Outcomes and Factors Influencing Response to an Individualized Multidisciplinary Chronic Disease Management Program for Hip and Knee Osteoarthritis.

BACKGROUND: The objective of the study was to investigate the effectiveness of, and factors associated with, response to a chronic disease management program for patients with hip and knee osteoarthritis (OA). METHODS: Over a 2-year period (2012-2014), 218 patients (97 hip OA; 121 knee OA) were managed with an individualized program of interventions that could include education, physiotherapy, orthotics, occupational therapy, or dietitian referral. Changes in Oxford Hip Score or Oxford Knee Score and Short Form-12 (SF-12) Physical and Mental Component Summary Score (PCS, MCS) were analyzed by joint affected, both unadjusted, and gender and age adjusted. A further analysis also adjusted for body mass index. RESULTS: At mean 12-month follow-up, patients with knee OA had a statistically significant improvement in Oxford Knee Score and PCS, while patients with hip OA had a statistically significant deterioration in all 3 scores. There was evidence that these changes differed between joints for Oxford and PCS scores. Older age was associated with worse outcomes for Oxford scores. Higher body mass index was associated with worse outcomes for Oxford and PCS scores. Patients with hip OA (35%) were more likely to deteriorate to a clinically significant extent (5 points) for Oxford scores than those with knee OA. Gender was not associated with outcomes. Patients with hip OA (54%) were more likely than those with knee OA (24%) to have subsequently had surgery (P < .001). CONCLUSIONS: Patients with knee OA were more likely to improve with a chronic disease management plan than patients with hip OA and efforts should be directed to them.

The Joint Clinic: Managing Excess Demand for Hip and Knee Osteoarthritis Referrals Using a New Physiotherapy-Led Outpatient Service.

BACKGROUND: There are increasing problems with access to both outpatient assessment and joint replacement surgery for patients with hip or knee osteoarthritis. METHODS: Data were collected on all patients seen at the Joint Clinic over a 2-year period with minimum 12-month follow-up. Patients were assessed by a nurse and a physiotherapist, baseline scores and demographic details collected, and an individualized personal care plan developed. Patients could be referred for a first specialist assessment (FSA) if their severity justified surgical assessment. RESULTS: Three hundred fifty-eight patients were seen at Joint Clinic, of whom 150 (44%) had hip and 189 (56%) had knee OA. The mean age was 67.4 years and there were 152 men (45%) and 187 women (55%). The mean baseline Oxford score was 19.8 (standard deviation 8.2). Fifty-four patients were referred directly to FSA (mean Oxford score 13.0, standard deviation 6.7) and 89 after a subsequent review. The scores of patients referred for FSA were significantly worse than those managed in the Joint Clinic (P < .001). Of the 143 referred for FSA, 115 underwent or were awaiting surgery, 18 were recommended surgery but scored below prioritization threshold, and 10 were not recommended surgery. The Oxford scores of the 194 patients managed non-operatively improved from 22.0 to 25.0 (P = .0013). CONCLUSION: This study shows that the Joint Clinic was effective as a triage tool with 93% of those referred for FSA being recommended surgery. This has freed up surgeon time to see only those patients most in need of surgical assessment.

Rationing for Total Hip and Knee Arthroplasty Using the New Zealand Orthopaedic Association Score: Effectiveness and Comparison With Patient-Reported Scores.

BACKGROUND: There is increasing interest in scoring systems to prioritize patients for hip and knee arthroplasty. The purpose of this study was to determine the effectiveness of the New Zealand Orthopaedic Association (NZOA) score and compare it with patient-reported scores of patients listed for hip and knee arthroplasty. METHODS: Over a 1-year period, all patients listed for primary hip and knee arthroplasty were scored by a prioritization nurse. The NZOA score, outcome, preoperative Oxford hip or knee score (OHKS) and reduced Western Ontario McMaster osteoarthritis index (WOMAC) score (RWS) were collected. RESULTS: Overall, 608 patients were listed for hip (319) or knee (289) arthroplasty. The mean scores for knees were all better than hips (P < .001). On initial scoring, 324 patients (53%) were given certainty (mean NZOA, 80.5; OHKS, 10.0; RWS, 35.1), 90 (15%) given clinical over-ride (NZOA, 69.6; OHKS, 12.0; RWS, 33.2), and 194 (32%) returned to general practitioner (NZOA, 64; OHKS, 14.2; RWS, 30.8). Knees (38%) were more likely to be returned than hips (26%; P = .002). Fifty (26%) were re-referred during the study period (mean, 5 months) and given certainty or over-ride. The difference at final outcome between patients with certainty and clinical over-ride was NZOA, 10.3 points; Oxford, 1.6 points; and RWS, 1.4 points. The difference between clinical over-ride and returned to general practitioner was NZOA, 7.2; Oxford, 4.4; RWS, 5.3. CONCLUSION: The NZOA score is an effective tool for rationing for joint arthroplasty. Patients around the threshold score of 70 may not have a clinically important difference compared with those above threshold.