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Non-Arthroplasty Treatment of Osteoarthritis of the Knee

Sanders, James O. MD; Murray, Jayson MA; Gross, Leeaht MPH

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: April 2014 - Volume 22 - Issue 4 - p 256–260
doi: 10.5435/JAAOS-22-04-256
AAOS Appropriate Use Criteria Summary

The American Academy of Orthopaedic Surgeons has developed an Appropriate Use Criteria (AUC) on the Non-Arthroplasty Treatment of Osteoarthritis of the Knee (OAK). Evidence-based information, in conjunction with clinical expertise of physicians, was used to develop the criteria to improve patient care and obtain best outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The OAK AUC clinical scenarios were derived from patient indications that generally accompany OAK as well as from the current evidence-based clinical practice guidelines and its supporting literature. The 576 patient scenarios and 10 treatments were developed by the Writing Panel, a group of clinicians who are specialists in this AUC topic. Next, the Review Panel, a separate group of volunteer physicians, independently reviewed these materials to ensure that they were representative of patient scenarios clinicians are likely to encounter in daily practice. Finally, the multidisciplinary Voting Panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as Appropriate (median rating, 7 to 9), May Be Appropriate (median rating, 4 to 6), or Rarely Appropriate (median rating, 1 to 3). The final appropriateness ratings assigned by the voting panel can be accessed online via the AAOS OAK AUC web-based mobile application at: www.aaos.org/aucapp.

From the Department of Orthopaedics, University of Rochester, Rochester, NY (Dr. Sanders), and the American Academy of Orthopaedic Surgeons, Rosemont, IL (Mr. Murray and Ms. Gross).

Dr. Sanders or an immediate family member has stock or stock options held in Abbott, AbbVie, GE Healthcare, and Hospira, and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the Pediatric Orthopaedic Society of North America, and the Scoliosis Research Society. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Mr. Murray and Ms. Gross.

These appropriate use criteria were approved by the American Academy of Orthopaedic Surgeons on December 6, 2013.

The complete Appropriate Use Criteria for Non-Arthroplasty Treatment of Osteoarthritis of the Knee includes all tables, figures, and appendices, and is available at http://www.aaos.org/research/Appropriate_Use/oakaucfull.pdf. The OAK AUC content is also available in a web-based mobile app and can be accessed at the following address: www.aaos.org/aucapp.

Non-Arthroplasty Treatment of Osteoarthritis of the Knee AUC Writing Panel: David F. Dalury, MD, Craig J. Della Valle, MD, Mark I. Ellen, MD, Eric P. Gall, MD, MACP, MACR, Brian J. McGrory, MD, Jennifer Stevens-Lapsley, PT, PhD, and AJ Yates, Jr, MD. Review Panel: Miguel A. Ayerza, MD, PhD, Santiago de Solo, MD, Robin Dore, MD, G. Kelley Fitzgerald, PT, PhD, FAPTA, E. Robert Harris, MD, Richard Haynes, MD, William M. Jones, MD, Jeffrey Katz, MD, Kent Kwoh, MD, Amanda Nelson, MD, Lee Rosenzweig, PT, DPT, CHT, James A. Shaw, MD, Jasvinder Singh, MD, Mark Spangehl, MD, Audrey Tsao, MD, and Joseph Zeni, PT, PhD. Voting Panel: Joel Block, MD, Pablo Castaneda, MD, Dennis Chin, MD, T. Derek V. Cooke, MA, MB, BChir, FRCS(C), Charles M. Davis III, MD, PhD, Yvonne Golightly, PT, MS, PhD, T. David Hayes, MD, Kenneth Jaffe, MD, Nancy E. Lane, MD, Brian McCardel, MD, Arvind D. Nana, MD, MBA, Harold W. Rees, MD, Peter F. Sharkey, MD, Terence W. Starz, MD, Kimberly Templeton, MD, and Kevin R. Vincent, MD, PhD. Moderators: James O. Sanders, MD, and Michael Heggeness, MD. AAOS Staff: Deborah S. Cummins, PhD, Jayson Murray, MA, Ryan Pezold, MA, Patrick Donnelly, MA, Anne Woznica, MLS, Leeaht Gross, MPH, and Yasseline Martinez.

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Overview and Rationale

This Appropriate Use Criteria (AUC) was approved by the American Academy of Orthopaedic Surgeons (AAOS) Board of Directors on December 6, 2013. The purpose of the AUC is to help determine the appropriateness of treatments of the heterogeneous patient population routinely seen in practice. The best available scientific evidence is synthesized with collective expert opinion on topics for which gold standard randomized clinical trials are not available or are inadequately detailed for identifying distinct patient types. AAOS staff convened three independent volunteer clinician panels that developed this AUC.

Musculoskeletal care is provided in many settings by different providers. AAOS created this AUC as an educational tool to guide qualified physicians through a series of treatment decisions in an effort to improve the quality and efficiency of care. These criteria should not be construed as including all indications or excluding indications reasonably directed to obtaining the same results. The criteria intend to address the most common clinical scenarios facing all appropriately trained surgeons and all qualified physicians managing patients under consideration for managing osteoarthritis of the knee (OAK). The ultimate judgment regarding any specific criteria should address all circumstances presented by the patient and the needs and resources particular to the locality or institution. The Non-Arthroplasty Treatment of Osteoarthritis of the Knee developed appropriateness treatment ratings for 576 patient scenarios. The OAK AUC can be accessed via a web-based mobile application at www.aaos.org/aucapp.

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Potential Harms and Contraindications

Individuals with OAK often report joint pain, stiffness, and difficulty with purposeful movement. The aim of treatment is to provide pain relief and improve the patient’s functioning. Most interventions are associated with some potential for adverse outcomes, especially if invasive or operative. Contraindications vary widely by procedure. Reducing risks improves treatment efficacy and is accomplished through collaboration between patient and physician.1

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Methods

The AAOS uses the RAND/UCLA Appropriateness Method2 to develop AUCs. The process includes the following steps:

  1. Constructing a writing panel consisting of 6 to 10 clinicians who are experts in the topic under study to create a list of patient indications, assumptions, and treatments based on an evidence-based systematic review of the literature conducted by AAOS staff research analysts;
  2. Constructing a review panel consisting of 10 to 30 clinicians to review the writing panel’s materials and provide any suggestions for improvement;
  3. Constructing a multidisciplinary voting panel who uses a review of the most current and relevant literature along with their expert clinical judgment to rate the appropriateness of treatment of various patient scenarios.

General assumptions were developed by the OAK AUC panel members to clarify the interpretation of the patient scenarios and provide standardization for the parameters used to rate the appropriateness of treatment. This AUC was approved by the Appropriate Use Criteria Section of the Committee on Evidence-Based Quality and Value, the Council on Research and Quality, and the AAOS Board of Directors. All tables, figures, and appendices, as well as the details of the methods used to prepare this AUC, are detailed in the full AUC, which is available at www.aaos.org/auc.

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OAK AUC Patient Indications and Classifications

Table 1 provides the list of patient indications and classifications developed by the OAK AUC Writing Panel. Definitions of the patient indication classifications are indicated below.

Table 1

Table 1

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OAK AUC Covered Treatments

Table 2 provides treatments rated for appropriateness in the non-arthroplasty management of OAK.

Table 2

Table 2

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Results of Appropriateness Ratings

Out of 5,760 total voting items (ie, 576 patient scenarios and 10 treatments), 1,021 voting items (18%) were rated as Rarely Appropriate, 1,698 voting items (29%) were rated as May Be Appropriate, and 3,041 voting items (53%) were rated as Appropriate (Figure 1). Additionally, the voting panel members were in agreement on 2,048 voting items (36%) and were in disagreement on 184 voting items (3%). There were three treatments about which the voting panel had at least one disagreement: Hinged Knee Brace and/or Unloading Brace (73/576 within treatment voting items with disagreement), Arthroscopic Partial Meniscectomy or Loose Body Removal (95/576 within treatment voting items with disagreement), and Realignment Osteotomy (16/576 within treatment voting items with disagreement). The final appropriateness ratings assigned by the voting panel can be accessed online via the AAOS OAK AUC web-based mobile application at: www.aaos.org/aucapp.

Figure 1

Figure 1

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AUC Mobile Application

As part of the dissemination efforts for the OAK AUC, a web-based mobile application has been developed to provide physicians with immediate access to information to assist them with providing evidence-based patient care. The mobile application includes the list of patient indications and treatment recommendations. Once the clinician enters in a patient indication profile, a list of treatment recommendations is provided. For the selected patient profile, green circled checkmarks reflect appropriate treatments, yellow caution symbols reflect treatments that may be appropriate, and red circled X’s reflect treatments that are rarely appropriate (Figure 2). The app also includes a demonstration (“tour”), definitions, background information, assumptions, a literature review, and a list of contributors. The AAOS OAK AUC web-based mobile application is available at www.aaos.org/aucapp.

Figure 2

Figure 2

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References

1. American Academy of Orthopaedic Surgeons: The Burden of Musculoskeletal Diseases in the United States. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2008.
2. Fitch K, Bernstein SJ, Aguilar MD, et al.: The RAND/UCLA Appropriateness Method User's Manual. Santa Monica, CA, RAND Corporation, 2001.
© 2014 by American Academy of Orthopaedic Surgeons