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  • Study: Despite Guidelines for OA, Rates of Physician Referral to Physical Therapy Remained Low, Orthopedic Surgeon Narcotic Prescriptions Increased between 2007 and 2015

    In this review: Recommendation Rates for Physical Therapy, Lifestyle Counseling, and Pain Medications for Managing Knee Osteoarthritis in Ambulatory Care Settings
    (e-published ahead of print in Arthritis Care & Research, October 2019)

    The message
    Despite longstanding guidelines that recommend physical therapy and lifestyle changes over pharmacological approaches as a first line of treatment for knee osteoarthritis (OA), orthopedic surgeons and primary care physicians (PCPs) don't seem to be getting the message, according to researchers. If anything, they say, the situation deteriorated between 2007 and 2015, with orthopedic surgeons moving in the opposite direction from the guidelines, and PCPs making no significant changes apart from increasing a tendency to prescribe nonsteroidal antiinflammatory drugs (NSAIDs).

    The study
    Researchers reviewed data from National Ambulatory Medicare Care Surveys (NAMCS) administered between 2007 and 2015. The surveys, conducted by a branch of the US Centers for Disease Control and Prevention, focus on non-federally employed office-based physicians in direct patient care, and involve collection of data over a 1-week period, as well as practice visits and physician interviews.

    For the study, researchers focused on visits associated with a knee OA diagnosis, tracking whether the physician prescribed physical therapy, provided advice on exercise and/or weight reduction, or provided pain medications during the visit. The prescribed pain medications were categorized as NSAIDs, "narcotic analgesics," or "other." Researchers also tracked patient demographic data, as well as physician specialty, practice location, type, and ownership, among other characteristics.

    Researchers crunched the numbers to establish triennial rates of various recommendations during the 9-year study period. The results were based on 2,297 knee OA-related visits, which they approximated to about 8 million visits per year between 2007 and 2015. APTA members Samannaaz Khoja, PT, PhD; Gustavo Almeida, PT, PhD; and Janet Freburger, PT, PhD, coauthored the study.

    Findings

    • Authors found a "significant decline" in rates of physical therapy referral by orthopedic specialists, from 158 per 1,000 visits in 2007-2009 to 86 per 1,000 in 2013-2015. Lifestyle counseling also dropped, from 184 per 1,000 to 88. During the same 9-year period NSAID prescriptions increased from 132 per 1,000 visits 2007-2009 to 278 per 1,000 in 2013-2015. Even more concerning, prescription rates for narcotics tripled during the study period, from 77 per 1,000 visits in 2007-2009 to 236 per 1,000 by 2015.
    • Among PCPs, low initial rates of referral to physical therapy increased but remained low throughout the study period, moving from 26 per 1,000 visits to 46 per 1,000 visits. Recommendations for lifestyle changes remained about the same during the study period, ranging from 243/1,000 to 221. Researchers noted a slight uptick in prescriptions for narcotics (233 per 1,000 to 316 per 1,000), and a notable increase in NSAID prescriptions, from 221 per 1,000 visits in the 2007-2009 study period to 498 per 1,000 visits during 2013-2015.
    • Patients who visited an orthopedic specialist were more likely to be prescribed narcotics and NSAIDs if they were Hispanic, and more likely to receive a physical therapy referral if they were non-white and non-black. A decreased likelihood of receiving a physical therapy referral or lifestyle counseling was associated with orthopedic surgeons in rural areas.
    • In terms of referrals and prescriptions, patient demographics were not as much of a factor among patients who visited a PCP for knee OA, although there was a slightly higher likelihood of receiving narcotics among females and individuals who were black. Visits that included imaging were more likely to include narcotics prescriptions; visits covered by workers compensation were less likely to result in a prescription for NSAIDs.
    • Narcotic prescriptions were more likely among advanced practice orthopedic surgeons. That wasn't the case for PCPs.
    • The study sample was mostly white, female, and non-Hispanic, with an average age of 64. A chronic problem was the most common reason for the visit.

    Why it matters
    Knee OA is widely experienced, and its prevalence is on the rise, growing from an estimated 9 million individuals with the condition in 2005 to 15 million in 2012. Guidelines stressing the effectiveness of physical therapy and lifestyle modifications have been around since as far back as 1995, authors write, and the evidence supporting those recommendations has only increased. At the same time, the nation faces an opioid crisis at least partly linked to the use of prescription medications.

    Authors believe their study suggests a "counterintuitive" picture—"adherence to guideline-based care for non-pharmacological, non-surgical treatments such as [physical therapy], exercise, or weight loss is low for knee OA and does not seem to be improving over time." They write that "this contrasting trend suggests that knee OA is primarily managed from a perspective of symptom control and not from the perspective of improving physical function, fitness, and overall well-being."

    Related APTA resources
    The study's results are consistent with the policy recommendations in a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches. In addition, APTA offers a wide range of consumer-focused resources on pain and pain management at its ChoosePT.com website.

    APTA offers multiple resources to help physical therapists and physical therapist assistants develop community-based arthritis programs, including a reference guide to various programs, a consumer-focused webpage that helps patients and clients understand the importance of movement to address OA, and links to offerings from the US Bone and Joint Initiative, such as its "Experts in Arthritis" program. Further information is available at PTNow, including tests and clinical guidelines.

    Keep in mind…
    Authors write that because the study was based on visits and not the patient, the analysis may have missed referrals to physical therapy or counseling on lifestyle that was not a part of the NACMS data collection effort. The study was also limited by drug groupings that did not distinguish between types of opioids, and a lack of indicators for disease severity and degree of disability.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.