Many osteoarthritis patients can be managed conservatively and avoid total joint replacements – as long as they are kept away from orthopaedic surgeons.
Speaking at the Bone, Muscle & Joint Diseases Congress, Associate Professor Keith Lim said models of care such as the Osteoarthritis Hip and Knee Service (OAHKS) in Victoria were very effective.
Associate Professor Lim, director of rheumatology at Western Health, said about half of 40,000 patients managed at 15 OAHKS sites up to 2012 had not required referral to surgeons.
At the St Vincent’s Hospital site, which was led by a rheumatologist, only about 20% of patients were referred for a surgical consultation.
“The traditional model has been GPs refer patients onto a one to three year wait list where they are sent for surgery or told to come back in 10 years,” he said.
OAHKS patients are triaged by a multidisciplinary team and actively managed with diet, pain medicine rationalisation, education on joint protection, exercise and physical therapy, aspiration and injection, co-morbidities and counselling.
Patients who were referred for surgery when conservative management had failed were typically over 60 years, medically fit and with advanced radiographic changes.
Associate Professor Lim said an analysis of a subgroup of patients had shown referrals for surgery tapered off after three years in OAHKS.
“In the first three years, 20-3% of patients are referred for surgery. As time went on, the numbers requiring surgery decreases.”
He told the Congress that a better understanding of alternative management and a response shift were possible explanations.
“Patients are actively managed and treatment starts straight away. We also ‘treat’ the relatives.”
He said other reasons for the drop-off in surgery could be related to fear and ageing.
“It could be they are too ill – people get old and they have heart attacks and strokes. We don’t know the answer yet.”
Associate Professor Lim said there was an urgent need to rationalise surgery given its high costs and the fact that about 25% of patients did not have satisfactory outcomes.
“The real challenge is in funding these services. They need to move from the tertiary setting into the community.”
“GPs won’t be able to manage osteoarthritis the way we manage it. If they give five sessions in the chronic disease pathway to physiotherapy, how do patients get the other elements such as psychology?”
He said rheumatologists will need to be prepared to help train allied health professionals and GPs to be partners in the management of this large group of patients.