A study finds that many doctors aren’t treating their osteoarthritis, or OA, patients according to standard care guidelines. Rather than first recommending exercise and weight loss, they are jumping straight to prescribing medicines and ordering surgeries.
For the study, published in the January 2011 issue of Arthritis Care & Research, researchers reviewed medical and scientific literature and found that only about 5 to 10 percent of clinicians manage patients in a way that’s consistent with evidence-based guidelines established by groups like the American Academy of Orthopedic Surgeons, American College of Rheumatology and the European League Against Rheumatism.
In general, guidelines from scientific and health care groups advise conservative, non-pharmacologic therapies like weight loss, exercise and activity modification first, says study author David Hunter, MD, PhD, a professor of medicine at University of Sydney in Australia. If these conservative measures don’t work, then it’s recommended that doctors prescribe medicines like anti-inflammatories and pain pills. And if that, too, is unsuccessful, then surgery is recommended.
But Dr. Hunter says in the real world, treatment isn’t happening in that order.
“Typically what happens in clinical practice is pharmacologic intervention and then, when this is insufficient for pain relief, surgical referral with almost complete neglect of important non-pharmacologic treatments,” Dr. Hunter says.
The logical question is ‘why?’ Dr. Hunter says there’s no easy answer, but he doesn’t think it’s a lack of education on the part of clinicians.
“They know what needs to be done, but the processes to make this happen are more complex than writing a prescription for a pain medication,” Dr. Hunter says. “Taking a pill is definitely easier than losing weight through diet and exercise. But the long-term management of this disease is not enhanced by the short-term outlook.”
Dr. Hunter says his analysis also found that clinicians are overusing inappropriate diagnostic imaging. “Osteoarthritis in general can be diagnosed with an appropriate history and examination with no imaging required. If imaging is needed, usually a plain X-ray is sufficient,” Dr. Hunter says. “About 40 percent of patients presenting to clinicians also now get MRIs. Obtaining these images does not change the appropriate management, so why get them?”
“Guidelines are based on population as a whole, not on the individual patient,” says David Pisetsky, MD, a professor of medicine at Duke University in Durham, N.C. and a practicing rheumatologist. “The management of osteoarthritis has a lot of complexity to it. Weight loss and exercise are certainly very valuable. But as everyone knows, weight loss is not easy for patients, especially if they are hurt and can’t exercise. So we encourage people to lose weight, but that is one of the most difficult things to do. We can make the recommendation [but] it doesn’t mean it happens.
“When people come to you in pain, they want relief,” he continues. “They don’t want to wait a year to lose 10 pounds or 20 pounds. They want something today.”
Dr. Pisetsky says it’s also possible that conversations about diet and exercise are happening in doctor’s offices around the country, but aren’t being fully detailed and recorded in the medical charts researchers are studying.
“Getting people to exercise as much as you’d like them to is simply not easy, but we do put a lot of effort into it. It probably isn’t always documented though,” Dr. Pisetsky says.
With respect to radiographs, he says clinicians can diagnose OA through a patient’s history, feeling joints and doing X-rays. But he says sometimes other issues are at play that need to be thoroughly investigated.
“People with OA may have other problems in that knee in addition to OA, like a meniscal tear. So it is not unusual that we will do an MRI if the patient hasn’t responded adequately or has more pain than we might anticipate from an X-ray.”
Dr. Pisetsky says in the end, guidelines on paper just don’t always translate to real-life situations where a patient is standing in front of you in intense pain.
“Guidelines are guidance. They aren’t an absolute way. I think you have to leave it up to the clinician and patient to come up with what’s best for them,” Dr. Pisetsky says. “You have to respond to the patient’s needs. And sometimes it means immediately starting pain therapy and doing other things early. I think it’s very hard.”
Dr. Hunter agrees the issue is complex and says, going forward the medical community needs to set up electronic processes to remind doctors what they should do. He says patient awareness programs are key, too – so individuals are educated about options and can make informed decisions.
“Empowering and educating patients can go a long way to moving toward appropriate management,” Dr. Hunter says.