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Guideline for the management of knee and hip osteoarthritis

Chapter 1

Background

Osteoarthritis (OA) is a chronic disease that mostly affects the hands, knees and hips

The 2014–15 National health survey shows that an estimated 2.1 million Australians (9% of the population) of all ages have this condition.1 A more rapid increase in OA prevalence occurs after the age of 45 years; for those aged >55 years, the prevalence of OA increases to more than 60%.1

With the ageing Australian population, and increasing rates of obesity, the numbers of Australians with OA is expected to increase from an estimated 2.1 million in 2015 to an estimated 3.1 million (12% of the population) by 2030.1 Globally, hip and knee OA was ranked as the 11th highest contributor to global disability,2 and is the most notable non-communicable disease, with total disability-adjusted life-years (DALYs) rising by 35% between 1990 and 2015.3 OA is placing an increasing burden on individuals, societies and healthcare systems.

Overall health expenditure on arthritis exceeds that of numerous other chronic conditions, including coronary heart disease, diabetes, depression, stroke and asthma.4 Direct healthcare costs for OA were estimated to be more than $2.1 billion in 2015, and by 2030, these are forecast to exceed $2.9 billion.5 Broader economic costs are estimated to be around $22 billion annually.6

Strategies for relieving pain, minimising disability and slowing disease progression around OA are key treatment goals of conservative, non-surgical management. Implementing conservative management strategies at a population level for people with OA could result in substantial cost savings for the Australian healthcare system. For example, the potential cost savings from delaying knee replacements alone would be more than $233 million in 2030.5

General practitioners (GPs) are often the first point of contact within the healthcare system for someone with OA. In 2015–16, OA was managed in 26 per 1000 general practice encounters at all ages.7 While OA is a chronic condition that imposes a significant burden in terms of years lived with disability, it has a much lesser impact on mortality; therefore, it is often not prioritised by treating health practitioners.

The Royal Australian College of General Practitioners (RACGP) published Guidelines for the non-surgical management of hip and knee osteoarthritis in 2009.8 Since then, substantial progress has been made, evaluating the effectiveness and safety of commonly used and new therapies for OA. The objective of this review is to present the most up-to-date evidence for OA interventions, other than joint replacement for the hip and knee. Additionally, it is to inform the development of evidence-based recommendations for GPs working in the Australian healthcare setting.

The questions of specific interest to this literature review and guideline were:

  • What is the efficacy and safety of non-pharmacological (including complementary) interventions for adults with symptomatic knee and/or hip OA?
  • What is the efficacy and safety of pharmacological interventions for adults with symptomatic knee and/or hip OA?
  • What is the efficacy and safety of arthroscopic surgical procedures for adults with symptomatic knee and/or hip OA?

In developing and updating the guideline, we also aimed to ensure that the:

  • recommendations were based on the best available evidence
  • content was practical, useful and appropriate for GPs
  • accompanying treatment algorithm and summary of recommendations were updated.

A formal communication and implementation plan has been developed to promote the guideline to general practice and key stakeholders. This plan aims to:

  • increase awareness of the new release and improve uptake of the guideline
  • build awareness of project initiation and progress
  • seek support and buy-in from stakeholders
  • increase awareness and alignment with other national initiatives, including the Australian Commission on Safety and Quality in Health Care’s Osteoarthritis of the knee clinical care standard, RACGP’s Handbook of non-drug interventions (HANDI), RACGP gplearning’s osteoarthritis education module, and Arthritis Australia’s MyJointPain website.

This update of the 2009 guideline:

  • incorporates a review of the evidence of the safety and efficacy of new therapies for the management of knee and/or hip OA
  • revisits established therapies in light of more recent evidence.

This guideline will apply to all adults diagnosed with symptomatic OA of the knee and/or hip across the disease trajectory, and is intended primarily for use in the primary care setting by GPs to guide patient care. The recommendations are also relevant for other health professionals working in the management of people with knee and/or hip OA in the community. Although foot osteoarthritis is an important source of symptoms in the general community and a prevalent problem, it was not practical within the scope of work to include it in this guideline.

The primary target audience for this guideline is Australian GPs in primary care settings in metropolitan, regional, rural and remote areas. Given the wide range of health professionals who treat this condition, consideration of the relevance of this guideline was also given to other health professionals.

Additional target audiences include sport and exercise medicine physicians, rheumatologists, orthopaedic surgeons, physiotherapists, occupational therapists, pharmacists, podiatrists, pain physicians, psychologists, exercise physiologists, dietitians, nurses, chiropractors and osteopaths.

This is reflected in the composition of the guideline development working group.

Poor health outcomes are more frequent among individuals living in communities of low socioeconomic status (SES) who are more likely to be disadvantaged in receiving adequate healthcare. As seen with many other chronic conditions, areas of low SES have also been reported to have higher prevalence of OA.9 Social and economic circumstances, including income, education, employment and social support affect the health of individuals in these areas, placing them at greater risk of poor health.9 Furthermore, evidence suggests that poor health, including high rates of arthritis, may worsen poverty in low-income to middle-income countries because of the inability of individuals to work and fulfil community roles.10

In providing quality healthcare, the needs and issues faced by disadvantaged groups, including Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse (CALD) communities must be considered. In 2009–10, people in lower socioeconomic households spent proportionately less on medical and healthcare than those in households with higher SES (3% in low compared with 5.1% in high of weekly equivalised expenditure).11 The Australian Institute of Health and Welfare (AIHW) reports that Aboriginal and Torres Strait Islander peoples and CALD communities often lack access to nutritious and affordable food,12,13 are less likely to engage in physical activity and have higher rates of overweight and obesity.9,14

After adjusting for age, the prevalence of OA in Aboriginal and Torres Strait Islander peoples is similar to prevalence in the total Australian population.15 However, areas of lower socioeconomic status generally have higher prevalence of OA in comparison with areas with high socioeconomic status (9.5% compared to 7.2%).15

In Australia, Aboriginal and Torres Strait Islander peoples with arthritis have fewer visits to GPs and other health professionals.16 Ensuring access to appropriate and specialised services are particularly important to reduce any disparity gaps for Australians who live in rural and remote settings. In addition to good access to care, the provision of comprehensible resources in multiple languages for those with low literacy and low health literacy, relevant education materials, and interpreter services when required, will contribute to addressing the needs of socially disadvantaged groups.17 In Aboriginal and Torres Strait Islander and CALD communities, connecting individuals to community-based health programs has also been demonstrated to be effective.18,19

Barriers such as difficulties in communication and understanding cultural differences, and coordinated planning for better service provision also need to be addressed. Appropriate assistance and consumer consultation also needs to be in place for these communities to ensure uptake of services provided.

Holistic assessment

An initial assessment of people with OA should be based on a complete history and physical examination, including ascertaining the effect of OA on the person’s function, quality of life, occupation, mood, sleep, relationships and leisure activities.20 OA is a multifaceted disease in which the structural evidence of joint damage frequently does not correlate with the presence and severity of joint pain and disability. A holistic assessment better facilitates the patient–professional partnership, and collaborative care in which patients and healthcare professionals make shared decisions related to treatment to improve outcomes.21 Personal preferences for certain types of therapies should also be considered, as adherence to treatment recommendations and outcomes can be compromised if the management plan does not meet the person’s preferences and beliefs. Furthermore, people with OA are predominantly older adults and often have different personal priorities and aspirations, which may affect treatment choice. The use of patientreported measures, inclusive of outcomes and experience, is an important beginning of, and component of, holistic assessment of individuals with hip and/or knee OA. These measures capture a patients’ perspective about how their OA impacts on their life, health and wellbeing, and their experience in receiving care. Patient-reported measures are important tools used during the clinical consultation and in multidisciplinary team discussions to contribute to shared clinical decision making and patient-centred care.

People with knee and/or hip OA should be asked about their knowledge of the disease and treatment alternatives, previous experiences with treatment, and expectations of current treatment. The presence of some misconceptions (eg exercise will worsen OA, OA will inevitably get worse) may hamper the development of an appropriately tailored plan and limit the success of treatment, if not properly identified. Key factors that should be considered as part of the holistic assessment:

  • Social factors – effect of the condition on activities of daily living, relationships and quality of life; recreational and occupational activities
  • Health beliefs and concerns – previous knowledge of OA; expectations of treatment; understanding of treatment options, including benefits and harms
  • Psychological factors – screen for depression; stresses in life;  mood
  • Attitudes to physical activity and exercise – concerns; participation restriction; beliefs
  • Pain assessment – nature of pain, other sites of pain, self-help strategies; analgesics use, doses, frequency and side effects; current understanding about persistent pain
  • Functional capacity including walking ability, stair climbing, sit-to-stand, balance
  • Presence of support – concerns and expectations of carers; isolation issues
  • Influence of comorbidities – interaction of two or more morbidities; falls risk
  • Modifiable risk factors – overweight/obesity; joint alignment; injury/buckling

While not every factor will be a concern for a person with knee and/or hip OA, some issues may warrant greater consideration, depending on the person’s situation, preferences and priorities. After taking into account these factors, a personalised management plan can be developed in collaboration with the person.

Evaluation of treatment response

Periodic clinical assessments should be performed at regularly agreed intervals to assess the effects of treatment on symptoms, function and status, and to quantify objective changes in metrics related to interventions (eg weight, muscle strength). Assessing the person periodically enables regular coaching and reinforcement of the management plan. This also allows for monitoring of treatment effectiveness, side effects and alterations to the management plan according to outcome.

Diagnosis and evaluation of treatment response in OA is primarily based on clinical assessment. There is no established role for laboratory or imaging tests in assessing disease activity/status in clinical practice. As a result, these are not required for OA diagnosis or disease monitoring (refer to Section 1.7.1 Clinical diagnosis and Section 1.7.2 Limited role for imaging).

There is a variety of clinical tools aimed at evaluating the clinical status and patient-reported outcomes that are mainly used in clinical research. A few commonly used instruments for assessing self-reported pain and function include:

  • Numeric Pain Rating Scale (NPRS)22
  • Visual Analog Scale (VAS) for Pain23
  • Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire24
  • Knee Injury and Osteoarthritis Outcome Score (KOOS)25
  • Hip Disability and Osteoarthritis Outcome Score (HOOS).26

In addition, the 30-second chair-stand test, 40-metre fast-paced walk test, stair-climb test, timed up-and-go test, and six-minute walk test were recommended as complementary tests to patient report measures. The 30-second chair-stand test, 40-metre fast-paced walk test and stair-climb test were recommended by the Osteoarthritis Research Society International (OARSI) advisory group as the minimal core set of performance-based tests for hip or knee OA.27

Clinical diagnosis

The diagnosis of knee and/or hip OA can be made based on:

  • Background risk – population prevalence of knee or hip OA
  • Person’s risk factors for OA – for example, age, gender, body mass index (BMI), occupation
  • Person’s symptoms – persistent knee/hip pain, brief morning stiffness and functional limitation
  • Adequate physical examination – crepitus, restricted movement and bony enlargement. Plain radiograph is not needed, but could be considered for atypical presentations.28

A typical knee OA diagnosis can be made without requiring further investigations if a person:29,30

  • is aged 45 years or older
  • has activity-related joint pain
  • has morning stiffness that lasts <30 minutes20
  • has crepitus on active motion
  • has bony enlargement
  • has no detectable warmth.

Additional features that may be present include:31

  • deformity – fixed flexion and/or varus (less commonly valgus for the knee)
  • instability
  • peri-articular or joint-line tenderness
  • pain on patellofemoral compression.

Similar to knee OA, hip OA can be diagnosed by clinical features alone, according to American College of Rheumatology (ACR) criteria.32 Early physical signs of hip OA include restriction of internal rotation and abduction of the affected hip, with pain occurring at the end of the range of motion.32

Be aware that atypical features – such as a history of trauma, prolonged morning joint-related stiffness, rapid worsening of symptoms or the presence of a swollen hot joint – may indicate alternative or additional diagnoses. Consideration of concerning clinical features (eg severe local inflammation, erythema, progressive pain unrelated to usage) that are suggestive of tumour, septic arthritis, crystal arthritis, other inflammatory arthritides (eg rheumatoid arthritis), osteonecrosis, fracture or serious bony pathology, is required during the clinical examination. If any of these are detected, the individual should be referred to an appropriate health practitioner. Involvement of other joints may suggest a wide range of alternative diagnoses.

In clinical practice, laboratory tests (eg rheumatoid factor, erythrocyte sedimentation rate [ESR], synovial fluid aspirate for crystal confirmation, C-reactive protein [CRP]) would be requested to confirm or exclude co-existent inflammatory disease (eg calcium pyrophosphate crystal deposition, gout, rheumatoid arthritis) in people with suggestive symptoms or signs. However, laboratory tests on blood, urine or synovial fluid are not needed as a diagnosis of OA can be readily made in their absence. If a palpable effusion is present, synovial fluid should be aspirated and analysed to exclude inflammatory disease, and to identify urate and calcium pyrophosphate crystals. OA synovial fluid is typically non-inflammatory with <2000 leucocytes/mm3; if specifically sought, basic calcium phosphate crystals are often present.31

Limited role for imaging

OA is typically diagnosed clinically, and the role of imaging is limited. In atypical presentations, imaging might be considered when diagnoses other than OA are suspected. Imaging can also be helpful when the clinical diagnosis is uncertain. It may be beneficial for people with atypical symptoms to be referred to a specialist for magnetic resonance imaging (MRI) investigation as referral by a GP is not reimbursed by the Medicare Benefits Schedule (MBS). Imaging for OA follow-up is recommended only if there are unexpected rapid progression of symptoms or change in clinical characteristics that need to be confirmed (eg increasing severity of OA).20, 28 However, it has been noted that many structural abnormalities seen on imaging are very common in older populations,33 and these abnormalities should be considered in the appropriate clinical context.

There is a lack of co-occurrence of the radiographic changes and symptoms of OA.34 In people with frequent hip pain, only 15.6% showed evidence of radiographic OA (Kellgren–Lawrence grade 3 or 4).35 Studies have shown that 15–81% of people with radiographic OA have knee pain.34 In addition, the accuracy of the association between symptoms and radiographic OA could be affected by:36–38

  • extent of radiographic views
  • definitions of pain measurements
  • different groups (eg ethnicity, gender) included in the study
  • other potential confounders.

If imaging is required, conventional (plain) radiography should be used before other modalities. Soft tissues are best imaged by ultrasound or MRI, and bone by computed tomography (CT) or MRI.

Consideration of radiographic views is important for optimising detection of OA features; in particular, for the knee, weight-bearing and patellofemoral views28 are recommended. A full history, clinical examination and anteroposterior X-ray of the affected hip should be the first-line choice of imaging to diagnose the cause of hip pain. However, MRI has a definite role in excluding or confirming infrequent differential diagnoses (eg osteonecrosis, avascular necrosis, insufficiency fracture). The systematic use of imaging in the diagnostic process is not recommended in cases with a typical clinical presentation because of the absence of strong evidence supporting the additional impact on the certainty of diagnosis using imaging.28

Key messages regarding imaging in OA:

  • OA can be diagnosed clinically, and imaging is not needed but could be considered for atypical presentations. • Radiographic changes and meniscal tears are an almost universal finding in people with OA, and are typically just age-related abnormalities and not related to symptoms.39, 40
  • Serious underlying pathologies are unlikely to be missed, even if people with a clinical diagnosis of OA have no routine imaging.20
  • Imaging can lead to increased use of harmful interventions.

OA management should include a holistic assessment considering the global needs of the individual.20 Personal preferences for certain types of therapies should be assessed, as adherence and outcomes may be compromised if the management plan does not match the person’s preferences and beliefs.

Broadly speaking, OA management goals are to minimise pain, optimise function and participation, and to empower the person to self-manage. Given the modest effects of individual treatment approaches, a combination of therapeutic approaches is commonly used. Clinicians should also aim to target modifiable risk factors (eg obesity, strength, depression).

The principles of chronic disease management apply to the care of people with OA, and are based on the following:41

  • care should be continuous; tailored to the person according to individual needs, goals, and values; and be person-centred
  • decision-making should be based on the best evidence available, and personal preferences and values
  • information should be widely accessible to individuals
  • anticipation of needs should be prioritised over a reactive health service.

The number of joints involved, degree of pain, movement restriction and functional impairment, and presence of comorbidities should also guide the management plan. Involvement of partners, family and friends is important to provide the individual with support to self-manage their condition, and is one of the pillars of patient-centred care.

Efforts should be made to prioritise interventions that are safer, more accessible and more cost-effective over treatments that have greater adverse events, are less feasible and more expensive. Active, non-pharmacological interventions are the mainstay of OA management, and should be tried first, followed by or in concert with medications to relieve pain when necessary. Non-pharmacological therapies include weight management, promotion of physical activity, strengthening exercises, education and behaviour change support.42

Patient adherence, optimal uptake of recommendations and behaviour modifications are key elements of OA treatment, and can be optimised by education, establishing treatment goals and periodic monitoring.

Education

Education for people with OA is important to improve their understanding of their disease and the importance of self-management.43 Individuals should be informed about the aetiology of OA, the typical fluctuating nature of pain, risk factors (especially those that are modifiable and specific to the person), and expected prognosis, including most people not progressing to requiring joint replacement.44

Clear information about treatment options along with their benefits, harms and costs should be discussed. Providing this information helps to counter common misconceptions and encourages individuals to adopt an active approach in the management of their own disease.45 Language is important, and terms such as ‘wear and tear’ and ‘bone-on-bone’ should be avoided, as this can lead to pessimism about treatment outcomes (ie nothing can be done) and misbeliefs (eg exercise is detrimental and unsafe) that can affect individual engagement. It is also important to instil a sense of optimism and hope, and facilitate positive expectations about treatment outcome.

Goal setting helps the informed person identify current issues, set priorities and focus on specific changes. To develop a realistic plan, goals should be agreed upon with the individual, considering their preferences and biopsychosocial context. In addition, appropriate goals should be specific, timely and measurable, and should be reviewed periodically.

Multidisciplinary care

As OA is a chronic condition that is often associated with a number of comorbidities and psychosocial issues, many people receive substantial benefits when care is provided using a multidisciplinary team approach. While it is recognised that not all people will require such an approach to management, a key role of GPs is to determine whether a multidisciplinary team approach is necessary, and if so, to refer to appropriately skilled health professionals (actual or virtual) in the community or hospital settings. Many people with chronic pain are best managed in primary care or the community level with multidisciplinary support, including self-care, while specialist services in hospitals typically focus on treating people who are more complex. GPs are ideally placed to play the role of care coordinator to ensure management continuity, whereby there is a consistent, coherent and collaborative approach to management from all team members who are responsive to the person’s changing needs. The GP can also delegate certain care coordination activities to another suitable health professional, such as practice nurse or team physiotherapist.

Practice nurses can be invaluable in partnership with GPs in care planning and goal setting. Support of allied health professionals will greatly enhance capacity to include all the concepts of chronic care. It will also add value to the person’s experience and outcomes with allied health professionals’ expertise in the care of people with OA and the common comorbidities. Some people may need to be referred to practitioners with requisite knowledge and skills in exercise therapy and behaviour change (eg physiotherapists, sports and exercise physicians, exercise physiologists) to prescribe an individualised exercise/physical activity program and facilitate long-term adherence. Physiotherapists and other practitioners with expertise in manual therapy/massage can provide this as a short-term adjunct to facilitate engagement in lifestyle interventions. Referral to dietitians/nutritionists may benefit people who are overweight or obese and require an individualised dietary assessment and management plan. Occupational therapists can provide specific approaches to self-management (eg occupational and home adaptations). Podiatrists/orthotists may be consulted for prescription of shoe orthoses and braces.

While pain management is a high priority in the clinical care of people, there are broader psychological effects arising from a physical health condition that may necessitate psychological intervention to improve a person’s ability to live with and manage OA. For some individuals, referral to a multidisciplinary pain clinic or a pain specialist may be warranted, particularly if the person is having difficulties managing pain despite current best practice. Based on a systematic assessment of falls risk, referral to a falls clinic may be beneficial. Referral to other medical practitioners (eg rheumatologists, sports and exercise physicians) may be appropriate for complicated cases, or if symptoms persist or worsen. For people with advanced knee and/or hip OA who continue to have substantial pain and functional difficulty despite high-quality conservative management, referral to an orthopaedic surgeon could be considered in discussion with the person (refer to Section 1.9 Timing of and need for referral to an orthopaedic surgeon).

Implementation and referral pathways

As part of the development of this guideline, a specific implementation plan was developed to ensure and optimise appropriate dissemination and use of the guideline. It is important to recognise that there are already a number of good resources in existence that should be used to facilitate evidence-based care. These include:

Consumer information resources and services for patient education and support for self-management are provided by support organisations:

These organisations provide printed and online information, which help reinforce education and self-management advice provided to individuals by clinicians. They may also offer support groups, exercise sessions and other services valuable for social support.

Where possible, GPs should use existing services and referral pathways to optimise targeting appropriate evidencebased care and recommendations within this guideline. These could include allied health referrals (using the Chronic Disease Management MBS items) and access to relevant multidisciplinary state/territory government initiatives.

Total joint replacement surgery is the most cost-effective and clinically effective treatment for end-stage OA46,47 in appropriately selected individuals. It should be noted that the lifetime risk of undergoing total joint replacement is estimated to be substantially less than the risk of developing symptomatic hip and/or knee OA. In the UK, the estimated mortality-adjusted lifetime risk of total hip replacement at age 50 in 2005 was 11.6% for women and 7.1% for men. For total knee replacement, the risks were 10.8% for women and 8.1% for men.48

GPs should consider referring individuals with end-stage OA when all appropriate conservative options, delivered for a reasonable period of time, have failed. The indication for referral to an orthopaedic surgeon should be based on a significant decline in quality of life because of established and end-stage joint OA. The hallmarks of end-stage OA include significant joint pain, swelling and deformity, which disrupts normal sleep patterns, causes a severe reduction in walking distance such that people become housebound and avoid ambulation outside, and marked restriction of activities of daily living (eg rising from a chair or toilet seat, difficulty with climbing stairs).48 It is important that careful history, examination and investigations (plain joint radiography) are obtained to avoid up to 25% of people who have been shown to undergo inappropriate joint replacement surgery, including minimal symptoms, less radiographic abnormality and unrealistic expectations.49 People who receive the best outcomes following total joint replacement have:

  • significant pre-operative radiographic joint change (Kellgren–Lawrence grade 3 or 4)50,51
  • well-controlled comorbidities
  • a BMI no greater than 30 or no lower than 20
  • good mental health status.52

GPs should consider optimising the medical status of people to improve post-operative outcomes and reduce peri-operative complications.53 In this regard, individuals may benefit from pre-operative expert internal medicine referral. The most common pre-operative morbidities include low ferritin, diabetes, hypertension, hyperlipidaemia, back pain, depression, cardiac arrhythmia, coronary artery disease, chronic obstructive pulmonary disease and obesity.54

People who are planning surgery should maintain the range of motion of their arthritic joint, and should engage in as much strengthening and physical activity as possible (eg walking, hydrotherapy).55,56 Individuals should also ensure that their dental and pedal health is maintained, and any dermatologic conditions are treated and stabilised prior to surgery to minimise the devastating complication of prosthetic joint infection.

Not all people do well even after uncomplicated surgery. Up to 25% of individuals who had a total joint replacement continue to complain of pain and disability after well-performed surgery.57,58 These individuals continue to use health resources. Careful pre-operative patient selection – including considering the poor outcomes that are more common in people who are depressed, have minimal radiographic disease, minimal pain and who are morbidly obese – shared decision-making about surgery and informing individuals about realistic outcomes of surgery are required to minimise the likelihood of dissatisfaction. Objective evidence is available that may identify this cohort of individuals,52 and for whom alternate non-operative interventions may be more appropriate.

Patient decision aids support individuals by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values.59 According to the International Patient Decision Aids Standards (IPDAS) collaboration description, decision aids are evidence-based tools designed to prepare individuals to participate in making specific and deliberated choices among healthcare options.60 Patient decision aids should not replace, but may act as an adjunct to, good clinical practice. Patient decision aids are not necessary to deliver good shared decision-making; however, well-developed tools will facilitate patient engagement and can be used at various points throughout the person’s journey, and surround decisions on every aspect of care including exercise and diet, pharmacological management and in consideration of joint replacement.20 Decision aids are different from patient information leaflets, which aim to only provide information.

In 2014, the UK National Institute for Health and Care Excellence (NICE) reviewed the clinical effectiveness of OA-specific decision aids that may be used to enable individuals to participate in the management of their condition. There was moderate-quality evidence that the video booklet decision aid may reduce decisional conflict more than an education leaflet alone,61 and low-quality evidence that patients’ confidence in decision making, selfefficacy and preparation for decision making are increased with decision aids.62 Despite a paucity of high-quality evidence for any given decision aid, it is important to highlight that decision aids should be used as support tools as part of a discussion with a clinician and not as stand-alone tools.

There is currently no systematic way of determining what types of clinical decision-making support tools are used in Australia, or how commonly they are used by clinicians and their patients. However, practitioners could refer to the principles of shared decision making outlined in the patient experience guideline. The UK National Health Service RightCare has recently developed shared decision programs that are available on the NICE evidence search website, including aids specifically designed for hip and knee OA.

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