General findings
Our study shows that only about half of the QIs for OA care are achieved and that patients are moderately satisfied with the quality of OA care. Achievement of individual QIs differed strongly, with referral for weight reduction least often achieved and receiving advice on managing/living with osteoarthritis most often. Moreover, none of the QIs exceed a 75% pass rate. Associations were found between summary QI pass rates and presence of OA in other joints, presence of comorbidities and having a knee replacement. In addition, having had contact with several healthcare professionals in the last year was also a related to QI summary pass rates. Lastly, the majority of participants wanted to see change in the care for KOA in terms of more information and education, and better alignment and tailoring of care.
Comparison with literature
The overall QI pass rate in the present study was similar to the patient-reported OA-QI achievement rates in primary healthcare in the UK [23], lower than in the US [22], and higher than in Canada [24, 27], Denmark [23], Portugal [23] and Norway [25, 26]. On the basis of these observations one might conclude that the quality of care for KO in the Netherlands is satisfactory. However, comparing QI pass rates should be done with caution because the study samples, settings and methods may differ, as well as healthcare systems and access to OA care across countries. For instance, in the Netherlands the general practitioner acts as a gatekeeper for referral to secondary care services such as an orthopaedic surgeon, whereas other services such as dietary or physical therapy are freely accessible.
Our results suggest that little progress has been made in the past four years in the improvement of quality of care in the Netherlands as our results are comparable with the 2016 report on rheumatology care in the Netherlands [40], which concluded that although individuals with OA are generally satisfied with the quality of OA care, there was still room for improvement. In line with previous studies, our findings reveal that core elements of treatment are sub optimally utilized in daily practice. Pass rates of QIs reflecting provision of education and support in self-management performed relatively well. However, one out of four participants did not receive adequate education, indicating substantial room for improvement. The latter finding is underscored by the need for more and tailored information as expressed in free text. Noteworthy, only half of the participants indicated that referral for exercise therapy and/or weight reduction was offered as a treatment option, whereas both treatment options are an essential part of Dutch guideline recommendations [41]. Healthcare providers might need better education on availability and efficacy of physical exercise and weight loss programs for the management of OA [42, 43]. They should furthermore develop more trust towards in the efficacy of these programs in terms of patient’s efforts as well as their service providers [20, 44, 45].
In contrast to other studies, we found no relationship between QI summary pass rates and demographic variables found in other studies, such as age [24, 27, 33, 34], gender [27, 34], and educational level [27, 34]. Our finding suggests QIs cannot identify most vulnerable patient groups by demographic variables, as treatment modalities seem to be used for patients of all ages, regardless of their gender or educational level. We did find a relation between QI summary pass rates and the presence of comorbidities, in line with several other studies [26, 34]. This might be due to more frequent visits with the healthcare professional, which offers more opportunity for treatment. People who have moderate OA complaints without other comorbidities might not visit a healthcare professional on a regular basis, believing there simply is no cure for their osteoarthritis. Another explanation is the lack of follow-up appointments offered by the professional, as results show a low pass rate on this particular quality indicator. As found in a previous study [24], contact with healthcare professionals was strongly related to higher QI pass rates, suggesting patient who do not visit their healthcare professional on a regular basis might miss out on appropriate care and information. In addition, in line with previous research [27, 33] we found that having had a knee prosthetic and the presence of OA symptoms in other joints was strongly related with higher QI pass rates. These findings also underline the need for more continuous guidance of patients with hip and knee OA.
Strengths and limitations
The present study was the first to make use of KOA patient-reported QIs in the Netherlands. Mapping patients’ experiences is a valuable and important step in the process of improving quality of care. The use of patient-reported QIs provides a better understanding whether the recommendations actually transpire in practice and enable us to identify possible areas for improvement in current OA care. In addition, the Dutch Knee Panel, used in the present study for patient recruitment, consists of people with OA symptoms in the knee from all over the country, making the sample more diverse than most studies, often centered in a specific region. Sociodemographic and disease related characteristics corresponded well to the general population of Dutch primary care.
The present study also has several limitations. A first limitation of the present study could be the self-reporting of OA by the patient instead of a clinical diagnosis. However, the accuracy of self-reported OA has been found to be acceptable (sensitivity of 0.75 and specificity of 0.89) for large scale studies [46], and the Knee panel has the advantage of offering such large sample size. In addition, quality of care was also assessed by means of self-report, which might be more prone to accuracy and recall bias [47]. Nonetheless, quality of care is in the ‘eye of the beholder’ and patients are the ones at the receiving end of care. Moreover, most participants had had fairly recent contact with a healthcare professional (4 out of 5 in the last year) in the present study, making recollections retrieved by study participants regarding events or experiences from the past less prone to bias. Furthermore, the average time difference of 6 months between the baseline questionnaire and survey could have resulted in imprecise results, in particular with regard to the association between daily functioning and perceived quality of care. Lastly, a Dutch version of the OA-QI questionnaire is used for the present study which has not yet been validated. Small changes have been made to the original validated questionnaire for a better fit with the Dutch OA healthcare guidelines, of which measurement and psychometric properties have not been tested. However, the contribution from patient representatives as well as experts within the field ensured that the resulting OA-QI incorporated issues relevant to patients with OA, written in a language that patients found easy to understand. Given the similarity between the construct and wording of the questionnaires, for the current Dutch version of the questionnaire similar measurement properties as the validated original version of the OA-QI from Norway were assumed, as did a subsequent version from the UK [48]. However, two findings in the present study (data not shown) reinforce construct validity of our Dutch version of the OA-QI questionnaire: 1) Overall rating for the quality of care on a scale from 1 to 10 was positively correlated with QI summary pass rates - the higher the rating, the higher the pass rate; 2) Participants who wanted to see change in the care they had received scored significantly lower in QI summary pass rates. Nonetheless, the assumption that the measurement properties of the questionnaires are similar may need further exploration and conducting a full validation study is recommended.
Recommendations
Based on our findings we recommend that health professionals should aim for higher adherence to standards of care and guideline recommendations, as it may improve patients’ outcomes and postpone the need for total joint replacements. Special attention to weight loss services is needed. Alignment of care between GPs and other healthcare providers, as also often mentioned in the recommendations by patients, might improve referral to such services. The recommendations made via the open-ended question in this study offered a first glance on areas of improvement in KOA care as experienced by patients. It is recommended to further investigate these patient recommendations as certain themes seem to recur more often than not. Lastly, preparing the survey we noticed that the common questionnaires on osteoarthritis quality indicators often do not include the assessment of follow-up appointments in patient-provider consultations (QI no. 18 of the present study). Considering the patients’ need for guidance in the self-management process of their OA, we strongly advise to include such a question in the future.