Clinical Inertia in Osteoarthritis

Osteoarthritis (OA), or degenerative joint disease, refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life (QoL). Moreover OA is one of the leading causes of pain and disability worldwide. Any synovial joint can develop osteoarthritis but hips, knees, ankles and small hand joints are the peripheral sites most commonly affected. Risk factors include age older than 50, injury to a joint, obesity, competitive contact sports, and heredity. The number of people with osteoarthritis or low back pain is increasing as the population ages, and as the prevalence of risk factors such as obesity and poor levels of physical activity also continues to rise.¹

The concept - clinical inertia - appeared indexed for first time in 2001 by Philips et al.,² and defined as “failure of healthcare providers to initiate or intensify therapy when indicated” and “recognition of the problem, but failure to act”. Although - therapeutic inertia – may be used in the literature to mean failure to use pharmacological treatments, the term clinical inertia is used more broadly and can be synonymous.

Observational and qualitative studies found that pain, disability and depressed mood were important factors affecting the QoL of patients with OA, but these patients also have fatigue, stiffness, anxiety, sleep disturbances and depression. There are a wide range of clinical patterns: patients that believe OA is not a serious disease and view its symptoms as an inevitable part of getting old, disabled patients with affected mood, patients that know how to manage an acute episode, or patients who consult their family doctor too often. Probably for this reason, and due to the fact that pain threshold is different for each patient, the family doctors may underestimate or overestimate the care they give.

Clinical inertia has been studied in many diseases such as hypertension, diabetes, cardiovascular diseases, osteoporosis, etc.^3,4 Most of them have clear clinical outcomes (goals), a treatment efficacy that can be measured, and numerical variables available that may improve disease control. Sometimes in OA is difficult to collect these features. In the case of OA there is evidence to show that patients’ perception of how patient centred a consultation is strongly predicts positive health outcomes and health resource efficiency (that is, fewer referrals), as Tejedor et al. demonstrated in their study.⁵ Recently, Lineker et al.⁶ review studies evaluating the influence of educational programs to implement clinical practice guidelines for OA and rheumatoid arthritis in primary care, and their conclusion is similar to Tejedor again. Literature on educational programs for the implementation of OA clinical guidelines in primary care is sparse, and it's difficult to change health professional behaviors because only the structural and organizational behavior changes might improve the educational interventions. Nevertheless, Lineker et al. demonstrated that educational intervention leaded by trained physicians may improve physician prescribing, and workshops with nurse case-management support decrease referrals to orthopedics (grade A evidence). Self-management can be part of the solution. Patients who are able to believe in their ability to control pain can become more active participants in making decisions regarding their disease (such as exercise or weight loss).

In accordance with the recommendation of Royal College of Physicians,¹ there are three core interventions which should be considered for OA: a) Education, advice and information access, b) strengthening exercise aerobic fitness training, and c) weight loss if overweight or obese. General Practitioners and nurses should be trained to promote self-care in the core interventions, and every follow-up visit should include a patient-centered assessment of progress, a review of pharmacological treatment and adverse effects, considerations related to general health promotions and disease prevention, and a review of functional abilities. If patient requires pharmacological treatment we should to consider patient's needs, preferences and comorbid conditions.

Tejedor et al found that patients did not seem to obtain a clinical benefit from the intervention, but there are still many unanswered questions that can be studied in the future: we have a very little data about use of non-pharmacological therapy in very elderly, we don’t know the long-term benefits that can offer a patient-centred approach for pain management, or long-term benefits by self-management programmes. We still have much to do.

Key points

In the case of OA there is evidence to show that patients’ perception of how patient centered a consultation is strongly predicts positive health outcomes and efficiency (that is, fewer referrals).

It's difficult to change health professional behaviors because only the structural and organizational behavior changes might improve the educational interventions.

Self-management can be part of the solution. Patients who are able to believe in their ability to control pain can become more active participants in making decisions regarding OA.