Assessing the Quality of Care for Knee Osteoarthritis in Singapore: A Cross-sectional Study

doi:10.21203/rs.3.rs-4963107/v1

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Research Article

Assessing the Quality of Care for Knee Osteoarthritis in Singapore: A Cross-sectional Study

https://doi.org/10.21203/rs.3.rs-4963107/v1

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Introduction

The aim of this study was to assess the self-reported quality of care for people with knee osteoarthritis in Singapore and to explore the associations between participant characteristics and functional outcomes at 1 year in relation to the reported quality of care.

Methods

Patients with knee osteoarthritis completed the osteoarthritis quality indicator (OA-QI) questionnaire between June 2021 and February 2022. The OA-QI includes 17 indicators, with "achievement" defined as a 'Yes' response for each. We calculated individual per-item, overall per-item mean, and per-person achievement rates (%) and explored associations between participant characteristics, achievement rates, and function at 1 year.

Results

A total of 314 participants completed the OA-QI. Referral for physical activity (87.5%) and referral for daily activity aid assessment (15.7%) had the highest and lowest per-item achievement rates, respectively. The overall mean per-item and per-person achievement rates were both 62.2%. Participants educated about steroid injections (adjusted coefficient [95% CI]: 7.23 [1.42–13.04]; p= 0.015) or surgery (adjusted coefficient [95% CI]: 12.65 [5.89–19.40]; p< 0.001) had worse functional outcomes at one year than those who were eligible but not informed. Those not assessed for walking aids and indicating walking issues had poorer outcomes one year later (adjusted coefficient [95% CI]: -9.89 (-19.63, -0.15); p= 0.0470). However, no significant associations were found between per-person achievement rates and 1-year functional outcomes.

Conclusions

The quality of care in Singapore for people with knee osteoarthritis is suboptimal, especially for those needing walking aids and weight loss assistance. However, the quality of care alone does not fully account for long-term outcomes, suggesting that other factors need to be considered.

Clinical Trial Number: clinicaltrials.gov registry (Identifier: NCT04942236)

Trial registration date: 25^th June 2021

Osteoarthritis is a leading cause of disability worldwide¹. In Singapore, symptomatic knee osteoarthritis affects 1 in 10 people over the age of 50². The number of people living with osteoarthritis is expected to continue to rise, in part owing to aging populations, plus increased levels of modifiable risk factors such as obesity and sedentary behavior³. Osteoarthritis most often affects the knee joints⁴ and commonly results in pain, functional disability, and decreased quality of life⁵.

Most international clinical practice guidelines for knee osteoarthritis recommend a stepwise approach to management where surgical intervention is considered only after non-surgical and pharmacological interventions have been exhausted^6–9. Non-surgical care is prioritized, as it produces similar outcomes and reduces the risk of severe adverse events compared with surgical interventions^10–12. Furthermore, non-surgical care is a more cost-effective option, with mean direct costs that are 4 times lower than those of surgical management in Singapore¹¹³. Additionally, evidence indicates that as many as 25% of knee replacements can be avoided by engaging in appropriate guideline-recommended first-line care¹⁴. Despite clear guidance, many people with knee osteoarthritis around the world are not provided with guideline-adherent first-line care before surgery^15,16. Implementing guideline recommendations in clinical practice can be challenging due to several factors, such as clinician and patient preferences and the support/culture of the healthcare system¹⁷. Therefore, overuse of surgical interventions is likely due to the failure of healthcare systems providing optimal and effective guideline-recommended care rather than to the failure of nonsurgical and pharmacological treatments for people with knee osteoarthritis.

The osteoarthritis quality indicator (OA-QI) questionnaire was developed in 2010 to evaluate the quality of non-surgical care that is provided to people with osteoarthritis¹⁸. The OA-QI has been applied to various populations and has demonstrated significant variation in the quality of care provided to people with knee osteoarthritis worldwide^19–22. To the best of the authors’ knowledge, no studies have used the OA-QI to explore the self-reported quality of care that people with osteoarthritis receive in Asia or whether this influences future functional outcomes. Exploration is warranted to understand what treatments are regularly being discussed with individuals with knee osteoarthritis and to identify opportunities to improve the provision of first-line, non-surgical care.

The primary aim of this study was to investigate the self-reported quality of care for people with knee osteoarthritis in Singapore. The secondary aims included exploring whether associations exist between; i) participant characteristics and the overall quality of care reported or, ii) the overall quality of care reported or individual indicators being addressed with functional outcomes at 1 year.

Ethical approval and study design

Ethical approval for a large multi-centre prospective cohort study, the Singapore KneE osteoarthriTis CoHort (SKETCH) study, was granted by the National Healthcare Group Domain Specific Review Board (NHG DSRB) Singapore (Reference number: WHC/2020–00076). The SKETCH protocol has been published previously elsewhere²³. This manuscript reports findings related to the OA-QI questionnaire and is written in alignment with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines²⁴.

Participants and recruitment

Participants were recruited from two different public hospitals within the National Healthcare Group, Singapore, between June 2021 and February 2022. Specifically, recruitment occurred when people with knee osteoarthritis attended an orthopedic or physiotherapy appointment at either hospital. Participants were eligible if they were independent community mobilizers, met the National Institute for Health and Care Excellence (NICE) clinical diagnostic criteria for knee osteoarthritis⁶ and were conversant in English or Mandarin. Participants were excluded if they; i) had an alternate diagnosis of knee OA (e.g., referred pain from the hip or spine), ii) had other forms of knee arthritis (e.g., inflammatory, posttraumatic), iii) had moderate to severe cognitive impairment (e.g., dementia), iv) had received a previous knee arthroplasty, v) were wheelchair bound, vi) were pregnant or vii) had medical conditions that would medically interfere with rehabilitation involvement (e.g., decompensated heart failure, stroke with significant deficit, or end-stage renal failure). The participants were informed of the study directly at their orthopedic or physiotherapy appointment and had the option to engage immediately during their appointment visit or via a web-based form (FormSG) after their appointment at their own convenience.

Survey questions

After confirming eligibility and providing informed consent, the survey consisted of 3 sections: i) participant characteristics, ii) knee osteoarthritis symptoms and iii) the OA-QI questionnaire. First, the participants reported their age, height and weight, gender, ethnicity, occupational status (employed, unemployed, homemaker, retired), education level (no formal education, elementary school, high school, diploma holder, degree holder, others) and housing type (public housing, condominium, terrace house, others). The participants then reported the site of their symptomatic knee osteoarthritis (left/right/both) and how long they had a diagnosis of knee osteoarthritis. Joint-specific pain and function were then investigated via the Knee Osteoarthritis Outcome Scale-12 (KOOS-12)²⁵. The KOOS-12 is frequently used in knee osteoarthritis research and consists of three sections of four items related to pain, function (activities of daily living and sport/recreation), and quality of life (QOL). The participants responded to each item via a five-point Likert scale (0 represents no knee problems, and 4 represents extreme knee problems). Section scores and total KOOS-12 scores were then calculated for each participant before being normalized on a 0–100 scale. Finally, the participants completed the 17-item OA-QI questionnaire¹⁸. The OA-QI questionnaire requires participants to respond to varying questions about their experience of care for their knee osteoarthritis, such as “yes”, “no” or “do not remember/not relevant”. The questions are broad and include topics related to referrals, clinical assessment, and treatments. The OA-QI is aligned with international clinical practice guidelines and has adequate content and construct validity in populations with knee osteoarthritis^26,27.

Sample size estimation

The sample size was estimated with the objective of exploring the factors associated with the provision of more or less comprehensive care via G*Power 3.1.9.4. Given a type I error of 0.05 with 80% power of study, we needed data for at least 264 participants to detect a small effect size of Cohen’s f²= 0.03 in the multiple linear regression model.

Statistical analyses

Participant responses were deidentified, given a unique identifier number and stored on a secure web-based data management application (Research Electronic Data Capture [REDCAP]). The data were cleaned and analysed by one member of the research team (LCJ) via SPSS version 26.0. The participants’ weight and height were used to calculate their body mass index (BMI kg/m²). The BMI, age and KOOS-12 scores are presented as the means and standard deviations for each outcome. Other summarized participant demographic data are presented descriptively (frequency [n=] and proportion [%]).

For the OA-QI questionnaire, only ‘yes’/’no’ responses were considered to calculate the achievement rates (i.e., any responses of ‘Don’t remember’, ‘Not overweight’, ‘No such problems’, ‘No pain/discomfort’ or ‘Not severely troubled’ were excluded from analysis). Three types of achievement rates were then calculated; i.e., per item (i.e., the number of ‘yes’ responses/number of participants who responded ‘yes’ or ‘no’ for that particular OA-QI item) presented as % and 95% CI, ii. Overall mean per-item OA-QI achievement rate (calculating the mean achievement rate [% and 95% CI] for all 17 OA-QI items), and iii. The mean per-person achievement rate (number of items that an individual reported ‘yes’/number of ‘yes’ or ‘no’ responses they provided) is presented as the mean and 95% CI. The mean achievement rate per person provides a measure of the ‘comprehensiveness’ of treatment.

Linear regression modelling was used to explore the factors associated with the per-person and per-item OA-QI achievement rates. Simple linear regression was used to screen the variables, and variables with p<0.200 were included in the variable selection process via the stepwise variable selection method. The multicollinearity and interaction of the final model were checked, and heteroskedasticity was checked via the Bruesch-Pegan/Cook-Weisberg test.

On the other hand, multiple linear regression was used to explore the ability of the per-person OA-QI achievement rate and per-item OA-QI achievement rate to predict the 1-year change in functional outcomes, adjusting for baseline age, sex, BMI and KOOS total scores. All the tests were two sided, and statistical significance was denoted by p< 0.05.

We retrieved data for 314 participants. The majority of participants (83.1%, n = 261/314) were recruited at orthopedic consultations. Participant characteristics are presented in Table 1. In summary, mean age of participants was 63.38 (SD 8.13), mean BMI was 26.05 (SD 5.98) and KOOS-12 was 64.63 (SD 15.85). Most participants were female (66.6%, n = 209/314), of Chinese ethnicity (78.7%, n = 247/314), employed (58.2%, n = 182/314), had attained at least high school education (47.8%, n = 150/314), lived in public housing (83.4%, n = 261/314) and reported bilateral knee osteoarthritis symptoms (42.4%, n = 133/214).

Table 1

– Participant characteristics
Characteristic or outcome	Mean (SD)
Age (years)	63.38 (8.13)
BMI (kg/m²)	26.05 (5.98)
Total KOOS-12 score	64.63 (15.85)
Subsections:
Pain	63.82 (17.84)
Function in daily living (ADL)	74.14 (19.37)
Knee-related quality of life (QOL)	55.85 (18.77)
	n (%)
Gender
Female	209 (66.6)
Male	105 (33.4)
Ethnicity
Chinese	247 (78.7)
Indian	31 (9.9)
Malay	30 (9.6)
Others	6 (1.9)
Occupational Status
Employed	182 (58.2)
Unemployed	14 (4.5)
Homemaker	34 (10.9)
Retired	83 (26.5)
Education
No formal education	13 (4.1)
Elementary school	46 (14.6)
High school	150 (47.8)
Diploma holder	53 (16.9)
Degree holder	40 (12.7)
Others	12 (3.8)
Housing
Public housing	261 (83.4)
Condominium	23 (7.3)
Terrace house	23 (7.3)
Others	6 (1.9)
Localization of knee osteoarthritis
Unilateral	181 (57.6)
Bilateral	133 (42.4)
Time since OA diagnosis
< 1 year	45 (14.4)
1 to 3 years	103 (32.9)
4 to 6 years	70 (22.4)
7–10 years	69 (22.0)
more than 10 years	26 (8.3)
BMI – Body mass index

Per-item and overall mean per-item and per-person OA-QI achievement rates

The per-item and overall mean per-item OA-QI achievement rates are presented in Table 2. In summary, large variation was observed between each indicator (ranging from 15.68% − 87.50%). The highest per-item achievement rates were for referrals for physical activity (mean [95% CI] 87.50%, [83.31, 90.96]), physical activity education (mean [95% CI] 82.74% [78.03, 86.79]) and pain assessment (mean [95% CI] 80.97% [75.96, 85.33]). The lowest per-item achievement rates were for referrals to daily activity aid assessment (mean [95% CI] 15.68% [7.02, 28.59]), referrals to walking aid assessment (mean [95% CI] 25.61% [16.60, 35.1]) and weight reduction referrals (mean [95% CI] 27.41% [21.31, 34.20]). Overall, the mean per-item OA-QI achievement rate was 62.21% (95% CI: 59.71, 64.71).

Table 2

– Per-item and overall mean per-item OA-QI achievement rates
	Answered Yes or No n=/314	Answered Yes n=	Achievement rate
OA-QI indicator	Answered Yes or No n=/314	Answered Yes n=	Per- item %	95% CI Lower, Upper
1. Have you been given information about how the disease usually develops over time?	279	182	65.23	59.33, 70.81
2. Have you been given information about different treatment alternatives?	305	203	66.56	60.96, 71.83
3. Have you been given information about how you can live with the disease?	299	145	48.49	42.70, 54.32
4. Have you been given information about how you can change your lifestyle?	299	164	54.85	49.02, 60.58
5. Have you been given information about the importance of physical activity and exercise?	307	254	82.74	78.03, 86.79
6. Have you been referred to someone who can advise you about physical activity and exercise? (e.g. a physiotherapist)	312	273	87.50	83.31, 90.96
7. If you are overweight, have you been advised to lose weight?	196	149	76.02	69.42, 81.82
8. If you are overweight, have you been referred to someone who can help you to lose weight?	197	54	27.41	21.31, 34.20
9. If you have had problems related to daily activities, have these problems been assessed by health personnel in the past year?	97	51	52.58	42.18, 62.81
10. If you have problems with walking, has your need for a walking aid been assessed? (e.g. stick, crutch or walker)	82	21	25.61	16.60, 35.1
11. If you have problems related to other daily activities, has your need for different appliances and aids been assessed? (e.g. splints, assistive technology for cooking or personal hygiene, a special chair)	51	8	15.68	7.02, 28.59
12. If you have pain, has it been assessed in the past year?	289	234	80.97	75.96, 85.33
13. If you have pain, was paracetamol the first medicine that was recommended for your osteoarthritic pain?	280	208	74.28	68.75, 79.30
14. If you have prolonged severe pain, which is not relieved sufficiently by paracetamol, have you been offered stronger pain killers? (e.g. Co-proxamol, Co-dydramol, Tramadol, Co-codamol, Dihydrocodeine, Codeine)	193	100	51.81	44.52, 59.05
15. If you are taking anti-inflammatory drugs, have you been given information about the effects and possible side-effects of this medicine? (e.g. Ibuprofen, Nurofen, Brufen, Diclofenac, Voltarol, Naproxen, Naprosyn, Celebrex)	184	84	45.65	38.31, 53.14
16. If you have experienced an acute deterioration of your symptoms, has a corticosteroid injection been considered?	177	87	49.15	41.57, 56.76
17. If you are severely troubled by your osteoarthritis, and exercise and medicine do not help, have you been referred and assessed for an operation (e.g. joint replacement)?	120	62	51.67	42.37, 60.88
Mean overall OA-QI achievement rate	314		62.21	59.71, 64.71

Associations of per-person OA-QI achievement rates with participant characteristics

Differences in mean per-person achievement rates between categorical outcomes are presented, and the relationships between demographics and the OA-QI achievement rate are explored in Table 3. Three significant relationships were observed: i) those who were identified as Indian ethnicity had higher mean per-person OA-QI achievement rates than those who were identified as Chinese (adj. coef [95% CI], 10.94 [2.70, 19.17], p = 0.009); ii) those who lived in public housing had higher mean per-person OA-QI achievement rates than those who resided in condominiums did (adj. coef [95% CI], -12.02 [-21.64, -2.41], p = 0.014); and iii) those who had had osteoarthritis for less than 1 year had lower mean per-person OA-QI achievement rates than those who had been living with osteoarthritis for 1–3 years (adjusted coefficient [95% CI], 9.37 [1.60, 17.15], p = 0.018), 4–6 years (adjusted coefficient [95% CI], 11.27 [2.99, 19.55], p = 0.008), 7–10 years (adjusted coefficient [95% CI], 10.26 [1.92, 18.60], p = 0.016) and 10 + years (adjusted coefficient [95% CI], 13.70 [3.01, 24.38], p = 0.012), respectively.

Table 3

– Comparison of the mean per-person OA-QI achievement rate with demographic outcomes
Characteristic	OA-QI achievement rate, mean (95% CI)	Coef (95% CI)	p value	Adj. coef (95% CI)	P value
Age	NA	-0.26 (-0.57, 0.04)	0.093	-	-
Gender
Male	62.00 (57.37, 66.63)	Ref	-	-	-
Female	62.31 (59.33, 65.29)	0.31 (-5.00, 5.62)	0.908	-	-
Ethnicity
Chinese	61.14 (58.30, 63.98)	Ref	-	Ref	-
Malay	59.30 (51.76, 66.84)	-1.84 (-10.34, 6.67)	0.671	-	-
Indian	71.60 (63.20, 80.01)	10.47 (2.08, 18.85)	0.015	10.94 (2.70, 19.17)	0.009
Others	72.24 (56.39, 88.10)	11.11 (-7.07, 29.28)	0.230	-	-
BMI	NA	-0.21 (-0.63, 0.22)	0.341	-	-
Occupational Status
Employed	63.55 (60.23, 66.87)	Ref	-	-	-
Unemployed	64.20 (49.30, 79.10)	0.65 (-11.65, 12.96)	0.917	-	-
Homemaker	63.42 (56.07, 70.77)	-0.12 (-8.41, 8.17)	0.977	-	-
Retired	58.38 (53.52, 63.25)	-5.16 (-11.04, 0.71)	0.085	-	-
Education
No formal education	54.93 (45.43, 64.44)	Ref	-	-	-
Elementary school	63.03 (57.20,68.87)	8.10 (-5.90, 22.10)	0.256	-	-
High school	62.79 (58.99, 66.59)	7.86 (-5.03, 20.74)	0.231	-	-
Diploma holder	61.14 (54.57, 67.72)	6.21 (-7.58, 20.00)	0.376	-	-
GCE A level, IB	62.52 (55.47, 69.57)	7.58 (-6.64, 21.81)	0.295	-	-
University	63.29 (47.90, 78.67)	8.35 (-9.49, 26.19)	0.358	-	-
Housing
Public housing	62.58 (59.82, 65.34)	Ref	-	Ref	-
Condominium	51.81 (42.96, 60.67)	-10.77 (-20.36, -1.17)	0.028	-12.02 (-21.64, -2.41)	0.014
Terrace house	65.61 (56.04, 75.19)	3.03 (-6.56, 2.63)	0.535	-	-
Others	69.79 (49.70, 89.88)	7.21 (-11.01, 25.43)	0.437	-	-
Localization of knee osteoarthritis
Unilateral	62.01 (58.64, 65.38)	Ref	-	-	-
Bilateral	62.48 (58.71, 66.24)	0.47 (-4.60, 5.54)	0.857	-	-
Time since OA diagnosis
< 1 year	54.03 (46.42, 61.63)	Ref	-	Ref	-
1 to 3 years	61.92 (57.78, 66.05)	7.89 (0.02, 15.76)	0.050	9.37 (1.60, 17.15)	0.018
4 to 6 years	64.69 (59.57, 69.82)	10.67 (2.25, 19.09)	0.013	11.27 (2.99, 19.55)	0.008
7–10 years	63.44 (57.81, 69.08)	9.42 (0.97, 17.86)	0.029	10.26 (1.92, 18.60)	0.016
more than 10 years	66.93 (58.42, 75.45)	12.91 (205, 23.76)	0.020	13.70 (3.01, 24.38)	0.012
KOOS	NA	-0.12 (-0. 27, 0.04)	0.145	-	-
Pain	NA	-0.02 (-0.16, 0.12)	0.774	-	-
ADL	NA	-0.12 (-0.24, 0.01)	0.080	-	-
QoL	NA	-0.11 (-0.24, 0.02)	0.100	-	-
BMI = Body Mass Index, ADL = Activities of Daily Living, QoL = Quality of Life

Relationships of per-item and per-person OA-QI achievement rates with functional outcomes at 1 year

One-year follow-up data were available for 202 participants. The relationships between the per-item OA-QI achievement rate and functional outcomes at 1 year are presented in Table 4. In summary, those who indicated that they had walking issues and indicated that they did not receive a walking aid assessment had poorer outcomes after 1 year (adjusted coefficient [95% CI]: -9.89 (-19.63, -0.15); p = 0.047). In addition, those who were not informed about injection or surgical options had greater improvements in the KOOS-12 score at 1 year than did those who received information about injections (adjusted coefficient [95% CI]: 7.23 [1.42–13.04]; p = 0.015) or surgery (adjusted coefficient [95% CI]: 12.65 [5.89–19.40]; p < 0.001), respectively. The relationships between the per-person achievement rate and functional outcomes at 1 year are presented in Table 5. In summary, no significant associations were observed.

Table 4

– Relationships between the per-item OA-QI achievement rate and changes in functional outcomes (total KOOS-12) at 1 year
OA-QI item number and summarized topic	Achieved?	Mean change in KOOS-12 ± SD	Adj Coeff (95% CI)	P value
1. Disease development	Yes No	3.98 ± 16.96 4.61 ± 15.60	Ref -0.83 (-6.03, 4.37)	0.754
2. Treatment	Yes No	3.52 ± 17.07 5.44 ± 15.30	Ref 1.78 (-3.21, 6.78)	0.482
3. Self-management	Yes No	2.32 ± 16.58 5.71 ± 16.06	Ref 3.16 (-1.39, 7.71)	0.173
4. Lifestyle	Yes No	3.97 ± 16.24 4.25 ± 16.76	Ref -0.33 (-5.11, 4.45)	0.892
5. Physical activity	Yes No	3.91 ± 17.00 4.70 ± 13.70	Ref 0.73 (-5.16, 6.63)	0.806
6. Referral physical activity	Yes No	4.54 ± 16.52 -0.45 ± 14.87	Ref -2.54 (-9.44, 4.35)	0.468
7. Weight reduction	Yes No	4.27 ± 17.35 5.73 ± 12.34	Ref 0.37 (-6.47, 7.21)	0.915
8. Referral weight reduction	Yes No	8.23 ± 17.13 2.20 ± 16.90	Ref -4.69 (-10.71, 1.32)	0.125
9. Functional assessment	Yes No	3.27 ± 17.87 0.77 ± 16.95	Ref -2.53 (-10.10, 5.04)	0.510
10. Walking aid assessment	Yes No	14.26 ± 14.46 3.99 ± 18.19	Ref -9.89 (-19.63, -0.15)	0.047
11. Other aids assessment	Yes No	6.60 ± 18.70 -3.49 ± 17.76	Ref -6.52 (21.13, 8.09)	0.380
12. Pain assessment	Yes No	3.84 ± 16.09 6.03 ± 17.40	Ref 2.36 (-3.39, 8.10)	0.420
13. Paracetamol	Yes No	3.29 ± 16.94 6.25 ± 15.24	Ref 4.37 (-0.97, 9.70)	0.108
14. Stronger pain killers	Yes No	3.28 ± 17.71 5.65 ± 14.05	Ref 4.18 (-1.39, 9.75)	0.141
15. NSAIDS information	Yes No	2.73 ± 18.66 6.89 ± 14.27	Ref 4.93 (-0.80, 10.66)	0.091
16. Joint injection	Yes No	0.65 ± 17.24 6.19 ± 17.10	Ref 7.23 (1.42, 13.04)	0.015
17. Surgery	Yes No	-4.98 ± 18.24 8.39 ± 16.78	Ref 12.65 (5.89, 19.40)	< 0.001

Adjusted for age, sex, BMI and total KOOS score at baseline

Table 5

– Relationships between the per-person OA-QI achievement rate and changes in functional outcomes at 1 year
Outcome	Adj. Coeff	95% CI	p value
KOOS Total	-0.05	-0.16 0.05	0.307
KOOS Pain	-0.07	-0.19, 0.04	0.216
KOOS ADL	-0.02	-0.14, 0.10	0.757
KOOS QoL	-0.07	-0.21, 0.07	0.313

Adjusted for age, sex, BMI and total KOOS score at baseline.

In general, the quality indicator achievement rates were underwhelming but were similar to those reported in previous research from outside Asia^19,21,22. Encouragingly, participants frequently reported being provided with information about first-line interventions, namely, physical activity, exercise, and weight loss. However, information about self-management and coping strategies is infrequently provided, and referrals to specialist weight loss or supportive services (e.g., walking aids and splints) are rarely provided when indicated. The overall quality of care provided was associated with participant ethnicity, housing type, and time since diagnosis, suggesting that care is provided inconsistently. Furthermore, the provision of information about certain topics (i.e., walking aids, injections or surgery) was associated with functional outcomes at 1 year. Overall, our findings can be used to inform initiatives to improve the quality of care that is being provided to people with knee osteoarthritis in Singapore.

Improving the quality of osteoarthritis care in Singapore

Encouragingly, most participants reported being provided information about, and referred to, an appropriate service for, physical activity and exercise, considering that three-quarters of people with knee osteoarthritis in Singapore reported low levels of physical activity ²⁸. Physical activity and exercise should be encouraged in this population, as they are inexpensive and effective guidelines that recommend first-line interventions that are suitable for all people regardless of age, sex, ethnicity or severity of the disease ⁶. However, other important information that may facilitate becoming more physically active, such as lifestyle changes or coping strategies, is often not provided. Encouragingly, weight management was reported as being discussed with the majority of individuals for whom it was appropriate. However, disappointingly, only one in two people were referred to appropriate weight loss services. Considering that weight management is an integral part of guideline-adherent care^6–8, the reasons for the lack of referrals should be investigated further. Improving knowledge about, and access to, weight management services, among other services for which referral rates are low (i.e., walking and daily mobility aids) available in Singapore, has great potential to improve patient outcomes for patients with knee osteoarthritis and its associated comorbidities.

An investigation of the relationship of the per-item OA-QI achievement rate with 1-year KOOS-12 outcomes revealed that participants who experienced acute deterioration of symptoms and who were engaged in a discussion about corticosteroid injections had worse 1-year KOOS-12 outcomes than those who also experienced an acute exacerbation but did not engage in a discussion about corticosteroid injections. However, we are unable to tell if an injection was actually offered or received. Injections are widely perceived as a treatment option to provide immediate symptom relief during an acute exacerbation²⁹. It is possible that discussion about injections may have put people off engaging in other long-term management strategies, such as physical therapy or lifestyle modifications, which provides a more sustainable solution for behavioral change³⁰.

We also observed that participants who experienced walking difficulties but were not assessed for walking aids demonstrated a greater improvement in their 1-year KOOS than did those whose need for walking aids was evaluated. This observation suggests a potential benefit of walking aid assessment in knee osteoarthritis patients experiencing mobility challenges. The assessment and subsequent use of walking aids might contribute to better outcomes by improving mobility, reducing pain, and enhancing overall quality of life⁶. This aligns with the literature emphasizing the importance of addressing mobility issues in osteoarthritis management^6–8.

Going beyond quality of care to achieve good outcomes

We did not identify any significant relationships between age, sex, BMI, education, or severity of knee symptoms and the per-person OA-QI achievement rate. However, we did observe that individuals of Indian ethnicity and those residing in public housing had higher per-person OA-QI achievement rates (indicating more comprehensive care) than those who were of Chinese ethnicity or who were residing in condominiums, respectively. These findings were unexpected, and the reasons behind these associations are not immediately clear. It is possible that socioeconomic factors, cultural attitudes towards healthcare, or accessibility to healthcare resources could play a role. However, without further research specifically targeting these demographics, it is challenging to draw definitive conclusions. Importantly, these findings should also be interpreted with caution because of the lower sample sizes in the comparator groups. Further research is encouraged to understand the complex interplay of ethnicity, living conditions, and healthcare quality in the context of knee osteoarthritis treatment.

We did not identify any relationship between the comprehensiveness of care (i.e., per-person OA-QI achievement rate) at baseline and 1-year KOOS-12 outcomes. One potential explanation for this finding is the multifactorial nature of health outcomes in patients with knee osteoarthritis. The quality of clinical care contributes to only 20% of the social determinants of health. Other factors, such as socioeconomic status (40%), the physical environment (10%), and health behaviors (30%), play greater roles in determining and improving health. These findings suggest that factors other than the quality of care might have a more significant impact on KOOS outcomes than the comprehensiveness of osteoarthritis care alone^31–33. This underscores the complexity of healthcare outcomes and the necessity of adopting a holistic approach for managing knee osteoarthritis, which takes into account the wide array of factors influencing patient health and well-being. Our findings suggest that while comprehensiveness or quality of care is undoubtedly important, it is just one of many components that contributes to overall health outcomes in patients with knee osteoarthritis. Much of osteoarthritis care needs to be targeted at behavioral changes, and one session of information might not be sufficient to provide the necessary push to lead to such changes³⁰.

Strengths and Limitations

It is important to consider the limitations of our study when interpreting our findings. Specifically, our findings may not be fully generalizable to all individuals with knee osteoarthritis in Singapore. Furthermore, Singapore is a unique country in Asia with a diverse ethnicity mix and relatively high average income rates compared with other Asian countries; therefore, the findings of our study may not represent the wider Asian region. Notably, the majority of participants in our study were recruited through orthopedic surgeons. Evidence from around the world suggests that relatively few people with knee osteoarthritis are referred beyond primary care; therefore, investigations of care provided by first-contact practitioners in Singapore (i.e., general practitioners) are warranted. Additionally, as mentioned above, relying on self-reported data carries a risk of bias and difficulty in determining how accurate the patient’s responses are. This challenge underscores the need for more robust methods to assess patient-reported data, such as qualitative interviews and documentation reviews. Nonetheless, the depth and breadth of our analysis contribute significantly to advancing our understanding and enhancing the quality of osteoarthritis care.

In conclusion, this study provides valuable insights into the quality of osteoarthritis care in Singapore, which appears to be suboptimal. Notably, the high achievement rates in areas such as physical activity referrals and education and pain assessment strongly align with international care standards. However, the study also highlights several areas needing attention, particularly in referrals for daily activity aids and walking aid assessments, as well as in comprehensive support for weight management. The OA-QI appears to be a poor indicator of 1-year outcomes for people with knee osteoarthritis, suggesting that the determinants of outcomes in patients with knee OA are multifaceted and extend beyond the scope of quality indicators traditionally used. Future research should aim to unravel these multifactorial influences in greater depth, contributing to more effective and nuanced treatment strategies for knee OA patients.

Ethics approval and consent to participate:

Ethical approval was obtained from National Healthcare group, Domain Specific Review Board, Ref no. WHC/2020-0076 and patient consent was taken prior to taking part in the study.

Consent for publication:

Manuscript does not contain data from a single individual.

Availability of data and materials:

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests:

The authors declare that they have no competing interests.

Funding:

None to declare.

Authors' contributions:

Study design – including conceptualization and methodology: BTY, LCJ.

Data collection and data analysis: LTR, AJG, BTY, LCJ.

Data interpretation: LTR, AJG, BTY, LCJ.

Generation of figures: LCJ

All authors were involved in writing the paper and had final approval of the submitted and published versions

Acknowledgements:

We would like to thank Pearl Koh Yuan Zhen and Koong Mun Ee for their initial work on this project.

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Assessing the Quality of Care for Knee Osteoarthritis in Singapore: A Cross-sectional Study

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Abstract

Introduction

Methods

Results

Per-item and overall mean per-item and per-person OA-QI achievement rates

Associations of per-person OA-QI achievement rates with participant characteristics

Discussion

Improving the quality of osteoarthritis care in Singapore

Going beyond quality of care to achieve good outcomes

Strengths and Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1