Patient, Provider and Organizational 

Interventions for

Managing Osteoarthritis (OA) in 

Veterans 

Kelli D. Allen, PhD

Research Health Scientist, Center for Health Services Research in Primary 

Care, Durham VA Medical Center

Research Professor, Department of Medicine and Thurston Arthritis Research 

Center, University of North Carolina at Chapel Hill 
Poll Question #1

What is your primary role in the VA?

• Student, trainee, fellow

• Clinician

• Researcher 

• Manager, Policy-Maker

• Other 
Burden of Osteoarthritis

• Highly Prevalent

– Lifetime risk of symptomatic knee OA is 45%

– Lifetime risk of symptomatic hip OA is 25%* 

* Johnston County Osteoarthritis Project; 

Murphy et al., Arthritis Rheum, 2008; Murphy 

et al., Osteoarthritis Cartilage, 2010

0

10

20

30

40

50

60

70

80

2005 2010 2015 2020 2025 2030

Number 

(in millions)

Women

Men Projected 

prevalence of 

doctor-diagnosed 

arthritis among US 

adults (18+)

National Health 

Interview Survey

Hootman et al., Arthritis 

Rheum, 2006 
Burden of Osteoarthritis

• Highly Disabling

*Centers for Disease Control and 

Prevention, MMWR, 2005
Burden of Osteoarthritis in Veterans

• Arthritis is 3rd most prevalent health problem among 

veterans* 

• Prevalence of arthritis is higher in veterans than non- veterans:

– Data from CDC, arthritis affects§: 

• 22% of non-veterans 

• 30% of veteran non-VA users

• 43% of VA users 

• Among veterans with arthritis, activity-limiting joint 

symptoms are more common among VA users than non- users (63% vs. 42%, p<0.001)§ 

*National Survey of Veterans; §Dominick et al, J Rheum, 2006; 
Gaps in Management of OA: 

Patient Behaviors

 Patients often symptomatic for long duration 

before seeking care

• Many individuals have limited knowledge about 

OA, self-management strategies, and treatment 

options

• Physical Activity: 60-75% of individuals with OA do 

not meet recommendations

• Weight: majority of individuals with lower 

extremity OA (~90%) are overweight or obese
Gaps in Management of OA: 

Health Care Systems

• Detection & diagnosis often late; no systematic screening

– No good early “markers” for OA, but we know risk factors and 

early symptoms

• Gaps in recommended care* 

 Overall quality indicator pass rates 22-57% § 

 In particular, low use of conservative, non-pharmacological 

strategies (exercise, weight loss, physical therapy, assistive 

devices) 

*Hunter et al, Arthritis Care Res, 2011; Brand et al., Rheum Dis Clin N Am, 2013; § Li et al., J Rheumatol, 2011; Ganz et al., 

Arthritis Rheum, 2006
Poll Question #2

Describe your familiarity with osteoarthritis treatment 

guidelines (any set):

• Did not know there were any 

• Know they exist but unfamiliar with content

• Somewhat familiar with content

• Very familiar with content
Patient and Provider Interventions for Managing 

Osteoarthritis in Primary Care (PRIMO)* 

• Objective: Examine the effectiveness of a comprehensive 

intervention, involving both patients and providers, for improving 

OA-related outcomes in a real-world VA clinical setting 

• Study Design

– Randomized Controlled Trial: 

• Patient + Provider Intervention vs. Usual Care

– N=30 primary care providers (randomized) 

– Aimed to enroll 10 each of their patients (5 white, 5 non-white) 

• Some enrolled providers left the VA during study period; range of enrolled 

patients per provider was 3-12 

*VA HSR&D IIR 10-126; Allen et al., BMC Musculoskelet Disord, 2012 
Patient and Provider Interventions for Managing 

Osteoarthritis in Primary Care (PRIMO)

• Participants

– Under care at VAMC in Durham, NC

– Symptomatic hip and / or knee OA (radiographic evidence or clinical 

criteria) 

– BMI ≥ 25

– Not meeting DHHS physical activity recommendations

• Measures

– Primary Outcome: Western Ontario and McMaster Universities 

Osteoarthritis Index (WOMAC): self-reported pain, stiffness, and 

function

– Short Performance Physical Battery (SPPB): objectively assessed 

physical function

– Depressive Symptoms (PHQ-8)
PRIMO Interventions

• Patient Intervention

– 12-months, telephone-based 

– Focus on physical activity, weight management, cognitive behavioral 

pain management skills

– Emphasis on goal-setting; motivational interviewing approaches

• Provider Intervention

– Overall goal – enhance use of guideline-based treatment, with 

emphasis on non-pharmacological therapies

– Patient-specific treatment recommendations issued at point of care

– Based on treatment guidelines and patient clinical status & 

preferences (baseline assessments)




PRIMO Interventions

• Patient Intervention

– 12-month, telephone-based 

– Focus on physical activity, weight management, cognitive behavioral 

pain management skills

– Emphasis on goal-setting

• Provider Intervention

– Overall goal – enhance use of guideline-based OA treatment, with 

emphasis on non-pharmacological therapies

– Patient-specific treatment recommendations issued at point of care 

(EMR), optimally in conjunction with routine visit

– Based on published OA treatment guidelines and patient clinical 

status & preferences (baseline assessments)
PRIMO Interventions

• Provider Intervention: Recommendation Example

– Refer to physical therapist for evaluation and / or therapeutic exercises

• Patient indicates interest in being referred for physical therapy for OA if their provider recommends AND

• Patient is not doing strengthening exercises ≥2 times per week AND

• Patient indicates being dissatisfied with their ability to perform one more activities on the Satisfaction with 

Physical Function Scale (walking, lifting / carrying, stair climbing, housework) AND 

• Patient has not seen a physical therapist for their OA in the past year 

• Other Recommendations: 

– Knee braces

– Referral for weight management program

– Referral for physical activity programs

– Joint injections

– Topical NSAIDs / capsaicin

– Adding gastroprotective agent

– Trying new pain medication

– Referral to orthopedist (evaluation for surgery)
PRIMO Participant Characteristics

Mean (SD) or % (N=300) 

Mean Age 61 (SD = 9)

Race

 White

 Non-White

50%

50% 

Male 91%

Mean BMI 34 (SD = 6)

Hip OA 21%

Knee OA 89%

Mean duration of arthritis 

symptoms

14 years (SD = 11)

Mean WOMAC Score 48 (SD = 18)
PRIMO Baseline Data: Pain Medication Use

Any (Prescription or OTC) 77%

Acetaminophen 19%

NSAIDs 54%

Opioids 29%

 How well are your medications controlling your arthritis pain 

(0=not at all, 10=very well)? 

 Mean = 5.2, SD = 2.6

 Would you be interested in talking with your health care provider 

about the possibility of trying a different medication for your 

arthritis pain?

 Yes: 78%, Maybe: 14%, No: 8%
PRIMO Baseline Data: Joint Injections

Have you ever had an injection into your hip / 

knee for your arthritis?

Knee (Any) 55%

Hip (Any) 18%

 Would you be interested in having a knee or hip joint injection if 

your healthcare provider thought it may be appropriate for you?

 Yes: 60%, Maybe: 22%, No: 18%
PRIMO Baseline Data: Topical Creams 

& Knee Braces

 Have you ever used a topical cream to treat your 

arthritis?

 Yes: 69%

 96% interested in trying a topical cream if recommended by 

provider 

 Have you ever used a knee brace (if knee OA)?

 Yes: 81%

 Half of brace use was elastic sleeve only

 92% interested in trying brace (or new kind of brace) if 

recommended by provider
PRIMO Baseline Data: Physical Therapy

 Have you ever seen a physical therapist for your knee / 

hip arthritis?

 Knee: 47%

 Hip: 31%

 If no PT in past year: Would you be interested in seeing a 

physical therapist for your knee / hip arthritis if your 

healthcare provider thought it might be appropriate for 

you?

 Knee: Yes: 80%, Maybe: 10%, No: 8%

 Hip: Yes: 68%, Maybe: 16%, No: 15%
PRIMO: Intervention Delivery

 Patient Intervention:

 Mean calls completed (out of possible 18): 12.0 (SD=4.3)

 Average call duration: 16.7 minutes

 Preliminary cost estimate: ~$300 / patient

 Provider Intervention:

 Treatment recommendations successfully issued for all 

but 6 participants within study period

 68% were delivered within 2 weeks prior to non-acute 

clinic visit
PRIMO: Treatment Recommendations & 

Consults

Treatment Recommendation

% Issued to 

Provider

% With 

Consult† 

Knee Brace 41% 35%

Refer to PT – eval and exercises 49% 20%

Weight Management (MOVE!) 82% 23%

Physical Activity (MOVE!) 77% 23%

† Of those receiving recommendation
PRIMO: Treatment Recommendations & 

Consults

Treatment 

Recommendation

% Issued to 

Provider

% With 

Consult† 

Joint Injection 22% 15%

Topical NSAID / Capsaicin 50% N/A

Add gastroprotective / remove 

from NSAID

11% N/A

Discuss new / alternative pain 

medication 

83% N/A

Refer to Ortho – Discuss Joint 

Replacement 

12% 11%

40% were issued ≥1 consult

† Of those receiving recommendation
PRIMO Preliminary Results:

WOMAC Total Score

Estimated 

Difference 

-4.1 points 

[-7.2,-1.1]

p=0.008
PRIMO Preliminary Results:

WOMAC Pain Subscale

Estimated 

Difference 

-0.5 points 

[-1.2,0.1]

p=0.12
PRIMO Preliminary Results:

WOMAC Function Subscale

Estimated 

Difference 

-3.4 points 

[-5.6,-1.0]

p=0.005
PRIMO Preliminary Results:

SPPB Objective Function Tests

Estimated 

Difference 

0.6 points 

[0.1,1.2]

p=0.02
Summary & Conclusions

 A combined patient and provider intervention 

improved key OA outcomes

 Relatively inexpensive and could be delivered centrally in 

the VA

 Remaining questions:

 Longer term outcomes?

 Relative importance of patient vs. provider intervention?

 Simple, automated method to deliver provider-based 

intervention?

 Your suggestions for additional research and 

implementation?
Acknowledgements 

John Bartle, PT

Dennis Bongiorni, DPT

Hayden B. Bosworth, PhD

Brittany Cant, DPT

Jennifer G. Chapman, BASW

Ranee Chatterjee, MD, MPH

Cynthia J. Coffman, PhD

Santanu K. Datta, PhD

Rowena J. Dolor, MD, MHS

David Edelman, MD, MHS

Katherine S. Hall, PhD

Gloria Hansen, PTA

Helen Hoenig, MD, MPH

Kim Huffman, MD, PhD

Amy S. Jeffreys, MStat

Caroline Jennings, PTA

Karen A. Juntilla, MEd

Virginia B. Kraus, MD, PhD

Jennifer H. Lindquist, MStat

Laurie E. Marbrey, AAS

Jennifer McDuffie, PhD

Eugene Z. Oddone, MD, MHSc 

Joanne Senick, MPH

John C. Sizemore, DPT

Battista Smith, MPH

Jamie St. John, PT

Jennifer L. Strauss, PhD

Tessa A. Walker, MPH

William S. Yancy Jr., MD, MHS

Durham VA Rehabilitation Service and 

Ambulatory Care Service

Funding:

VA Health Services Research and 

Development