How to Make Sure Your Patient with Osteoarthritis Gets the Best Care
Although total joint arthroplasty (TJA) is a highly effective treatment for individuals with moderate to severe osteoarthritis who have not responded to medical therapy, disparities in TJA utilization based on gender, race/ethnicity, and socioeconomic status are well documented. These disparities may be due in part to patient-level factors such as perceptions of, and willingness to consider, TJA. Another possible explanation is that subtle or overt biases may inappropriately influence physicians’ treatment recommendations regarding this procedure. Because of the potential for an increased quality of life among TJA recipients, disparity in rates of use of TJA among individuals with an identified need represents inadequate care. In this article, we make recommendations about how to make sure your patient gets the best care.
Key words: quality of care, osteoarthritis, joint arthroplasty, disparities.
Introduction
Osteoarthritis (OA) is the most common type of arthritis1 and a leading cause of chronic musculoskeletal pain and disability in older adults.2 Osteoarthritis affects as many as 30% of people over age 65, with the number of people with arthritis disability expected to double by 2020, largely due to the obesity epidemic and the greying of the baby boomer generation.3 The large weight-bearing joints (hips and knees) are those most commonly associated with OA pain and disability. Osteoarthritis ranks second as the reason for visiting a primary care physician, with pain being the main symptom that causes patients to seek care.3 Pain is also the primary reason for undergoing total joint arthroplasty (TJA).4
Despite the increased utilization of TJA,5 there is compelling evidence that some patients receive inadequate OA care based on patient characteristics such as gender, race/ethnicity, and socioeconomic status (SES). Research suggests that TJA is underused among women, Blacks, and Hispanics, and individuals with a low income, relative to men, Whites, and those with higher income, respectively,6–11 despite the fact that these former groups have a greater prevalence of disabling OA. Disparities in TJA rates are a matter of concern because differences in the use of this highly effective treatment may adversely affect the health of vulnerable population subgroups.12 Health care disparities refer to population-specific differences in health care utilization and, hence, quality of care. The aim of this article is to review the evidence of disparities in the quality of OA care and to recommend strategies to address these disparities within your own clinical practice.
Quality Osteoarthritis Care
Treatment of hip and knee OA is focused on pain relief and preserving or improving physical function.13,14 Current treatment guidelines recommend that optimal care of individuals with OA should combine nonpharmacological interventions (e.g., patient education, exercise, weight loss, assistive devices, and physiotherapy) with pharmacological interventions (e.g., the use of acetaminophen, non-steroidal anti-inflammatory drugs [NSAIDs], or intra-articular cortico-steroids).15–17 Medical management of OA is mostly symptomatic since none of these conservative therapies, with the possible exception of weight loss, can reverse or halt the progression of joint cartilage destruction and underlying bone changes. Currently, many barriers to optimal treatment exist, including safety concerns and side effects associated with pharmacological interventions as well as societal and patient beliefs that OA is a “natural and inevitable part of aging”18,19 and that pain medications are “addictive.”20 Additionally, there is general underuse of effective nonpharmacological interventions, such as physical therapy and self-management strategies.21