Ep 283: Who gets best-practice care for osteoarthritis? With Dr Jodi Young

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[00:01:13] Then my question would be, well, were they receiving opioids for something else? And they said, well, this works for me, so let's keep using it. So they continue to prescribe. But it does boggle my mind a little bit to think that that was the first place they went for prescriptions is opioids rather than something a little less potentially harmful.

[00:01:38] Hello, and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. How many patients come to see you and describe receiving what sounds like inadequate care before they reached your clinic?

[00:02:04] Osteoarthritis is one of the most common chronic musculoskeletal conditions, and there are loads of trustworthy clinical guidelines available from large international organizations that clearly outline what best practice care should entail. So why then, as we'll discuss in today's episode, are there so many patients who are missing out on high-value care for osteoarthritis?

[00:02:26] Joining me is Dr. Jodie Young to discuss her team's analysis of data from nearly 25,000 patients who were receiving osteoarthritis care in the United States, and what those data say about osteoarthritis care. Dr. Young is the Director of Research for the Doctor of Science in Physical Therapy program at Bellin College in Green Bay, Wisconsin. There, she mentors doctoral students and helps turn clinical and education research questions into meaningful, publishable research.

[00:02:56] Dr. Young is also a Fellow of the American Academy of Orthopaedic and Manual Physical Therapists. Dr. Jodie Young, welcome back to JOSPT Insights. Thank you for having me again. It's good to be back. It's wonderful to have you back, and today we're talking about who gets best practice care for osteoarthritis. I think let's start, Jodie, by having you characterize what you see is best practice first-line care for someone with knee osteoarthritis, which will be our focus for today.

[00:03:25] I believe, obviously, most of the listeners are going to agree with us too, that conservative management is the place to start. But what does that mean? So what types of conservative management are we talking about? Well, first and foremost, exercise has to be at the top of the list. And then along with that is education, which would include education on self-management. So some will separate those two, but I would keep them together.

[00:03:49] So really focusing on pain management, coping, joint protection, exercise compliance, and medication compliance or adherence. And those are really the top three for me. And then I would add manual therapy to that as an adjunct to exercise. I would never say do it on its own and use it as appropriate.

[00:04:11] The last thing I would add to that for first-line care would be if there is a need for NSAIDs or corticosteroid injections, I would say yes, use them. To summarize, exercise, education, self-management, and manual therapy as needed. And I'll invite our listeners to hold manual therapy and exercise in their minds. We will come back to that because that's really a big focus of today's podcast chat.

[00:04:38] And that's, I think, a nice segue into a recent big review of real-world data from the military health system that you led. And that was looking specifically at who gets what type of care for knee osteoarthritis, which is why we wanted to set the scene with this what is best practice care. Before we talk about what you found, first, I think it's important for us to set the scene of what the military health system looks like for people who are unfamiliar with it.

[00:05:06] And let's talk a bit about what data are captured and what makes this system particularly good for the type of research that we're talking about today, Jodi. So the military health system is a great system for this type of research, these large data sets, this cohort studies. It's a single-payer health system, and it captures all of the care, both across military and civilian clinics.

[00:05:31] And it's not only just active duty members, but it's also their dependents and then retirees. So because of that, you're going to get a wide age range. You're going to get any and every diagnosis, a range of patients who have a variety of symptoms and various severities and various levels of chronicity, whether it's surgical, non-surgical. So that in and of itself is great right there because it captures all the care.

[00:05:58] And then it uses electronic medical record data as well as insurance payer claims to give a comprehensive data set. And when I say comprehensive, it really can be almost anything and everything that you want, depending on the study. So it's going to give you any and all type of costs and break it down by whether it's just all of medical care costs or, in our case, is it related to the knee or specific to knee OA.

[00:06:23] And then it's going to give you visits to any type of provider, including physical therapy. And then from there, what are the different interventions you received and the number of visits that you had? It also collects medication, injections. I mean, I could go on and on about what it collects. And so it's very unique and it gives you a very deep data set. There's some limitations.

[00:06:46] You don't get, you know, patient reported outcome measure data, which I know is a large thing for RCTs. But of course, again, we're doing these observational cohort studies with this. And it is reliant on coding. And we know that there can be some errors in coding. But it's a really deep data set. And I will say that there's a lot of checks and balances within the military health system with that data to make sure that the coding is as accurate as possible.

[00:07:12] And I think your point about capturing everything points to this sense that this is the real world. And I think sometimes we can read an RCT and feel like, yeah, that's lovely in this very controlled, very rigid research project. That doesn't really reflect necessarily what happens in my clinic.

[00:07:34] Whereas what you're talking about is this data set captures exactly what's happening in real life clinical practice, which is why it's particularly valuable for looking at who's getting access to what types of care. And as you say, the detail is there. So let's dive into what you found. What were the key findings regarding people's care for NEOA in this military health system? We really investigated a number of things in this study. If you look at it, there's a lot that went on in there.

[00:08:02] But essentially our cohort was data collected from 2013 to 2017. And those who met inclusion, it was a cohort of 24,496 individuals. And then we categorized them by intervention they received, whether they received no intervention, exercise only, manual therapy only, or a combination of manual therapy and exercise concurrently. And what we found is that only 10.9% actually received treatment.

[00:08:30] So that is a talking point in and of itself. Of the people who did get treatment, a little over half received only exercise. Only 1.4% got manual therapy only. And then a little under half got both manual therapy and exercise. We also looked at downstream health care use and costs. And we really focused on opioids and corticosteroids for the downstream health care.

[00:08:56] And what we found is that opioid prescriptions were higher in those who received exercise and manual therapy. But the mean number of prescription fills was actually the highest in those who had no treatment. And then corticosteroid injections and costs across the groups were pretty similar. But the last main point is that only 1% of the whole group went on to have a total knee arthroplasty during this time frame.

[00:09:23] I want to underscore this point that 1 in 10 people got what we would broadly consider best practice care for knee OA. So that in itself, I think, is a really stark finding. What do you make of that, Jodi? Any suspicions on why that might be? Particularly in this, it surprises me because the military health system, as you say, is a single-payer system. It's much more like people outside the U.S. might think of a publicly funded health system.

[00:09:52] So it's not like people are having to find the money necessarily to pay for expensive care. Okay. So I do think that some people likely missed out on a treatment plan, right? If 9 out of 10 didn't get any exercise or manual therapy or no treatment, that's problematic. However, as we noted, only 1% went on to arthroplasty. So it's possible that there's severity of symptoms, which again, we cannot access that with this type of data. But it's possible that self-management was appropriate.

[00:10:21] They were at a place in their care where that's all they needed. The other thing is we don't know if they were actually referred to PT at all or if their preference was not to go to PT. They said, no, I don't want to do that. Or if they had misconceptions about the value behind conservative management, which I've not treated in the military health system. But outside, I can see that with people where they say, no, there's no value in this. I'm going to do it on my own.

[00:10:48] The other thing to address about the military health system, and I want to put this caveat on top of it, is that the majority of people that were in our study actually were non-active duty, which kind of makes sense. The average age was nearly 56 years old, and we're talking about NEOA. But something that often does happen in the military health system is they have these very transient schedules.

[00:11:12] They often have to move or they get a deployment, or they have to prioritize training for a future deployment over that. Now, again, that's a small number that were in our study, but that is also a possibility. So there's really just a lot that we don't know about the cohort. But I will say that there was likely a missed opportunity with some people. I want to pick up on this idea of medications and particularly looking at opioids.

[00:11:41] Opioid prescribing was pretty common in the data set, and you found that over 40% of people received at least one opioid prescription in a given year. Did that surprise you? Well, without knowing some of the background related to the opioid prescribing patterns in the military health system, I think that somebody would say yes. But if you looked at the typical prescribing patterns, even outside of the military health system at this time, I think no.

[00:12:11] It's probably not that uncommon of what we've seen. And I want to just point out, as I said earlier, the data collection was from 2013 to 2017. So I don't want to call the data old, but they are aging. I'll say they're aging. And so we have to think about what may have changed since then. There was a study at the same time, 2013 to 2015, where they did a trial with Veterans Affairs Primary Care Clinics. And it was those who had low back pain, hip, and knee OA.

[00:12:40] And they looked at opioids versus non-opioid prescription for 12 months. And they actually found that there was no difference between the two in decreasing pain-related function. So at the same time, that was being investigated. There's also a very large study that looked at what was going on with active duty service members, as well as non-active duty from 2006 to 2014.

[00:13:04] And there were 7 million prescriptions filled during that time by 1.5 million active duty service members. So I just need to say that again. So in an eight-year time frame, there were 7 million prescriptions filled by 1.5 active duty service members. Now, there was some combat and war going on during that time.

[00:13:24] There were also directives during that same time frame from the Department of Defense and then also this Army Pain Task Force to kind of mitigate the risk, learn more about prescribing patterns. How do we safely prescribe? When is it appropriate? And they started to promote physical therapy more. There was kind of this drop-off at 2011 during that time frame where they did see a decline. So that's 2011. Our data were 2013 to 2017.

[00:13:52] Since then, they have seen this relative reduction overall. But what I will say is that a lot of these studies are on active duty service members. And as I mentioned, the majority of ours were not active duty. And so that doesn't really track if you think about it. But we demographically have found in the literature that older personnel have a higher likelihood of opioid prescription. And again, I said ours were 56 years old on average.

[00:14:19] And then also nearly half in the study were in the Army. And higher rates of opioid use have been used in Army and the Marine Corps. So I think with that decline, I said, that started in 2011, there was a decline both in active duty and civilian. But it was actually higher in active duty than it was civilian. And so, again, we had non-active duty members and we had retirees and tenants. And so it's possible that that tracks.

[00:14:49] So to kind of summarize that, I don't know if it's as much of a surprise. I do think it would be interesting to look at it now. And I do think it would be different based on kind of some of the numbers I've outlined here with relative reductions and whatnot. It's really interesting, particularly what we're increasingly knowing and where the guidelines are directing. And as you say, lots of unanswered questions there. And hopefully those data are tracking in the direction of fewer opioid prescriptions being filled,

[00:15:18] given what we know about the harm profile of opioids and the fact that best practice guidelines absolutely advise against opioid prescribing as first-line care. So the one thing that I just find interesting, too, is opioids for OA. Like, why not NSAIDs? I mean, like you said, the guidelines say don't use them. But why is that the first thought? So then my question would be, well, were they receiving opioids for something else? And they said, well, this works for me, so let's keep using it.

[00:15:48] Or so they continue to prescribe. But it does boggle my mind a little bit to think that that was the first place they went for prescriptions is opioids rather than something a little less potentially harmful. Jodi, I want to move our conversation to exercise with or without manual therapy. In people who received exercise with or without manual therapy, the likelihood of having a subsequent joint replacement reduced by about 10%,

[00:16:16] although I should stress that the hazard ratio wasn't significant and the numbers were small. So the statistics, as you acknowledge in the paper, are uncertain. Nevertheless, what do you make of those numbers? So I think first and foremost, guideline treatments work, right? So that's what that would say to me. The interesting thing, I joked about the data being aging, not old. But we acknowledge this in the paper.

[00:16:44] We cited so many guidelines that actually didn't come out until after the data were collected. However, this is a positive for this particular cohort. And this is positive for the military health system because they were essentially adhering, for those who did get treatment, they were adhering to what guidelines would say. They were using exercise as their first and foremost. And then so few people, the 1% that actually got manual therapy alone, which is pretty common.

[00:17:12] And something that we've talked about before, I think in my last insights with you, I talked about these camps and how I don't know if they're really camps. I don't think there's a manual therapy camp and an exercise camp because the manual therapists are not arguing that we want to do it on its own without exercise. And I don't think exercise is the exercise camp is always saying, no, don't ever use manual therapy. And in this case, we proved that really wasn't a problem because only 1% got manual therapy on their own.

[00:17:40] But when they used exercise alone or they used exercise with manual therapy, again, not significant, but they did have a lower hazard of going on to a knee arthroplasty. So I would say it just shows the positive of using guideline recommended treatments for this population. I love that message. And I want to underscore it again, that the guidelines, there's so much work internationally that has gone into guidelines for OA.

[00:18:05] We all recognize the prevalence of OA, that prevalence is increasing. We've got really good tools in the toolkit. PT, physiotherapists are key healthcare members of that team. And I think what you're saying there is that this reinforces the role that we can play. It doesn't mean that people are necessarily going to avoid a joint replacement altogether. It might delay someone's surgery, which is also a good thing. I think there's a lot of positives here.

[00:18:34] We can take, at least I see lots of positives that musculoskeletal rehabilitation clinicians can take from these data. Yeah, no, I absolutely agree with you on that. And that's what was fun, I would say, from this paper is knowing that it was this data collection from a time that was quite long ago. And we're still seeing that they were doing the quote right thing, you know, per the guidelines, which is just so great to see. Absolutely. Jodi, this has been a wonderful dive into.

[00:19:02] I like how you frame the data as aging. It's nice to look back to see what's been happening. You've left us with really important messages about the role of PT, musculoskeletal rehabilitation specialists in providing care for people with osteoarthritis. Dr. Jodi Young, thanks for joining me on JOSPT Insights. Thank you for having me again. Thanks for listening to this episode of JOSPT Insights.

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[00:20:00] Talk with you next time.