Adherence to stepped care for the management of knee osteoarthritis in the Netherlands

To gain insight in Stepped Care (SC) adherence prior to orthopedic consultation in patients 55 years of age or older with a symptomatic knee, in treatment choices following orthopedic consultation and in factors associated with arthroplasty as preferred treatment.

Prospectively collected Computer-Assisted History Taking data from three hospitals was used to allocate included patients (n=7874, average age 66.8 years (SD: ±8.2), 54% female) into a full SC (three steps: non anti-inflammatory analgesics, anti-inflammatory drugs, exercises), a partial SC (missing 1 or 2 steps) or a no SC group (no steps applied). Regression analyses were used to evaluate how clinical features, SC adherence and radiographic severity were associated with arthroplasty as a treatment choice following orthopedic consultation.

Prior to orthopedic consultation, full SC adherence was 12%, partial SC 66.3% and no SC 21.7%. For the majority of patients (71.6%), treatment following orthopedic consultation consisted of non-operative OA management options. Increasing age, higher BMI, longer symptom duration, greater pain during activity, reduced walking ability, and full adherence to SC were all associated with higher odds of arthroplasty, with a highest Odds Ratio of 4.4 (95% Confidence Interval: 3.7-5.3) for symptom duration.

Despite clinical guidelines outlining a SC approach to manage knee OA, only a small proportion of patients of 55 years of age or older with knee complaints have utilized all non-surgical treatment options before being referred for orthopedic consultation in the Netherlands. Most patients consulting an orthopedic surgeon receive conservative treatment modalities, also included in the Dutch clinical guideline on knee symptoms for GPs.