title: Effect of stepped care on health outcomes in patients with osteoarthritis: an observational study in Dutch general practice.
abstract: BACKGROUND
  A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands.
  
  
  OBJECTIVE
  To assess the association between care that is in line with the SCS recommendations and health outcomes.
  
  
  METHODS
  Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis.
  
  
  METHODS
  Care was considered 'SCS-consistent' if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0-100); active pain coping with the Pain Coping Inventory (range 10-40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12-48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations.
  
  
  RESULTS
  No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). This was also the case after adjusting for possible confounders, that is, -4.3 (95% confidence interval [CI] = -10.3 to 1.7) and -1.9 (95% CI = -7.0 to 3.1), respectively. Furthermore, no differences were found in changes over time between groups in self-efficacy and pain coping.
  
  
  CONCLUSIONS
  The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects.
authors.affiliation: Department of Rheumatology.
authors.forename: Agnes J
authors.initials: AJ
authors.lastname: Smink
authors.affiliation: Department of Rheumatology.
authors.forename: Cornelia H M
authors.initials: CH
authors.lastname: van den Ende
authors.affiliation: Departments of Rheumatology and Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Thea P M
authors.initials: TP
authors.lastname: Vliet Vlieland
authors.affiliation: Department of Rheumatology and Clinical Immunology, University Medical Center, Utrecht, the Netherlands.
authors.forename: Johannes W J
authors.initials: JW
authors.lastname: Bijlsma
authors.affiliation: Department of Orthopaedics, Sint Maartenskliniek, Nijmegen, the Netherlands.
authors.forename: Bart A
authors.initials: BA
authors.lastname: Swierstra
authors.affiliation: Dutch Patient Organization for Rheumatic Diseases, Amersfoort, the Netherlands.
authors.forename: Joke H
authors.initials: JH
authors.lastname: Kortland
authors.affiliation: Department of Primary and Community Care.
authors.forename: Theo B
authors.initials: TB
authors.lastname: Voorn
authors.affiliation: Department for Health Evidence, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands.
authors.forename: Steven
authors.initials: S
authors.lastname: Teerenstra
authors.affiliation: Department of Primary and Community Care.
authors.forename: Henk J
authors.initials: HJ
authors.lastname: Schers
authors.affiliation: Department of Rehabilitation Medicine, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Joost
authors.initials: J
authors.lastname: Dekker
authors.affiliation: Departments of General Practice and Orthopaedics, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Sita M A
authors.initials: SM
authors.lastname: Bierma-Zeinstra
mesh_terms: D000368:Aged; D000700:Analgesics; D001291:Attitude of Health Personnel; D037001:Directive Counseling / Q000706:statistics & numerical data*; D005260:Female; D058006:General Practice; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D010003:Osteoarthritis / Q000453:epidemiology / Q000628:therapy*; D059408:Pain Management / Q000379:methods*; D010353:Patient Education as Topic; D026741:Physical Therapy Modalities; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D011787:Quality of Health Care
chemical_list: D000700:Analgesics
keywords: general practice; osteoarthritis; outcome of care; stepped care strategy