Background/Purpose: Musculoskeletal (MSK) pain is the leading cause of disability in older adults. Specifically, knee osteoarthritis (OA) accounts for a large burden of MSK disability worldwide. A multi-modal approach is necessary to treat this common disease. Current guidelines recommend a combination of pharmacologic and non-pharmacologic treatments. A multi-phase quality improvement project was conducted at the Dallas VAMC Rheumatology clinic to improve documentation of non-pharmacologic therapies offered to older veterans with knee OA. The VA is an ideal location to conduct a quality improvement project to enhance MSK pain care as many of the guideline-concordant referrals are readily available, accessible and integrated into the care for Veterans.

Methods: Fifty charts from a VA rheumatology clinic were reviewed for documentation of non-pharmacologic knee OA therapies during outpatient office visits in May 2018. Then, a new note template dedicated to MSK pain management was developed and implemented in August 2019. The Assessment and Plan utilized pre-written management options for specific non-pharmacologic modalities: aerobic exercise, aquatic exercise, weight loss, nutrition counseling, physical therapy referral, use of assistive devices, Yoga/Tai Chi, thermal therapies, and psychological interventions. The pre-written plans permitted editing by the note author. Next, a rheumatology grand rounds presentation emphasized the importance of non-pharmacologic interventions for knee OA to both trainees and faculty. A post-intervention chart review was conducted on a subsequent 50 charts in November 2019.

Results: The majority of patients were men aged 65 years or older. All patients had a documented history of knee OA in a rheumatology clinic note. Therapies with the most improvement in documentation rates were: thermal therapies (2% to 58%), use of topical therapies (66% to 94%), weight loss (36% to 64%), physical therapy (60% to 86%), and exercise regimens (42% to 62%) (Figure 1). Psychological therapies were the least documented therapy and had the lowest rate of improvement (2% to 8%) as seen in Figure 1.

Conclusion: A dedicated MSK pain template note and departmental presentation on OA management improved documentation rates of non-pharmacologic therapies for knee OA. Further improvement is needed, as important modalities, specifically mental health interventions, remain under-utilized. Documentation is important for continuity of care for this clinic. Many medical trainees rotate through the clinic, and a patient is unlikely to have the same provider on subsequent visits, making the note a vital tool of care continuity. Future providers now have access to all prior treatment strategies and the current treatment plan in one well-organized location –the clinic note. The next step in this quality improvement project is to assess if increasing documentation rates of non-pharmacologic modalities is associated with increased referral rates for these interventions, followed by an increased use of non-pharmacologic therapies by patients, and ultimately improved patient outcomes.

Pre-intervention versus post-intervention rates of documentation for non-pharmacologic knee osteoarthritis treatment modalities

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-documentation-rates-of-non-pharmacologic-therapies-for-knee-osteoarthritis/