Contextualizing Osteoarthritis Care and the Reasons for the Gap Between Evidence and Practice
Section snippets
Best practice guidelines for the management of osteoarthritis
Osteoarthritis (OA) is not an easy condition to manage. It is very heterogeneous, has an unpredictable natural history, and has variable effects on health status. As it primarily affects older adults it is often associated with comorbidities that have significant effects on its impact.1, 2 In addition, there is a wide range of management options available to patients and their health care advisors.3, 4, 5
Guidelines should help clinicians through this complexity. By synthesizing the best
The NICE guidelines on the management of osteoarthritis
There is clear consensus in the literature that empowering self-management alongside help with understanding the condition, encouraging general fitness and moderate activity, keeping muscles strong, and losing weight if obesity is present are the mainstays of the management of OA.3, 4, 5, 7, 11 Interventions that require medical supervision and/or have potential adverse effects should only be used if these measures are insufficient, and if the patient wants them. Within the NICE guideline these
Contextualizing care
NICE strongly emphasizes that management needs to be both individualized and patient-centered.11 This requires an “holistic” approach with careful patient assessment, taking into account a variety of other variables, including:
- 1.
OA-related factors (eg, the site and number of joints involved, the severity of joint damage, and any associated muscle weakness or periarticular problems)
- 2.
Person-specific factors (eg, age, sex, ethnicity, socioeconomic and educational status, activity requirements,
The gap between evidence and practice
Useful guidelines that exist for the management of people with OA should help health care practitioners deal with the complexity of the condition and their patients. However, there is good evidence that the management of OA remains poor and that most people who seek help for this condition are not managed in accordance with the best practice guidance available.15, 16, 17, 18 Therefore there is, in the management of OA as in so many other chronic diseases, a gap between what evidence-based
The 3 pillars of best practice
One of the reasons for the gap is that recommendations for best practice often focus on just 1 or 2 of the 3 pillars of best practice, which are:
- 1.
Research evidence (including clinical trials)
- 2.
The experienced practitioners' expert opinion and advice
- 3.
The patients' opinion and experience.
All 3 need to have equal weight if we are to claim that we have genuine “best practice” (Fig. 2).14
As discussed below, guidelines can only do full justice to the research-based evidence.
The pathway from research-based evidence to best practice
There is a complex pathway between the production of the evidence base to the optimum management of the patient, as shown in Fig. 3. There are serious problems within each step in the process, contributing to the gap between evidence and practice. Some of these problems are now briefly summarized.
Comorbidity and complexity
These aspects of OA were mentioned in the first paragraph of this article, and they represent another major barrier to the implementation of good management in OA, and possible explanation of the gap between evidence and practice.
OA is a disease of older people. It is associated with obesity (and therefore diabetes, hypertension, and other associated disorders), as well as other age-related conditions including cardiovascular disease, reduced renal function, and sensory deficits. Many older
The art of medicine and the context of care
The “art of medicine” involves good communication, compassion, and caring. It is about individualizing treatment and finding the person behind the patient, and is centered around the clinical encounter between patient and health care professional.46, 47
Good communication allows the health care professional to find out what matters most to an individual, and to treat them as a whole person rather than someone with a disease (or set of diseases). As an example, based on data quoted earlier,
A way forward: contextualizing osteoarthritis care
OA is common and important—people with it deserve the best available help.There are two sides to that: The patient: self-management and taking responsibility is as important as anything that the health care professionals can offer. The health care professionals: they need to realize the shortcomings of EBM and guidelines in the management of complexity and comorbidities in older people, and to understand the importance of context, communication, and caring.
This means that we need a different framework and model for the care
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