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Osteoarthritis official healthOsteoarthritis official healthcare protocolcare protocol

What is an official health care protocol?

A health care protocol is designed to coordinate all the healthcare professionals involved in the provision of care for a patient to ensure that patients receive the best possible treatment for their specific condition.

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• Avenir de l’Assurance Maladie: les options du Haut Conseil pour l’Avenir de l’Assurance Maladie (HCAAM)http://www.securite-sociale.fr/IMG/pdf/l_avenir_de_l_assurance_maladie_les_options_du_hcaam.pdf• Médecine de parcours: un objectif et des enjeux à confirmer. Interview with Denis Piveteau, Chairman of the Haut Conseil pour l’Avenir de l’Assurance

Maladie, Le Concours médical, June 2012 (pages 428-429).

This type of official protocol is particularly useful for patients with chronic conditions requiring input from several healthcare professionals:the patient's GP therefore plays a central, coordinating role.

Health care protocol efficiency (in other words the best treatmentat the best price) is one of the priority focuses identified by the Haut Conseil pour l'Avenir de l'Assurance (National Council for the Futureof Healthcare Insurance) and is seen as a means of ensuring the continued existence of the healthcare system and its founding principles, especially equality of access to quality care and solidarity between the sickand the healthy.

An example of a conditionthat has become chronic

Type 2 diabetes: the incidence of this disease is rising rapidly, hand in hand with the number of overweightand obese patients. However, when properly managed, many of the complications of type 2 diabetes canbe avoided: myocardial infarction, renal failure, blindnessand amputations, etc.

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Several healthcare professionals with complementary skills are involved caring for patients with chronic conditions:this is the patient's health care protocol or pathway.

Osteoarthritis is a chronic condition

As people are living longer and obesity is a growing problem, the number of patients with osteoarthritis is continuously rising: 65% of people aged over 65 have radiological osteoarthritis 80% of people over the age of 80 have osteoarthritis

Osteoarthritis has a negative impact on quality of lifeand could, in some cases, increase mortality by augmenting the cardiovascular risk which is at least partially related to a sedentary lifestyle.

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The management of osteoarthritic patients is more complicated than it appears. As the population gradually ages and the number of replacement procedures rises, this disease places a considerable financial burdenon society as a whole.

Société Française de rhumatologie website: http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/A0_definition.asp

The goals of treatment for patientswith osteoarthritis

Limit joint stiffness. Manage pain, while reducing the long-term consumption

of NSAIDs especially. Encourage patients to take exercise adapted to their

condition. Encourage patients to maintain a healthy bodyweight. Have recourse to surgery when necessary.

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Société Française de rhumatologie website: http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/sommaire-arthrose.asp ANSM: http://www.ansm.sante.fr/var/ansm_site/storage/original/application/257d8be960ac8372dbdc513708956d50.pdf OARSI:http://www.oarsi.org/pdfs/oarsi_recommendations_for_management_of_hip_and_knee_oa.pdf

The main healthcare providers involved

The official treatment goals for patients with osteoarthritis clearly list the healthcare professionals liable to become involved, the first of these being the treating physician, almost always a GP.

Some specialists play an important role in caring for patients with osteoarthritis.The rheumatologist: for cases that are difficult to manage (refractory pain, extensive joint damage), the GP may refer the patient to a rheumatologist for needle aspiration followed,in most cases, by injections of steroids or a hyaluronic acid into the joint space.An orthopaedic surgeon: when joint replacement or corrective surgery is necessary(this mainly concerns the hip or knee).The radiologist: the images obtained are used to diagnose osteoarthritis and assess the extent of the joint damage.An endocrinologist to provide support for patients who need to lose weight.

A community pharmacist, who is trained to advise patients who have been officially diagnosed with a chronic condition. And various other healthcare professionals, for instance:

A physiotherapist: to teach patients how to move an osteoarthritic joint correctlyand to strengthen the muscles supporting the damaged joint.A nutritionist or dietician: to help overweight or obese patients.

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The GP as coordinator of the healthcare protocol

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All patients must have their own doctor; in most cases this will be a GP. These doctors know their patients, their medical history and personal situation (family, social and working lives) best.

The GP will refer his/her patients to other healthcare

professionals for treatment (physiotherapist, dietician or nutritionist, etc.) or a specialist opinion (rheumatologist or orthopaedic surgeon, etc.)

Are tests necessary?

The diagnosis of OA can usually be made on clinical grounds alone. The only tests that are essential in patients with osteoarthritis are

those allowing a precise evaluation of the structural conditionof the joints. These are standard x-rays of the joints.More sophisticated examinations, such as an MRI or CT scan,are of no use for the diagnosis of osteoarthritis and are not appropriate.

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When should these tests be done? Standard x-rays are essential during the diagnostic work-up and it is rarely necessary to repeat them unless surgery is being discussed or rapidly progressing osteoarthritis is suspected.

Société Française de rhumatologie website: http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/sommaire-arthrose.asp

Conversely, no specific blood tests are necessary A CT or MRI scan is rarely necessary.

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Frontal radiographs of the hips. Right supra-external hip osteoarthritis (condition); early osteoarthritis on L.

Recourse to surgery

10Site de la Société Française de rhumatologie : http://www.rhumatologie.asso.fr/04-Rhumatismes/grandes-maladies/0B-dossier-arthrose/sommaire-arthrose.asp

The decision to replace a damaged joint with a prosthetic jointis no simple matter. It depends on:The impact of osteoarthritis on the patient's quality of lifeFailure to derive sufficient improvement on conservativemanagement aloneThe age of the patient and his or her comorbiditiesAnd indeed, his or her life expectancy

The following are recommended before surgery: Exercises to "prepare" the muscles, tendons and ligamentsfor the roles they will have after the replacement jointhas been inserted; and to reduce joint stiffness to a minimum.

And, as is the case before any surgical procedure, give up smoking which reduces the risk of infection and improves the post-operative course.

Is hydrotherapy a legitimate partof the health care protocol for patients with osteoarthritis?

A recent study showed that hydrotherapy can improve the painful symptoms of knee osteoarthritis .

Hydrotherapy can be beneficial by giving patients the chance to recommence appropriate physical exercise, change their eating habits and lose some weight within the framework of treatment education programmes. This is why hydrotherapy can be useful in the health care protocolfor patients with osteoarthritis.

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