The effect of stepped care on health outcomes in patients with osteoarthritis : an observational study chapter 7

Background We developed the stepped care strategy (SCS) to improve adequate health care use in patients with osteoarthritis (OA) and implemented it in a primary care region in the Netherlands. Aim To assess the association between care that is in line with the SCS-recommendations and health outcomes. Design and setting We used data from the 2-year observational study with 313 patients who had consulted their general practitioner (GP) due to OA. Method We considered care SCS-consistent if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. We measured pain and physical function with the Western Ontario and McMaster Universities Osteoarthritis index (range 0-100); active pain coping with the Pain Coping Inventory (range 10-40); self-efficacy with the Dutch General Self-Efficacy Scale (range 12-48). We estimated crude and adjusted associations between SCS-consistent care and outcomes with generalized estimating equations. Results We found no statistically significant differences in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n=163) and patients who received SCS-consistent care (n=117), also after adjusting for possible con-founders, i.e.-4.3 (-10.3 to 1.7) and-1.9 (-7.0 to 3.1) respectively. Furthermore, we found no differences in changes over time between groups in self-efficacy and pain coping. Conclusion Our results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons for GPs to provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side-effects. abstract 111 effect of the stepped care strategy on health outcomes How this fits in We developed a stepped care strategy (SCS) to improve the management of hip and knee osteoarthritis (OA). We assumed that that implementation of this strategy in primary care would ultimately improve patients' health outcomes. This study describes the changes in different health outcomes in patients with hip or knee OA after its implementation in clinical practice. Although, we could not demonstrate that SCS-consistent care results is associated with better health outcomes at two years after implementation, our results raise several important issues that need to be considered when bringing the SCS in clinical practice and in further research regarding the additional value of the SCS.