Decreasing the number of arthroscopies in knee osteoarthritis - a service evaluation of a de-implementation strategy

Use of Implementation Strategies to Promote the Uptake of Knee Osteoarthritis Practice Guidelines and Improve Patient Outcomes: A Systematic Review

OBJECTIVE

Translation of knee osteoarthritis (KOA) clinical practice guidelines (CPGs) to practice remains suboptimal. The primary purpose of this systematic review was to describe the use of implementation strategies to promote KOA CPG-recommended care.

METHODS

Medline (via PubMed), Embase, CINAHL, and Web of Science were searched from inception to February 23, 2023, and the search was subsequently updated and expanded on January 16, 2024. Implementation strategies were mapped per the Expert Recommendations for Implementing Change taxonomy. Risk of bias (RoB) was assessed using the Cochrane Effective Practice and Organisation of Care criteria. The review was registered prospectively (PROSPERO identifier: CRD42023402383).

RESULTS

Nineteen studies were included in the final review. All (100% [n = 4]) studies that included the domains of "provide interactive assistance," "train and educate stakeholders" (89% [n = 16]), "engage consumers" (87% [n = 13]), and "support clinicians" (79% [n = 11]) showed a change to provider adherence. Studies that showed a change to disability included the domains of "train and educate stakeholders," "engage consumers," and "adapt and tailor to context." Studies that used the domains "train and educate stakeholders," "engage consumers," and "support clinicians" showed a change in pain and quality of life. Most studies had a low to moderate RoB.

CONCLUSION

Implementation strategies have the potential to impact clinician uptake of CPGs and patient-reported outcomes. The implementation context, using an active learning strategy with a patient partner, restructuring funding models, and integrating taxonomies to tailor multifaceted strategies should be prioritized. Further experimental research is recommended to determine which implementation strategies are most effective.

A tailored intervention does not reduce low value MRI's and arthroscopies in degenerative knee disease when the secular time trend is taken into account: a difference-in-difference analysis

PURPOSE

To evaluate the effectiveness of a tailored intervention to reduce low value MRIs and arthroscopies among patients ≥ 50 years with degenerative knee disease in 13 Dutch orthopaedic centers (intervention group) compared with all other Dutch orthopaedic centers (control group).

METHODS

All patients with degenerative knee disease ≥ 50 years admitted to Dutch orthopaedic centers from January 2016 to December 2018 were included. The tailored intervention included participation of clinical champions, education on the Dutch Choosing Wisely recommendation for MRI's and arthroscopies in degenerative knee disease, training of orthopaedic surgeons to manage patient expectations, performance feedback, and provision of a patient brochure. A difference-in-difference analysis was used to compare the time trend before (admitted January 2016-June 2017) and after introduction of the intervention (July 2017-December 2018) between intervention and control hospitals. Primary outcome was the monthly percentage of patients receiving a MRI or knee arthroscopy, weighted by type of hospital.

RESULTS

136,446 patients were included, of whom 32,163 were treated in the intervention hospitals. The weighted percentage of patients receiving a MRI on average declined by 0.15% per month (β =  - 0.15, P < 0.001) and by 0.19% per month for arthroscopy (β =  - 0.19, P < 0.001). However, these changes over time did not differ between intervention and control hospitals, neither for MRI (β =  - 0.74, P = 0.228) nor arthroscopy (β = 0.13, P = 0.688).

CONCLUSIONS

The extent to which patients ≥ 50 years with degenerative knee disease received a MRI or arthroscopy declined significantly over time, but could not be attributed to the tailored intervention. This secular downward time trend may reflect anoverall focus of reducing low value care in The Netherlands.

LEVEL OF EVIDENCE

III.

ARthroscopy in Knee OsteoArthritis (ARK-OA): a multicentre study assessing compliance to national guidelines

INTRODUCTION

The use of arthroscopy to alleviate the symptoms of osteoarthritis has been questioned by recent high quality evidence. This has led to the development of guidelines by specialist and national bodies advocating against its use.

AIMS

To examine the trends of the rates of arthroscopy in patients with knee osteoarthritis over the past five years and determining compliance with guidelines.

METHODS

Multi-centre, retrospective audit in five hospital trusts in the United Kingdom. The number of arthroscopies performed by month from 2013 to 2017 was identified through hospital coding. Fifty randomly selected records from the year 2017 were further analysed to assess compliance with NICE guidelines.

RESULTS

Between 2013 and 2017, the number of arthroscopies performed annually in five trusts dropped from 2028 to 1099. In the year 2017, 17.7% of patients with no mechanical symptoms and moderate-to-severe arthritis pre-operatively had arthroscopy.

CONCLUSION

Knee arthroscopy continues to be used as a treatment for osteoarthritis, against national guidelines. Whilst overall numbers are declining, further interventions, including implementation of high-quality conservative care is required to further eliminate unnecessary procedures.