Osteoarthritis, the most common type of arthritis, is a progressive condition that can affect any moveable joint of the body but most commonly the hips, knees, and hands. Studies in various populations show that about 20% to 30% of adults have osteoarthritis in at least one of these joints. The condition starts as a change to the biological processes within a joint, leading to structural changes such as cartilage breakdown, bone reshaping, bony lumps, joint inflammation, and loss of joint function. This often results in pain, stiffness, and loss of movement. Osteoarthritis is characterized by fluctuating symptoms and increased intensity of joint pain over time. Certain factors make some people more vulnerable to developing osteoarthritis: genetic factors, being overweight or obese, injury from accidents or surgery, and heavy physical activity in some sports or at work.
In Canada, the overall prevalence of diagnosed osteoarthritis in primary care is 14% and is expected to increase to about 25% in the next 30 years. The condition is more common in middle to older age (prevalence is 35% in those aged 80 years and older), affects more women than men, and is associated with other chronic health conditions such as depression and high blood pressure. In Ontario, people with osteoarthritis report a quality of life 10% to 25% lower than those without osteoarthritis, and they incur health care costs two to three times higher. The rising rates of osteoarthritis will have a substantial impact on the lives of people living with the condition and their families, on costs to the health care system, and on the broader economy through lost productivity, people leaving the workforce, and long-term disability.
Despite the obvious personal and societal burden of osteoarthritis, it is underdiagnosed and undertreated, resulting in missed opportunities for people to benefit from high-quality care. While there is no cure for osteoarthritis, there are several ways to effectively manage symptoms through nonpharmacological and pharmacological treatments that can help reduce pain, improve function, maintain quality of life, and delay disability. Early intervention is best. Poorly managed hip and knee osteoarthritis leads to avoidance of physical activity and exacerbation of pain. This in turn can lead to fatigue, disability, and depressed mood, and is linked with heart disease, diabetes, and obesity.
Substantial gaps in the quality of osteoarthritis care exist all along the care pathway. Many people delay seeking care: in a Canadian study, about 40% of patients with osteoarthritis had symptoms for more than a year before they were diagnosed, and the average time elapsed was more than 7 years. First-line treatment for osteoarthritis should include nonpharmacological approaches: education, therapeutic exercise, daily physical activity, weight loss (if appropriate), and self-management support. These treatments are underused. A study in British Columbia found that only 25% of patients with hip or knee osteoarthritis received therapeutic exercise or weight management as part of their management plan, and advice to use these approaches differed across the patients’ gender, age, disability, and education. Only 29% received an assessment of their ability to walk (ambulatory function) and only 7% were assessed for nonambulatory functions such as dressing, cooking, and the ability to rise from sitting to standing. A survey of Canadians diagnosed with osteoarthritis shows relatively few are seeking advice from health professionals who can provide effective nonpharmacological management. Only 22% had consulted a physiotherapist or occupational therapist in the previous year, and 12% had attended an educational class to help them manage arthritis-related problems.
These shortfalls in access to needed care could be influenced by a misconception among health care professionals and patients that osteoarthritis symptoms are a normal part of aging with limited treatment options. The cost of services and/or a lack of extended health insurance coverage also play a role. Most community-based services for osteoarthritis (such as physiotherapy, occupational therapy, weight-management programs) are not widely available, at least not without substantial costs to patients that must be borne out-of-pocket or with private insurance.
In contrast, most people with osteoarthritis are prescribed some form of pharmacological treatment. In a 2015 study of primary care in Canada, 57% of patients with osteoarthritis had a prescription for a nonsteroidal anti-inflammatory drug, and about 33% were prescribed an opioid for pain management. This is an underestimate of medication use, given that many people with osteoarthritis use over-the-counter medications, which are not often captured in data from electronic medical records. In another national study, 66% of people with osteoarthritis (any joint) used nonprescription medications. Among those with hip and/or knee osteoarthritis, the figure was 74%.
For a small percentage of people, their condition will deteriorate to the extent that surgical options such as joint replacement, joint fusion, or joint-conserving surgery may be necessary. Surgical treatment should be offered to people with moderate to severe joint damage that causes unacceptable pain or limitation of function despite the use of interventions described in this quality standard.