Published 11/1/2013
Alexandra Page, MD

Addressing Arthritis as a Chronic Disease

How do you counsel a 15-year-old girl who has had an anterior cruciate ligament (ACL) reconstruction about osteoarthritis (OA)? What do you say about OA to the 45-year-old weekend athlete who, during a routine follow-up visit after rotator cuff repair, incidentally mentions feeling a sporadic knee ache? What do you tell the 30-year-old laborer who has a fracture affecting a joint or his 50-year-old foreman whose knees hurt all day?

For too many orthopaedic patients, risk counseling and prevention of OA isn’t adequately addressed. In most primary care settings, due to other pressing health issues and/or lack of provider exposure or training, joint pain is often minimized or not asked about.

This is one of the issues that the U.S. Bone and Joint Initiative (USBJI) hopes to address through its Chronic Osteoarthritis Management Initiative (COAMI). This multidisciplinary team recently met in Rosemont, Ill., to focus on how to address OA as a chronic disease, with risk factors across the lifespan. In addition, OA affects or is affected by almost all other chronic health conditions, including obesity, diabetes, and heart disease.

Lateral radiograph of an elbow showing radiographic changes typical of OA; elbow OA is most often seen in manual laborers and weight lifters.
Reprinted from from Sarwark JF (ED).
Essentials of Musculoskeletal Care 4. Rosemont, Ill., American Academy of Orthopaedic Surgeons, 2010, page 345

OA as a chronic condition
The team began by comparing the management of OA to the way other chronic diseases—like diabetes—are managed. Successful management of OA may require treating other chronic diseases, as well as symptoms of sleep deprivation and depression, which chronic joint pain can induce.

The Arthritis Alliance of Canada presented their stepped-care approach, which focuses on the following three goals:

  • advancing knowledge and awareness of arthritis
  • identifying opportunities and prescribing plans to improve prevention and care
  • supporting ongoing collaboration among stakeholders, government, and other chronic disease groups

Another area that the group addressed was the need to make compromises between delivering patient-centered care and following clinical practice guidelines. As OA treatment guidelines are developed, including patient representatives will be important. Patients may also play a role in evaluating grants geared toward treating OA.

Many COAMI members noted that, although most chronic diseases have objective findings—such as blood pressure for hypertension or blood sugar levels for diabetes—many OA patients find that healthcare providers ignore or minimize their subjective complaints of joint pain. This can occur because primary care providers may have limited training in evaluating and treating musculoskeletal problems. All too frequently, joint symptoms are brushed over because patients and many providers view joint pain as inevitable.

During the many breakout sessions, diverse groups could address opportunities and barriers to implementing chronic care treatment for OA. Among the topics considered were prevention and screening for OA. The groups also explored the ideal vision of OA care and brainstormed ideas to achieve that vision.

In a follow-up to the 2012 COAMI report, COAMI Chair Joanne M. Jordan, MD, MPH, director of the Thurston Arthritis Research Center at the University of North Carolina, led a team that reviewed current evidence-based guidelines and outcome measures for OA. Attendees discussed the results of this review and identified areas of further refinement. Although the final summary of this discussion and development of action plan are pending, identified potential opportunities and next steps include the following:

  • critically review OA risk assessment tools and obesity guidelines
  • critically review OA diagnosis criteria, including imaging
  • develop a consensus on treatment guidelines, which should be flexible to reflect patient choices and values
  • educate both patients and care providers about OA as a chronic disease, including the provision of interdisciplinary CME
  • improve patient access to community resources
  • improve OA education in family practice and internal medicine residency and fellowship education
  • achieve sustainability through payment reform

Orthopaedic contributions
Among the orthopaedic surgeons who attended and contributed were Kimberly J. Templeton, MD, past president of both the USBJI and the Ruth Jackson Orthopaedic Society (RJOS) and Constance R. Chu, MD, representing the American Orthopaedic Society for Sports Medicine. Kenneth Lee Caldwell, MD, a PGY-5 resident, and I served as the AAOS representatives.

Other stakeholders in attendance represented the gamut of care providers and included physicians from rheumatology, family practice, internal medicine, and physical medicine and rehabilitation; allied health professionals such as physical therapists, registered nurse practitioners, physician assistants, and athletic trainers; arthritis-based groups such as the Osteoarthritis Research Society International, Movement Is Life, Arthritis Foundation, and the OA Action Alliance; and groups interested in chronic disease treatment, such as the American Public Health Association, the National Association of Chronic Disease Directors, and the American Geriatric Society.

As current RJOS President Amy L. Ladd, MD, notes, a disproportionate number of OA patients are women. Many have knee OA, which, due to its frequency and cost, drives many conversations about arthritis. The increasing frequency of sports injuries (notably anterior cruciate ligament injuries) among young female athletes portends the accelerated development of arthritis in these women. As a result, consideration of musculoskeletal issues must consider sex and gender.

As orthopaedic surgeons, we are trained to provide surgical treatment of end-stage OA. As we move into an era of value-based care delivery and reimbursement, we must focus our attention on the early diagnosis of OA, as well as the delivery of coordinated, patient-centered care.

The importance of preventive care is reflected in quality metrics for reimbursement. The 2014 Physician Fee schedule from the Centers for Medicare & Medicaid Services proposes reimbursing physicians for complex chronic care management and recognizes the importance of addressing OA as a chronic condition. Models such as accountable care organizations are motivated to prevent—rather than treat—expensive, life-changing diagnoses such as OA.

Much as we own the bone in other ways, COAMI and the AAOS can help us address OA as a chronic disease in our practices, possibly using a team-based approach. Alternatively, collaboration with primary care physicians can improve our ability to screen for and prevent/delay symptomatic OA. When surgery cannot be avoided, patients and referring physicians will be reassured knowing that an orthopaedic surgeon is a member of the care team.

Alexandra Page, MD, is a member of the AAOS Health Care Systems Committee. She can be reached at alexe.page@gmail.com

Bottom Line

  • Orthopaedic surgeons and other musculoskeletal care providers must recognize and treat OA as a chronic disease.
  • Stakeholders across specialties and disciplines are working on solutions to the difficulties in preventing and treating OA.
  • Orthopaedic surgeons can add value to OA prevention and early treatment.

Additional Information
A New Vision for Chronic Osteoarthritis Management