Factors associated with access to health services and quality of life in knee osteoarthritis patients: a multilevel cross-sectional study

In large epidemiology studies, osteoarthritis (OA) has been reported as a major common cause of extremely poor quality of life (QoL) for hundreds of millions of adults of all ages worldwide [1]. The QoL of knee OA patients was found to be almost 50% lower than that of non-OA patients [2], and patients with end-stage OA reported a health state equal to or worse than that of patients with other chronic diseases [3]. OA has all the hallmarks of a harmful condition. It has been found to have the fourth greatest impact on the overall health of the world population in terms of both death and disability [4], highlighting the need for health system reforms.

In 2000, a worldwide campaign called the “Bone and Joint Decade” was launched to address this burden [5, 6]. Additionally, the Institute of Medicine (IOM) has advocated the Chronic Disease Management (CDM) policy to redesign the health service system at all levels [7, 8]. Since then, many countries, including Thailand, have established and implemented health policy, strategy, and planning at a national or institutional level. Subsequently, OA guidelines have been developed and implemented to provide a standard of care and assist physicians worldwide in tailoring OA management [9]. However, in reality, nearly half of knee OA patients in the health system do not have access to optimal health services, and their QoL remains immensely poor [10, 11], even in developed countries where health resources are plentiful.

Traditionally, physicians have had the authority to tell patients what to do and have expected patients to follow their orders. They have also tended to use management options such as medication and surgery for quick solutions, with a great focus on pain management [12, 13]. However, the actual provision of physician services remains limited. Safety, long waiting times, and health financing have been identified as problems [14]. Consequently, knee OA patients have tried to manage their care themselves, and they needed appropriate information and practical skills [15, 16]. They desire to live well with their condition [17]. Therefore, responsibility for the management of OA overlaps among patients, providers, and health systems.

The prevalence of knee OA in developing countries, including Thailand, is generally similar to that seen in high-income countries (HIC) [18]. In addition, the feasibility of implementing a full multidisciplinary care team in Thailand given the restrictions of a limited health workforce and funding is low. A rational prediction is that the impact of the disease may be extreme because of the low general standard of living. However, the situation is more complex than this. The body of evidence substantiates that access to health services and QoL are complex constructs that are correlated with health service system factors and patient factors. However, a dearth of research on the topic is available. Furthermore, the effect of interplay of patient factors and health service system factors on access to health services and QoL has rarely been explored. To address this evidence gap, research is needed to determine whether certain factors can improve access to health services and QoL in knee OA patients.

In total, 618 knee OA patients were included in the analyses. The response rate was 100%. The mean age was 64.7 years (SD 8.6). Only 32.3% had completed secondary school. Most (77.9%) were employed, and 77.7% had a low income. More than two-thirds (68.3%) of the participants had been diagnosed in the severe stage. The mean QoL was 33.8 (SD 12.7), while the mean SM was 35.1 (SD 5.3) (Table 1).

The access rate percentage was 54.2 (SD 14.1). Nonsteroidal anti-inflammatory drugs (NSAIDs) and/or other types of analgesics were prescribed to all knee OA patients. Only 39.4% of knee OA patients could access appropriate interventions before being referred for total knee replacement (Table 2).

There was a non-statistically significant difference in the mean of CDM policy implementation (all components) between the different levels of health services, with a total CDM policy implementation mean score of 5.9 (Table 3).

SEM showed that both health system factors (β = .10) and patient factors (β = .29 for SM and β = −.49 for disease factors) were directly or indirectly associated with QoL. However, the association between access to health services and QoL was not statistically significant. SM played an important mediating role and was correlated with access to health services (β = .13). This finding was robust across symptom severity and remained significant after other factors associated with QoL were adjusted for (Fig. 1).

This study demonstrated that the majority of knee OA patients were of early retirement age and had low socioeconomic status (SES). This finding could be attributed to economic factors as most elderly patients cannot afford to retire. It has been estimated that 80–90% of the population in low- and middle-income countries (LMIC) is involved in “heavy work”. There is evidence that knee OA patients with a lower SES have a poorer QoL [27]. However, this study found that SES factors affected QoL not directly but through SM. This finding is similar to findings in many recent studies that revealed that SES alone is not associated with QoL in knee OA patients [28‐30].

The basic finding of this study was that worsening knee OA symptoms were related to the deterioration of QoL (β = −.49, p = .00). The QoL of knee OA patients appeared to be low. However, after symptom severity was adjusted for, the mean QoL scores in this study were closely linked to those found in the rest of the world [31‐33]. This indicates that the QoL of knee OA patients is dependent on their disease severity rather than their country-specific context.

Additionally, this study found that knee OA patients with a higher SES might not have better access to health services. These data are inconsistent with those of previously published reports [34, 35]. One reason for this discrepancy is that this study was conducted in a country where national health care use tends to favor the poor, especially since the implementation of a universal coverage policy in 2011 and a free medical care program for destitute elderly people in 2009. These two programs help facilitate equal access to health services for all Thais by removing cost barriers [36].

Most importantly, this study found that knee OA patients who had better SM not only had better QoL (β = .29, p = .00) but also had better access to health services (β = .18, p = .00). This finding was robust across symptom severity levels and remained significant after many factors associated with QoL were adjusted for. Findings from qualitative studies have indicated that the majority of knee OA patients view individual responsibility as a key to maintaining health and living well with knee OA [13]. Conceivably, OA patients’ desire to manage the impact of their condition on their life facilitates SM. Patients in a study by Miller et al. [37] reported that they attempted to adapt their lifestyle to reduce knee joint symptoms. Some patients took the initiative to start medication and nonpharmacological treatment on their own. Most of these patients sought information to gain control over their condition using a variety of sources, such as multimedia platforms and peers [38]. Therefore, they also had to access appropriate information to increase their knowledge how to self-manage their problem to improve QoL.

Interestingly, SM was strongly linked to patients’ socioeconomic (SES) factors (β = .28, p = .00) and disease factors (β =. -43, p = .00). Thus, QoL improved or worsened the effects of SES and disease factors on patients’ ability to manage their own disease. The mechanisms for the association between SES and SM remain unclear. Indirect evidence suggests that SES plays a pivotal role in the lives of citizens [39]. It is essential that patients with low SES receive sufficient knowledge to empower them to actively manage their health.

Unsurprisingly, knee OA patients attempt SM when their symptom severity increases. This finding contrasts with the findings of previous research showing that COPD patients who reported a higher symptom burden also reported lower SM [40]. There is a misbelief that knee OA is just part of the aging process. Knee OA patients might simply be told that there is nothing to be done except knee arthroplasty [41]. Although health care professionals state that SM is useful in improving patients’ health outcomes, it is often completely under recognized and omitted from patient education [42, 43]. Thus, knee OA patients are left underprepared for SM when their symptom severity is mild. Furthermore, most health care providers have focused on SM-related support rather than on patient SM. However, a recent review reported that SM support alone likely has little to no effect on improving knee OA patients’ health outcomes [44].

Knee OA patients have expressed disappointment that the public health care system does little to help them [45]. Given this reality, to improve patients’ SM, a better understanding of how to deliver health services and align evidence with policy and practice is required. We must also reshape our mindsets and imagine ourselves as patients, particularly those with SES disadvantages. Increasing awareness among the public and clinicians regarding the multifaceted impact of OA on the lives of a large segment of the population may increase attention to the problem and elicit more proactive management by both patients and physicians.

The present study has several limitations. First, it was conducted in government hospital settings with specific recruitment requirements. Thus, it cannot be extrapolated to other settings (private hospitals, home health care, populations with other ethnic backgrounds, etc.). The data were collected in a single country. Therefore, the results of this study may not always be extrapolated to countries with different health care policies. This was not a placebo-controlled trial; thus, the extent to which QoL improvements may have been related to placebo effects cannot be estimated. Other limitations of the study are that the access rates may not reflect the care quality, as perceived by the patients, and health care providers may interpret the quality differently from their patients. However, self-reports might represent a weakness because there is potential for recall bias, which might have led to over- or underestimated access rates in the study.

A key strength of this study of knee OA patients is that it provides powerful information about access to health services and QoL from the individual and health system perspectives. One of the first steps toward improving QoL in adults with OA is to develop a better understanding of the factors that coexist with and influence QoL. Most studies focus on single variables concerned with individual factors (e.g., gender, education level, income, career and severity of disease), while QoL involves multiple factors. This study strongly supports the notion that SM is independently correlated with improved QoL. Therefore, understanding patient SM is important to identifying other factors for best practice and potential strategies to create more patient-centered health services for OA care.

This study highlights the strengths of existing OA clinical practices and the opportunity to create health service systems that positively influence future care. Health service system factors and patient factors all appear to influence QoL in knee OA patients. Most importantly, the effective management of OA care begins and ends with the patients. Moreover, there is a need to target research efforts toward specific interventions to improve patient SM, which remains a key patient factor.