Improving osteoarthritis care in family practice

Life is pain, Highness. Anyone who says differently is selling something.

William Goldman

Osteoarthritis (OA) is one of the most common conditions seen in family practice¹ and it is the most common cause of musculoskeletal pain in older people, most commonly affecting the knees, hips, shoulders, and hands. Not surprisingly, many people living with OA suffer functional impairment and decreased quality of life—worldwide it is the fastest growing cause of years lived with disability.²

There are many challenges for family physicians in caring for people with OA. The first is our failure to identify it, name it, and prioritize it for our patients.

An interesting observational study using video analysis of real-life encounters between British GPs and their patients revealed that OA has an “identity crisis.”³ The researchers observed that OA frequently occurs in patients with other chronic health conditions and is often not an explicit part of their health agendas during encounters. They also observed that GPs often normalized OA symptoms as “part of life” and reassured patients who were not seeking reassurance. Furthermore, they observed that GPs used the term wear and tear in preference to osteoarthritis or didn’t name the condition at all. Last, GPs subconsciously made assumptions that patients did not consider OA a priority and that symptoms raised late in the consultation were not troublesome. The authors concluded that we need a clearer medical language with which to explain OA to patients and that we must prioritize OA in the context of comorbidity.

A more recent study in French general practice revealed that patients are much more likely to prioritize chronic conditions that affect the quality of their daily life or that are symptomatic, such as OA, than their family physicians are, leading to underdiagnosis and undertreatment.⁴

The second key challenge in the management of OA is the limitations of non-surgical therapeutic options. There are no “disease-modifying drugs” that can halt or reverse the condition, and many treatments have been tried, ranging from over-the-counter options, such as glucosamine, to joint injections to exercise. A plethora of treatments often means that none are particularly effective. Could a perceived lack of effective treatments for OA pain lead family physicians to ignore or downplay its importance as a health concern for patients?

This month’s edition of Canadian Family Physician presents a simplified decision aid for OA treatment options in primary care (page 191)⁵ from the PEER (Patients, Experience, Evidence, Research) group in the Department of Family Medicine at the University of Alberta in Edmonton. The tool is designed to support family physicians in caring for patients with OA. It provides a double-sided, 1-page summary of estimates of the effectiveness of a range of available treatments (including benefits and harms), basic prescribing tips, and estimated costs. Like other PEER tools and guidelines, this one has many strengths: it is supported by a systematic review of systematic reviews (page e89)⁶; it compares publicly funded studies when available; and it was reviewed by patients and the Patient Education Committee of the College of Family Physicians of Canada.

This month’s issue also features the launch (page 172) of a new evidence-informed series (page 186) in the journal from the Family Physicians Inquiries Network in the United States.^7,8 The first installment examines the evidence for acupuncture for low back pain.⁸ We hope that readers will find this series to be another useful tool supporting patient care.