Personalizing non-surgical care in patients with osteoarthritis of the hip or knee

Abstract

Osteoarthritis (OA) of the hip and/or knee is a heterogeneous, musculoskeletal disorder. To improve the functioning of a rising number of patients, there is a strong demand for efficient and effective treatment. Due to its’ heterogeneity and the expected increasing burden of disease, OA would be particularly suitable for personalized treatment. In this thesis, two drivers which potentially contribute to personalized treatment were on interest: ‘timing of care’ and ‘focus of care’. Timing of care concerns the phasing of interventions over time. To facilitate the use of non-surgical interventions prior to a referral to secondary care, a Stepped-Care-Strategy (SCS) has been developed by Smink et al. (2011). Based on routinely registered data in NIVEL Primary Care Database, it could be concluded that Dutch GPs already phase their interventions over time. Room for improvement concerns the use of all interventions that are recommended within one step. The setting in which OA care is provided is closely related to the timing of care. As little was known regarding factors supporting the choice to stay in primary care, to refer for treatment in secondary care or to conduct total joint replacement surgery, we performed logistic multilevel analyses on data gathered in a cohort of 313 patients with hip/knee OA treated by 70 GPs in 38 general practices. These analyses showed that associated factors mainly concern the patient level, particularly the content of previously utilized care. This result could have been expected based on the SCS. Focus of care has been operationalized by ‘treatment stratification’ and ‘personalized measurement’. Treatment stratification aims to better account for different subgroups within a population as treatment is adapted to those different subgroups. By a clinical vignette study, hypotheses were tested for five phenotype of knee OA regarding preferred treatment strategies, the referral policy, and the considered number of applied treatment sessions. Statistically significant differences were found regarding the content and the amount of care between phenotypes of knee OA, mainly in accordance with predefined hypotheses. Personalized measurement aims to incorporate patients’ preferences and priorities since commonly used fixed-item tools lack this possibility. We performed a systematic review to indicate the availability of those personalized-measurement tools in patients with musculoskeletal disorders, including hip/knee OA. Overall, the Patient-Specific Functional Scale was the most reported patient-specific measurement tool. At this moment, the psychometric properties of personalized measurement tools are only moderately reported. Therefore, we subsequently evaluated the psychometric qualities of the Dutch McMaster Toronto Arthritis Patient Preference Questionnaire (MACTAR). Based on our results, clinicians could be recommended to use the MACTAR to evaluate patient-specific physical functioning in addition to fixed-item tools. Recapitulating, it could be concluded that aspects of personalized care are already extensively applied in current clinical OA care. GPs, physical therapists, and orthopedic surgeons differentiate their treatment both in timing of care and in focus of care. Future research is necessary to reach the ultimate goals of personalized healthcare: to treat the right patients, at the right time, with the right interventions at the lowest possible price.