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Factors associated with referral to secondary care in patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy.

Barten, D.J.A., Smink, A., Swinkels, I.C.S., Veenhof, C., Schers, H.J., Vliet Vlieland, T.P., Bakker, D.H. de, Dekker, J., Ende, C.H.M. van den. Factors associated with referral to secondary care in patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy. Arthritis Care and Research: 2017, 69(2), p. 216-225.
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Objective
We introduced a Stepped-Care-Strategy (SCS) for hip/knee osteoarthritis focusing on delivery of high quality, and stepped care. In this study, we aimed to identify factors associated with various steps of the SCS.

Methods
We used data from a two-year observational prospective cohort study, including 313 patients visiting their general practitioner (GP) with a new episode of hip/knee osteoarthritis. We used logistic multilevel analyses to identify factors at the level of the patient, the GP, and the general practice, related to 1) treatment limited to primary care, 2) referral to non-surgical secondary care, 3) surgical procedures.

Results
Patients whose treatment had been limited to primary care, tended to function physically better (OR1.03). Furthermore, they less often received exercise therapy (OR.46), intra-articular injections (OR.08), and radiological assessments (OR.06). Continuation of non-surgical care after referral was more likely in employed patients (OR2.90) and patients who had no exercise therapy (OR.19) nor non-steroidal anti-inflammatory drugs (OR.35). Surgically treated patients more often received exercise therapy (OR7.42). Referral and surgical treatment depend only to a limited extent on the GP or the general practice.

Conclusion
After implementation of the SCS in primary care, the performance of exercise therapy seems to play a key role in the decision whether or not to refer for (non)-surgical treatment in secondary care, rather than disease severity or psychological factors. To optimize patient-tailored treatment, future research should be adressed to determine the optimal moment of switch from primary to secondary care in patients with hip/knee osteoarthritis. (aut. ref.)