title: Health care use of patients with osteoarthritis of the hip or knee after implementation of a stepped-care strategy: an observational study.
abstract: OBJECTIVE
  To enhance guideline-based nonsurgical management of osteoarthritis (OA), a multidisciplinary stepped-care strategy has been implemented in clinical practice. This study aimed to describe health care use after implementation of this strategy and to identify factors related to such use at multiple levels.
  
  
  METHODS
  For this 2-year observational prospective cohort, patients with symptomatic hip or knee OA were included by their general practitioner. Activities aligned with patients and health care providers were executed to implement the strategy. Health care use was described as the cumulative percentage of "users" for each modality recommended in the strategy. Determinants were identified at the level of the patient, general practitioner, and practice using backward stepwise logistic multilevel regression models.
  
  
  RESULTS
  Three hundred thirteen patients were included by 70 general practitioners of 38 practices. Their mean ± SD age was 64 ± 10 years and 120 (38%) were men. The most frequently used modalities were education, acetaminophen, lifestyle advice, and exercise therapy, which were used by 242 (82%), 250 (83%), 214 (73%), and 187 (63%) patients, respectively. Fourteen percent of the overweight patients reported being treated by a dietician. Being female, having an active coping style, using the booklet "Care for Osteoarthritis," and having limitations in functioning were recurrently identified as determinants of health care use.
  
  
  CONCLUSIONS
  After implementation of the stepped-care strategy, most recommended nonsurgical modalities seem to be well used. Health care could be further improved by providing dietary therapy in overweight patients and making more efforts to encourage patients with a passive coping style to use nonsurgical modalities.
authors.affiliation: Sint Maartenskliniek, Nijmegen, The Netherlands.
authors.forename: Agnes J
authors.initials: AJ
authors.lastname: Smink
authors.forename: Joost
authors.initials: J
authors.lastname: Dekker
authors.forename: Thea P M
authors.initials: TP
authors.lastname: Vliet Vlieland
authors.forename: Bart A
authors.initials: BA
authors.lastname: Swierstra
authors.forename: Joke H
authors.initials: JH
authors.lastname: Kortland
authors.forename: Johannes W J
authors.initials: JW
authors.lastname: Bijlsma
authors.forename: Steven
authors.initials: S
authors.lastname: Teerenstra
authors.forename: Theo B
authors.initials: TB
authors.lastname: Voorn
authors.forename: Sita M A
authors.initials: SM
authors.lastname: Bierma-Zeinstra
authors.forename: Henk J
authors.initials: HJ
authors.lastname: Schers
authors.forename: Cornelia H M
authors.initials: CH
authors.lastname: van den Ende
mesh_terms: D000223:Adaptation, Psychological; D000368:Aged; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use; D003131:Combined Modality Therapy; D019091:Critical Pathways / Q000706:statistics & numerical data*; D017723:Drug Utilization Review; D005081:Exercise Therapy / Q000706:statistics & numerical data; D005260:Female; D058006:General Practice; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D006295:Health Resources / Q000706:statistics & numerical data*; D006302:Health Services Research; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D051346:Mobility Limitation; D016017:Odds Ratio; D015207:Osteoarthritis, Hip / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D020370:Osteoarthritis, Knee / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D050177:Overweight / Q000503:physiopathology / Q000523:psychology / Q000628:therapy; D010348:Patient Care Team / Q000706:statistics & numerical data*; D010353:Patient Education as Topic; D015397:Program Evaluation; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data; D040242:Risk Reduction Behavior; D012737:Sex Factors; D013997:Time Factors; D016896:Treatment Outcome; D015431:Weight Loss
chemical_list: D018712:Analgesics, Non-Narcotic; D000894:Anti-Inflammatory Agents, Non-Steroidal