A Call to Action from the Chronic Osteoarthritis Management Initiative (COAMI), September 2012

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Missed Opportunities to Detect and Treat Osteoarthritis (OA)

Imagine if the trigger for treating heart disease were a first heart attack, or for treating hypertension, a stroke. For some patients, these debilitating and often deadly symptoms are indeed the first signs of trouble. However, the treatment goals for these and other chronic conditions is to detect and modify risk factors early, before symptoms appear, so that the disease’s devastating outcomes can be prevented altogether.

Unfortunately, the same approach does not currently apply to osteoarthritis (OA), the most common type of arthritis and leading cause of disability in the United States.¹ OA afflicts 27 million Americans — over 10 percent of adults in this country.²

Although a quarter of adults over the age of 60 experience significant pain and disability due to OA, it is by no means a condition affecting only older adults. OA interferes with work and activities of daily living, and also undermines the ability of patients to pursue the levels of physical activity recommended for weight loss, cardiovascular health, diabetes control, and other health goals. Since OA frequently co-occurs with other conditions, its adverse health effects — and contributions to health costs — are amplified.

OA should be viewed as a chronic condition, subject to screening for risk factors, prevention-oriented interventions, ongoing monitoring, and comprehensive care models typical of other chronic diseases. Instead, many patients and health care providers tolerate and expect pain and disability as an inevitable trajectory of OA and aging. In addition, many health care providers assume an inevitable, gradual progression to “joint death” and, often, joint “re-birth” in the form of knee and hip replacements.

Changing this paradigm — especially among health care providers — was the focus of the first Work Group meeting of the Chronic OA Management Initiative, or COAMI, held in Chicago, Illinois in May 2012, and convened by the United States Bone and Joint Initiative (USBJI). This Call to Action for a change in the paradigm of intervention is one of the products of this initial meeting.

A Clinical Rationale for Changing How OA is Managed

OA is a product of multiple risk factors, including obesity, genetics, aging, and the consequences of joint injuries and trauma. Even though some of these risk factors (such as genetics and aging) are not modifiable, they do offer the potential for identifying segments of the population at higher risk for OA so that they can be screened and treated earlier. Doing so could help reverse or at least slow the considerable costs to our health care system — such as the $42.3 billion spent on 905,000 knee and hip replacements in 2009 alone (most associated with OA).³

OA often co-occurs with other chronic conditions (such as diabetes and obesity) and affects their progression as well. For example, people with OA are likely to experience enough joint pain and stiffness that they are unable to undertake the level of physical activity that could help them lose weight — and thus improve their outcomes for both OA and many other chronic conditions.

Even though OA is common, it is not consistently detected and treated. Half of OA patients are seen in primary care settings, where they may not report — or be asked about — their joint pain.⁴

Learning from Other Chronic Diseases

Although OA is a chronic, progressive, and debilitating disease, its management and treatment often has little in common with the approach used effectively for other chronic diseases.

Episodic and reactive care — in contrast to proactive, longitudinal, coordinated, and multidisciplinary care — represents many missed opportunities to treat OA more effectively and deprives patients of attainable options for pain relief, increased function, and decreased or slowed OA progression.

Changing the Paradigm

Many providers share with members of the public a lack of awareness about OA, its symptoms, and treatment options. Because so many people with or at risk for OA are seen in non-specialist settings such as primary care (and, increasingly, pediatric providers due to the child obesity epidemic and the increasing prevalence of sports injuries), a lack of provider awareness about OA constitutes a significant missed opportunity. Relatively little time is devoted to OA within professional education venues, across many different disciplines.

Even among providers who are aware of OA, additional barriers remain. Currently, multi-disciplinary approaches are not the norm for dealing with OA, nor is there a consistent set of recommendations or messages about measures to manage the pain and disability of OA, especially for patients with moderate symptoms on an ongoing basis.

Providers also lack basic tools for gauging levels of risk, disability, pain or loss of function, such as a joint health score that could be monitored over time. Screening tools or questions that have been tested in different settings (similar to the World Health Organization’s Fracture Risk Assessment Tool, or FRAX) also are lacking.

Paying attention to patients’ symptoms (beginning by asking about them in various settings), following up both proactively and longitudinally, and applying the principles of integrated, multi-specialty systems of care all would improve outcomes for the millions of people with OA. Moreover, these changes could be implemented now, and do not necessarily require additional research or testing. What they do require is increased visibility of OA among clinicians, so that OA is routinely considered when patients seek screening and treatment for other chronic diseases and conditions.

Priority Actions

In addition to disseminating this Call to Action through their respective professional networks and beyond, Work Group participants identified several other high-priority actions to increase the visibility of OA among health care providers and to take better advantage of opportunities to screen and treat those at risk. They include:

• Convening an OA Management Conference that would identify areas of agreement across disciplines/specialties within the health care system, identify gaps or areas of disagreement, review models of care and how to establish these for management of OA, specify gaps in research and treatment protocols, and set forth a rationale for research and management approaches based on patient-centered outcomes and functional status. In particular, the meeting would address the incomplete and inconsistent approaches to managing OA in patients with mild or moderate presentation of symptoms, and propose models, possibly leading to pilot programs. Agreements reached during the meeting would be published and disseminated more broadly.
• Reaching out to other partners to include them in future COAMI work. These include the U.S. Preventive Services Task Force, federal agencies involved in prevention, associations representing other chronic diseases, payors and insurers, researchers and practitioners in the weight management and nutrition arena, mid-level providers, and those involved in sports and sports medicine.
• Exploring standardizing screening tools and indicators of OA, to make early diagnosis more consistent and likely. These include developing key questions that could be incorporated into patient histories at initial and follow-up visits, as well as intake questionnaires about physical activity and limitations, or tools that indicate the likelihood of developing OA (similar to the World Health Organization’s Fracture Risk Assessment Tool, or FRAX).
• Developing tools and prompts that promote patient engagement in learning about and managing OA (and pre-OA). Tools and prompts that support patients in their self-management of OA as a chronic disease — similar to tools used for diabetes, hypertension, and heart disease and including innovative uses of technology, such as Smartphone apps — should be identified, strengthened, and disseminated far more widely.
• Lending COAMI’s support to existing advocacy and awareness efforts and seeking specific opportunities to reinforce key messages, particularly:
  • OA should be considered — and treated — in a more multi-disciplinary, coordinated, and prevention-oriented way, similar to other chronic diseases.
  • Until OA is managed as a chronic disease, many opportunities to avoid costs, pain, disability, and loss of function will be missed.
  • Like metabolic syndrome and pre-diabetes, a “pre”-OA condition should be more systematically identified and addressed among the patients of many health care providers.
  • Health care providers can play a much stronger and more effective role in emphasizing the benefits of physical activity and weight management among their obese and overweight patients, and should elevate their efforts to support and motivate patients.
• Developing and supporting an OA-specific research agenda to fill gaps in evidence and practice. This is particularly true for the large number of patients with mild to moderate symptoms and limitations (as opposed to those with no or severe limitations about whom there is far more consensus about how to proceed clinically).

A Vision for Improved Management of Osteoarthritis (OA)

Osteoarthritis (OA) affects 27 million Americans today, and will affect millions more in the decades to come as our population ages, continues to gain and maintain excess weight, becomes less active, and suffers the after-effects of earlier sports- and work-related bone and joint injuries. Not every case of OA can be prevented, but the Chronic OA Management Initiative (COAMI) believes that a significant degree of the pain and disability caused by OA can and should be prevented or ameliorated.

How? As health care professionals, we should direct our efforts to treating OA more as the chronic disease it really is, rather than intervening once patients have significant pain or are disabled. This means asking patients about joint pain, mobility, and function before they bring it up (at which point much joint damage has likely already occurred), in whichever setting patients encounter members of their health care teams. It means adopting the best practices of other successful chronic disease models: working as a coordinated team with consistent and reinforcing recommendations for weight loss, physical activity, and pain management when these are indicated; as well as monitoring and following up with patients to assess adherence and/or progression of symptoms. Lifestyle changes that reduce excess weight and support physical activity are beneficial not only for the management of OA, but also can help reduce risks for diseases such as diabetes and heart disease — yet another reason for identifying and addressing the symptoms of OA earlier than is currently the norm.

Health care professionals cannot accomplish these shifts in the conceptualization of OA management alone. The Work Group and organizing committee of COAMI applaud and support the public awareness and public health initiatives of the Arthritis Foundation, Ad Council, Centers for Disease Control and Prevention, and Osteoarthritis Action Alliance, among others. As clinicians and researchers, we join these colleagues in calling for greater awareness and commitment to preventing and ameliorating the symptoms of OA among all sectors — the public, employers, health insurance payers, school systems, media, elected officials, and of course the health systems and teams in which we function.

With greater awareness, earlier screening and detection, more consistent and evidence-based treatment and interventions, and environmental and policy supports for these interventions, we are confident that our combined efforts for joint health will pay off by reducing the pain, disability, and costs for which OA is responsible.

1. White PH and Waterman M. Making osteoarthritis a public health priority. AJN 2012:112(3):S20-S24.
2. Lawrence RC, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum 2008;58(1):26-35.
3. Agency for Healthcare Research and Quality. HCUPnet. National and regional estimates on hospital use for all patients from the HCUP nationwide inpatient sample (NIS). National statistics—principle procedure only. ICD-9-CM 81.54 and 81.51. 2011. http://hcupnet.ahrq.gov.
4. IHealthHealthcare Information Directory. Available at http://www.ihealthdirectory.com/osteoarthritis-treatmentoptions/. Accessed August 20, 2010.

For more information about COAMI, please contact the United States Bone and Joint Initiative at 847.430.5053 or [email protected].

Copyright 2012, United States Bone and Joint Initiative, NFP. All rights reserved.