Medical, Behavioral Intervention Improves Arthritis Care

Janis C. Kelly

January 14, 2016

A combined patient and provider intervention, including both medical and behavioral approaches to treatment, improved self-reported physical function in patients with hip and knee osteoarthritis (OA), as well as physical activity levels, according to the results of a randomized controlled trial published online December 22 in the Annals of Internal Medicine.

"I think one message of this study, in combination with prior studies on this topic, is that patients do benefit from lifestyle interventions for OA (eg, physical activity, weight management)," Kelli D. Allen, PhD, research professor of medicine and associate director, Center for Health Services Research in Primary Care, Durham VA Medical Center, told Medscape Medical News.

"There are programs available in many communities, and many patients could benefit from being referred to or guided to those existing programs," she said.

Patients in the intervention group were no more likely to actually undertake the recommended treatments than were those in the "usual care" control group, the researchers report; however, physicians in the intervention group were significantly more likely to refer patients for the recommended OA treatments than were physicians in the control group.

Combining clinical and behavioral interventions to manage hip and knee OA is standard of care but is often not done, Dr Allen and colleagues explain.

To examine whether a low-intensity patient–provider intervention could change this and produce better OA outcomes, Dr Allen's group randomly assigned 300 VA Medical Center patients and providers at a cluster of 30 VA outpatient clinics to either an intervention group plus usual care (n = 151) or usual care alone (n = 149). Patient eligibility criteria included radiographic hip or knee OA or both; joint pain, aching, stiffness, or swelling present on most days during the past month or for which the patient used pain medications on most days; overweight (body mass index ≥25 kg/m2); and low current physical activity. The 30 physicians participating in the study were primary care providers (PCPs) in the Ambulatory Care Service of the Durham VA Medical Center.

During baseline assessments, the study team collected information needed to complete a treatment algorithm for each patient. They then delivered patient-specific recommendations to participating PCPs via the electronic medical record as a progress note requiring an electronic signature 1 week before the patient's first routine visit. Possible referral recommendations included physical therapy, knee brace evaluation, MOVE! (the VA system's weight management program that includes physical activity counseling), referral or performance of intra-articular injection, recommendation of a topical nonsteroidal anti-inflammatory drug or capsaicin, adding a gastroprotective agent or discontinuing a nonsteroidal anti-inflammatory drug, discussion of a possible new or alternate pain medication, and orthopaedic evaluation for joint replacement.

Patients randomly assigned to the 12-month intervention group received counseling focused on physical activity, weight management, and cognitive behavioral pain management. Counselors with training in OA and behavioral change called each participant twice per month for the first 6 months, and monthly for the last 6 months, using motivational interviewing strategies and emphasizing goal setting and action planning. Patients also received written education materials, an OA exercise video, and a relaxation training audio CD.

Outcomes were assessed at baseline and at 12 months in person and at 6 months by telephone. Participants were paid $25 for in-person interviews and $10 for telephone interviews.

The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score. Secondary outcomes were the WOMAC pain and function subscales, the Short Physical Performance Battery, and the Patient Health Questionnaire-8 for depression. Self-reported physical activity was assessed using the Community Health Activities Model Program for Seniors.

The 300-patient sample size was powered to detect a moderate change of about 0.30 for mean total WOMAC scores between groups. The authors write that this translates to a 4.2-point difference, an improvement of about 11% from anticipated mean baseline. Mean WOMAC scores at baseline were 48.9 in the intervention group and 47.8 in the usual care group.

4.1-Point Difference in Total WOMAC Score at 12 Months

At 12 months, the estimated mean difference in change in WOMAC total score was −4.1 points between groups (P = .009): −4.0 points (95% confidence interval, −6.2 to −1.8 points) in the intervention group and −0.1 point (95% confidence interval, −2.1 to 2.3 points) in the control group. This difference was statistically significant, but less than what the researchers described as a clinically relevant difference in WOMAC score (12% - 18%, 5.8-point to 8.7-point decrease).

At 6 months, both groups had shown improvements in WOMAC, but the control group score drifted back to baseline by 12 months, whereas the intervention group score also increased but remained about 4 points below baseline at 12 months. The authors suggest this change might reflect the decrease in frequency of telephone counseling contacts, which changed from twice per month to once per month at the 6-month point.

Analysis of secondary endpoints showed no differences between the intervention and control groups in WOMAC pain scores at 6 or 12 months. WOMAC self-reported physical function score was 3.3 points (95% confidence interval, −5.7 to −1.0 points) lower at 12 months in the intervention group (>P = .005). There were no differences in objectively measured physical function, in depressive symptoms, or in body mass index. The intervention group reported significantly increased frequency and duration of exercise.

PCPs in the intervention group increased referrals for physical therapy (12% vs 7% in the control group), knee braces (19% vs 11%), and MOVE! (20% vs 3%). However, this did not increase the numbers of patients making use of these interventions. Dr Allen said the researchers are hoping to look further into the compliance issues through other open-ended questions they asked of patients and through interviews that are planned with PCPs. "But one possible factor is that some veterans live relatively far from the [Durham VA Medical Center], and getting back for additional services may be challenging," she said.

The researchers are also examining whether intervention-related variables or patient characteristics predicted who would benefit more from the intervention.

"We are very interested in understanding who benefitted most from this program, since only some patients experienced changes defined as clinically relevant. I think it will help to understand who may benefit from this type of relatively low-intensity, phone-based type of intervention and who may need a more intensive program," said Dr Allen.

The researchers also suggest that the promising changes seen with the low-intensity intervention warrant further exploration in higher-intensity studies.

"Another key question is how we can best facilitate proactive, chronic care for OA in the primary care setting, with patients being referred more often to (and actually receiving) other services like physical therapy," Dr Allen added. She also noted that a key difference between the intervention in this study and current clinical practice is that many patients with OA do not get behavioral interventions for it.

David S. Jevsevar, MD, vice chair, orthopaedics, and assistant professor of orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New York, who was not involved in the study, told Medscape Medical News that many factors likely contribute to the low rate of patients receiving recommended treatments in this study.

"Patients generally gravitate toward 'quick-fix' solutions, and the programs [in this intervention] take time to achieve improvement. Weight loss is obviously a huge issue, and many patients don't buy in to these programs. In this study, patients with severe OA would be less likely to improve with these treatments, and that may also have affected participation," said Dr Jevsevar.

He added, "I think that the authors tried an appropriate patient activation strategy, but this may have also been affected by the patients all being within the VA system, which may or may not mimic other healthcare settings. Physician buy-in to sell these programs is also critical, and it takes time and effort to discuss these strategies and convince patients to give them a try. Ultimately and unfortunately, we don't really know at any given point of time for a patient with OA what conservative treatment is most likely to improve their situation."

Dr Jevesar also said that, from the American Academy of Orthopaedic Surgery perspective, the study used a slightly outdated clinical practice guideline (2009 instead of the 2012 update), and that intervention strategies would have changed slightly based on the updated guideline.

The study was funded by the US Department of Veterans Affairs, Health Services Research and Development Service. Dr Allen reported grants from the Department of Veterans Affairs Health Services Research and Development Service during the conduct of the study. One coauthor reported personal fees from Nutrisystem and University of Pennsylvania/Weight Watchers International outside the submitted work. One coauthor reported grants from Sanofi, Johnson & Johnson, Takeda Pharmaceutical Company, and the PhRMA Foundation, and personal fees from CVS and Walgreens. The other authors and Dr Jevsevar have disclosed no relevant financial relationships.

Ann Intern Med. Published online December 22, 2015. Abstract

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