A Combined Patient and Provider Intervention for Management of Osteoarthritis in Veterans: A Randomized Clinical Trial

Abstract

Background: Management of osteoarthritis requires both medical and behavioral strategies, but some recommended therapies are underused.

Objective: To examine the effectiveness of a combined patient and provider intervention for improving osteoarthritis outcomes.

Design: Cluster randomized clinical trial with assignment to osteoarthritis intervention and usual care groups. (ClinicalTrials.gov: NCT01130740).

Setting: Department of Veterans Affairs Medical Center in Durham, North Carolina.

Participants: 30 providers (clusters) and 300 outpatients with symptomatic hip or knee osteoarthritis.

Intervention: The telephone-based patient intervention focused on weight management, physical activity, and cognitive behavioral pain management. The provider intervention involved delivery of patient-specific osteoarthritis treatment recommendations to primary care providers through the electronic medical record.

Measurements: The primary outcome was total score on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 12 months. Secondary outcomes were WOMAC function and pain subscale scores, physical performance (Short Physical Performance Battery), and depressive symptoms (Patient Health Questionnaire-8). Linear mixed models that were adjusted for clustering of providers assessed between-group differences in improvement in outcomes.

Results: At 12 months, WOMAC scores were 4.1 points lower (indicating improvement) in the osteoarthritis intervention group versus usual care (95% CI, -7.2 to -1.1 points; P = 0.009). WOMAC function subscale scores were 3.3 points lower in the intervention group (CI, -5.7 to -1.0 points; P = 0.005). WOMAC pain subscale scores (P = 0.126), physical performance, and depressive symptoms did not differ between groups. Although more patients in the osteoarthritis intervention group received provider referral for recommended osteoarthritis treatments, the numbers who received them did not differ.

Limitation: The study was conducted in a single Veterans Affairs medical center.

Conclusion: The combined patient and provider intervention resulted in modest improvement in self-reported physical function in patients with hip and knee osteoarthritis.

Primary funding source: Department of Veterans Affairs, Health Services Research and Development Service.

Figure A1C1

Box plot of WOMAC by Provider, Randomization Arm, and Time Period^ ^ Box on box plot indicates the interquartile range, dash is the median, diamond is the mean, upper and lower lines extend to the max and min values, respectively.

Figure 1

CONSORT Diagram. * One patient switched from a Usual Care Provider to an Osteoarthritis Intervention Provider before being notified of randomization and was analyzed with the Osteoarthritis Intervention Group.