Healthcare Services Utilisation in Portugal
In this study, we identified three profiles of healthcare utilisation according to the services most used by the participants with knee OA. The profile with the highest healthcare utilisation – HighUsers, represents more than 35% of the sample and was characterised by participants with appointments with the GP, orthopaedic surgeon, physiotherapy sessions and/or with hospitalisation. Given the high number of other medical appointments, this profile is possibly responsible for a high proportion of the total costs spent with people with knee OA in Portugal. As Warwick et al. (2020) concluded, analysing an insurance database with more than 40 000 of people with knee OA, the top 30% of high-payment patients with OA accounted for more than 70% of overall non-arthroplasty payments (26).
Primary care is considered the most relevant setting for prevention and management of knee OA, where the conservative non-pharmacological interventions should be considered early, and throughout the progression of the disease (8, 9). However, in our sample, few participants were enrolled in physiotherapy or regular exercise programmes and a high proportion were overweight. The study of Østeras et al. (2015) found similar data, when analysing a sample of Portuguese people with knee OA in primary healthcare: only 20% of participants were referred to weight management programmes, and only 43% were referred to physical exercise programmes, in a similar fashion to other European countries included (27). However, in our sample, the proportion of participants who had undergone physiotherapy treatments (14.4%) was much lower compared to the 39%-52% observed, for example, in the UK (28). Overall, this data may suggest a weak adoption of the core recommended interventions for the management of knee OA, and possibly, be responsible for suboptimal outcomes and higher health costs, in Portugal. Moreover, Bedard et al. (2017) estimated that if health professionals followed current clinical practice guidelines, the non-inpatient costs with OA would decrease by 45% (29). This data should sufficiently alarm health politicians regarding the need for the implementation of effective and recommended modalities in the management of people with knee OA at a national level.
Determinants for Healthcare Services Utilisation
Overall, the characteristics of our sample are similar to other data related to people with multimorbidity and the older adult population in Portugal, namely given the high proportion of people with lower education, high proportion being overweight or obese, and physically inactive (5, 30).
Our findings show that, regardless of clinical need, predisposing characteristics and enabling factors such as age, geographic location, health insurance and employment status, play an important role in healthcare utilisation. This data may disclose that, possibly, the current management of knee OA is heterogenous, not consistent with the needs of the patients, and also, highlights possible inequities in the access of health care (16).
In our analysis, younger and employed participants were positively associated with HighUsers profile. Unlike the data related to general older adults population in Portugal (31), evidence suggests that older adults with knee OA are less likely to be referred to specialised services, like an orthopaedic surgeon, rheumatologist (32) or to physiotherapy (28). Qualitative data suggests that GP’s often consider OA as a normal consequence of ageing, attributing low importance to this condition in older adults (33). In contrast, knee OA is associated with work-related disability, absenteeism, early retirement, psychological distress and low HRQoL in younger patients (4, 34). Thus, employed or younger adults with knee OA seem to behave more proactively in seeking help and their physical limitations are generally taken more seriously by GP’s, with higher referral rates and consequently, a higher utilisation of healthcare services (33).
Our findings also suggest that geographic location is a determinant to healthcare services utilisation, namely the Islands and Centre region. Both of these regions are far from city centres, with higher proportion of older, less educated and poorer people. These regions experience a shortage of medical specialists such as orthopaedic surgeons. Moreover, Madeira and Azores are underserved by primary care units (35). International data suggests that the distance from healthcare units, lack of transport and consequent isolation, and the perception of OA as self-limited condition, may prevent people from rural areas of seeking healthcare services timely, with lower healthcare resources utilisation as consequence (36, 37).
Participants with additional healthcare coverage were more likely to be HighUsers, suggesting that the NHS may not provide optimal access to the appropriate interventions according to the patients’ needs, or that the facilitation of access to private sector may enhance the utilisation of healthcare services, regardless of the severity of the disease (38). In accordance with our study, private health insurance was the most frequently cited enabler in Australia for surgical and conservative OA treatments, such as physiotherapy (39).
Overall, our findings suggest that the delivery of healthcare for Portuguese people with knee OA may be inefficient and unfair, where people with better predisposing and enabling features consume a higher amount of healthcare services, than people without those features. Our findings, with the support of the presented literature, should raise concerns regarding the need to tackle health access inequities in Portugal. In this way, the organisation of the health system should guarantee that people with OA receive effective interventions according to clinical severity, and not according to sociodemographic factors.
For predisposing variables, our findings showed that the number of comorbidities is associated with higher healthcare utilisation profiles, mainly with GPUsers profile, as well as anxiety symptoms. People with OA visit primary care mostly in case of multimorbidity (40). However, evidence shows that, in people with OA and multimorbidity, joint pain is often seen as a low priority problem, brought up late in the consultation, with low referral rates to physiotherapy or specialised care targeted to OA (40, 41). This information may explain the stronger association of number of comorbidities with GPUsers profile, than with HighUsers. Regarding anxiety symptoms, contradictory data was found in literature. Anxiety is associated both negatively and positively with the utilisation of healthcare services (42, 43). However, it is well known that mental health comorbidities, like anxiety and depression, as well as cardiovascular and metabolic comorbidities are associated with higher severity symptoms and poor outcomes in people with OA (43, 44). Thus, the management of people with OA, especially with anxiety and/or multimorbidity, should be multidisciplinary personalised and targeted (8, 9), which would justify a higher utilisation of healthcare, mostly specialised services, partly in contrast to our data. Thus, we may argue that this subpopulation of patients with knee OA is undertreated in Portugal, recognising the urge to organise services across healthcare sectors to pursue the delivery of recommended and more effective interventions, mainly to people with poor prognosis.
In our study, physical inactivity was associated with both profiles of higher healthcare utilisation. Sedentary behaviour and being overweight in people with knee OA is associated with worst physical function, higher risk of cardiovascular comorbidities (7), higher healthcare consumption and higher health-related costs (45). Barriers to physical exercise have been identified in literature that justify the low adherence of patients, namely the misbeliefs of health professionals regarding exercise and physiotherapy (46).
As expected, low levels of physical function and HRQoL are associated with HighUsers. A 10-year UK survey reported that disability was the strongest predictor for referral to specialised care and for TKR in people with knee pain (32). Similarly to our data, worse physical function, associated comorbidities, and also radiologic severity were also associated with higher direct and indirect costs in a Spanish survey (47). From another point of view, our data could suggest that people with higher healthcare utilisation in the previous 12 months, do not have better physical function, better quality of life or are undertaking of physical exercise, thus, higher healthcare utilisation does not necessarily reflect better outcomes.
Strengths and Limitations
This is the first study in Portugal analysing the health services utilisation by people with knee OA at a national level. The large sample, the multi-domains of the dataset and its framing on Andersen’s model, provides a comprehensive view of the current healthcare utilisation profiles and its determinants.
Nevertheless, it has some limitations. The cross-sectional design does not does not allow the establishment of a temporal relationship between determinants and healthcare utilisation; thus, cause and effect can be overestimated mainly in modifiable variables like physical function or HRQoL.
Behavioural variables for healthcare utilisation were not controlled. The physical activity variable did not take into account the amount of time spent per week, neither its intensity, thus our results may be, even so, overestimated comparing to the recommendations for physical activity. Public or private appointments, were not distinguished, which could increase the importance of predisposing characteristics and enabling factors in the variance of healthcare utilisation. As self-reported healthcare utilisation relates to the previous 12 months, we acknowledge the possibility of memory bias. The reason for medical appointments or physiotherapy attendance was not controlled, which could increase the association of healthcare insurance with the utilisation of health services. The data used was collected in 2011–2013 but, due to the few specific strategies directed to musculoskeletal diseases in the last decade in Portugal, we cautiously believe that the actual management of OA does not differ from this study.