Sint Maartenskliniek, Nijmegen, The Netherlands.
Arthritis Care Res (Hoboken). 2014 Jun;66(6):817-27. doi: 10.1002/acr.22222.
To enhance guideline-based nonsurgical management of osteoarthritis (OA), a multidisciplinary stepped-care strategy has been implemented in clinical practice. This study aimed to describe health care use after implementation of this strategy and to identify factors related to such use at multiple levels.
For this 2-year observational prospective cohort, patients with symptomatic hip or knee OA were included by their general practitioner. Activities aligned with patients and health care providers were executed to implement the strategy. Health care use was described as the cumulative percentage of "users" for each modality recommended in the strategy. Determinants were identified at the level of the patient, general practitioner, and practice using backward stepwise logistic multilevel regression models.
Three hundred thirteen patients were included by 70 general practitioners of 38 practices. Their mean ± SD age was 64 ± 10 years and 120 (38%) were men. The most frequently used modalities were education, acetaminophen, lifestyle advice, and exercise therapy, which were used by 242 (82%), 250 (83%), 214 (73%), and 187 (63%) patients, respectively. Fourteen percent of the overweight patients reported being treated by a dietician. Being female, having an active coping style, using the booklet "Care for Osteoarthritis," and having limitations in functioning were recurrently identified as determinants of health care use.
After implementation of the stepped-care strategy, most recommended nonsurgical modalities seem to be well used. Health care could be further improved by providing dietary therapy in overweight patients and making more efforts to encourage patients with a passive coping style to use nonsurgical modalities.
为了加强骨关节炎（OA）的基于指南的非手术管理，已在临床实践中实施了多学科阶梯式护理策略。本研究旨在描述该策略实施后的医疗保健使用情况，并确定多个层面与这种使用相关的因素。
在这项为期 2 年的观察性前瞻性队列研究中，由全科医生纳入有症状的髋或膝关节 OA 患者。根据患者和医疗保健提供者的活动执行与策略一致的活动，以实施该策略。描述了根据策略中推荐的每种模式的累积“使用者”百分比来表示医疗保健使用情况。使用向后逐步逻辑多元回归模型确定患者、全科医生和实践层面的决定因素。
由 38 个实践中的 70 名全科医生纳入了 313 名患者。他们的平均年龄±标准差为 64±10 岁，120 名（38%）为男性。最常使用的模式是教育、对乙酰氨基酚、生活方式建议和运动疗法，分别有 242 名（82%）、250 名（83%）、214 名（73%）和 187 名（63%）患者使用。14%的超重患者报告接受了营养师的治疗。女性、积极的应对方式、使用“骨关节炎护理手册”和功能受限是反复确定的医疗保健使用的决定因素。
实施阶梯式护理策略后，大多数推荐的非手术模式似乎得到了很好的应用。通过为超重患者提供饮食疗法，并努力鼓励采用被动应对方式的患者使用非手术模式，可以进一步改善医疗保健。
