title: Inequalities in primary care management of knee pain and disability in older adults: an observational cohort study.
abstract: OBJECTIVE
  To describe primary care management of knee pain, in relation to National Institute for Health and Clinical Excellence (NICE) OA guidelines, and examine variation in management by patient characteristics.
  
  
  METHODS
  Subjects were 755 adults aged ≥50 years who responded to baseline and 3-year surveys and had consulted primary care for knee pain. Medical records (1997-2006) were searched. Associations of having interventions from the outer circle (adjunctive treatments or Step 3) of the NICE guidelines with self-reported socio-demographic and knee-specific factors were determined.
  
  
  RESULTS
  Eighty per cent had received a Step 3 intervention. Thirty-eight per cent had been referred to secondary care, and 10% had received a knee replacement. Forty-three per cent had been prescribed an opioid and 41% an NSAID. Severe knee pain or disability at baseline and follow-up was the main association with receiving a Step 3 intervention [adjusted odds ratio (OR) 2.26; 95% CI 1.38, 3.70] and with referral (OR 2.57; 95% CI 1.72, 3.83). Older patients were less likely to be referred. Although non-significant, those of higher social class, in more affluent areas, older age or overweight or obese, appeared more likely to receive a knee replacement. Fifty per cent of those reporting severe knee pain or disability in both surveys had not been referred to secondary care.
  
  
  CONCLUSIONS
  Most of the older adults who consult primary care with knee pain receive at least one Step 3 intervention from the OA guidelines. Inequalities in the management and referral of knee problems in primary care were generally not observed, although there were some trends towards differences in likelihood of total knee replacement.
authors: Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele ST5 5 BG, UK. c.jinks@cphc.keele.ac.uk
authors: Clare
authors: C
authors: Jinks
authors: Kanchan
authors: K
authors: Vohora
authors: Julie
authors: J
authors: Young
authors: June
authors: J
authors: Handy
authors: Mark
authors: M
authors: Porcheret
authors: Kelvin P
authors: KP
authors: Jordan
mesh_terms: D000368:Aged; D015331:Cohort Studies; D004185:Disability Evaluation; D006233:Persons with Disabilities; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D007719:Knee Joint / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D020370:Osteoarthritis, Knee / Q000453:epidemiology / Q000503:physiopathology / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D010146:Pain / Q000453:epidemiology / Q000503:physiopathology; D059408:Pain Management; D010147:Pain Measurement; D010342:Patient Acceptance of Health Care; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D006113:United Kingdom / Q000453:epidemiology