University of Miami School of Medicine, Miami, FL.
Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT.
J Arthroplasty. 2020 Feb;35(2):347-352. doi: 10.1016/j.arth.2019.08.051. Epub 2019 Aug 29.
The American Academy of Orthopaedic Surgeons (AAOS) has published evidence-based Clinical Practice Guidelines (CPGs) for the nonarthroplasty management of knee osteoarthritis (OA). The purpose of this study is to determine how closely our orthopedic providers adhered to the recommendations included in those CPGs.
We retrospectively reviewed 1096 consecutive ambulatory visits with primary diagnosis of knee OA at a single center. Demographic, radiographic, and treatment information was collected. The primary outcome was the frequency of agreement between our treatment recommendations and the AAOS CPGs. A secondary outcome was the associated costs of care.
The total number of interventions generated during the visits was 1955. Adherence to the AAOS guidelines was 65% (362/557), 60% (226/377), and 40% (413/1021) in new/never treated, new/previously treated, and return patients, respectively. Intra-articular injection with either corticosteroids or hyaluronic acid was the most common intervention (32%) followed by physical therapy (29%). As the severity of OA increased, adherence to the AAOS guidelines decreased (61%, 60%, 54%, and 49% for Kellgren-Lawrence grades I through IV, respectively). The estimated annual costs associated with our treatment recommendations were $2,403,543.18, of which $1,206,757.8 (50.2%) was supported by evidence. The most expensive treatment intervention was intra-articular hyaluronic acid injection, which carried a strong evidence against its use.
Adherence to the recommendations contained within the AAOS CPGs was modest regardless of the Kellgren-Lawrence grade or history of treatment. Given the size of the affected patient population, there is a need for uniformly accepted guidelines to clarify the role and timing of the different treatment interventions. CPGs should be combined with education, patient engagement, and shared decision-making to minimize variation in treatment patterns, improve patient outcomes, and lower overall costs of care.
美国骨科医师学会（AAOS）已经发布了针对膝关节骨关节炎（OA）非关节置换管理的循证临床实践指南（CPG）。本研究的目的是确定我们的骨科医生在多大程度上遵循了这些 CPG 中的建议。
我们回顾性分析了在一家单中心就诊的 1096 例膝关节 OA 初诊患者的连续门诊病历。收集了人口统计学、影像学和治疗信息。主要结局是我们的治疗建议与 AAOS CPG 之间的一致性频率。次要结局是相关的护理费用。
就诊期间共产生 1955 项干预措施。在新/从未治疗、新/之前治疗和复诊患者中，对 AAOS 指南的依从率分别为 65%（362/557）、60%（226/377）和 40%（413/1021）。关节内注射皮质类固醇或透明质酸是最常见的干预措施（32%），其次是物理治疗（29%）。随着 OA 严重程度的增加，对 AAOS 指南的依从率下降（Kellgren-Lawrence 分级 I 至 IV 分别为 61%、60%、54%和 49%）。与我们的治疗建议相关的估计年度费用为 2403543.18 美元，其中 1206757.8 美元（50.2%）有证据支持。最昂贵的治疗干预措施是关节内透明质酸注射，该治疗方法的使用证据很强。
无论 Kellgren-Lawrence 分级或治疗史如何，对 AAOS CPG 中建议的依从性都只是中等水平。鉴于受影响的患者人群规模庞大，需要有统一认可的指南来阐明不同治疗干预措施的作用和时机。CPG 应与教育、患者参与和共同决策相结合，以最大限度地减少治疗模式的差异，改善患者的治疗效果，并降低总体护理成本。
