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Arthritis Patients Are Too Often Directed Toward Surgery Rather Than Weight Loss And Exercise

January 17, 2011

New research found clinicians who care for patients with osteoarthritis (OA) are likely not following standard care guidelines that are based on current medical evidence. Researchers noted physicians were prescribing medications for pain and inflammation or opting for surgical interventions rather than recommending weight loss plans or exercise programs to OA patients. The study is available in the January 2011 issue of Arthritis Care & Research, a journal published by Wiley-Blackwell on behalf of the American College of Rheumatology.

A 2002 report by the World Health Organization estimated OA to be the fourth leading cause of years lost due to disease worldwide. OA disability is quickly becoming a major public health concern with experts suggesting that by 2020 the number of people with OA will have doubled due to growing obesity prevalence and the aging of the baby boomer generation. According to the Centers for Disease Control and Prevention, arthritis and other rheumatic conditions cost the US $128 billion in 2003—a 24% increase since 1997. Much of the cost burden in arthritis care can be attributed to OA, which accounts for a large volume of surgical procedures including total joint replacements.

Dr. David Hunter from the University of Sydney in Australia and New England Baptist Hospital in Boston and colleagues reviewed how standard clinical practice diverges from evidence-based recommendations in the management of OA. "We present a potential roadmap for optimizing the quality of OA healthcare for those developing and enforcing policy decisions, and for clinicians on the frontlines of OA management to enact practice change," said Dr. Hunter. Treatment OA patients are likely to get does not reflect recommendations based on medical evidence. The authors report that therapeutic interventions are primarily aimed at reducing pain and improving joint function by using therapies that target symptoms, but do not help improve either the joint structure or long-term betterment of the disease. Frequently, physicians do not recommend conservative non-drug management therapies, and this leads to unnecessary diagnostic imaging testing and inappropriate referrals to orthopedic surgeons.

Many people with OA are overweight or obese. The authors support medical evidence that recommends conservative non-drug management for OA patients. "Weight management and exercise programs tend to be overlooked by clinicians," said Dr. Hunter. "These conservative approaches are beneficial to patients who adhere to weight-loss and exercise programs." Researchers further suggest that surgery be resisted when symptoms can be well managed by other treatment methods. The typical indications for a surgical approach in treating OA are debilitating pain and major limitation of functions such as walking, working or sleeping. However, prior studies have shown that up to 30% of some surgical procedures are inappropriate and recent recommendations suggest routine arthroscopy for knee OA management should be avoided.

The study team also noted an overuse of inappropriate diagnostic imaging instead of making a diagnosis based on patient history and physical examination. Based on current guidelines, imaging should be reserved for instances where a diagnosis is unclear and radiography could rule out other diseases that may produce similar symptoms. Research studies estimate there are 95 million high-tech scans, like CT, MRI and PET tests, done annually in the US—representing a $100 billion industry, of which $14 billion has been shouldered by Medicare—and 20% to 50% of these scans were unnecessary as the results failed to help treat or diagnose the patient's symptoms. "Eliminating unproven procedures and reducing needless costs is necessary to improve the quality and lower the cost of healthcare in the US," concluded Dr. Hunter. "The management of OA should focus on a patient-centered and provider integrated approach that improves quality and reduces cost by following evidence-based recommendations."