Physician Recommendation Rates for Managing Knee Osteoarthritis in Ambulatory Care Settings

Based on data from the National Ambulatory Medical Care Survey, a group of investigators compared physician recommendation rates for physical therapy (PT), lifestyle counseling, and pain medication to manage knee osteoarthritis (OA). This report was published in Arthritis Care & Research.

Investigators performed a cross-sectional analysis of data from 2297 visits related to knee OA to orthopedists and primary care providers (PCPs) between 2007 and 2015, calculating triennial rates for PT referrals, lifestyle counseling, nonsteroidal anti-inflammatory drug (NSAID) prescriptions, and narcotics prescriptions. They examined referral patterns in association with patient, physician, and practice-level characteristics.

Overall, adherence to guideline-based care for first-line nonpharmacologic, nonsurgical treatments (eg, PT and lifestyle modifications) was low during the triennial period; however, NSAID and narcotics prescriptions increased between 30% and 50% and approximately 10% and 15%, respectively. According to the investigators, recommendations for managing knee OA should address methods to improve the use of PT and lifestyle counseling and reduce variation in care.

Recommendation Trends by Provider Specialty

Orthopedic Specialists

The triennial rates of physical therapy and lifestyle recommendations (eg, exercise and weight management) by orthopedic specialists declined significantly from 2007 to 2015 (β=-0.012, P =.013 and β=-0.020, P =.018, respectively), whereas NSAID and narcotics prescriptions nearly doubled in the same period (β=0.019, P =.017 and β=0.021, P =.001, respectively).

PCPs

Triennial rates for NSAID prescriptions increased among PCPs from 2007 to 2015 (β=0.039, P =.005), whereas referrals for PT, lifestyle counseling, and narcotics prescriptions did not change significantly in the same period (β<0.001, P =.988; β=0.003, P =.837; and β=0.016, P =.243, respectively).

Recommendation Trends by Patient Characteristics

Compared with men, a greater percentage of women who visited an orthopedic specialist or a PCP were prescribed PT and lifestyle counseling. Compared with white or Hispanic patients, black patients had a higher proportion of visits that resulted in prescriptions for all 4 treatments; however, Hispanic patients were more likely to be prescribed NSAIDs and narcotics without referrals for PT or lifestyle modifications.

For visits to PCPs, women and black patients were more likely to be prescribed narcotics.. Visits covered by workers’ compensation were less likely to involve NSAID prescriptions.

Recommendation Trends by Clinical Characteristics

Although chronic problems were the result of most orthopedic visits involving knee OA, a higher proportion of visits for acute problems resulted in NSAID prescriptions. On the other hand, surgical-related visits for knee OA were more likely to result in PT referrals and narcotics prescriptions and less likely to involve NSAID prescriptions. Preventative visits to an orthopedic specialist were also associated with fewer NSAID prescriptions. Visits to orthopedic surgeons in rural areas, however, were less likely to involve PT referrals or lifestyle counseling.

In terms of primary care visits, those that included CT or MRI were associated with higher rates of narcotics prescriptions; patients seen by advanced practice providers were also more likely to receive referrals for NSAIDs and narcotics. Overall, compared with orthopedic clinics in the northeast of the United States, orthopedic clinics in the southern region were more likely to prescribe pain medications.

Recommendations for Treatment of Knee OA

According to the investigators, adherence to PT and lifestyle counseling is recommended to manage knee OA, as this approach may reduce overall healthcare use and minimize the continuous need for pain medication. Although symptom control through pain medication is an evidence-based approach for treating knee OA, the researchers note that medications alone cannot reverse or mitigate disability, and PT and lifestyle modifications can complement or even replace the need for pharmacologic therapy or surgery.

Reference

Khoja SS, Almeida GJ, Freburger JK. Recommendation rates for physical therapy, lifestyle counseling, and pain medications for managing knee osteoarthritis in ambulatory care settings: a cross-sectional analysis of the National Ambulatory Care Survey (2001-2015). Arthritis Care Res. 2020;72(2):184-192.