Background/Purpose: Adequate management of osteoarthritis (OA) requires both medical and behavioral strategies. However, some recommended therapies are under-utilized in clinical settings, and there is low use of behavioral strategies among patients. Consequently, interventions at the provider and patient levels both have potential for improving outcomes. The objective of this trial was to examine the effectiveness of a combined patient + provider intervention for managing OA in a primary care setting.

Methods: 300 patients with diagnoses of hip and / or knee OA at the VA Medical Center in Durham, NC (mean age = 61, SD = 11; 91% male; 50% non-white) were randomized to a combined patient + provider intervention for managing OA versus usual care. The 12-month, telephone-based patient intervention focused on weight management, physical activity and cognitive behavioral pain management.  The provider intervention involved delivery of patient-specific recommendations for OA treatments (based on multiple sets of published guidelines and including non-pharmacological treatments such as physical therapy), delivered in the electronic medical record.  The primary outcome was the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC), including the overall score (range: 0-96) and pain and function subscales.  Secondary outcomes were objective physical function (Short Physical Performance Battery; SPPB, range: 0-20), weekly hours of any exercise and moderate or greater intensity exercise (Community Healthy Activities Model Program For Seniors or CHAMPS questionnaire) and depressive symptoms (Patient Health Questionnaire; PHQ-8, range: 0-24).  Linear mixed models (LMM) were used to assess the difference in improvement in outcomes between the intervention and usual care groups, adjusting for clustering within physicians.  

Results: At 12-month follow-up, WOMAC scores were 4.2 points lower in the intervention group vs. usual care [95% confidence interval (CI) = -7.2, -1.1; p=0.008], indicating improvement in symptoms and function. The WOMAC function subscale was 3.4 points lower in the intervention group compared to usual care [95% CI = -5.7, -1.0; p=0.005], but there was no significant difference in WOMAC pain subscale scores between groups (p=0.12). SPPB scores were 0.6 points higher in the intervention group than the usual care group [95% CI = 0.1, 1.2; p=0.02], indicating improvement in function.  Weekly hours of exercise were also higher in the intervention group relative to the usual care group at 12-month follow-up: any exercise = 3.7 hours [95% CI = 1.5, 5.8; p=0.001] and moderate or greater intensity exercise = 1.6 hours [95% CI = 0.3, 2.9; p=0.02]. There was no significant difference between groups in PHQ-8 scores. 

Conclusion: This combined patient and provider intervention improved physical function (self-reported and objectively assessed) and physical activity levels in patients with hip and knee OA.  The telephone-based patient intervention is relatively low-cost and could be disseminated widely, and the provider intervention could be integrated in an automated manner within electronic medical record systems.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/randomized-clinical-trial-of-a-patient-and-provider-intervention-for-managing-osteoarthritis-in-veterans/