Patient, Provider, and Combined Interventions for Managing Osteoarthritis in Primary Care: A Cluster Randomized Trial

Abstract

Background: A single-site study showed that a combined patient and provider intervention improved outcomes for patients with knee osteoarthritis, but it did not assess separate effects of the interventions.

Objective: To examine whether patient-based, provider-based, and patient-provider interventions improve osteoarthritis outcomes.

Design: Cluster randomized trial with assignment to patient, provider, and patient-provider interventions or usual care. (ClinicalTrials.gov: NCT01435109).

Setting: 10 Duke University Health System community-based primary care clinics.

Participants: 537 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 electronic delivery of patient-specific osteoarthritis treatment recommendations to providers.

Measurements: The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score at 12 months. Secondary outcomes were objective physical function (Short Physical Performance Battery) and depressive symptoms (Patient Health Questionnaire). Linear mixed models assessed the difference in improvement among groups.

Results: No difference was observed in WOMAC score changes from baseline to 12 months in the patient (-1.5 [95% CI, -5.1 to 2.0]; P = 0.40), provider (2.5 [CI, -0.9 to 5.9]; P = 0.152), or patient-provider (-0.7 [CI, -4.2 to 2.8]; P = 0.69) intervention groups compared with usual care. All groups had improvements in WOMAC scores at 12 months (range, -3.7 to -7.7). In addition, no differences were seen in objective physical function or depressive symptoms at 12 months in any of the intervention groups compared with usual care.

Limitations: The study involved 1 health care network. Data on provider referrals were not collected.

Conclusion: Contrary to a previous study of a combined patient and provider intervention for osteoarthritis in a Department of Veterans Affairs medical center, this study found no statistically significant improvements in the osteoarthritis intervention groups compared with usual care.

Primary funding source: National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Figure 1.

CONSORT diagram. CONSORT = Consolidated Standards of Reporting Trials; DPC = Duke Primary Care; OA = osteoarthritis. * Reasons for being dropped after randomization: total knee replacement (n = 13), total hip replacement (n = 4), change in primary care clinic (n = 6), primary care provider not in study (n = 1), enrollment in another OA intervention study (n = 1), serious medical event making study intervention potentially unsafe (n = 1). For patients who withdrew or were dropped after randomization, all data collected up to that time point were used in analyses. † Participants who could not be reached for 6-mo follow-up were still eligible for 12-mo assessments; participants who could not be reached at 12 mo are still being followed for subsequent time points.

Figure 2.

Estimated mean WOMAC scores by study group and time point and 95% CI (error bars) from hierarchical linear mixed models. WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index.