Rheumatologists sidelined in OA management; still plenty of low value care

Management of osteoarthritis in primary care has changed slightly over time to be more consistent with guidelines but there’s still scope for improvement, an Australian study suggests.

Data from the BEACH study, comparing GP management of Australians with hip and knee OA over an 11-year period, showed some improvement in the use of non-pharmacological approaches.

The research, published in The Lancet Regional Health – Western Pacific, comprised data from 6,565 GPs and 9,196 patient encounters for hip and knee OA.

It found overall the rates at which knee and hip OA were managed by GPs significantly increased in 2010-2016 compared to 2005-2010.

However OA encounters in some vulnerable subgroups of patients – Indigenous Australians, people from non-English speaking backgrounds, people residing outside major cities, and those with the most socio-economic disadvantage – remained stable over time.

“Nationally, GPs managed knee OA at approximately 940,000 encounters per year in period two, and hip OA at 340,000 encounters, an increase of 38% for both problems.”

“These findings are consistent with national joint replacement registry data showing a 130% and 82% rise respectively in rates of primary total knee and hip replacements from 2003 to 2015,” the study said.

The study showed use of Medicare chronic disease management items rose in the second period but remained low.

“Referral rates to other health practitioners increased, driven by more referrals to allied health professionals, particularly physiotherapists for knee OA.”

Referral rates to medical specialists – mostly orthopaedic surgeons, rarely rheumatologists – did not change over time and were more than double those to allied health professionals.

“Our study shows small changes in GP management of OA, particularly knee OA, that were somewhat in the direction of these guideline recommendations.”

“For example, positive changes included increased use of Medicare chronic disease management items, referrals to allied health professionals (predominantly physiotherapists), advice/education and lifestyle management.”

“Despite this, use of imaging did not change and it is notable that around half of all new knee and hip OA problems were still referred for imaging. X-ray was the predominant imaging modality accounting for 88% and 86% of modalities for knee and hip OA, respectively.”

MRI use rose 5-fold for knee OA and 10-fold for hip OA in the second period but remained at a low 4% of imaging modalities for knee OA and 2-3% for hip OA.

“This increase aligns with findings using Medicare Benefits Scheme claims data in Australians aged over 55 years,” the study said.

“Thus GP education should emphasise that imaging in OA should be reserved for cases where a differential diagnosis needs to be excluded or if joint replacement surgery is being considered.”

The study also noted that use of NSAIDs and glucosamine for both knee and hip OA had declined while paracetamol for knee OA and opioids for both knee and hip OA had increased.

Lead author Professor Kim Bennell, from the department of physiotherapy at the University of Melbourne, told the limbic the findings showed some but not enough improvements in OA management despite the advent of guidelines.

“Hardly anyone was referred for exercise or to a dietician … very low referrals to the professionals who are supposed to be delivering the core recommended treatment for OA and many more to orthopaedic surgeons,” she said.

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