Knee osteoarthritis: a new clinical care standard

OSTEOARTHRITIS (OA) of the knee is a common condition among people who are aged 45 years and over, and can be painful and debilitating. The care people get for symptoms of knee pain varies. For example, it has been shown that rates of knee surgery vary up to four-fold across Australia.

The clinical care standard regarding OA of the knee, developed by leading clinicians and released this week by the Australian Commission on Safety and Quality in Health Care, is an important national approach for improving the care of people aged 45 years and over who have knee pain and who are suspected of having knee OA.

Clinical care standards aim to support the delivery of appropriate care, reduce unwarranted variation in practice and promote shared decision making between patients, carers and clinicians. This is the sixth clinical care standard released by the commission. As with its predecessors, the Osteoarthritis of the knee clinical care standard includes a number of “quality statements” about the care that patients can expect to receive. The statements provide people with this condition with information about what they can do to manage their condition themselves, as well as information on the care they should be offered. The statements also guide health professionals on the delivery of appropriate and high quality care, and help health services to identify systems required to support and monitor appropriate care.

As with all clinical care standards, the Osteoarthritis of the knee clinical care standard brings together the highest quality available evidence on the treatment of knee OA, following a robust process of review and consideration, involving a multidisciplinary expert group of clinicians, researchers and consumers.

The quality statements translate that evidence into a form that can be used in daily practice. This clinical care standard has been endorsed by nine leading health, medical consumer organisations – including the Australian Rheumatology Association, the Australian and New Zealand College of Anaesthetists and the Royal Australian and New Zealand College of Radiologists.

The standards emphasise the role of a comprehensive clinical assessment of patients, and underline the fact that this is a critical part of diagnosing OA of the knee. For diagnosis of OA, imaging may be warranted only in limited circumstances, if more serious pathology is suspected. There is poor correlation between radiological findings and symptoms, which is why imaging is not recommended to confirm a diagnosis.

For treatment options, the standard highlights less invasive and more effective options for high quality care, including the use of non-addictive pain-relieving medicines and encouragement for patients to lose weight and do more exercise in the first instance. Surgical options should be considered only if symptom relief is no longer present, and the standard makes clear that knee arthroscopy is not recommended for uncomplicated knee OA.

Patient education and guiding patients in the development of a self-management plan will help patients understand their condition and achieve their treatment goals. These are important aspects of the clinical care standard that underpin the fundamentals of patient-centred care.

About 2.1 million Australians are living with OA, with that number expected to climb as our population ages. Australia spends an estimated $5.7 billion each year treating musculoskeletal conditions; OA accounts for nearly one-third of this spending.

People who are overweight have double the risk of developing knee OA, and those who are obese have four times the risk. About 70% of knee replacements are carried out on patients whose weight is significantly contributing to their OA. However, only about 8% of Australians incorporate weight loss as part of their OA treatment, even though symptoms may be reduced if patients shed just 5% of their body weight.

The new Osteoarthritis of the knee clinical care standard is an affirmation of the importance of the GP’s role and diagnostic skills, and the wider role of primary care practitioners more generally.

Dr John North is a senior orthopaedic surgeon and was a member of the Australian Commission on Safety and Quality in Health Care’s Topic Working Group that developed the Osteoarthritis of the knee clinical care standard.

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