Analgesic prescriptions received by patients before commencing the BOA model of care for osteoarthritis: a Swedish national registry study with matched reference and clinical guideline benchmarking

Figures & data

Flow chart displaying the included OA cohort and matched reference cohort. Adapted with permission from Gustafsson et al. (11)

Table 2. OA cohort and reference cohort characteristics. Values are count (%) unless otherwise specified

	OA cohort	Reference cohort
	n = 72,069	n = 216,207
Age, mean (SD)	66.4 (9.6)	66.4 (9.6)
Women	49,494 (69)	148,482 (69)
Worst affect joint in OA cohort
Knee	49,366 (68)
Hip	22,703 (32)
Pain NRS, mean (SD)	5.4 (2.0)
Missing	621 (< 0.1)
Charnley score
A	27,242 (38)
B	13,471 (18)
C	30,918 (43)
Missing	438 (< 0.1)
Born outside Sweden	6,474 (9)	28,554 (13)
Missing	0	12 (< 0.1)
Married	42,359 (59)	117,616 (54)
Missing	9 (< 0.1)	162 (0.1)
Educational level^a
Low (≤ 9 years)	16,276 (23)	61,212 (28)
Medium (10–14 years)	43,492 (60)	119,416 (55)
High (≥ 15 years)	12,111 (17)	33,260 (15)
Missing	190 (0.3)	2,319 (1.1)
Disposable annual income (Ђ) year of T0, median (IQR)^b	20,022 (11,936)	18,559 (12,516)
Missing	4 (< 0.1)	132 (0.1)

T0 = Baseline in the BOA national quality register

a For the participants with T0 during 2016, the highest achieved level up to 2015 was used.

b Data only reported for those in the cohorts with T0 between 2008–2015. During 2008–2015, the average exchange rate was 1 Ђ = 9.3 SEK

Table 3. Comparisons of proportion and type of dispensed analgesic prescriptions in Sweden received by patients before commencing non-pharmacological primary care interventions for osteoarthritis (OA, n = 72,069) compared a general population cohort (Ref. n = 216,207)

	Proportion of individuals with dispensed prescriptions for analgesics prior to commencing the BOA model of care for symptomatic hip or knee OA
	Between 3 and 2 years			Between 2 and 1 years				Between 1 and 0 year
Analgesic medications	OA	Ref.	A. Δ (95% CI)	OA	Ref.	B. Δ (95% CI)	B/A	OA	Ref.	C. Δ (95% CI)	C/B
NSAIDs non-selective per os	25	16	8.8 (8.4 to 9.2)	26	15	10 (9.8 to 11)	1.2	41	15	26 (25 to 26)	2.5
NSAIDs non-selective topical	1.8	1.3	0.5 (0.4 to 0.6)	1.9	1.3	0.6 (0.5 to 0.7)	1.2	2.8	1.3	1.5 (1.4 to 1.6)	2.5
NSAIDs selective COX inhibitors per os	2.9	1.6	1.3 (1.2 to 1.4)	3.2	1.6	1.6 (1.5 to 1.7)	1.2	5.8	1.7	4.1 (3.9 to 4.3)	2.6
Paracetamol	23	18	5.0 (4.7 to 5.3)	26	20	6.0 (5.6 to 6.4)	1.2	41	21	19 (19 to 20)	3.2
Weak opioids	11	9.7	1.7 (1.4 to 2.0)	11	9.3	2.0 (1.7 to 2.3)	1.2	16	9.0	6.9 (6.6 to 7.2)	3.5
Strong opioids	4.1	4.2	–0.1 (–0.3 to 0.1)	4.6	4.8	–0.2 (–0.4 to 0.0)	–2.0	6.7	5.8	0.9 (0.7 to 1.1)	4.5
Antiepileptics	1.3	1.4	–0.1 (–0.2 to 0.0)	1.5	1.6	–0.1 (–0.2 to 0.0)	1.0	1.7	1.8	–0.1 (–0.2 to 0.0)	1.0
Other joint pain related analgesics	8.6	5.9	2.7 (2.5 to 2.9)	8.7	5.9	2.8 (2.6 to 3.0)	1.0	10	6.1	4.3 (4.1 to 4.5)	1.5

Δ Difference between OA and Ref.

Table 4. Comparisons of the proportion of dispensed analgesic prescriptions in terms of clinical guideline recommendations before (01/01/2008-31/05/2012) compared to after (01/06/2012-31/12/2016) guideline publication

Guideline recommendations for hip or knee OA according to stepped care priority		OA cohort (n = 72,069)			Reference cohort (n = 216,207)
		Before	After		Before	After
• Dispensed analgesic prescriptions	Total no. =	10,862	61,207		32,586	183,621
	Knees =	7,539	41,827		2,617	125,481
	Hips =	3,323	19,380	Δ (95% CI)	9,969	58,140	Δ (95% CI)
1. A moderate–strong priority recommendation for first step interventions such as exercise (3/10) ^a, patient education (6/10) ^a, and weight management (5/10) ^a, before considering adjunct pharmacological interventions
• No dispensed analgesic		18	23	5.0 (4.2 to 5.9)	47	48	0.6 (–0.0 to 1.1)
2. A low–moderate priority recommendation (6–7/10^a for NSAIDs (selective COX inhibitors per os) as an adjunct treatment if first step interventions do not give satisfactory results
• COX-2 inhibitors		9.1	8.9	–0.2 (–0.8 to 0.4)	3.3	3.6	0.3 (0.0 to 0.5)
3. A low–moderate priority (7/10)^a recommendation for NSAIDs (non-selective per os) as an adjunct treatment if first step interventions have not given satisfactory results
• NSAIDs		63	55	–8.6 (–9.6 to –7.6)	32	30	–2.7 (–3.3 to –2.2)
4. A low priority recommendation (7/10)^a for intra-articular glucocorticoid injection for knee OA as an adjunct treatment if first step interventions do not give satisfactory results
• Intra-articular glucocorticoid injection for knee OA		11	11	0.2 (–0.6 to 0.9)	8.2	8.7	0.5 (0.1 to 0.8)
5. A low priority recommendation (8/10)^a for paracetamol as an adjunct treatment if first step interventions do not give satisfactory results
• Paracetamol		50	51	0.6 (–0.3 to 1.7)	30	32	2.1 (1.6 to 2.7)
6. A low priority recommendation (9/10)^a for weak opioids as an adjunct treatment if first step interventions do not give satisfactory results
• Weak opioids		32	25	–6.8 (–7.7 to –5.9)	20	17	–3.2 (–3.7 to –2.8)
7. Weakest priority recommendation (10/10)# for NSAIDs (non-selective topical) as an adjunct treatment if first step interventions do not give satisfactory results
• Topical non-selective NSAIDs for knee OA		6.3	5.3	–1.0 (–1.5 to –0.6)	3.5	3.1	–0.3 (–0.6 to –0.2)
8. Weakest priority recommendation (10/10)# for strong opioids as an adjunct treatment if first step interventions or other pharmacological interventions do not give satisfactory results
• Strong opioids		10	13	2.8 (2.1 to 3.4)	9.3	11	1.9 (1.5 to 2.3)
! Recommendation against the prescription of glucosamine
• Glucosamine		13	4.1	–9.5 (–9.8 to –8.8)	3.3	1.1	–2.2 (–2.3 to –2.0)
! Recommendation against the prescription of hyaluronic acid injection
• Hyaluronic acid		2.1	0.5	–1.6 (–1.8 to –1.5)	0.2	0.1	–0.1 (–0.2 to –0.1)
! Recommendation against the prescription of glucocorticoid injection for hip OA
• Glucocorticoid injection for hip OA		8.7	11	2.1 (1.0 to 3.1)	7.7	9.3	1.6 (1.0 to 2.2)

Δ Difference between After and Before

a Guideline recommendation priority ranking according to a 1–10 graded scale, where 1 is the highest degree of priority and 10 the least degree of priority.

Gustafsson K, Rolfson O, Eriksson M, Dahlberg L, Kvist J. Study protocol for an observational register-based study on health and risk factors in patients with hip and knee osteoarthritis. BMJ Open 2018; 8(10): e022812.

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