Impact of Evidence-Based Nonsurgical Management Guidelines on Outcomes for Disabling Knee Injuries: Long-Term Health Deficits, Disability, and Economic Analysis
Abstract
Osteoarthritis (OA) is a painful and disabling disorder among the most prevalent chronic health conditions in the United States. It imposes a tremendous economic burden on individuals and society, responsible for an estimated 185 billion dollars of medical expenditures. Rates of OA are substantially greater, and the age at onset is younger among active duty military personnel relative to the general population. From the years 2008 to 2013, there were 160,000 medical visits related to knee osteoarthritis for Tricare beneficiaries. Knee OA diminishes quality of life across several dimension and can undercut the ability to remain physically active and maintain good health. Many patients newly diagnosed with knee OA become caught in a downward spiral of activity-limiting pain, reduced physical activity, leading to weight gain and worsening pain with activity. Despite the negative pattern of diminishing function and health following diagnosis of knee OA, reports on healthcare utilization from civilian and military health systems in the U.S. indicate that non-surgical management is highly variable and for many patients the majority of the time between diagnosis and eventual total knee arthroplasty (TKA) is simply spent waiting for symptoms to worsen sufficiently to warrant the surgery. As with many chronic health conditions, early management of knee OA appears to be episodic and uncoordinated, focusing on symptom control without a consistent strategy to maintain function and manage pain. Most research and quality improvement efforts to date have focused on end-stage disease and TKA even though the greatest impact on the health of individuals and economic costs might be achieved through effective early management before a negative trajectory of diminishing health can take hold. For the military health system, the challenge of developing effective early management strategies is critical because knee OA afflicts younger individuals in military populations, making costs from lost work productivity and management across the lifespan particularly challenging. OA is the most common cause of disability among Service members separating from active duty. Moving those with knee OA more rapidly towards total knee replacement surgery is not an adequate response to this challenge as clinical outcomes are worse, and risk for revision procedures greater for younger patients who undergo surgery. What is clearly needed are effective early management strategies that maximize function, maintain health and readiness for duty, while delaying or avoiding the need for invasive procedures. The Guidelines from the Departments of Veterans Affairs and Defense recommend early use of a core set of management strategies to include patient education on their condition and the role of obesity in disease progression, activity and lifestyle modification focusing on physical activity, and a therapeutic exercise program. Referral to physical therapy (PT) is recommended as a consideration to “augment the medical plan.” Implementation of the core set is recommended prior to any referral for consultation about invasive procedures such as intra-articular injections or TKA surgery. Little is known about the effectiveness and cost-effectiveness of early referral to PT alongside the core set of management strategies for knee OA. PT protocols for knee OA have been shown to be efficacious in clinical trials. Fewer have focused on active duty personnel diagnosed more recently. Prior studies have also failed to include a cost-effectiveness analyses to understand the policy implications of recommending early PT for patients in addition to the core set of management strategies. A rigorous study examining these questions is high priority. Our overall objective is to improve the non-surgical management of Service members who have been recently diagnosed with knee OA. More effective early management following diagnosis may afford the greatest opportunity to
Document Details
- Document Type
- DoD Grant Award
- Publication Date
- Oct 29, 2018
- Source ID
- W81XWH1810788
Entities
People
- Daniel I Rhon
Organizations
- San Antonio Military Medical Center
- United States Army