T
arget Audience and Goal Statement:
Orthopedists, geriatricians, pain management
specialists/anesthesiologists, primary care physicians, internists,
family medicine physicians
The goal of this study was to compare rates of physicians’
recommendations for physical therapy (PT), lifestyle counseling, and
pain medication prescriptions for osteoarthritis (OA) of the knee, and
to identify patient-, physician-, and practice-level factors associated
with each treatment recommendation.
Questions Addressed:
- What were the rates of physician recommendations for PT, lifestyle
counseling, and pain medication prescriptions for patients with knee OA
over the years 2007-2015?
- How closely did practice coincide with recommendations from professional societies?
- Physical therapy and lifestyle interventions remain underutilized in
the management of knee osteoarthritis (OA), while reliance on drug
treatment, including opioids, continues to rise, according to a
nationwide survey.
- Understand that these trends suggest that knee OA is primarily
managed by controlling symptoms and not by improving physical function,
fitness, and overall well-being; the rise in narcotic prescriptions is
concerning and warrants attention.
Study Synopsis and Perspective:
According to a nationwide survey, PT and lifestyle interventions
remain underutilized in the management of knee OA, while reliance on
drug treatment, including opioids, continues to rise.
The rate of referrals to PT by orthopedic specialists fell from 158
per 1,000 visits in the years 2007-2009 to 86 per 1,000 visits in
2013-2015 (β = -0.012,
P=0.013), and lifestyle counseling was
offered in 184 per 1,000 visits in 2007-2009, but in only 88 per 1,000
in 2013-2015 (β = -0.020,
P=0.018), said Samannaaz S. Khoja, PT, PhD, of the University of Pittsburgh, and colleagues.
At those same time points, rates of prescriptions for nonsteroidal
anti-inflammatory drugs (NSAIDs) during visits to orthopedic specialists
more than doubled, from 132 per 1,000 visits to 278 per 1,000 (β =
0.19,
P=0.017), while prescriptions for narcotics tripled, from 77 per 1,000 visits to 236 per 1,000 (β = 0.021,
P=0.001), they reported in
Arthritis Care & Research.
These trends suggest “that knee OA is primarily managed from a
perspective of symptom control and not from the perspective of improving
physical function, fitness, and overall well-being,” the researchers
wrote.
OA, which is the most common type of arthritis, affects over 30
million American adults. Characterized by the breakdown of cartilage
within joints and changes in the underlying bone, it usually develops
slowly and worsens over time. OA can inhibit proper function and is a
major cause of disability among adults, leaving them less able to
perform daily tasks and work activities, creating a major source of
financial burden.
Evidence-based clinical practice guidelines have been developed by
several professional organizations, which promote nonpharmacological,
nonsurgical approaches such as PT and lifestyle modifications (weight
loss and exercise) as first-line treatment. These approaches can delay
or reduce need for pain medication, knee surgery, and other invasive
procedures such as intra-articular injections.
The prevalence of knee OA in the U.S. has risen dramatically in
recent years, from 9 million in 2005 to 15 million in 2012, and costs
have increased accordingly.
Patients who seek treatment from either orthopedic specialists or
primary care physicians may be treated largely pharmacologically —
despite the realization that pain medications are not likely to affect
disability but only treat symptoms. Little has been known, however,
about actual patterns of physician referral, advice, and prescription
use for these patients.
To study these questions, the research team analyzed data from the
National Ambulatory Medical Care Survey database, which conducts an
annual survey of office-based physicians on patient characteristics,
reasons for visits, diagnoses, therapeutic choices, and practice types
and locations. The data were analyzed in 3-year intervals, from 2007 to
2015.
During that period, the survey included 2,297 visits for knee OA,
which represented approximately 67 million weighted physician visits, or
about 8 million per year. Two-thirds were to orthopedic surgeons, 21%
were to primary care physicians, and the remainder were to other types
of specialists.
The majority of patients were white women, with an average age of 64.
Different patterns of treatment were seen for primary care
physicians. Unlike with orthopedic specialists, referrals for PT in
primary care were low, and did not significantly change from 2007-2009
to 2013-2015 (26 vs 46 per 1,000 visits, β < 0.001,
P=0.988). Lifestyle counseling also did not change significantly, from 243 to 221 per 1,000 visits (β = 0.003,
P=0.837).
However, significant increases were seen for NSAID prescriptions, from 221 per 1,000 visits to 498 per 1,000 (β = 0.039,
P=0.005), along with nonsignificant increases in prescriptions for narcotics, from 233 to 316 per 1,000 visits (β = 0.016,
P=0.243).
The observed increases in use of narcotics for pain relief “seems
counterintuitive, especially because of the increased awareness of the
hazards of chronic narcotic (opioid) use, and because clinical practice
guidelines for knee OA either have uncertain or inconclusive
recommendations for opioid analgesics or recommend using them very
sparingly and in selected cases (e.g., if other treatments failed or
patients cannot undergo replacement surgery),” the researchers wrote.
They noted that orthopedic specialists in rural locations were less
likely to refer for PT or offer lifestyle advice, which may be due to
lack of resources and time pressures. Those practicing in the South were
also more likely than those in the Northeast to rely on medications.
Demographic factors such as patient age and sex did not appear to
influence treatment choices.
One study limitation was its cross-sectional design.
Source Reference: Arthritis Care & Research 2019; DOI: 10.1002/acr.24064
Study Highlights and Explanation of Findings:
In this cross‐sectional analysis examining data from 2007 to 2015
from the National Ambulatory Medical Care Survey, researchers noted that
PT and lifestyle counseling were underutilized for managing patients
with OA of the knee, “with no trends in improvement over time, while
pain medication use has significantly increased” in this patient
population, they wrote.
Although PT and lifestyle interventions for knee OA have been part of
guideline-based care since 1995, the utilization of these
recommendations remains low.
“Physicians seem more focused on helping their patients manage their
pain with medications, which includes both NSAIDs and narcotic
medications,” Khoja told
MedPage Today. “However, it is
important to consider the long-term benefits of lifestyle interventions,
such as weight management, exercise, and PT, for mitigating declines in
physical health and reducing dependence on medications.”
“Management of knee OA through physical therapy or lifestyle
counseling may reduce overall healthcare utilization by minimizing the
continuous need for pain medication and delay the need for knee surgery
and other invasive procedures (e.g., intra-articular injections),” Khoja
and colleagues wrote.
“Future research to develop strategies to overcome barriers to
patient care and to effectively implement guideline-based care for
patients with knee OA is warranted,” they concluded.
Last Updated October 18, 2019
Reviewed by
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco
Primary Source
Arthritis Care & Research
