{
  "abstract": "Objectives Knee arthroplasty rates show considerable variability across and within health systems, raising concerns about potential overuse, inequities in the management of knee osteoarthritis (OA) and increasing waiting lists. This study aimed to: (1) assess geographical and organizational variations in knee arthroplasty rates in Catalonia, (2) identify low-value practices contributing to overuse, and (3) develop evidence-based strategies to promote conservative management and ensure appropriate surgical use.Methods A retrospective analysis of knee arthroplasty rates was conducted using 2023 administrative health data from Catalonia. A mixed-methods approach was adopted: rates were calculated per 100,000 inhabitants across rural and urban basic healthcare areas and provider institutions, with separate models developed to predict the intervention’s incidence in rural and urban settings. This quantitative analysis was complemented by a participatory process involving an expert committee of 16 professionals from major hospitals, 9 from the Catalan Agency for Health Quality and Assessment, and one from the Catalan Health Service.To inform the development of improvement strategies, a systematic review of clinical guidelines was conducted. Patients’ experiences were obtained through three interviews: two with individuals who had undergone knee arthroplasty and one with a person who completed a rehabilitation program. The expert committee contributed to the development of strategies, and final validation was obtained from all relevant scientific societies prior to publication.Results The coefficient of variation for knee arthroplasty rates was 49.4% in rural areas and 40.5% in urban areas, indicating greater variability in rural settings. Poisson regression models incorporating demographic and socioeconomic variables explained only a small proportion of this variation (R²=0.10 for rural and R²=0.07 for urban areas), suggesting that hospital-level clinical practices play a major role in the observed variation. Significant differences in practice were also observed between provider institutions, with some hospitals reporting rates above 150 per 100,000 inhabitants, while others remained below 50.Contributing factors to potential overuse may include organizational issues such as clinical pathways that favour surgical referral (e.g., patients referred from primary care to orthopaedic surgeons may be more likely to undergo surgery than those referred to rehabilitation professionals), non-standardised surgical indications, limited promotion of conservative treatments (e.g., therapeutic exercise, weight loss), and a lack of evidence-based resources to support shared decision-making. Eighteen low-value practices in OA diagnosis and treatment were identified, with two practices prioritized for inclusion in the ‘Do Not Do’ recommendations: (1) performing arthroplasty without prior conservative treatment or in the absence of severe symptoms, and (2) the use of MRI for OA diagnosis. Additionally, a revised Patient Decision Aid for knee OA was developed, emphasizing conservative treatment options and clarifying surgical criteria.Conclusions The observed variability in knee arthroplasty rates underscores the need for more consistent, evidence-based clinical decision-making. A multilevel strategy combining data analysis, expert consensus, and decision-support tools may effectively reduce overuse and promote high-value care. Engaging both clinicians and patients in shared decision-making, with a focus on conservative management, is essential to ensuring the appropriate use of knee arthroplasty in OA care.",
  "authors": [
    {
      "affiliations": [
        "Catalan Agency for Health Quality and Assessment, Barcelona, Spain"
      ],
      "name": "Laia Ramos-Masdeu"
    },
    {
      "affiliations": [
        "Catalan Agency for Health Quality and Assessment, Barcelona, Spain"
      ],
      "name": "Johanna Caro-Mendivelso"
    },
    {
      "affiliations": [
        "Health Department, Generalitat de Catalunya, Barcelona, Spain"
      ],
      "name": "Montse Moharra"
    },
    {
      "affiliations": [
        "Catalan Agency for Health Quality and Assessment, Barcelona, Spain"
      ],
      "name": "Helena Bentué-Jiménez"
    },
    {
      "affiliations": [
        "Catalan Agency for Health Quality and Assessment, Barcelona, Spain"
      ],
      "name": "Garazi Carrillo-Aguirre"
    },
    {
      "affiliations": [
        "Catalan Agency for Health Quality and Assessment, Barcelona, Spain"
      ],
      "name": "Claudia Malca"
    },
    {
      "affiliations": [
        "Catalan Agency for Health Quality and Assessment, Barcelona, Spain"
      ],
      "name": "Dolors Benítez"
    },
    {
      "affiliations": [
        "Catalan Agency for Health Quality and Assessment, Barcelona, Spain"
      ],
      "name": "Gemma Rabal"
    },
    {
      "affiliations": [
        "Catalan Agency for Health Quality and Assessment, Barcelona, Spain"
      ],
      "name": "Mireia Espallargues"
    }
  ],
  "title": "094 Improving the appropriateness of knee arthroplasty: a multilevel strategy to prevent overuse in Catalonia, Spain",
  "uid": "b7f4854d-4978-51da-8bf1-e6a8564529f9"
}