Osteoarthritis—the forgotten chronic disease. Time for a multimorbid approach?

The rise of non-communicable disease (such as diabetes, coronary heart disease and asthma) continues and is now responsible for over 60% of deaths worldwide. Managing the rising prevalence of these conditions represents the major global challenge faced by governments and health care systems (1,2). The role of general practice in improving the health of the population has never been more important.

Over the past decade the contribution made by primary care in caring for people with chronic disease has changed dramatically, with conditions previously managed in secondary care settings now being almost exclusively managed in the community. This change in the setting of health care delivery and the heightened awareness of the importance of these conditions has resulted not only in significant changes to how health care is organized, but has also impacted on the way in which we now consider chronic disease.

Whilst the quality of care provided for many chronic conditions is improving, there is abundant evidence that the clinical care provided for patients with osteoarthritis continues to be suboptimal (3) despite being the commonest chronic disease managed in a general practice setting. In the UK, osteoarthritis is the most prevalent chronic disease among adults aged 65 years and over, affecting 32% of men and 47% of women (4) with 25% of adults aged 50 years and over reporting severely disabling knee pain. In an ‘average’ general practice, around a third of all patients aged 50 years and over will consult with a musculoskeletal problem in a one year period (5), yet many GPs fail to receive formal postgraduate training in managing these problems.

Osteoarthritis patients share a number of characteristics that are commonly found in patients with other chronic diseases. They suffer high levels of disability, and have a poor quality of life. Depression and anxiety symptoms are common and mortality rates are higher than those seen in the general population. Yet whilst primary care has developed and embraced sophisticated models for managing other chronic conditions such asthma, coronary heart disease and diabetes, we currently lack the systems needed to optimize the care received by patients with osteoarthritis. Do we need to adopt a new way of thinking about osteoarthritis management to prevent the commonest chronic disease from being forgotten?

In people aged 65 years and over, osteoarthritis frequently co-exists with other chronic diseases (6). Multimorbidity, often defined as the co-existence of two or more long-term conditions in an individual is the norm, rather than the exception in primary care patients. A large Irish study of patients aged 50 years found that more than 60% of patients had multimorbidity (7), a figure that rises with increasing age (8).

Improvement in the continuity and coordination of care for people with multimorbidity is a key challenge for clinicians caring for patients in the community, as a generalist approach will typically be needed and wanted by patients (2,9). Current systems of ‘disease-specific’ care are not appropriate as guidelines and clinical trials simply cannot cope with complex patients with multiple health problems. ‘Disease-specific’ care has a tendency to prioritize ‘high-profile’ disorders and as such, conditions that are deemed ‘less important’ by policy makers, such as osteoarthritis, frequently get neglected or forgotten. Taking a multimorbid approach to patient care in the community has the potential to improve these shortcomings by considering the specific health care needs of the individual.

Whilst robust evidence on how best to deliver care for multimorbid patients is currently lacking, it is a clear that a patient centred, personalized health care approach is needed to account fully for the complexity encountered when managing these patients (10). Identifying and targeting clinical outcomes that are important to patients is essential to allow treatment to be tailored to the specific needs of the individual. Tackling logistical barriers to accessing health care by reorganizing the delivery of clinical services to allow a ‘one-stop shop’ rather than the current system of multiple appointments for disease-specific clinics will enhance the patient experience and help to promote a holistic approach to chronic disease management that includes all relevant medical conditions.

Patients are far more than the sum of their chronic diseases, especially when doctors and policy makers decide which conditions are the most important to consider. If we are to address the growing burden associated with non-communicable disease, we have to start to consider alternative models to provide care to our most vulnerable patients. Taking a ‘multimorbid approach’ to managing patients in primary care has the potential to improve not only care for patients with ‘traditional’ disease but also to improve outcomes for conditions that are too frequently neglected or forgotten.