Effect of stepped care on health outcomes in patients with osteoarthritis: an observational study in Dutch general practice.
BACKGROUND
A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands.


AIM
To assess the association between care that is in line with the SCS recommendations and health outcomes.


DESIGN AND SETTING
Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis.


METHOD
Care was considered 'SCS-consistent' if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0-100); active pain coping with the Pain Coping Inventory (range 10-40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12-48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations.


RESULTS
No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). This was also the case after adjusting for possible confounders, that is, -4.3 (95% confidence interval [CI] = -10.3 to 1.7) and -1.9 (95% CI = -7.0 to 3.1), respectively. Furthermore, no differences were found in changes over time between groups in self-efficacy and pain coping.


CONCLUSION
The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects.