) of 8 experts from 3 continents developed guidelines for the diagnosis of OA in primary care. The focus was three major topologies: hip, knee, and hand/finger OA. The IRB used American College of Rheumatology diagnostic criteria.ResultsCare pathways based on clinical and radiological findings were developed to identify intervention thresholds for GPs/specialists. To optimize usefulness in the primary care setting, the guidelines were formatted as an uncomplicated, but comprehensive one-page decision tree for each topology, highlighting key aspects of the evaluation process and incorporating red flags. In a two-phase validation stage, the draft guidelines were evaluated by rheumatologists and GPs for project execution, content and perceived benefit. The strength of the guidelines lies in their user-friendly diagram and potential for broad application. Such guidelines will allow GPs to make an easy but definite diagnosis of OA and offer clear guidance about situations requiring an expert opinion. The guidelines have potential to improve patient outcomes and reduce the number of unnecessary procedures.Discussion and conclusionsThis project demonstrated the feasibility of developing easy-to-use and effective visual decision trees to facilitate the diagnosis and management of OA of the hip, knee and hand/finger in primary care. The next step should be to conduct a large impact study of implementation of these recommendations in the diagnostic management of OA in general practice in different areas.

A nurse-led clinic for patients consulting with osteoarthritis in general practice: development and impact of training in a cluster randomised controlled trial

BackgroundDespite a lack of service provision for people with osteoarthritis (OA), each year 1 in 5 of the general population consults a GP about a musculoskeletal condition such as OA. Consequently this may provide an opportunity for practice nurses to take an active role in helping patients manage their condition. A nurse led clinic for supporting patients with OA was developed for the MOSAICS study investigating how to implement the NICE 2014 OA Guideline core recommendations. This paper has two main objectives, firstly to provide an overview of the nurse-led OA clinic, and secondly to describe the development, key learning objectives, content and impact of the training to support its delivery.MethodsA training programme was developed and delivered to provide practice nurses with the knowledge and skill set needed to run the nurse-led OA clinic. The impact of the training programme on knowledge, confidence and OA management was evaluated using case report forms and pre and post training questionnaires.ResultsThe pre-training questionnaire identified a gap between what practice nurses feel they can do and what they should be doing in line with NICE OA guidelines. Evaluation of the training suggests that it enabled practice nurses to feel more knowledgeable and confident in supporting patients to manage their OA and this was reflected in the clinical management patients received in the nurse-led OA clinics.ConclusionsA significant gap between what is recommended and what practice nurses feel they can currently provide in terms of OA management was evident. The development of a nurse training programme goes some way to develop a system in primary care for delivering the core recommendations by NICE.Trial registrationThe cluster trial linked to this training was conducted from May 2012 through February 2014 by the Arthritis Research UK Primary Care Centre, Keele University, UK (Trial registration number ISRCTN06984617).Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0568-y) contains supplementary material, which is available to authorized users.

Patient-reported quality indicators for osteoarthritis: a patient and public generated self-report measure for primary care.

Plain English summaryPeople with osteoarthritis desire high quality care, support and information. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators can be used to benefit patients by measuring whether minimum standards of quality care are being met from a patient perspective.The aim of this study was to describe how a Research User Group (RUG) worked alongside researchers to co-produce a set of self-reported quality indicators for people with osteoarthritis when visiting their general practitioner or practice nurse (primary care). These were required in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE quality standards for OA.This article describes the public involvement in the MOSAICS study. This was 1) the co-development by RUG members and researchers of an Osteoarthritis Quality Indicators United Kingdom (OA QI (UK)) questionnaire for use in primary care, and 2) the comparison of the OA QI (UK) with a similar questionnaire developed in Norway.This study shows how important and effective a research user group can be in working with researchers in developing quality care indicators for osteoarthritis for use in a research study and, potentially, routine use in primary care. The questionnaire is intended to benefit patients by enabling the assessment of the quality of primary care for osteoarthritis from a patient’s perspective. The OA QI (UK) has been used to examine differences in the quality of osteoarthritis care in four European countries. Background People with osteoarthritis (OA) desire high quality care, support and information about OA. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators (QI) can be used to benefit patients by measuring whether minimum standards of quality care (e.g. NICE quality standards) are being met from a patient perspective. A Research User Group (RUG) worked with researchers to co-produce a set of self-report, patient-generated QIs for OA. The QIs were intended for use in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE guidelines. We report on 1) the co-development of the OA QI (UK) questionnaire for primary care; and 2) the comparison of the content of the OA QI (UK) questionnaire with a parallel questionnaire developed in Norway for the Musculoskeletal Pain in Ullensaker (MUST) study. Methods Researchers were invited to OA RUG meetings. Firstly, RUG members were asked to consider factors important to patients consulting their general practitioner (GP) for OA and then each person rated their five most important. RUG members then discussed these in relation to a systematic review of OA QIs in order to form a list of OA QIs from a patient perspective. RUG members suggested wording and response options for a draft OA QI (UK) questionnaire to assess the QIs. Finally RUG members commented on draft and final versions of the questionnaire and how it compared with a translated Norwegian OA-QI questionnaire. Results RUG members (5 males, 5 females; aged 52–80 years) attended up to four meetings. RUG members ranked 20 factors considered most important to patients consulting their GP for joint pain. Following discussion, a list of eleven patient-reported QIs for OA consultations were formed. RUG members then suggested the wording and response options of 16 draft items – four QIs were split into two or more questionnaire items to avoid multiple dimensions of care quality within a single item. On comparison of this to the Norwegian OA-QI questionnaire, RUG members commented that both questionnaires contained seven similar QIs. The RUG members and researchers agreed to adopt the Norwegian OA-QI wording for four of these items. RUG members also recommended adopting an additional seven items from the Norwegian OA-QI with some minor word changes to improve their suitability for patients in the UK. One other item from the draft OA QI (UK) questionnaire was retained and eight items were excluded, resulting in a 15-item final version. Conclusions This study describes the development of patient-reported quality indicators for OA primary care derived by members of a RUG group, working in partnership with the research team throughout the study. The OA QI (UK) supports the NICE quality standards for OA and they have been successfully used to assess the quality of OA consultations in primary care in the MOSAICS study. The OA QI (UK) has the potential for routine use in primary care to assess the quality of OA care provided to patients.Ongoing research using both the UK and Norwegian OA-QI questionnaires is assessing the self-reported quality of OA care in different European populations.Electronic supplementary materialThe online version of this article (doi:10.1186/s40900-016-0019-x) contains supplementary material, which is available to authorized users.

Defining knee pain trajectories in early symptomatic knee osteoarthritis in primary care: 5-year results from a nationwide prospective cohort study (CHECK).

GPs have high consultation rates for symptoms related to knee osteoarthritis (OA). Many risk factors for symptomatic knee OA progression remain unknown. To define distinct knee pain trajectories in individuals with early symptomatic knee OA and determine the risk factors for these pain trajectories. Data were obtained from the multicentre prospective Cohort Hip and Cohort Knee study in the Netherlands. Participants with knee OA, according to the clinical criteria of the American College of Rheumatology, and a completed 5-year follow-up were included. Baseline demographic, anamnestic, and physical examination characteristics were assessed. Outcome was annually assessed by the Numeric Rating Scale for pain. Pain trajectories were retrieved by latent class growth analysis. Multinomial logistic regression was used to calculate relative risk ratios. In total, 705 participants were included. Six distinct pain trajectories were identified with favourable and unfavourable courses. Statistically significant differences were found in baseline characteristics, including body mass index (BMI), symptom severity, and pain coping strategies between the different trajectories. Higher BMI, lower level of education, greater comorbidity, higher activity limitation scores, and joint space tenderness were more often associated with trajectories characterised by more pain at first presentation and pain progression--compared with the reference group with a mild pain trajectory. No association was found for baseline radiographic features. These results can help differentiate those patients who require more specific monitoring in the management of early symptomatic knee OA from those for whom a 'wait-and-see' policy seems justifiable. Radiography provided no additional benefit over clinical diagnosis of early symptomatic knee OA in general practice.

Management of Osteoarthritis in General Practice in Australia

To describe management of osteoarthritis (OA) of the hip (OA-hip) and knee (OA-knee) by Australian general practitioners (GPs). We analyzed data from the Bettering the Evaluation and Care of Health program, from April 1, 2005 to March 31, 2010. Patient and GP characteristics and encounter management data were extracted. Data were classified by the International Classification of Primary Care, version 2, and summarized using descriptive statistics and 95% confidence intervals around point estimates. There were 489,900 GP encounters at which OA was managed (rate of 26.4 per 1,000 encounters). OA-hip was managed at a rate of 2.3 per 1,000 encounters (n = 1,106, 8.6% OA) and OA-knee at a rate of 6.2 per 1,000 (n = 3,058, 23.7% OA). The encounter management rate per 1,000 for OA-hip was higher among non-metropolitan dwellers (2.85 per 1,000 versus 1.97 per 1,000) and lower for non-English-speaking people (1.53 per 1,000 encounters versus 2.39 per 1,000). The rate for OA-knee was higher for non-English-speaking background (8.50 per 1,000 encounters versus 6.24 per 1,000) and lower among indigenous people (3.16 per 1,000 encounters versus 6.46 per 1,000). Referral to an orthopedic surgeon was the most frequently used nonpharmacologic management (OA-knee 17.4 per 100 contacts and OA-hip 17.7 per 100), followed by advice, education, and counselling. As first-line treatment, medication prescription rates (OA-knee 78.7 per 100 contacts and OA-hip 73.2 per 100) were substantially higher than rates of lifestyle management (OA-knee 20.7 per 100 contacts and OA-hip 14.8 per 100). OA-hip and OA-knee encounters and management differ. Nonpharmacologic treatments as first-line management were low compared with pharmacologic management rates, and surgical referral rates were high. However, lack of longitudinal data limits definitive assessment of appropriateness of care.

AB0950 Management of osteoarthritis in general practice in the netherlands

BackgroundRecently, a stepped care strategy presenting the optimal order of conservative treatment options for osteoarthritis (OA) of the hip or knee has been developed.1 It suggests in three steps that...

Osteoarthritis of the hip and/or knee in Dutch general practice and physiotherapy practice

Purpose: To describe demographic characteristics and the treatment process of patients with hip osteoarthritis (OA) or knee OA treated in Dutch general practice (GP) and/or physiotherapy practice. Additionally, to investigate whether there are differences in characteristics between referred and non-referred patients with hip or knee OA in GP and physiotherapy practice. Methods: Data from two, separate national registration networks were used. Patients who visited their general practitioner and/or physiotherapist between 2006 and 2009 on account of hip or knee OA were included. Demographic data concerned prevalence and incidence rates, gender and age. In GP, prescriptions and referrals were analyzed. In physiotherapy practice, the health problem, the number of treatment sessions, the duration of a treatment episode, the applied interventions and the treatment results were investigated. In case of continue data, two sample t-tests were used to compare between patients with hip OA and patients with knee OA, respectively between referred patients and non-referred patients in GP and in physiotherapy practice. Chi square tests were used to compare categorical variables. Results: In total, 7477 patients were included. Prevalence rates for hip/knee OA comprised 10.4 / 1000 patients in GP and 18.4 / 1000 patients in physiotherapy practice. Both in GP and physiotherapy practice, the OA population included more females than males and more patients with knee OA than hip OA. Forty-five percent of the patients in GP received a medicine, mostly a NSAID. Prescriptions were significantly more common in patients with knee OA than in patients with hip OA. About 5% of the hip/knee population was referred to a physiotherapist. Referred patients were more often treated pharmacologically than non-referred patients. In physiotherapy practice, patients with hip OA were faced significantly longer with complaints than patients with knee OA. There were no significant differences in treatment characteristics between referred patients (68%) and patients who seek help from a physiotherapist on their own initiative (32%). Patients with hip or knee OA in GP who are referred to a physiotherapist were significantly older and more often females in comparison to patients with hip or knee OA in physiotherapy practice who are referred by their GP. Conclusion: In GP, patients with knee OA are more often treated pharmacologically than patients with hip OA. The same applies to patients who are referred for physiotherapy compared to non-referred patients. General practitioners should reconsider the frequent use of NSAID's, because guidelines recommend the use of analgesics as first medicine of choice. In physiotherapy practice, the duration of complaints differs between patients with hip OA and patients with knee OA. There are no differences referred and non-referred patients. At this moment, patient- and treatment characteristics of patients with hip or knee OA are extracted from two separate registration networks. Patient characteristics differed significantly between referred patients in GP and referred patients in physiotherapy practice. Therefore, to enable longitudinal observation of care in patients with hip or knee OA, it is desirable to create a multidisciplinary registration network in which patient oriented data from different care providers is clustered. (aut. ref.)

Effectiveness of diclofenac versus acetaminophen in primary care patients with knee osteoarthritis: [NTR1485], DIPA-Trial: design of a randomized clinical trial

BackgroundOsteoarthritis is the most frequent chronic joint disease which causes pain and disability of especially hip and knee. According to international guidelines and the Dutch general practitioners guidelines for non-traumatic knee symptoms, acetaminophen should be the pain medication of first choice for osteoarthritis. However, of all prescribed pain medication in general practice, 90% consists of non-steroidal anti-inflammatory drugs compared to 10% of acetaminophen. Because general practitioners may lack evidence showing a similar efficacy of acetaminophen and non-steroidal anti-inflammatory drugs, we present the design of a randomized open-label trial to investigate the efficacy of a non-steroidal anti-inflammatory drug (diclofenac) compared with acetaminophen in new consulters with knee osteoarthritis in general practice.Methods/DesignPatients aged 45 years or older consulting their general practitioner with non-traumatic knee pain, meeting the clinical American College of Rheumatology criteria, and with a pain severity score of 2 or higher (on a 0-10 scale), will be randomly allocated to either diclofenac (maximum daily dose of 150 mg) or acetaminophen (maximum daily dose of 3000 mg) for 2 weeks and, if required, an additional 1-2 weeks, with a total follow-up period of 12 weeks. The primary outcomes are knee pain measured with a daily diary, and pain and function measured with the Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline, and at 3, 6, 9, and 12-weeks follow-up. Secondary outcomes are patients' perceived recovery, quality of life, medical, patient, and productivity costs, compliance to therapy, co-interventions, and adverse reactions.DiscussionThe successful completion of this trial would lead to a better understanding of which medication should be used in the treatment of primary care patients with mild knee osteoarthritis.Trial registrationDutch trial registry NTR1485.

WITHDRAWN: Non-aspirin, non-steroidal anti-inflammatory drugs for treating osteoarthritis of the knee.

Reason for withdrawal from publication Review has been withdrawn until an update can be undertaken to reflect the current evidence. To view the published versions of this article, please click the 'Other versions' tab.

The prevalence and history of knee osteoarthritis in general practice: a case-control study

There is no clear published estimate of the prevalence of diagnosed knee osteoarthritis based on consultation in primary care. Further, little is known about the clinical history of patients who are subsequently diagnosed with knee osteoarthritis. Our aims were (i) to determine the prevalence of knee osteoarthritis diagnosed in primary care; (ii) to compare the medical history of patients currently diagnosed with knee osteoarthritis with that of controls; and (iii) to determine factors associated with X-ray at the time of first diagnosis. A case-control study was carried out in one general practice in North Staffordshire. Cases aged > or =45 years were identified from computer searches for knee osteoarthritis between 1 January 1998 and 31 January 2000. Matched controls had no diagnosis of knee osteoarthritis during that same period. The medical records for both groups were examined to identify recorded knee-related symptoms, X-rays and secondary care referrals. A total of 146 cases and controls were reviewed; 49% of cases and 15% of controls had a previous (pre-1998) diagnosis of knee osteoarthritis. This gives an estimated prevalence of diagnosed knee osteoarthritis in the general population aged > or =45 years of 12.5%. Cases were more likely to have had a prior history of knee-related disorders, X-rays and referral to secondary care than controls. There was no association between an X-ray at first diagnosis and previous knee symptoms (odds ratio 0.98; 95% confidence interval 0.49-1.97) and only weak associations of X-ray with gender (male), age (under 60) of patient and time of diagnosis (pre-1998). Diagnosed knee osteoarthritis is common in general practice and diagnosed patients often have a long history of knee symptoms prior to diagnosis. Further research might usefully consider what influences GPs' diagnosis of knee osteoarthritis and how diagnosis relates to management and outcome.

Managing osteoarthritis in general practice: a long-term approach.

Managing osteoarthritis in general practice: a long-term approach.

Non-aspirin, non-steroidal anti-inflammatory drugs for osteoarthritis of the knee.

To determine whether there is a difference in the relative efficacy of individual non-steroidal anti-inflammatory drugs (NSAIDs) when used in the management of osteoarthritis (OA) of the knee. We searched Medline (1966-1995) and Bids Embase (Jan-Dec, 1980-1995). The searches were limited to publications in the English language, and were last perfomed in November 1996. We used modified Cochrane Collaboration search strategy to identify all randomised controlled trials. The MeSH heading osteoarthritis was combined with the generic names of the 17 non-aspirin NSAIDs licensed in the UK for the management of OA in general practice. The search of Embase used the term "osteoarthritis" if present in the abstract, title or keywords, and was combined with the generic names of the 17 non-aspirin NSAIDs, only if they were mentioned in the title, abstract or keywords. All double blind, randomised controlled trials, in the English language, comparing the efficacy of two non-aspirin NSAIDs in the management of osteoarthritis of the knee, were selected. Only trials with subjects aged 16 years and over, with clinical and/or radiological confirmation of the diagnosis of OA knee were included. Studies which compared one "trial" NSAID with one "reference" NSAID were included provided they were non-aspirin NSAIDs available in the UK and were licensed for the treatment of OA by general practitioners. Trials which were placebo-controlled and which also involved the comparison of two NSAIDs were also included. The methodological design of each study was scored according to a pre-determined system. The three main outcome measures of pain, physical function and patient global assessment were chosen based on the core set agreed upon by OMERACT (Outcome Measures in Rheumatology Clinical Trials). These were used to determine the power of each trial. The equivalency of NSAID doses was calculated using the percentage of the recommended maximum daily dose. Sample size estimates for the detection of clinically relevant changes in outcome measures used in the assessment of OA knee were used for power calculations. These calculations were performed to determine whether the trials were of a sufficient size to detect clinically relevant differences which were statistically significant. The calculations incorporate estimates of standard deviation, and minimum, median and maximum differences (delta) between drugs which are deemed to be clinically important. The number of "withdrawals due to lack of efficacy" was also selected as an outcome measure for this review. The Peto odds ratio and 95% confidence intervals were calculated where possible. The results of studies which compared the same trial and reference NSAIDs were combined where possible. Of the 1151 trials identified by the search strategy, 22 involved knee osteoarthritis only. Sixteen of these trials fulfilled the inclusion criteria and were entered in the review. Eight NSAIDs were represented in these trials. Etodolac was represented in 11 trials. The reference NSAID in these trials was piroxicam (n=3), naproxen(n=3), diclofenac (n=3), indomethacin (n=1), and, nabumetone (n=1). The reported methodological design of the trials was poor, with a median score of 3 (out of a maximum of 8). The results of the trials comparing the same trial and reference NSAIDs were pooled for the outcome "withdrawal due to lack of efficacy". For the comparison, etodolac vesus piroxicam, the odds ratio favoured etodolac i.e. patients receiving etodolac were less likely to withdraw due to lack of efficacy. The dose of etodolac used in each of these three studies, however, was greater than the corresponding dose of piroxicam (based on percentage maximum daily dose). The significance of these results is therefore questionable. For the comparisons etodolac versus diclofenac, and etodolac versus naproxen, there were no clear differences betw