title: Factors Associated With Referral to Secondary Care in Patients With Osteoarthritis of the Hip or Knee After Implementation of a Stepped-Care Strategy.
abstract: We introduced a stepped-care strategy (SCS) for hip and knee osteoarthritis, focusing on delivery of high-quality stepped care. In this study, we aimed to identify factors associated with various steps of the SCS.
  
  
  
  We used data from a 2-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 treatment limited to primary care, referral to nonsurgical secondary care, or surgical procedures.
  
  
  
  Patients whose treatment had been limited to primary care tended to function physically better (odds ratio [OR] 1.03). Furthermore, they less often received exercise therapy (OR 0.46), intraarticular injections (OR 0.08), and radiologic assessments (OR 0.06). Continuation of nonsurgical care after referral was more likely in employed patients (OR 2.90) and patients who had no exercise therapy (OR 0.19) or nonsteroidal antiinflammatory drugs (OR 0.35). Surgically treated patients more often received exercise therapy (OR 7.42). Referral and surgical treatment depended only to a limited extent on the GP or the general practice.
  
  
  
  After implementation of the SCS in primary care, the performance of exercise therapy, rather than disease severity or psychologic factors, seems to play a key role in the decision whether or not to refer for surgical or nonsurgical treatment in secondary care. To optimize patient-tailored treatment, future research should be adressed to determine the optimal moment of switching from primary to secondary care in patients with hip/knee osteoarthritis.
authors.affiliation: Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
authors.forename: Di-Janne J A
authors.initials: DJ
authors.lastname: Barten
authors.affiliation: Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands.
authors.forename: Agnes
authors.initials: A
authors.lastname: Smink
authors.affiliation: Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
authors.forename: Ilse C S
authors.initials: IC
authors.lastname: Swinkels
authors.affiliation: University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Cindy
authors.initials: C
authors.lastname: Veenhof
authors.affiliation: Radboud University Nijmegen Medical Centre, Nijmegen, Gelderland, The Netherlands.
authors.forename: Henk J
authors.initials: HJ
authors.lastname: Schers
authors.affiliation: University Medical Center Leiden, Leiden, The Netherlands.
authors.forename: Thea
authors.initials: T
authors.lastname: Vliet Vlieland
authors.affiliation: Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
authors.forename: Dinny H
authors.initials: DH
authors.lastname: de Bakker
authors.affiliation: VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Joost
authors.initials: J
authors.lastname: Dekker
authors.affiliation: Sint Maartenskliniek, Nijmegen, Gelderland, The Netherlands.
authors.forename: Cornelia H M
authors.initials: CH
authors.lastname: van den Ende
mesh_terms: D000368:Aged; D000465:Algorithms; D019643:Arthroplasty, Replacement / Q000706:statistics & numerical data; D015331:Cohort Studies; D005081:Exercise Therapy / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015207:Osteoarthritis, Hip / Q000628:therapy*; D020370:Osteoarthritis, Knee / Q000628:therapy*; D011320:Primary Health Care; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data; D063127:Secondary Health Care / Q000706:statistics & numerical data*; D013038:Specialization