Problema de Salud AUGE N°41
Tratamiento médico en personas de 55 años y más con artrosis de cadera y/o rodilla, leve o moderado
ETD-2-2018
En personas mayores de 55 años con diagnóstico clínico de artrosis de cadera y/o rodilla leve o moderada, el Ministerio de Salud SUGIERE realizar intervención estructurada de educación por sobre realizar educación no estructurada.
Comentarios del Panel de Expertos:
► El programa de educación estructurada es el que cual cuyo contenido ha sido planificado previamente, de modo que el programa apoye el proceso de aprendizaje en relación a ciertos temas clave.
El panel de expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente, cuando el panel emitió su juicio sobre todas las preguntas, se formuló la recomendación.
A continuación, se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
1.- ¿El problema es una prioridad?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
2.- ¿Qué tan significativos son los efectos deseables anticipados?
| Triviales | Pequeños | Moderados | Grandes | Varía | No lo sé |
|---|
Pequeños: El panel de expertos de la Guía estimó que los efectos deseables de «realizar intervención estructurada de educación» en comparación a «realizar no estructurada» son pequeños, considerando la evidencia y experiencia clínica. La intervención podría mejorar la adherencia y efectos positivos de los tratamientos indicados y la participación en actividades grupales podría mejorar la calidad de vida de las personas.
Evidencia de investigación
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Educación estructurada comparado con educación no estructurada para artrosis. |
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Pacientes |
Personas mayores de 55 años con diagnóstico clínico de artrosis de cadera y/o rodilla leve o moderada. |
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Intervención |
Educación estructurada. |
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Comparación |
Educación no estructurada. |
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Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Dolor |
— 751 pacientes / 3 ensayos [80, 90] |
DME: 0,07 menos* (0,21 menos a 0,08 más) |
⊕⊕⊕◯1 Moderada |
La educación estructurada, en comparación con la educación no estructurada, probablemente tiene un impacto mínimo o nulo sobre el dolor. |
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|
Funcionalidad |
— 854 pacientes / 4 ensayos [80, 90, 105, 107] |
DME: 0,09 menos* (0,22 menos a 0,05 más) |
⊕⊕⊕◯1 Moderada |
La educación estructurada, en comparación con la educación no estructurada, probablemente tiene un impacto mínimo o nulo sobre la funcionalidad. |
|
|
Calidad de vida |
— 648 pacientes / 2 ensayos [80, 105] |
DME: 0,05 más* (0,1 menos a 0,21 más) |
⊕⊕⊕◯1 Moderada |
La educación estructurada, en comparación con la educación no estructurada, probablemente tiene un impacto mínimo o nulo sobre la calidad de vida |
|
IC 95%: Intervalo de confianza del 95%.
DME: Diferencia de medias estandarizada.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* La diferencia de medias estandarizada se utiliza cuando el desenlace ha sido medido en diferentes escalas y es difícil de interpretar clínicamente. Una regla general es que valores menores a 0,2 son de poca relevancia clínica, valores de 0,5 de relevancia moderada y 0,8 relevancia clínica importante.
1 Se disminuyó un nivel de certeza de la evidencia por riesgo de sesgo, ya que ninguno de los ensayos fue ciego.
Fecha de elaboración de la tabla: Octubre, 2018.
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Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de los efectos deseables e indeseables
3.- ¿Qué tan significativos son los efectos indeseables anticipados?
| Grandes | Moderados | Pequeños | Triviales | Varía | No lo sé |
|---|
Triviales: El panel de expertos de la Guía estimó que los efectos indeseables de «realizar intervención estructurada de educación» en comparación a «realizar no estructurada» son triviales o no relevantes, considerando la evidencia y experiencia clínica.
Evidencia de investigación
|
Educación estructurada comparado con educación no estructurada para artrosis. |
|
||||
|
Pacientes |
Personas mayores de 55 años con diagnóstico clínico de artrosis de cadera y/o rodilla leve o moderada. |
|
|||
|
Intervención |
Educación estructurada. |
|
|||
|
Comparación |
Educación no estructurada. |
|
|||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Dolor |
— 751 pacientes / 3 ensayos [80, 90] |
DME: 0,07 menos* (0,21 menos a 0,08 más) |
⊕⊕⊕◯1 Moderada |
La educación estructurada, en comparación con la educación no estructurada, probablemente tiene un impacto mínimo o nulo sobre el dolor. |
|
|
Funcionalidad |
— 854 pacientes / 4 ensayos [80, 90, 105, 107] |
DME: 0,09 menos* (0,22 menos a 0,05 más) |
⊕⊕⊕◯1 Moderada |
La educación estructurada, en comparación con la educación no estructurada, probablemente tiene un impacto mínimo o nulo sobre la funcionalidad. |
|
|
Calidad de vida |
— 648 pacientes / 2 ensayos [80, 105] |
DME: 0,05 más* (0,1 menos a 0,21 más) |
⊕⊕⊕◯1 Moderada |
La educación estructurada, en comparación con la educación no estructurada, probablemente tiene un impacto mínimo o nulo sobre la calidad de vida |
|
IC 95%: Intervalo de confianza del 95%.
DME: Diferencia de medias estandarizada.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* La diferencia de medias estandarizada se utiliza cuando el desenlace ha sido medido en diferentes escalas y es difícil de interpretar clínicamente. Una regla general es que valores menores a 0,2 son de poca relevancia clínica, valores de 0,5 de relevancia moderada y 0,8 relevancia clínica importante.
1 Se disminuyó un nivel de certeza de la evidencia por riesgo de sesgo, ya que ninguno de los ensayos fue ciego.
Fecha de elaboración de la tabla: Octubre, 2018.
Referencias
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2. Astin JA, Beckner W, Soeken K, Hochberg MC, Berman B. Psychological interventions for rheumatoid arthritis: a meta-analysis of randomized controlled trials. Arthritis and rheumatism. 2002;47(3):291–302.
3. Beatty L, Lambert S. A systematic review of internet-based self-help therapeutic interventions to improve distress and disease-control among adults with chronic health conditions. Clinical psychology review. 2013;33(4):609–22.
4. Bekker H, Thornton JG, Airey CM, Connelly JB, Hewison J, Robinson MB, et al. Informed decision making: an annotated bibliography and systematic review. Health technology assessment (Winchester, England). 1999;3(1):1–156.
5. Bender JL, Radhakrishnan A, Diorio C, Englesakis M, Jadad AR. Can pain be managed through the Internet? A systematic review of randomized controlled trials. Pain. 2011;152(8):1740–50.
6. Berzins K, Reilly S, Abell J, Hughes J, Challis D. UK self-care support initiatives for older patients with long-term conditions: a review. Chronic illness. 2009;5(1):56–72.
7. Beumer L, Wong J, Warden SJ, Kemp JL, Foster P, Crossley KM. Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis. British journal of sports medicine. 2016;50(8):458–63.
8. Borkhoff CM, Wieland ML, Myasoedova E, Ahmad Z, Welch V, Hawker GA, et al. Reaching those most in need: a scoping review of interventions to improve health care quality for disadvantaged populations with osteoarthritis. Arthritis care & research. 2011;63(1):39–52.
9. Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: evidence for the institute of medicine’s “Retooling for an aging America” report. Journal of the American Geriatrics Society. 2009;57(12):2328–37.
10. Boyers D, McNamee P, Clarke A, Jones D, Martin D, Schofield P, et al. Cost-effectiveness of self-management methods for the treatment of chronic pain in an aging adult population: a systematic review of the literature. The Clinical journal of pain. 2013;29(4):366–75.
11. Brand CA, Ackerman IN, Tropea J. Chronic disease management: improving care for people with osteoarthritis. Best practice & research Clinical rheumatology. 2014;28(1):119–42.
12. Brand E, Nyland J, Henzman C, McGinnis M. Arthritis Self-Efficacy Scale Scores in Knee Osteoarthritis: A Systematic Review and Meta-analysis Comparing Arthritis Self-Management Education With or Without Exercise. The Journal of orthopaedic and sports physical therapy. 2013;43(12):895–910.
13. Cao L, Zhang XL, Gao YS, Jiang Y. Needle acupuncture for osteoarthritis of the knee. A systematic review and updated meta-analysis. Saudi medical journal. 2012;33(5):526–32.
14. Carnes D, Homer KE, Miles CL, Pincus T, Underwood M, Rahman A, et al. Effective Delivery Styles and Content for Self-management Interventions for Chronic Musculoskeletal Pain: A Systematic Literature Review. The Clinical journal of pain. 2012;28(4):344–54.
15. Caroline Smith, Saravana Kumar, Nadine Pelling. The effectiveness of self-management educational interventions for osteoarthritis of the knee. JBI Library of Systematic Reviews. 2009;7(25):1091–118.
16. Chiung‐ju Liu, Nancy K Latham. Progressive resistance strength training for improving physical function in older adults. Cochrane Database of Systematic Reviews. 2009;(3):CD002759.
17. Chodosh J, Morton SC, Mojica W, Maglione M, Suttorp MJ, Hilton L, et al. Meta-analysis: chronic disease self-management programs for older adults. Annals of internal medicine. 2005;143(6):427–38.
18. Choi W, Zheng H, Franklin P, Tulu B. mHealth technologies for osteoarthritis self-management and treatment: A systematic review. Health informatics journal. 2017;1460458217735676.
19. Christopher Eccleston, Emma Fisher, Lorraine Craig, Geoffrey B Duggan, Benjamin A Rosser, Edmund Keogh. Psychological therapies (Internet‐delivered) for the management of chronic pain in adults. Cochrane Database of Systematic Reviews. 2014;2(2):CD010152.
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Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de los efectos deseables e indeseables
4.- ¿Cuál es la certeza general de la evidencia sobre efectos?
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Moderada: Existe confianza respecto del efecto de «realizar intervención estructurada de educación» en comparación a «realizar no estructurada». La certeza de la evidencia se basó en los desenlaces de salud establecidos como críticos por el panel, en este caso dolor y calidad de vida.
Evidencia de investigación
|
Desenlaces |
Importancia |
Certeza en la evidencia (GRADE) |
|
Dolor |
CRÍTICO |
⊕⊕⊕◯1 Moderada |
|
Funcionalidad |
IMPORTANTE |
⊕⊕⊕◯1 Moderada |
|
Calidad de vida |
CRÍTICO |
⊕⊕⊕◯1 Moderada |
|
|
||
1 Se disminuyó un nivel de certeza de la evidencia por riesgo de sesgo, ya que ninguno de los ensayos fue ciego.
5.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Probablemente no hay incertidumbre ni variabilidad importantes: En función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud, el panel de expertos de la Guía consideró que probablemente no hay incertidumbre ni variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «realizar intervención estructurada de educación» y «realizar no estructurada». La mayoría de las personas escogerían realizar intervención estructurada de educación.
Evidencia de investigación
La educación estructurada, en comparación con la educación no estructurada, probablemente tiene un impacto mínimo o nulo sobre el dolor (1, 2) y la calidad de vida (1, 3) en las personas mayores de 55 años con diagnóstico clínico de artrosis de cadera y/o rodilla leve o moderada, con diferencia de media estandarizada de 0,07 menos y 0,05 más, respectivamente, y certeza de la evidencia moderada.
Referencias
1. Ackerman IN, Buchbinder R, Osborne RH. Challenges in evaluating an Arthritis Self-Management Program for people with hip and knee osteoarthritis in real-world clinical settings. The Journal of rheumatology. 2012;39(5):1047-55.
2. Hughes SL, Seymour RB, Campbell R, Pollak N, Huber G, Sharma L. Impact of the fit and strong intervention on older adults with osteoarthritis. The Gerontologist. 2004;44(2):217-28.
3. Patel A, Buszewicz M, Beecham J, Griffin M, Rait G, Nazareth I, Atkinson A, Barlow J, Haines A. Economic evaluation of arthritis self management in primary care. BMJ (Clinical research ed.). 2009;339:b3532.
2. Hughes SL, Seymour RB, Campbell R, Pollak N, Huber G, Sharma L. Impact of the fit and strong intervention on older adults with osteoarthritis. The Gerontologist. 2004;44(2):217-28.
3. Patel A, Buszewicz M, Beecham J, Griffin M, Rait G, Nazareth I, Atkinson A, Barlow J, Haines A. Economic evaluation of arthritis self management in primary care. BMJ (Clinical research ed.). 2009;339:b3532.
Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de las preferencias de los pacientes
6.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
Favorece la intervención: Considerando que la intervención es «realizar intervención estructurada de educación» y la comparación es «realizar no estructurada», el panel de expertos de la Guía opinó que el balance entre efectos deseables e indeseables claramente favorece «realizar intervención estructurada de educación». Considerando que los efectos deseables son pequeños, los indeseables triviales, que la certeza de la evidencia es moderada y que probablemente no hay incertidumbre ni variabilidad importante en lo que escogerían las personas.
7.- ¿Qué tan grandes son los recursos necesarios (costos)?
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos y ahorros despreciables: El panel de expertos de la Guía consideró que los costos y ahorros de «realizar intervención estructurada de educación» son despreciables si se compara con «realizar no estructurada», en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
A continuación, se muestran los costos referenciales, es preciso considerar que estos costos fueron recogidos con el único objetivo de constituir un antecedente aproximado.
Tabla de costos referenciales
El porcentaje de cobertura del seguro de salud sobre el precio de las prestaciones sanitarias, dependerá del tipo de seguro de cada paciente.
|
ítem |
Intervención: realizar intervención estructurada de educación |
|
|
1 sesión |
2 sesiones* |
|
|
Educación de grupo médico 1 |
$ 4.110 |
$ 8.220 |
|
Educación de grupo por enfermera, matrona o nutricionista 1 |
$ 2.260 |
$ 4.520 |
|
Total |
$ 6.370 |
$ 12.740 |
* Se estima que una intervención estructurada de educación debe durar 2 sesiones individuales
Referencias
1. Precio total indicado de la base de datos Modalidad de Atención Institucional 2018, FONASA.
Búsqueda y Síntesis de Evidencia
Informe de búsqueda de costos referenciales de las intervenciones
8.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluido |
|---|
Probablemente favorece la intervención. Considerando que la intervención es «realizar intervención estructurada de educación» y la comparación es «realizar no estructurada», el panel de expertos de la Guía opinó que probablemente la alternativa más costo-efectiva es «realizar intervención estructurada de educación».
No se realizó la búsqueda de evidencia que abordaran la costo-efectividad ya que las intervenciones evaluadas no es consideraron de alto costo, según el Decreto 80 «Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la Ley 20.850».
9.- ¿Cuál sería el impacto en equidad en salud?
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Probablemente reducida: El panel de expertos de la Guía consideró que la equidad en salud probablemente se reduciría si se recomendase «realizar intervención estructurada de educación», dado que identificó grupos o contextos que actualmente tiene barreras de acceso, por ejemplo en el sistema privado de salud generalmente no se dan sesiones educativas.
10.- ¿La intervención es aceptable para las partes interesadas?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Sí: El panel de expertos de la Guía consideró que «realizar intervención estructurada de educación» SÍ es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos de centros de salud, pacientes, cuidadores, seguros de salud, otros).
11.- ¿Es factible implementar la intervención?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Sí: El panel de expertos de la Guía consideró que «realizar intervención estructurada de educación» SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.