A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative
Introduction
Arthritis, rheumatism, and back/spine problems were the leading causes of disability in the U.S. in 2005, resulting in more cases of disability than the next 8 causes combined [1]. In 2008, 13% of adults over 18 years of age had self-reported arthritis-attributable activity limitations, up from less than 9% in 2003–2005 [2]. Osteoarthritis (OA) is the most common form of arthritis, affecting more than 27 million people in the U.S. [3]. OA is one of several chronic conditions that are becoming more prevalent with the aging of the population and increasing prevalence of obesity. Data from the 2009 Behavioral Risk Factor Surveillance System indicated that the top 2 most prevalent conditions in those over 50 years of age were hypertension (36.5% for age 50–59 years, increasing to 60.7% for those over the age of 70 years) and arthritis (35% for age 50–59 years, increasing to more than 55% over the age of 70 years); the average number of conditions increased with age and was associated with a higher prevalence of activity limitations [4], highlighting the potential future burden of OA and other chronic diseases [5]. Gadermann et al. used U.S. National Comorbidity Survey Replication data to assess disease burden and comorbidities, finding that arthritis was the second most common reported disorder (prevalence 27%). More importantly, 88% of those reporting arthritis had at least one other physical or mental comorbidity (mean of 2.4 disorders) [6]. The importance of OA management as part of the care of individuals with multiple chronic conditions cannot be overlooked, given its impact on disability and functional limitation, as well as management of other chronic health conditions.
Numerous guidelines for OA management exist, but despite their many commonalities, and general agreement with these published recommendations among providers, there remains poor implementation in clinical practice [7], [8]. With the goal of improving the current approach to OA management, the Chronic Osteoarthritis Management Initiative (COAMI) Work Group was convened by the U.S. Bone and Joint Initiative in May 2012. This work group includes orthopedic nurses and surgeons, rheumatologists, rehabilitation and sports medicine providers, primary care and osteopathic physicians, physical therapists, athletic trainers, and patients. COAMI issued a Call to Action in September 2012, which mentions several priority actions, including convening an OA management conference, including other partners (U.S. Preventative Services Task Force, other federal agencies, other chronic disease and professional advocacy groups, and researchers and practitioners) in ongoing efforts, exploring standardized screening tools and indicators of OA, supporting advocacy endeavors, and developing and supporting an OA-specific research agenda [9]. This systematic review is one of the recommended outcomes of the first COAMI meeting and will serve as part of the background to support these initiatives by identifying, evaluating, and summarizing existing guidelines for management of symptomatic OA at the hip, knee, or hand, with the goal of determining commonalities more directly translatable to clinical practice.
Section snippets
Methods
Following a protocol designed by the authors and adherent to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a librarian-assisted literature search of the MEDLINE database was performed on April 1, 2013 using the Medical Subject Heading (MeSH) search term “osteoarthritis” with the publication type “guideline,” and subsequently with keywords “recommendation” and “management”; all searches were limited to English-language articles published since January 1,
Results
We reviewed 188 articles and included a total of 16 articles describing guidelines for OA management (Fig. 1). Five were from the United States [14], [15], [16], [17], [18], one from Canada [19], eight from Europe [20], [21], [22], [23], [24], [25], [26], [27], one from Asia [28], and one with international input from the U.S., Canada, and Europe [29]. Most recommendations were directed toward physicians and allied health professionals, and most had multidisciplinary input from general
Discussion
In this systematic review, we summarize the current guidelines for OA management from several stakeholder organizations. Many of the recommendations are generally agreed upon and could be readily implemented in clinical practice for a variety of specialties providing care to OA patients. As the vast majority of OA care occurs in primary care settings, dissemination and implementation of OA management guidelines will need to be directed toward these providers for maximum impact. In a concurrent
Conclusions
There is essential agreement on many recommendations for OA management across multiple societies making such recommendations. There is not a lack of quality guidelines, but rather a deficit in dissemination and implementation of the recommendations. Future efforts should focus on optimizing implementation in primary care settings, where the majority of OA care occurs, and in other specialty clinics where many individuals are likely to have OA.
Contributions
Conception and design: A.E.N. and J.M.J.; acquisition/analysis/interpretation of data: A.E.N., K.D.A., Y.M.G., A.P.G., and J.M.J. Drafting the article: A.E.N.; critical revisions for important intellectual content: A.E.N., K.D.A., Y.M.G., A.P.G., and J.M.J. Final approval of the submitted version: A.E.N., K.D.A., Y.M.G., A.P.G., and J.M.J.
Conflict of interest
A.E.N.: Has received research grants from NIH/NIAMS and the Rheumatology Research Foundation, serves on committees for ACR and OARSI, is on the Editorial Board for Osteoarthritis and Cartilage, and for Chronic OA Management, a CME publication by Vindico Medical Education; she also receives royalties from Health Press Limited for Fast Facts: Osteoarthritis, 2nd Edition.
K.D.A.: Has received research grants from NIH/NIAMS and NIA, the Rheumatology Research Foundation, Department of Veterans
Acknowledgments
We would like to acknowledge the efforts of Adam Doré, DO, and Holly R. Thompson, BA, SPT, for performing the initial data extractions.
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Support: This review was commissioned and partially funded by the U.S. Bone and Joint Initiative via the Chronic Osteoarthritis Management Initiative Work Group.
Role of funding source: This review was commissioned and partially funded by the U.S. Bone and Joint Initiative via the Chronic Osteoarthritis Management Initiative Work Group. The study sponsor had no role in study design, collection, analysis, or interpretation of data, writing the manuscript, or the decision to submit for publication.