A comparison of the views of rheumatologists, general practitioners and patients on the treatment of osteoarthritis

J. Chard, J. Dickson1,, D. Tallon and P. Dieppe

MRC Health Services Research Collaboration and
1 Primary Care Rheumatology Society, Bristol, UK

SIR, Osteoarthritis (OA) is the most common form of joint disease and is an almost universal problem in people aged over 65 yr [1, 2]. Current management remains largely symptomatic [3] and involves a wide variety of options provided by a multitude of health professionals [4]. Given the number of professions involved in treatment and the importance of service provision for the successful management of chronic conditions [5], it is perhaps surprising that there is very limited evidence on how different groups view the management of OA [68]. This research has shown that mismatches between professionals and patients exist, and that these have important implications for service provision, satisfaction and compliance.

This study describes and compares the views of patients, rheumatologists and general practitioners (GPs) on the management of OA in the UK. We report the results of three different postal questionnaires used in three studies undertaken between 1997 and 2001, which included similar questions. The first was sent to people diagnosed with mild to moderate OA of the knee; these people were part of a cohort involved in a study examining a hospital-based physiotherapy service. The second survey was carried out in association with the Primary Care Rheumatology Society and explored service provision and treatment for OA within primary care. The third survey was of rheumatologists and was undertaken through the British Society for Rheumatology (BSR). This survey explored service provision and treatment patterns within rheumatology services. Statistical comparisons were made using Fisher's exact test.

The patient survey was sent to 112 people and achieved a response rate of 86%. The GP survey was sent to 400 and achieved a response rate of 27%. The survey of rheumatologists was sent to 200 individuals and achieved a 62.5% response rate. Table 1Go shows a comparison of the treatments that GPs and rheumatologists said they would provide to patients with OA and also shows what patients said they used and how effective they thought these treatments were.


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TABLE 1. Comparison of patients, GPs, and rheumatologists views on treatment for OA

 
The results show that the treatment plans of GPs and rheumatologists were broadly similar. However, GPs were less likely to use or refer to support groups than rheumatologists (60 vs 77%, P = 0.017) but more likely to use complementary therapy (78 vs 53%, P < 0.001). GPs were also less likely to consider minor surgical procedures than rheumatologists (70 vs 82%, P = 0.09). In all other respects the treatment options of GPs and rheumatologists were the same (Table 1Go).

The results show that patients felt that joint replacement was the most effective treatment, and ‘no treatment at all’ the least effective. Of the patients receiving interventions about which professional views differed, 23% reported using complementary therapy, 39% of these finding it helpful; 39% had had fluid or debris removed from their knee (minor surgery), 53% finding this helpful; and 46% felt that having someone to talk to was helpful, although they had not been asked directly about support groups (Table 1Go).

The data show a high level of similarity between GPs and rheumatologists in the treatment of OA. The patient survey emphasizes interesting variations in the reporting of the value of the different treatments.

GPs used complementary and alternative medicine more than rheumatologists. There are several possible explanations for this. First, there may be differences in attitude to treatment between the two groups, those trained in secondary care being less willing than GPs to accept ‘unscientific’ complementary approaches. Secondly, GPs may be more responsive to patient preferences than rheumatologists. The greater use of support groups by rheumatologists than GPs is important, and it may reflect greater knowledge of support groups by rheumatologists. The lower proportion of GPs who would use minor surgery compared with rheumatologists may suggest that GPs are reluctant to refer for this type of treatment, as they know the waiting lists are long, whereas rheumatologists often have fast-track access or undertake such procedures themselves. The extensive use of education by both GPs and rheumatologists is a positive finding, and patient surveys show that this is preferred by patients [9]. However, the results of the patient survey showed that less than half of those surveyed found it effective. Clearly, more work still needs to be done on focusing education on the needs of the individual patient.

The study is limited in a number of ways. Only 27% of GPs responded to the questionnaire, which was ascertained by a specialist society. The patient group was limited to those with knee OA. The three surveys were done at different times, for different purposes and with slightly different content. Also, the study does not show how or when GPs and rheumatologists would apply each treatment.

Nevertheless, this study demonstrates the value of comparing the actions and views of different groups in relation to a specific condition. Such studies may become increasingly important as health-care becomes more fragmented and as the demand for more community-based care and more patient involvement [10] increases.

Bristol is the lead centre for the MRC Health Services Research Collaboration.

Notes

Correspondence to: J. Chard, MRC HSRC, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK. Back

References

  1. Felson DT, Radin EL. What causes knee osteoarthrosis—are different compartments susceptible to different risk-factors? J Rheumatol 1994;21:181–3.[ISI][Medline]
  2. McAlindon TE, Cooper C, Kirwan JR, Dieppe PA. Determinants of disability in osteoarthritis of the knee. Ann Rheum Dis 1993;52:258–62.[Abstract]
  3. Dieppe PA, Chard JA, Faulkner A, Lohmander S. Osteoarthritis. In: Barton S, ed. Clinical evidence. London: BMJ Publishing Group, 2001:808–22.
  4. Norris P. How ‘we’ are different from ‘them’: Occupational boundary maintenance in the treatment of musculo-skeletal problems. Sociol Health Illness 2001;23:24–43.[ISI]
  5. Hochberg M, Altman RD, Brandt K et al. Guidelines for the medical management of osteoarthritis: Part II. Osteoarthritis of the knee. Arthritis Rheum 1995;38:1541–6.[ISI][Medline]
  6. Tallon D, Chard JA, Dieppe PA. Relation between agendas of the research community and the research consumer. Lancet 2000;355:2037–40.[ISI][Medline]
  7. Mazzuca SA, Brandt KD, Katz BP, Dittus RS, Freund DA, Lubitz R. Comparison of general internists, family physicians, and rheumatologists managing patients with symptoms of osteoarthritis of the knee. Arthritis Care Res 1997;10:289–99.[ISI][Medline]
  8. Potts MK, Brandt KD. Various health professions groups' beliefs about people with arthritis. J Allied Health 1986;15:245–56.[Medline]
  9. Neville C, Fortin PR, Fitzcharles MA et al. The needs of patients with arthritis: the patient's perspective. Arthritis Care Res 1999;12:85–95.[ISI][Medline]
  10. Department of Health. The Expert Patient: a new approach to chronic disease management for the 21st century. London: Department of Health, 2001.
Accepted 16 April 2002