A new decision tree for diagnosis of osteoarthritis in primary care: international consensus of experts.

BACKGROUND AND AIMS: Although osteoarthritis (OA) is managed mainly in primary care, general practitioners (GPs) are not always trained in its diagnosis, which leads to diagnostic delays, unnecessary resource utilization, and suboptimal patient outcomes. METHODS: To address this situation, an International Rheumatologic Board (IRB) of 8 experts from 3 continents developed guidelines for the diagnosis of OA in primary care. The focus was three major topologies: hip, knee, and hand/finger OA. The IRB used American College of Rheumatology diagnostic criteria. RESULTS: Care pathways based on clinical and radiological findings were developed to identify intervention thresholds for GPs/specialists. To optimize usefulness in the primary care setting, the guidelines were formatted as an uncomplicated, but comprehensive one-page decision tree for each topology, highlighting key aspects of the evaluation process and incorporating red flags. In a two-phase validation stage, the draft guidelines were evaluated by rheumatologists and GPs for project execution, content and perceived benefit. The strength of the guidelines lies in their user-friendly diagram and potential for broad application. Such guidelines will allow GPs to make an easy but definite diagnosis of OA and offer clear guidance about situations requiring an expert opinion. The guidelines have potential to improve patient outcomes and reduce the number of unnecessary procedures. DISCUSSION AND CONCLUSIONS: This project demonstrated the feasibility of developing easy-to-use and effective visual decision trees to facilitate the diagnosis and management of OA of the hip, knee and hand/finger in primary care. The next step should be to conduct a large impact study of implementation of these recommendations in the diagnostic management of OA in general practice in different areas.

A consensus statement on the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-From evidence-based medicine to the real-life setting.

The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) published a treatment algorithm for the management of knee osteoarthritis (OA) in 2014, which provides practical guidance for the prioritization of interventions. Further analysis of real-world data for OA provides additional evidence in support of pharmacological interventions, in terms of management of OA pain and function, avoidance of adverse events, disease-modifying effects and long-term outcomes, e.g., delay of total joint replacement surgery, and pharmacoeconomic factors such as reduction in healthcare resource utilization. This article provides an updated assessment of the literature for selected interventions in OA, focusing on real-life data, with the aim of providing easy-to-follow advice on how to establish a treatment flow in patients with knee OA in primary care clinical practice, in support of the clinicians' individualized assessment of the patient. In step 1, background maintenance therapy with symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) is recommended, for which high-quality evidence is provided only for the prescription formulations of patented crystalline glucosamine sulfate and chondroitin sulfate. Paracetamol may be added for rescue analgesia only, due to limited efficacy and increasing safety signals. Topical non-steroidal anti-inflammatory drugs (NSAIDs) may provide additional symptomatic treatment with the same degree of efficacy as oral NSAIDs without the systemic safety concerns. Oral NSAIDs maintain a central role in step 2 advanced management of persistent symptoms. However, oral NSAIDs are highly heterogeneous in terms of gastrointestinal and cardiovascular safety profile, and patient stratification with careful treatment selection is advocated to maximize the risk:benefit ratio. Intra-articular hyaluronic acid as a next step provides sustained clinical benefit with effects lasting up to 6 months after a short-course of weekly injections. As a last step before surgery, the slow titration of sustained-release tramadol, a weak opioid, affords sustained analgesia with improved tolerability.

Assessment and determinants of aesthetic discomfort in hand osteoarthritis.

BACKGROUND: Dissatisfaction with hand appearance is frequently the presenting complaint of patients with hand osteoarthritis (HOA), yet no tool exists for its measurement and few studies have examined aesthetic discomfort. OBJECTIVES: The aims of this study were to measure the extent and to explore the associations of aesthetic concerns in HOA. METHODS: 172 patients with HOA were assessed with tender joint and node count, global and pain scores, Functional Index for Hand Osteoarthritis, Short Form-12, Hospital Anxiety and Depression Scale and posterior-anterior hand radiographs. Patients scored the aesthetic impact of the disease on a Visual Analogue Scale of 0-100 mm and were classified into low, intermediate and high aesthetic concern (HAC) based on this score. RESULTS: Of 172 patients (155 women), the majority (92%) had nodes and 46% had erosive disease. The mean aesthetic score was 44.8 mm (SD 35.9), and 59 (34.3%) patients scored their aesthetic discomfort ≥ 66 mm. Factors associated with HAC were female gender, a high number of tender joints and nodes, high global and pain scores, high radiological damage scores, the presence of erosions and high depression and anxiety levels. The multivariate analysis identified two independent factors associated with HAC: patient's global assessment (p=0.0005) and radiographic erosions (p=0.03). CONCLUSIONS: Aesthetic discomfort is a major concern for a significant number of patients with HOA, particularly women, those with a high burden of HOA disease and those with erosive osteoarthritis, and is also associated with depression, anxiety and poor health-related quality of life.

Reproducibility and sensitivity to change of four scoring methods for the radiological assessment of osteoarthritis of the hand.

BACKGROUND: Osteoarthritis (OA) of the hand could be a relevant model to study the progression of OA in structure-modification trials. Various methods are proposed to assess hand OA and its progression radiologically. OBJECTIVE: To compare intra-reader and inter-reader precision and sensitivity to change of four radiological scoring methods proposed in hand OA. METHODS: 2 trained readers scored separately 105 pairs of radiographs (baseline; year 1), selected from patients enrolled in a randomised controlled trial, for inter-reader reliability and sensitivity to change. They scored twice 60 pairs among the 105 for cross-sectional and longitudinal intra-reader reliability. Radiological hand OA assessment used: global, Kellgren-Lawrence (KL), Kallman and Verbruggen scoring methods. Inter- and intra-reader reliabilities were studied using intraclass coefficient (ICC) and the Bland-Altman method. Sensitivity to change was compared by calculating the standardised response means. RESULTS: Transversal intra-reader reproducibility ICCs ranged from 0.922 to 0.999. Verbruggen ranked the highest, followed by the KL and Kallman methods. Inter-rater reliability was higher for the Verbruggen scores, followed by the KL, global and Kallman scores (ICC 0.706-0.999). Longitudinal intra-reader reliability (baseline; year 1) was better using the Kallman and KL (ICC 0.986 and 0.990), followed by the Verbruggen (0.941) or global methods (0.939). Standardised response means ranged from 0.24 (KL) to 0.29 (Kallman). CONCLUSION: All four methods compared well with respect to reliabilities. However, the Verbruggen and Kallman methods performed better. The method most sensitive to change was the Kallman method, followed by Verbruggen and global scores. This study also suggests that structural changes could be detected in hand OA over a 1-year period.