Osteoarthritis

Care for Adults With Osteoarthritis of the Knee, Hip, or Hand

Resources The Quality Standard In Brief Advisory Committee About

Summary

This quality standard addresses care for adults (18 years of age or older) with osteoarthritis of the knee, hip, or hand. The quality standard focuses on the assessment, diagnosis, and management of this condition for people across all health care settings and health care professionals.

Scope of This Quality Standard

This quality standard includes 10 quality statements addressing areas identified by Health Quality Ontario’s Osteoarthritis Quality Standard Advisory Committee as having high potential for improving the quality of osteoarthritis care in Ontario.

This quality standard addresses care for adults 18 years of age or older who have been diagnosed with or are suspected to have osteoarthritis of the knee, hip, or hand (i.e., thumb or fingers). The quality standard focuses on the assessment, diagnosis, and management of osteoarthritis for people across all health care settings and health care professionals. It provides guidance on nonpharmacological and pharmacological care. It covers referral for consideration of joint surgery but does not address specific surgical procedures. This quality standard does not apply to care for people with osteoarthritis affecting the spine, other peripheral joints (i.e., shoulder, elbow, wrist, foot, ankle), or neck or low back pain. Similarly, this quality standard also excludes those with inflammatory arthritis or medical conditions and treatments that can lead to osteoarthritis.

Terminology Used in This Quality Standard

When we refer to “people with osteoarthritis” in this quality standard, we mean those with knee, hip, or hand osteoarthritis. Only one quality statement (Quality Statement 5: Therapeutic Exercise) applies to people with hip or knee osteoarthritis, not to those with hand osteoarthritis.

The term “symptoms” in this quality standard means any symptom related to osteoarthritis. Typical symptoms include pain, aching, stiffness, swelling, functional limitations, disability, decreased physical activity, anxiety and mood disorders, fatigue, and/or poor sleep quality.

When we refer to “health care professionals” in this quality standard, this means the many types of people who may be part of the health care team. This includes, but is not limited to, the following regulated professionals: primary care providers (family physician or primary care physician, nurse practitioner); chiropractor, dietitian, nurse, occupational therapist, pharmacist, or physiotherapist; focused-practice physician (e.g., pain management, sport and exercise medicine); specialist physician (e.g., orthopaedic surgeon, physiatrist, plastic surgeon, rheumatologist); advanced/extended practice physiotherapist or occupational therapist; psychologist, counsellor, or other health care professional with additional skills in the management of osteoarthritis-related symptoms (e.g., pain, poor sleep quality, anxiety and mood disorders, weight management).

Why This Quality Standard Is Needed

Osteoarthritis, the most common type of arthritis, is a progressive condition that can affect any moveable joint of the body but most commonly the hips, knees, and hands. Studies in various populations show that about 20% to 30% of adults have osteoarthritis in at least one of these joints. The condition starts as a change to the biological processes within a joint, leading to structural changes such as cartilage breakdown, bone reshaping, bony lumps, joint inflammation, and loss of joint function. This often results in pain, stiffness, and loss of movement. Osteoarthritis is characterized by fluctuating symptoms and increased intensity of joint pain over time. Certain factors make some people more vulnerable to developing osteoarthritis: genetic factors, being overweight or obese, injury from accidents or surgery, and heavy physical activity in some sports or at work.

In Canada, the overall prevalence of diagnosed osteoarthritis in primary care is 14% and is expected to increase to about 25% in the next 30 years. The condition is more common in middle to older age (prevalence is 35% in those aged 80 years and older), affects more women than men, and is associated with other chronic health conditions such as depression and high blood pressure. In Ontario, people with osteoarthritis report a quality of life 10% to 25% lower than those without osteoarthritis, and they incur health care costs two to three times higher. The rising rates of osteoarthritis will have a substantial impact on the lives of people living with the condition and their families, on costs to the health care system, and on the broader economy through lost productivity, people leaving the workforce, and long-term disability.

Despite the obvious personal and societal burden of osteoarthritis, it is underdiagnosed and undertreated, resulting in missed opportunities for people to benefit from high-quality care. While there is no cure for osteoarthritis, there are several ways to effectively manage symptoms through nonpharmacological and pharmacological treatments that can help reduce pain, improve function, maintain quality of life, and delay disability. Early intervention is best. Poorly managed hip and knee osteoarthritis leads to avoidance of physical activity and exacerbation of pain. This in turn can lead to fatigue, disability, and depressed mood, and is linked with heart disease, diabetes, and obesity.

Substantial gaps in the quality of osteoarthritis care exist all along the care pathway. Many people delay seeking care: in a Canadian study, about 40% of patients with osteoarthritis had symptoms for more than a year before they were diagnosed, and the average time elapsed was more than 7 years. First-line treatment for osteoarthritis should include nonpharmacological approaches: education, therapeutic exercise, daily physical activity, weight loss (if appropriate), and self-management support. These treatments are underused. A study in British Columbia found that only 25% of patients with hip or knee osteoarthritis received therapeutic exercise or weight management as part of their management plan, and advice to use these approaches differed across the patients’ gender, age, disability, and education. Only 29% received an assessment of their ability to walk (ambulatory function) and only 7% were assessed for nonambulatory functions such as dressing, cooking, and the ability to rise from sitting to standing. A survey of Canadians diagnosed with osteoarthritis shows relatively few are seeking advice from health professionals who can provide effective nonpharmacological management. Only 22% had consulted a physiotherapist or occupational therapist in the previous year, and 12% had attended an educational class to help them manage arthritis-related problems.

These shortfalls in access to needed care could be influenced by a misconception among health care professionals and patients that osteoarthritis symptoms are a normal part of aging with limited treatment options. The cost of services and/or a lack of extended health insurance coverage also play a role. Most community-based services for osteoarthritis (such as physiotherapy, occupational therapy, weight-management programs) are not widely available, at least not without substantial costs to patients that must be borne out-of-pocket or with private insurance.

In contrast, most people with osteoarthritis are prescribed some form of pharmacological treatment. In a 2015 study of primary care in Canada, 57% of patients with osteoarthritis had a prescription for a nonsteroidal anti-inflammatory drug, and about 33% were prescribed an opioid for pain management. This is an underestimate of medication use, given that many people with osteoarthritis use over-the-counter medications, which are not often captured in data from electronic medical records. In another national study, 66% of people with osteoarthritis (any joint) used nonprescription medications. Among those with hip and/or knee osteoarthritis, the figure was 74%.

For a small percentage of people, their condition will deteriorate to the extent that surgical options such as joint replacement, joint fusion, or joint-conserving surgery may be necessary. Surgical treatment should be offered to people with moderate to severe joint damage that causes unacceptable pain or limitation of function despite the use of interventions described in this quality standard.

Principles Underpinning This Quality Standard

This quality standard is underpinned by the principles of respect, equity, and equality.

People with osteoarthritis should receive services that are respectful of their rights and dignity and that promote shared decision-making and self-management. People with osteoarthritis should be provided services that are respectful of their gender, sexual orientation, socioeconomic status, housing, age, background (including self-identified cultural, ethnic, and religious background), and disability. Equitable access to the health system also includes access to culturally safe care. Language, a basic tool for communication, is an essential part of safe care and needs to be considered throughout a person’s health care journey. For example, in predominantly English-speaking settings, services should be actively offered in French and other languages.

People with osteoarthritis should receive care through an integrated approach that facilitates access to interprofessional services from primary care providers, rehabilitation care professionals, referral to surgical and nonsurgical specialists, and programs in the community, according to the patient’s needs over time. Interprofessional collaboration, shared decision-making, coordination of care, and continuity of care (including follow-up care) are hallmarks of this patient-centred approach. Collaborative practice in health care “occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers, and communities to deliver the highest quality of care across settings.”

Health care professionals should be aware of the historical context of the lives of Canada’s Indigenous peoples and be sensitive to the impacts of intergenerational trauma and the physical, mental, emotional, and social harms experienced by Indigenous people, families, and communities.

A high-quality health system is one that provides good access, experience, and outcomes for everyone in Ontario, no matter where they live, what they have, or who they are.

How Success Can Be Measured

The Osteoarthritis Quality Standard Advisory Committee identified a small number of overarching goals for this quality standard. These have been mapped to indicators that may be used to assess quality of care locally.

How Success Can Be Measured Provincially

You may want to assess the quality of care you provide to your patients with osteoarthritis. You may also want to monitor your own quality improvement efforts. It may be possible to do this using your own clinical records, or you might need to collect additional data. We recommend the following list of potential indicators, which cannot be measured provincially using currently available data sources:

Percentage of people with osteoarthritis who report the long-term control of their pain as acceptable
Percentage of people with osteoarthritis who report a high level of success in coping with and self-managing their condition
Percentage of people with osteoarthritis who have timely access to appropriate rehabilitation management strategies (such as education, exercise, and weight management)
Median wait time to first appointment with a health care professional with additional skills in osteoarthritis management (i.e., additional skills in rheumatology, orthopaedic surgery, sport and exercise medicine, or pain management)
Percentage of people with osteoarthritis referred to a health care professional with additional skills in osteoarthritis management (i.e., additional skills in rheumatology, orthopaedic surgery, sport and exercise medicine, or pain management) who have their first appointment in a timely manner

Note:

The target timeframe to see a health care professional with additional skills in osteoarthritis management will vary depending on the type of professional and the clinical characteristics of the patient.

In addition, each quality statement within the standard is accompanied by one or more indicators. These indicators are intended to guide the measurement of quality improvement efforts related to the implementation of the statement. To assess the equitable delivery of care, the quality standard indicators can be stratified by patient or caregiver socioeconomic and demographic characteristics such as income, education, language, age, sex, and gender.

What Does It Mean for Patients and Caregivers?

There are many misconceptions surrounding osteoarthritis and a range of advice to sift through. General education for people with osteoarthritis is lacking, particularly around the importance of exercise to manage disease progression. The quality statements provide a springboard for discussion, helping to structure conversations with health care professionals, and highlight the key role of the primary care physician in providing continuous care.

Ten years ago, I had trouble going up and down the stairs. Initial opinion was that I didn’t have osteoarthritis, despite a family history. I started physiotherapy, which was helpful, but a diagnosis didn’t come until I was able to get an x-ray. Afterwards, there was no discussion about daily exercise, physical fitness, and overall health. My mother had a similar disease trajectory; she was referred for surgery, which she initially did not pursue, and later in life when she was ready for surgery she was turned down for the procedure. The impact on her life was visible; she has reduced mobility and experiences a lot of pain. Her experiences have inspired me to be proactive about my condition.

This quality standard will encourage early identification and will offer more options for individuals at initial stages of their disease, while closing the information gap within the health care system.

- Joan Conrad, Osteoarthritis Quality Standard Advisory Committee, Lived Experience Advisor

What Does It Mean for Providers?

This quality standard is a comprehensive set of agreed-upon principles to improve care for patients with osteoarthritis. It does not overwhelm the provider with what they need to know, but rather allows for the art of medicine—shaping the patient’s health destiny and creating an appropriate path of care.

There are many gaps in knowledge regarding the management of chronic musculoskeletal conditions, specifically the necessary role of mobility, physical activity, and weight management. Osteoarthritis is a pervasive condition that highlights overarching and underlying conditions. Although the morbidity and mortality association with osteoarthritis is not as high as with other conditions, it does affect quality of life and it does make other conditions more difficult to manage. The vast majority of patients are not eligible for surgery, but patients can be empowered to make lifestyle changes and improve their outcomes. The quality standard is a great starting off point to ensure that there is a framework in place for patient and provider education on these key issues pertaining to self-management.

The most important next step is implementation: the how part is key, including identifying available resources that support the care framework outlined in the quality statements.

- Zahra Bardai, Osteoarthritis Quality Standard Advisory Committee, panel member