Assessing the Quality of Care for Knee Osteoarthritis in Singapore: A Cross-sectional Study

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Methods Patients with knee osteoarthritis completed the osteoarthritis quality indicator (OA-QI) questionnaire between June 2021 and February 2022. The OA-QI includes 17 indicators, with "achievement" defined as a 'Yes' response for each. We calculated individual per-item, overall per-item mean, and per-person achievement rates (%) and explored associations between participant characteristics, achievement rates, and function at 1 year. Results A total of 314 participants completed the OA-QI. Referral for physical activity (87.5%) and referral for daily activity aid assessment (15.7%) had the highest and lowest per-item achievement rates, respectively. The overall mean per-item and per-person achievement rates were both 62.2%. Participants educated about steroid injections (adjusted coefficient [95% CI]: 7.23 [1.42–13.04]; p= 0.015) or surgery (adjusted coefficient [95% CI]: 12.65 [5.89–19.40]; p< 0.001) had worse functional outcomes at one year than those who were eligible but not informed. Those not assessed for walking aids and indicating walking issues had poorer outcomes one year later (adjusted coefficient [95% CI]: -9.89 (-19.63, -0.15); p= 0.0470). However, no significant associations were found between per-person achievement rates and 1-year functional outcomes. Conclusions The quality of care in Singapore for people with knee osteoarthritis is suboptimal, especially for those needing walking aids and weight loss assistance. However, the quality of care alone does not fully account for long-term outcomes, suggesting that other factors need to be considered. Clinical Trial Number: clinicaltrials.gov registry (Identifier: NCT04942236) Trial registration date: 25 th June 2021 Introduction Osteoarthritis is a leading cause of disability worldwide 1 . In Singapore, symptomatic knee osteoarthritis affects 1 in 10 people over the age of 50 2 . The number of people living with osteoarthritis is expected to continue to rise, in part owing to aging populations, plus increased levels of modifiable risk factors such as obesity and sedentary behavior 3 . Osteoarthritis most often affects the knee joints 4 and commonly results in pain, functional disability, and decreased quality of life 5 . Most international clinical practice guidelines for knee osteoarthritis recommend a stepwise approach to management where surgical intervention is considered only after non-surgical and pharmacological interventions have been exhausted 6 – 9 . Non-surgical care is prioritized, as it produces similar outcomes and reduces the risk of severe adverse events compared with surgical interventions 10 – 12 . Furthermore, non-surgical care is a more cost-effective option, with mean direct costs that are 4 times lower than those of surgical management in Singapore 113 . Additionally, evidence indicates that as many as 25% of knee replacements can be avoided by engaging in appropriate guideline-recommended first-line care 14 . Despite clear guidance, many people with knee osteoarthritis around the world are not provided with guideline-adherent first-line care before surgery 15 , 16 . Implementing guideline recommendations in clinical practice can be challenging due to several factors, such as clinician and patient preferences and the support/culture of the healthcare system 17 . Therefore, overuse of surgical interventions is likely due to the failure of healthcare systems providing optimal and effective guideline-recommended care rather than to the failure of nonsurgical and pharmacological treatments for people with knee osteoarthritis. The osteoarthritis quality indicator (OA-QI) questionnaire was developed in 2010 to evaluate the quality of non-surgical care that is provided to people with osteoarthritis 18 . The OA-QI has been applied to various populations and has demonstrated significant variation in the quality of care provided to people with knee osteoarthritis worldwide 19 – 22 . To the best of the authors’ knowledge, no studies have used the OA-QI to explore the self-reported quality of care that people with osteoarthritis receive in Asia or whether this influences future functional outcomes. Exploration is warranted to understand what treatments are regularly being discussed with individuals with knee osteoarthritis and to identify opportunities to improve the provision of first-line, non-surgical care. The primary aim of this study was to investigate the self-reported quality of care for people with knee osteoarthritis in Singapore. The secondary aims included exploring whether associations exist between; i) participant characteristics and the overall quality of care reported or, ii) the overall quality of care reported or individual indicators being addressed with functional outcomes at 1 year. Methods Ethical approval and study design Ethical approval for a large multi-centre prospective cohort study, the Singapore KneE osteoarthriTis CoHort (SKETCH) study, was granted by the National Healthcare Group Domain Specific Review Board (NHG DSRB) Singapore (Reference number: WHC/2020–00076). The SKETCH protocol has been published previously elsewhere 23 . This manuscript reports findings related to the OA-QI questionnaire and is written in alignment with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines 24 . Participants and recruitment Participants were recruited from two different public hospitals within the National Healthcare Group, Singapore, between June 2021 and February 2022. Specifically, recruitment occurred when people with knee osteoarthritis attended an orthopedic or physiotherapy appointment at either hospital. Participants were eligible if they were independent community mobilizers, met the National Institute for Health and Care Excellence (NICE) clinical diagnostic criteria for knee osteoarthritis 6 and were conversant in English or Mandarin. Participants were excluded if they; i) had an alternate diagnosis of knee OA (e.g., referred pain from the hip or spine), ii) had other forms of knee arthritis (e.g., inflammatory, posttraumatic), iii) had moderate to severe cognitive impairment (e.g., dementia), iv) had received a previous knee arthroplasty, v) were wheelchair bound, vi) were pregnant or vii) had medical conditions that would medically interfere with rehabilitation involvement (e.g., decompensated heart failure, stroke with significant deficit, or end-stage renal failure). The participants were informed of the study directly at their orthopedic or physiotherapy appointment and had the option to engage immediately during their appointment visit or via a web-based form (FormSG) after their appointment at their own convenience. Survey questions After confirming eligibility and providing informed consent, the survey consisted of 3 sections: i) participant characteristics, ii) knee osteoarthritis symptoms and iii) the OA-QI questionnaire. First, the participants reported their age, height and weight, gender, ethnicity, occupational status (employed, unemployed, homemaker, retired), education level (no formal education, elementary school, high school, diploma holder, degree holder, others) and housing type (public housing, condominium, terrace house, others). The participants then reported the site of their symptomatic knee osteoarthritis (left/right/both) and how long they had a diagnosis of knee osteoarthritis. Joint-specific pain and function were then investigated via the Knee Osteoarthritis Outcome Scale-12 (KOOS-12) 25 . The KOOS-12 is frequently used in knee osteoarthritis research and consists of three sections of four items related to pain, function (activities of daily living and sport/recreation), and quality of life (QOL). The participants responded to each item via a five-point Likert scale (0 represents no knee problems, and 4 represents extreme knee problems). Section scores and total KOOS-12 scores were then calculated for each participant before being normalized on a 0–100 scale. Finally, the participants completed the 17-item OA-QI questionnaire 18 . The OA-QI questionnaire requires participants to respond to varying questions about their experience of care for their knee osteoarthritis, such as “yes”, “no” or “do not remember/not relevant”. The questions are broad and include topics related to referrals, clinical assessment, and treatments. The OA-QI is aligned with international clinical practice guidelines and has adequate content and construct validity in populations with knee osteoarthritis 26,27 . Sample size estimation The sample size was estimated with the objective of exploring the factors associated with the provision of more or less comprehensive care via G*Power 3.1.9.4. Given a type I error of 0.05 with 80% power of study, we needed data for at least 264 participants to detect a small effect size of Cohen’s f 2 = 0.03 in the multiple linear regression model. Statistical analyses Participant responses were deidentified, given a unique identifier number and stored on a secure web-based data management application (Research Electronic Data Capture [REDCAP]). The data were cleaned and analysed by one member of the research team (LCJ) via SPSS version 26.0. The participants’ weight and height were used to calculate their body mass index (BMI kg/m 2 ). The BMI, age and KOOS-12 scores are presented as the means and standard deviations for each outcome. Other summarized participant demographic data are presented descriptively (frequency [n=] and proportion [%]). For the OA-QI questionnaire, only ‘yes’/’no’ responses were considered to calculate the achievement rates (i.e., any responses of ‘Don’t remember’, ‘Not overweight’, ‘No such problems’, ‘No pain/discomfort’ or ‘Not severely troubled’ were excluded from analysis). Three types of achievement rates were then calculated; i.e., per item (i.e., the number of ‘yes’ responses/number of participants who responded ‘yes’ or ‘no’ for that particular OA-QI item) presented as % and 95% CI, ii. Overall mean per-item OA-QI achievement rate (calculating the mean achievement rate [% and 95% CI] for all 17 OA-QI items), and iii. The mean per-person achievement rate (number of items that an individual reported ‘yes’/number of ‘yes’ or ‘no’ responses they provided) is presented as the mean and 95% CI. The mean achievement rate per person provides a measure of the ‘comprehensiveness’ of treatment. Linear regression modelling was used to explore the factors associated with the per-person and per-item OA-QI achievement rates. Simple linear regression was used to screen the variables, and variables with p<0.200 were included in the variable selection process via the stepwise variable selection method. The multicollinearity and interaction of the final model were checked, and heteroskedasticity was checked via the Bruesch-Pegan/Cook-Weisberg test. On the other hand, multiple linear regression was used to explore the ability of the per-person OA-QI achievement rate and per-item OA-QI achievement rate to predict the 1-year change in functional outcomes, adjusting for baseline age, sex, BMI and KOOS total scores. All the tests were two sided, and statistical significance was denoted by p< 0.05. Results We retrieved data for 314 participants. The majority of participants (83.1%, n = 261/314) were recruited at orthopedic consultations. Participant characteristics are presented in Table 1 . In summary, mean age of participants was 63.38 (SD 8.13), mean BMI was 26.05 (SD 5.98) and KOOS-12 was 64.63 (SD 15.85). Most participants were female (66.6%, n = 209/314), of Chinese ethnicity (78.7%, n = 247/314), employed (58.2%, n = 182/314), had attained at least high school education (47.8%, n = 150/314), lived in public housing (83.4%, n = 261/314) and reported bilateral knee osteoarthritis symptoms (42.4%, n = 133/214). Table 1 – Participant characteristics Characteristic or outcome Mean (SD) Age (years) 63.38 (8.13) BMI (kg/m 2 ) 26.05 (5.98) Total KOOS-12 score 64.63 (15.85) Subsections: Pain 63.82 (17.84) Function in daily living (ADL) 74.14 (19.37) Knee-related quality of life (QOL) 55.85 (18.77) n (%) Gender Female 209 (66.6) Male 105 (33.4) Ethnicity Chinese 247 (78.7) Indian 31 (9.9) Malay 30 (9.6) Others 6 (1.9) Occupational Status Employed 182 (58.2) Unemployed 14 (4.5) Homemaker 34 (10.9) Retired 83 (26.5) Education No formal education 13 (4.1) Elementary school 46 (14.6) High school 150 (47.8) Diploma holder 53 (16.9) Degree holder 40 (12.7) Others 12 (3.8) Housing Public housing 261 (83.4) Condominium 23 (7.3) Terrace house 23 (7.3) Others 6 (1.9) Localization of knee osteoarthritis Unilateral 181 (57.6) Bilateral 133 (42.4) Time since OA diagnosis < 1 year 45 (14.4) 1 to 3 years 103 (32.9) 4 to 6 years 70 (22.4) 7–10 years 69 (22.0) more than 10 years 26 (8.3) BMI – Body mass index Per-item and overall mean per-item and per-person OA-QI achievement rates The per-item and overall mean per-item OA-QI achievement rates are presented in Table 2 . In summary, large variation was observed between each indicator (ranging from 15.68% − 87.50%). The highest per-item achievement rates were for referrals for physical activity (mean [95% CI] 87.50%, [83.31, 90.96]), physical activity education (mean [95% CI] 82.74% [78.03, 86.79]) and pain assessment (mean [95% CI] 80.97% [75.96, 85.33]). The lowest per-item achievement rates were for referrals to daily activity aid assessment (mean [95% CI] 15.68% [7.02, 28.59]), referrals to walking aid assessment (mean [95% CI] 25.61% [16.60, 35.1]) and weight reduction referrals (mean [95% CI] 27.41% [21.31, 34.20]). Overall, the mean per-item OA-QI achievement rate was 62.21% (95% CI: 59.71, 64.71). Table 2 – Per-item and overall mean per-item OA-QI achievement rates Answered Yes or No n=/314 Answered Yes n= Achievement rate OA-QI indicator Per- item % 95% CI Lower, Upper 1. Have you been given information about how the disease usually develops over time? 279 182 65.23 59.33, 70.81 2. Have you been given information about different treatment alternatives? 305 203 66.56 60.96, 71.83 3. Have you been given information about how you can live with the disease? 299 145 48.49 42.70, 54.32 4. Have you been given information about how you can change your lifestyle? 299 164 54.85 49.02, 60.58 5. Have you been given information about the importance of physical activity and exercise? 307 254 82.74 78.03, 86.79 6. Have you been referred to someone who can advise you about physical activity and exercise? (e.g. a physiotherapist) 312 273 87.50 83.31, 90.96 7. If you are overweight, have you been advised to lose weight? 196 149 76.02 69.42, 81.82 8. If you are overweight, have you been referred to someone who can help you to lose weight? 197 54 27.41 21.31, 34.20 9. If you have had problems related to daily activities, have these problems been assessed by health personnel in the past year? 97 51 52.58 42.18, 62.81 10. If you have problems with walking, has your need for a walking aid been assessed? (e.g. stick, crutch or walker) 82 21 25.61 16.60, 35.1 11. If you have problems related to other daily activities, has your need for different appliances and aids been assessed? (e.g. splints, assistive technology for cooking or personal hygiene, a special chair) 51 8 15.68 7.02, 28.59 12. If you have pain, has it been assessed in the past year? 289 234 80.97 75.96, 85.33 13. If you have pain, was paracetamol the first medicine that was recommended for your osteoarthritic pain? 280 208 74.28 68.75, 79.30 14. If you have prolonged severe pain, which is not relieved sufficiently by paracetamol, have you been offered stronger pain killers? (e.g. Co-proxamol, Co-dydramol, Tramadol, Co-codamol, Dihydrocodeine, Codeine) 193 100 51.81 44.52, 59.05 15. If you are taking anti-inflammatory drugs, have you been given information about the effects and possible side-effects of this medicine? (e.g. Ibuprofen, Nurofen, Brufen, Diclofenac, Voltarol, Naproxen, Naprosyn, Celebrex) 184 84 45.65 38.31, 53.14 16. If you have experienced an acute deterioration of your symptoms, has a corticosteroid injection been considered? 177 87 49.15 41.57, 56.76 17. If you are severely troubled by your osteoarthritis, and exercise and medicine do not help, have you been referred and assessed for an operation (e.g. joint replacement)? 120 62 51.67 42.37, 60.88 Mean overall OA-QI achievement rate 314 62.21 59.71, 64.71 Associations of per-person OA-QI achievement rates with participant characteristics Differences in mean per-person achievement rates between categorical outcomes are presented, and the relationships between demographics and the OA-QI achievement rate are explored in Table 3 . Three significant relationships were observed: i) those who were identified as Indian ethnicity had higher mean per-person OA-QI achievement rates than those who were identified as Chinese (adj. coef [95% CI], 10.94 [2.70, 19.17], p = 0.009); ii) those who lived in public housing had higher mean per-person OA-QI achievement rates than those who resided in condominiums did (adj. coef [95% CI], -12.02 [-21.64, -2.41], p = 0.014); and iii) those who had had osteoarthritis for less than 1 year had lower mean per-person OA-QI achievement rates than those who had been living with osteoarthritis for 1–3 years (adjusted coefficient [95% CI], 9.37 [1.60, 17.15], p = 0.018), 4–6 years (adjusted coefficient [95% CI], 11.27 [2.99, 19.55], p = 0.008), 7–10 years (adjusted coefficient [95% CI], 10.26 [1.92, 18.60], p = 0.016) and 10 + years (adjusted coefficient [95% CI], 13.70 [3.01, 24.38], p = 0.012), respectively. Table 3 – Comparison of the mean per-person OA-QI achievement rate with demographic outcomes Characteristic OA-QI achievement rate, mean (95% CI) Coef (95% CI) p value Adj. coef (95% CI) P value Age NA -0.26 (-0.57, 0.04) 0.093 - - Gender Male 62.00 (57.37, 66.63) Ref - - - Female 62.31 (59.33, 65.29) 0.31 (-5.00, 5.62) 0.908 - - Ethnicity Chinese 61.14 (58.30, 63.98) Ref - Ref - Malay 59.30 (51.76, 66.84) -1.84 (-10.34, 6.67) 0.671 - - Indian 71.60 (63.20, 80.01) 10.47 (2.08, 18.85) 0.015 10.94 (2.70, 19.17) 0.009 Others 72.24 (56.39, 88.10) 11.11 (-7.07, 29.28) 0.230 - - BMI NA -0.21 (-0.63, 0.22) 0.341 - - Occupational Status Employed 63.55 (60.23, 66.87) Ref - - - Unemployed 64.20 (49.30, 79.10) 0.65 (-11.65, 12.96) 0.917 - - Homemaker 63.42 (56.07, 70.77) -0.12 (-8.41, 8.17) 0.977 - - Retired 58.38 (53.52, 63.25) -5.16 (-11.04, 0.71) 0.085 - - Education No formal education 54.93 (45.43, 64.44) Ref - - - Elementary school 63.03 (57.20,68.87) 8.10 (-5.90, 22.10) 0.256 - - High school 62.79 (58.99, 66.59) 7.86 (-5.03, 20.74) 0.231 - - Diploma holder 61.14 (54.57, 67.72) 6.21 (-7.58, 20.00) 0.376 - - GCE A level, IB 62.52 (55.47, 69.57) 7.58 (-6.64, 21.81) 0.295 - - University 63.29 (47.90, 78.67) 8.35 (-9.49, 26.19) 0.358 - - Housing Public housing 62.58 (59.82, 65.34) Ref - Ref - Condominium 51.81 (42.96, 60.67) -10.77 (-20.36, -1.17) 0.028 -12.02 (-21.64, -2.41) 0.014 Terrace house 65.61 (56.04, 75.19) 3.03 (-6.56, 2.63) 0.535 - - Others 69.79 (49.70, 89.88) 7.21 (-11.01, 25.43) 0.437 - - Localization of knee osteoarthritis Unilateral 62.01 (58.64, 65.38) Ref - - - Bilateral 62.48 (58.71, 66.24) 0.47 (-4.60, 5.54) 0.857 - - Time since OA diagnosis < 1 year 54.03 (46.42, 61.63) Ref - Ref - 1 to 3 years 61.92 (57.78, 66.05) 7.89 (0.02, 15.76) 0.050 9.37 (1.60, 17.15) 0.018 4 to 6 years 64.69 (59.57, 69.82) 10.67 (2.25, 19.09) 0.013 11.27 (2.99, 19.55) 0.008 7–10 years 63.44 (57.81, 69.08) 9.42 (0.97, 17.86) 0.029 10.26 (1.92, 18.60) 0.016 more than 10 years 66.93 (58.42, 75.45) 12.91 (205, 23.76) 0.020 13.70 (3.01, 24.38) 0.012 KOOS NA -0.12 (-0. 27, 0.04) 0.145 - - Pain NA -0.02 (-0.16, 0.12) 0.774 - - ADL NA -0.12 (-0.24, 0.01) 0.080 - - QoL NA -0.11 (-0.24, 0.02) 0.100 - - BMI = Body Mass Index, ADL = Activities of Daily Living, QoL = Quality of Life Relationships of per-item and per-person OA-QI achievement rates with functional outcomes at 1 yea r One-year follow-up data were available for 202 participants. The relationships between the per-item OA-QI achievement rate and functional outcomes at 1 year are presented in Table 4 . In summary, those who indicated that they had walking issues and indicated that they did not receive a walking aid assessment had poorer outcomes after 1 year (adjusted coefficient [95% CI]: -9.89 (-19.63, -0.15); p = 0.047). In addition, those who were not informed about injection or surgical options had greater improvements in the KOOS-12 score at 1 year than did those who received information about injections (adjusted coefficient [95% CI]: 7.23 [1.42–13.04]; p = 0.015) or surgery (adjusted coefficient [95% CI]: 12.65 [5.89–19.40]; p < 0.001), respectively. The relationships between the per-person achievement rate and functional outcomes at 1 year are presented in Table 5 . In summary, no significant associations were observed. Table 4 – Relationships between the per-item OA-QI achievement rate and changes in functional outcomes (total KOOS-12) at 1 year OA-QI item number and summarized topic Achieved? Mean change in KOOS-12 ± SD Adj Coeff (95% CI) P value 1. Disease development Yes No 3.98 ± 16.96 4.61 ± 15.60 Ref -0.83 (-6.03, 4.37) 0.754 2. Treatment Yes No 3.52 ± 17.07 5.44 ± 15.30 Ref 1.78 (-3.21, 6.78) 0.482 3. Self-management Yes No 2.32 ± 16.58 5.71 ± 16.06 Ref 3.16 (-1.39, 7.71) 0.173 4. Lifestyle Yes No 3.97 ± 16.24 4.25 ± 16.76 Ref -0.33 (-5.11, 4.45) 0.892 5. Physical activity Yes No 3.91 ± 17.00 4.70 ± 13.70 Ref 0.73 (-5.16, 6.63) 0.806 6. Referral physical activity Yes No 4.54 ± 16.52 -0.45 ± 14.87 Ref -2.54 (-9.44, 4.35) 0.468 7. Weight reduction Yes No 4.27 ± 17.35 5.73 ± 12.34 Ref 0.37 (-6.47, 7.21) 0.915 8. Referral weight reduction Yes No 8.23 ± 17.13 2.20 ± 16.90 Ref -4.69 (-10.71, 1.32) 0.125 9. Functional assessment Yes No 3.27 ± 17.87 0.77 ± 16.95 Ref -2.53 (-10.10, 5.04) 0.510 10. Walking aid assessment Yes No 14.26 ± 14.46 3.99 ± 18.19 Ref -9.89 (-19.63, -0.15) 0.047 11. Other aids assessment Yes No 6.60 ± 18.70 -3.49 ± 17.76 Ref -6.52 (21.13, 8.09) 0.380 12. Pain assessment Yes No 3.84 ± 16.09 6.03 ± 17.40 Ref 2.36 (-3.39, 8.10) 0.420 13. Paracetamol Yes No 3.29 ± 16.94 6.25 ± 15.24 Ref 4.37 (-0.97, 9.70) 0.108 14. Stronger pain killers Yes No 3.28 ± 17.71 5.65 ± 14.05 Ref 4.18 (-1.39, 9.75) 0.141 15. NSAIDS information Yes No 2.73 ± 18.66 6.89 ± 14.27 Ref 4.93 (-0.80, 10.66) 0.091 16. Joint injection Yes No 0.65 ± 17.24 6.19 ± 17.10 Ref 7.23 (1.42, 13.04) 0.015 17. Surgery Yes No -4.98 ± 18.24 8.39 ± 16.78 Ref 12.65 (5.89, 19.40) < 0.001 Adjusted for age, sex, BMI and total KOOS score at baseline Table 5 – Relationships between the per-person OA-QI achievement rate and changes in functional outcomes at 1 year Outcome Adj. Coeff 95% CI p value KOOS Total -0.05 -0.16 0.05 0.307 KOOS Pain -0.07 -0.19, 0.04 0.216 KOOS ADL -0.02 -0.14, 0.10 0.757 KOOS QoL -0.07 -0.21, 0.07 0.313 Adjusted for age, sex, BMI and total KOOS score at baseline. Discussion In general, the quality indicator achievement rates were underwhelming but were similar to those reported in previous research from outside Asia 19 , 21 , 22 . Encouragingly, participants frequently reported being provided with information about first-line interventions, namely, physical activity, exercise, and weight loss. However, information about self-management and coping strategies is infrequently provided, and referrals to specialist weight loss or supportive services (e.g., walking aids and splints) are rarely provided when indicated. The overall quality of care provided was associated with participant ethnicity, housing type, and time since diagnosis, suggesting that care is provided inconsistently. Furthermore, the provision of information about certain topics (i.e., walking aids, injections or surgery) was associated with functional outcomes at 1 year. Overall, our findings can be used to inform initiatives to improve the quality of care that is being provided to people with knee osteoarthritis in Singapore. Improving the quality of osteoarthritis care in Singapore Encouragingly, most participants reported being provided information about, and referred to, an appropriate service for, physical activity and exercise, considering that three-quarters of people with knee osteoarthritis in Singapore reported low levels of physical activity 28 . Physical activity and exercise should be encouraged in this population, as they are inexpensive and effective guidelines that recommend first-line interventions that are suitable for all people regardless of age, sex, ethnicity or severity of the disease 6 . However, other important information that may facilitate becoming more physically active, such as lifestyle changes or coping strategies, is often not provided. Encouragingly, weight management was reported as being discussed with the majority of individuals for whom it was appropriate. However, disappointingly, only one in two people were referred to appropriate weight loss services. Considering that weight management is an integral part of guideline-adherent care 6 – 8 , the reasons for the lack of referrals should be investigated further. Improving knowledge about, and access to, weight management services, among other services for which referral rates are low (i.e., walking and daily mobility aids) available in Singapore, has great potential to improve patient outcomes for patients with knee osteoarthritis and its associated comorbidities. An investigation of the relationship of the per-item OA-QI achievement rate with 1-year KOOS-12 outcomes revealed that participants who experienced acute deterioration of symptoms and who were engaged in a discussion about corticosteroid injections had worse 1-year KOOS-12 outcomes than those who also experienced an acute exacerbation but did not engage in a discussion about corticosteroid injections. However, we are unable to tell if an injection was actually offered or received. Injections are widely perceived as a treatment option to provide immediate symptom relief during an acute exacerbation 29 . It is possible that discussion about injections may have put people off engaging in other long-term management strategies, such as physical therapy or lifestyle modifications, which provides a more sustainable solution for behavioral change 30 . We also observed that participants who experienced walking difficulties but were not assessed for walking aids demonstrated a greater improvement in their 1-year KOOS than did those whose need for walking aids was evaluated. This observation suggests a potential benefit of walking aid assessment in knee osteoarthritis patients experiencing mobility challenges. The assessment and subsequent use of walking aids might contribute to better outcomes by improving mobility, reducing pain, and enhancing overall quality of life 6 . This aligns with the literature emphasizing the importance of addressing mobility issues in osteoarthritis management 6 – 8 . Going beyond quality of care to achieve good outcomes We did not identify any significant relationships between age, sex, BMI, education, or severity of knee symptoms and the per-person OA-QI achievement rate. However, we did observe that individuals of Indian ethnicity and those residing in public housing had higher per-person OA-QI achievement rates (indicating more comprehensive care) than those who were of Chinese ethnicity or who were residing in condominiums, respectively. These findings were unexpected, and the reasons behind these associations are not immediately clear. It is possible that socioeconomic factors, cultural attitudes towards healthcare, or accessibility to healthcare resources could play a role. However, without further research specifically targeting these demographics, it is challenging to draw definitive conclusions. Importantly, these findings should also be interpreted with caution because of the lower sample sizes in the comparator groups. Further research is encouraged to understand the complex interplay of ethnicity, living conditions, and healthcare quality in the context of knee osteoarthritis treatment. We did not identify any relationship between the comprehensiveness of care (i.e., per-person OA-QI achievement rate) at baseline and 1-year KOOS-12 outcomes. One potential explanation for this finding is the multifactorial nature of health outcomes in patients with knee osteoarthritis. The quality of clinical care contributes to only 20% of the social determinants of health. Other factors, such as socioeconomic status (40%), the physical environment (10%), and health behaviors (30%), play greater roles in determining and improving health. These findings suggest that factors other than the quality of care might have a more significant impact on KOOS outcomes than the comprehensiveness of osteoarthritis care alone 31 – 33 . This underscores the complexity of healthcare outcomes and the necessity of adopting a holistic approach for managing knee osteoarthritis, which takes into account the wide array of factors influencing patient health and well-being. Our findings suggest that while comprehensiveness or quality of care is undoubtedly important, it is just one of many components that contributes to overall health outcomes in patients with knee osteoarthritis. Much of osteoarthritis care needs to be targeted at behavioral changes, and one session of information might not be sufficient to provide the necessary push to lead to such changes 30 . Strengths and Limitations It is important to consider the limitations of our study when interpreting our findings. Specifically, our findings may not be fully generalizable to all individuals with knee osteoarthritis in Singapore. Furthermore, Singapore is a unique country in Asia with a diverse ethnicity mix and relatively high average income rates compared with other Asian countries; therefore, the findings of our study may not represent the wider Asian region. Notably, the majority of participants in our study were recruited through orthopedic surgeons. Evidence from around the world suggests that relatively few people with knee osteoarthritis are referred beyond primary care; therefore, investigations of care provided by first-contact practitioners in Singapore (i.e., general practitioners) are warranted. Additionally, as mentioned above, relying on self-reported data carries a risk of bias and difficulty in determining how accurate the patient’s responses are. This challenge underscores the need for more robust methods to assess patient-reported data, such as qualitative interviews and documentation reviews. Nonetheless, the depth and breadth of our analysis contribute significantly to advancing our understanding and enhancing the quality of osteoarthritis care. Conclusion In conclusion, this study provides valuable insights into the quality of osteoarthritis care in Singapore, which appears to be suboptimal. Notably, the high achievement rates in areas such as physical activity referrals and education and pain assessment strongly align with international care standards. However, the study also highlights several areas needing attention, particularly in referrals for daily activity aids and walking aid assessments, as well as in comprehensive support for weight management. The OA-QI appears to be a poor indicator of 1-year outcomes for people with knee osteoarthritis, suggesting that the determinants of outcomes in patients with knee OA are multifaceted and extend beyond the scope of quality indicators traditionally used. Future research should aim to unravel these multifactorial influences in greater depth, contributing to more effective and nuanced treatment strategies for knee OA patients. Declarations Ethics approval and consent to participate: Ethical approval was obtained from National Healthcare group, Domain Specific Review Board, Ref no. WHC/2020-0076 and patient consent was taken prior to taking part in the study. Consent for publication: Manuscript does not contain data from a single individual. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: None to declare. Authors' contributions: Study design – including conceptualization and methodology: BTY, LCJ. Data collection and data analysis: LTR, AJG, BTY, LCJ. Data interpretation: LTR, AJG, BTY, LCJ. Generation of figures: LCJ All authors were involved in writing the paper and had final approval of the submitted and published versions Acknowledgements: We would like to thank Pearl Koh Yuan Zhen and Koong Mun Ee for their initial work on this project. References Vos T, Lim SS, Abbafati C, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet . 2020;396(10258):1204-1222. Leung YY, Ma S, Noviani M, et al. Validation of screening questionnaires for evaluation of knee osteoarthritis prevalence in the general population of Singapore. Int J Rheum Dis . 2018;21(3):629-638. Turkiewicz A, Petersson IF, Björk J, et al. Current and future impact of osteoarthritis on health care: a population-based study with projections to year 2032. Osteoarthritis Cartilage . 2014;22(11):1826-1832. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Ann Rheum Dis . 2014;73(7):1323-1330. Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. The Lancet . 2019;393(10182):1745-1759. National_Institute_for_Health_and_Care_Excellence. Osteoarthritis: Care and Management in Adults. Published online 2014. Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage . 2019;27(11):1578-1589. Fernandes L, Hagen KB, Bijlsma JW, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis . 2013;72(7):1125-1135. Kolasinski SL, Neogi T, Hochberg MC, et al. American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol . 2019;72(2):220-233. Skou ST, Roos EM, Laursen MB, et al. Total knee replacement and non-surgical treatment of knee osteoarthritis: 2-year outcome from two parallel randomized controlled trials. Osteoarthritis Cartilage . 2018;26(9):1170-1180. Skou ST, Roos E, Laursen M, et al. Cost-effectiveness of total knee replacement in addition to non-surgical treatment: a 2-year outcome from a randomised trial in secondary care in Denmark. BMJ Open . 2020;10(1):033495. Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med . 2015;373(17):1597-1606. Xie F, Thumboo J, Fong KY, et al. Direct and indirect costs of osteoarthritis in Singapore: a comparative study among multiethnic Asian patients with osteoarthritis. J Rheumatol . 2007;34(1):165-171. Allen KD, Choong PF, Davis AM, et al. Osteoarthritis: models for appropriate care across the disease continuum. Best Pract Res Clin Rheumatol . 2016;30(3):503-535. Bennell KL, Bayram C, Harrison C, et al. Trends in management of hip and knee osteoarthritis in general practice in Australia over an 11-year window: a nationwide cross-sectional survey. Lancet Reg Health-West Pac . 2021;12:100187. Cronström A, Dahlberg LE, Nero H, Hammarlund CS. I was considering surgery because I believed that was how it was treated”: a qualitative study on willingness for joint surgery after completion of a digital management program for osteoarthritis. Osteoarthritis Cartilage . 2019;27(7):1026-1032. Hunter DJ, Neogi T, Hochberg MC. Quality of osteoarthritis management and the need for reform in the US. Arthritis Care Res . 2011;63(1):31-38. Østerås N, Garratt A, Grotle M, Natvig B, Kjeken I, Kvien TK. Patient-reported quality of care for osteoarthritis: development and testing of the osteoarthritis quality indicator questionnaire. Arthritis Care Res . 2013;65. doi:10.1002/acr.21976 Ingelsrud LH, Roos EM, Gromov K, Jensen SS, Troelsen A. Patients report inferior quality of care for knee osteoarthritis prior to assessment for knee replacement surgery–a cross-sectional study of 517 patients in Denmark. Acta Orthop . 2020;91(1):82-87. Blackburn S, Higginbottom A, Taylor R, et al. Patient-reported quality indicators for osteoarthritis: a patient and public generated self-report measure for primary care. Res Involv Engagem . 2016;2(1):1-20. Grønhaug G, Østerås N, Hagen KB. Quality of hip and knee osteoarthritis management in primary health care in a Norwegian county: a cross-sectional survey. BMC Health Serv Res . 2014;14(1):1-7. Larmer PJ, Bennett K, Baldwin JN, Bassett S, O’Brien DW. Quality indicators for hip and knee osteoarthritis management in New Zealand: A patient survey. N Z J Physiother . Published online 2019:47 3. Tan BY, Goh ZZS, Lim CJ, et al. Singapore KneE osTeoarthritis CoHort (SKETCH): protocol for a multi-centre prospective cohort study. BMC Musculoskelet Disord . 2023;24(1):104. doi:10.1186/s12891-023-06207-1 Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med . 2007;147(8):573-577. Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)–development of a self-administered outcome measure. J Orthop Sports Phys Ther . 1998;28(2):88-96. Gandek B, Roos EM, Franklin PD, Ware JE. A 12-item short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-12): tests of reliability, validity and responsiveness. Osteoarthritis Cartilage . 2019;27. doi:10.1016/j.joca.2019.01.011 Østerås N, Hagen K, Garratt A, et al. Quality of osteoarthritis care: test-retest reliability and feasibility of the osteoarthritis quality indicator questionnaire. Osteoarthritis Cartilage . 2012;20:185-186. Goff AJ, Jones LE, Lim CJ, Tan BY. A cross sectional study exploring the relationship of self-reported physical activity with function, kinesiophobia, self-efficacy and quality of life in an Asian population seeking care for knee osteoarthritis. BMC Musculoskelet Disord . 2024;25(1):74. doi:10.1186/s12891-024-07181-y Ayub S, Kaur J, Hui M, et al. Efficacy and safety of multiple intra-articular corticosteroid injections for osteoarthritis-a systematic review and meta-analysis of randomized controlled trials and observational studies. Rheumatol Oxf Engl . 2021;60(4):1629-1639. doi:10.1093/rheumatology/keaa808 Willett M, Duda J, Fenton S, Gautrey C, Greig C, Rushton A. Effectiveness of behaviour change techniques in physiotherapy interventions to promote physical activity adherence in lower limb osteoarthritis patients: A systematic review. PloS One . 2019;14(7):e0219482. doi:10.1371/journal.pone.0219482 Allen KD, Golightly YM. State of the evidence. Curr Opin Rheumatol . 2015;27(3). https://journals.lww.com/co-rheumatology/fulltext/2015/05000/state_of_the_evidence.12.aspx Reyes C, Garcia-Gil M, Elorza JM, et al. Socio-economic status and the risk of developing hand, hip or knee osteoarthritis: a region-wide ecological study. Osteoarthritis Cartilage . 2015;23(8):1323-1329. doi:10.1016/j.joca.2015.03.020 Felson DT, Niu J, Clancy M, Sack B, Aliabadi P, Zhang Y. Effect of recreational physical activities on the development of knee osteoarthritis in older adults of different weights: the Framingham Study. Arthritis Rheum . 2007;57(1):6-12. doi:10.1002/art.22464 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Mar, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 10 Feb, 2025 Reviews received at journal 13 Nov, 2024 Reviewers agreed at journal 11 Nov, 2024 Reviews received at journal 19 Oct, 2024 Reviewers agreed at journal 11 Oct, 2024 Reviewers invited by journal 08 Sep, 2024 Editor assigned by journal 02 Sep, 2024 Submission checks completed at journal 02 Sep, 2024 First submitted to journal 23 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4963107","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":361466064,"identity":"0a39a608-e00f-49ff-b496-9e8f51a636cd","order_by":0,"name":"Ren Hao Linus Tan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACPmYkDjNDBYOBASEtbBAtBlAtZ4jRwoCshbGNGC3svMckfzD8kTdn4H3AXDivzticgfnhoxsMdXYNOB3GlybNw2BguLOB3YB55rbDZpYNbMbGOQyHk3Fr4TGTBjqMccMBNgZm3m0HbAwO8LBJ5zAcSMbpMKAWoMMM7CFa5tTBtNTh1SIBdFgiREsDsxlUC7MdHi3G1jwGxskbDrMxHOY5dtjY4DDILwaHE3Bp4ec/Y3jzR4Wc7YbjbYyPeWrqDDccb374OKeizh6XFggAxQUwTg+AOcwQkcQG/HqwAAK2jIJRMApGwQgCAKYDP/hm11KkAAAAAElFTkSuQmCC","orcid":"","institution":"Sengkang General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Ren","middleName":"Hao Linus","lastName":"Tan","suffix":""},{"id":361466065,"identity":"8b0e4fa6-5b91-4fc2-8758-68ffce68415f","order_by":1,"name":"Anthony J Goff","email":"","orcid":"","institution":"Singapore Institute of Technology","correspondingAuthor":false,"prefix":"","firstName":"Anthony","middleName":"J","lastName":"Goff","suffix":""},{"id":361466066,"identity":"d8fbd461-8fe9-43c4-bd4e-e9bada60bfc4","order_by":2,"name":"Chien Joo Lim","email":"","orcid":"","institution":"Woodlands Health Campus","correspondingAuthor":false,"prefix":"","firstName":"Chien","middleName":"Joo","lastName":"Lim","suffix":""},{"id":361466067,"identity":"6651a765-4ed6-4dd9-94e4-8cc74ed3f763","order_by":3,"name":"Yijia Bryan Tan","email":"","orcid":"","institution":"Woodlands Health Campus","correspondingAuthor":false,"prefix":"","firstName":"Yijia","middleName":"Bryan","lastName":"Tan","suffix":""}],"badges":[],"createdAt":"2024-08-23 09:22:49","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4963107/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4963107/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-025-08524-z","type":"published","date":"2025-03-26T15:57:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79605654,"identity":"219d94a0-6623-428c-aa8c-3c82042efbcc","added_by":"auto","created_at":"2025-03-31 16:11:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1461421,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4963107/v1/56124da0-a16f-4f42-b603-b774428e5604.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the Quality of Care for Knee Osteoarthritis in Singapore: A Cross-sectional Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteoarthritis is a leading cause of disability worldwide\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. In Singapore, symptomatic knee osteoarthritis affects 1 in 10 people over the age of 50\u003csup\u003e2\u003c/sup\u003e. The number of people living with osteoarthritis is expected to continue to rise, in part owing to aging populations, plus increased levels of modifiable risk factors such as obesity and sedentary behavior\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Osteoarthritis most often affects the knee joints\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e and commonly results in pain, functional disability, and decreased quality of life\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMost international clinical practice guidelines for knee osteoarthritis recommend a stepwise approach to management where surgical intervention is considered only after non-surgical and pharmacological interventions have been exhausted\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Non-surgical care is prioritized, as it produces similar outcomes and reduces the risk of severe adverse events compared with surgical interventions\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Furthermore, non-surgical care is a more cost-effective option, with mean direct costs that are 4 times lower than those of surgical management in Singapore\u003csup\u003e113\u003c/sup\u003e. Additionally, evidence indicates that as many as 25% of knee replacements can be avoided by engaging in appropriate guideline-recommended first-line care\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Despite clear guidance, many people with knee osteoarthritis around the world are not provided with guideline-adherent first-line care before surgery\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Implementing guideline recommendations in clinical practice can be challenging due to several factors, such as clinician and patient preferences and the support/culture of the healthcare system\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Therefore, overuse of surgical interventions is likely due to the failure of healthcare systems providing optimal and effective guideline-recommended care rather than to the failure of nonsurgical and pharmacological treatments for people with knee osteoarthritis.\u003c/p\u003e \u003cp\u003eThe osteoarthritis quality indicator (OA-QI) questionnaire was developed in 2010 to evaluate the quality of non-surgical care that \u003cem\u003eis\u003c/em\u003e provided to people with osteoarthritis\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The OA-QI has been applied to various populations and has demonstrated significant variation in the quality of care provided to people with knee osteoarthritis worldwide\u003csup\u003e\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. To the best of the authors\u0026rsquo; knowledge, no studies have used the OA-QI to explore the self-reported quality of care that people with osteoarthritis receive in Asia or whether this influences future functional outcomes. Exploration is warranted to understand what treatments are regularly being discussed with individuals with knee osteoarthritis and to identify opportunities to improve the provision of first-line, non-surgical care.\u003c/p\u003e \u003cp\u003eThe primary aim of this study was to investigate the self-reported quality of care for people with knee osteoarthritis in Singapore. The secondary aims included exploring whether associations exist between; i) participant characteristics and the overall quality of care reported or, ii) the overall quality of care reported or individual indicators being addressed with functional outcomes at 1 year.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthical approval and study design\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for\u0026nbsp;a\u0026nbsp;large multi-centre prospective cohort study,\u0026nbsp;the Singapore KneE osteoarthriTis CoHort (SKETCH) study,\u0026nbsp;was granted by the National Healthcare Group Domain Specific Review Board (NHG DSRB) Singapore (Reference number: WHC/2020\u0026ndash;00076). The SKETCH protocol has been published previously elsewhere\u003csup\u003e23\u003c/sup\u003e. This manuscript reports findings related to the OA-QI questionnaire and is written in alignment\u0026nbsp;with\u0026nbsp;the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eParticipants and recruitment\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited from two different public hospitals within the National Healthcare Group, Singapore, between June 2021 and February 2022. Specifically, recruitment occurred when people with knee osteoarthritis attended an\u0026nbsp;orthopedic\u0026nbsp;or physiotherapy appointment at either hospital. Participants were eligible if they were independent community\u0026nbsp;mobilizers, met the National Institute for Health and Care Excellence (NICE) clinical diagnostic criteria for knee osteoarthritis\u003csup\u003e6\u003c/sup\u003e and were conversant in English or Mandarin. Participants were excluded if they; i) had an alternate diagnosis\u0026nbsp;of\u0026nbsp;knee OA (e.g., referred pain from\u0026nbsp;the\u0026nbsp;hip or spine), ii) had other forms of knee arthritis (e.g., inflammatory,\u0026nbsp;posttraumatic), iii) had moderate to severe cognitive impairment (e.g., dementia), iv) had received a previous knee arthroplasty, v)\u0026nbsp;were\u0026nbsp;wheelchair bound, vi) were pregnant or vii) had medical conditions that would medically interfere with rehabilitation involvement (e.g., decompensated heart failure, stroke with significant deficit,\u0026nbsp;or end-stage renal failure).\u0026nbsp;The participants\u0026nbsp;were informed of the study directly at their\u0026nbsp;orthopedic\u0026nbsp;or physiotherapy appointment and had the option to engage immediately during their appointment visit or via a web-based form (FormSG) after their appointment at their own convenience.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSurvey questions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter confirming eligibility and providing informed consent, the survey consisted of 3 sections:\u0026nbsp;i) participant characteristics, ii) knee osteoarthritis symptoms and iii) the OA-QI questionnaire. First,\u0026nbsp;the\u0026nbsp;participants reported their age, height and weight, gender, ethnicity, occupational status (employed, unemployed, homemaker, retired), education level (no formal education, elementary school, high school, diploma holder, degree holder, others) and housing type (public housing, condominium, terrace house, others).\u0026nbsp;The participants\u0026nbsp;then reported the site of their symptomatic knee osteoarthritis (left/right/both) and how long they had a diagnosis of knee osteoarthritis. Joint-specific pain and function\u0026nbsp;were\u0026nbsp;then investigated\u0026nbsp;via\u0026nbsp;the Knee Osteoarthritis Outcome\u0026nbsp;Scale-12 (KOOS-12)\u003csup\u003e25\u003c/sup\u003e. The KOOS-12 is frequently used in knee osteoarthritis research and consists of three sections of four items\u0026nbsp;related\u0026nbsp;to pain, function (activities of daily living and sport/recreation), and quality of life (QOL).\u0026nbsp;The participants responded\u0026nbsp;to each item\u0026nbsp;via\u0026nbsp;a five-point Likert scale (0\u0026nbsp;represents\u0026nbsp;no knee problems,\u0026nbsp;and 4 represents\u0026nbsp;extreme knee problems). Section scores and total KOOS-12 scores were then calculated for each participant before being\u0026nbsp;normalized\u0026nbsp;on a\u0026nbsp;0\u0026ndash;100\u0026nbsp;scale. Finally,\u0026nbsp;the\u0026nbsp;participants completed the 17-item OA-QI questionnaire\u003csup\u003e18\u003c/sup\u003e. The OA-QI questionnaire requires participants to respond to varying questions about their experience of care for their knee osteoarthritis,\u0026nbsp;such as\u0026nbsp;\u0026ldquo;yes\u0026rdquo;, \u0026ldquo;no\u0026rdquo; or \u0026ldquo;do not remember/not relevant\u0026rdquo;.\u0026nbsp;The questions\u0026nbsp;are broad and include topics related to referrals, clinical assessment, and treatments. The OA-QI is aligned\u0026nbsp;with\u0026nbsp;international clinical practice guidelines and has adequate content and construct validity in populations with knee osteoarthritis\u003csup\u003e26,27\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSample size estimation\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe sample\u0026nbsp;size was estimated\u0026nbsp;with\u0026nbsp;the objective\u0026nbsp;of exploring\u0026nbsp;the factors associated with\u0026nbsp;the\u0026nbsp;provision of more or less comprehensive care\u0026nbsp;via\u0026nbsp;G*Power 3.1.9.4. Given\u0026nbsp;a\u0026nbsp;type I error of 0.05 with 80% power of study, we needed data for at least 264 participants to detect a small effect size of Cohen\u0026rsquo;s f\u003csup\u003e2\u003c/sup\u003e= 0.03 in\u0026nbsp;the\u0026nbsp;multiple linear regression model.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eStatistical analyses\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipant responses were\u0026nbsp;deidentified, given a unique identifier number and stored on a secure web-based data management application (Research Electronic Data Capture [REDCAP]).\u0026nbsp;The data\u0026nbsp;were cleaned and analysed by one member of the research team (LCJ)\u0026nbsp;via\u0026nbsp;SPSS version 26.0.\u0026nbsp;The participants\u0026rsquo;\u0026nbsp;weight and height were used to calculate\u0026nbsp;their body mass index\u0026nbsp;(BMI kg/m\u003csup\u003e2\u003c/sup\u003e).\u0026nbsp;The\u0026nbsp;BMI, age and KOOS-12\u0026nbsp;scores are\u0026nbsp;presented as\u0026nbsp;the means\u0026nbsp;and standard\u0026nbsp;deviations\u0026nbsp;for each outcome. Other\u0026nbsp;summarized\u0026nbsp;participant demographic data\u0026nbsp;are\u0026nbsp;presented descriptively (frequency [n=] and proportion [%]).\u003c/p\u003e\n\u003cp\u003eFor the OA-QI questionnaire, only \u0026lsquo;yes\u0026rsquo;/\u0026rsquo;no\u0026rsquo; responses were considered to calculate the achievement rates (i.e., any responses of \u0026lsquo;Don\u0026rsquo;t remember\u0026rsquo;, \u0026lsquo;Not overweight\u0026rsquo;, \u0026lsquo;No such problems\u0026rsquo;, \u0026lsquo;No pain/discomfort\u0026rsquo; or \u0026lsquo;Not severely troubled\u0026rsquo; were excluded from analysis). Three types of achievement\u0026nbsp;rates\u0026nbsp;were then calculated; i.e.,\u0026nbsp;per\u0026nbsp;item (i.e.,\u0026nbsp;the number of \u0026lsquo;yes\u0026rsquo; responses/number of participants who responded \u0026lsquo;yes\u0026rsquo; or \u0026lsquo;no\u0026rsquo; for that particular OA-QI item) presented as % and 95% CI, ii. Overall mean per-item OA-QI achievement rate (calculating the mean achievement rate [% and 95% CI] for all 17 OA-QI items), and iii.\u0026nbsp;The mean\u0026nbsp;per-person achievement rate (number of items that an individual reported \u0026lsquo;yes\u0026rsquo;/number of \u0026lsquo;yes\u0026rsquo; or \u0026lsquo;no\u0026rsquo; responses they provided)\u0026nbsp;is\u0026nbsp;presented as\u0026nbsp;the\u0026nbsp;mean and 95% CI. The mean achievement rate per person provides a measure of\u0026nbsp;the\u0026nbsp;\u0026lsquo;comprehensiveness\u0026rsquo; of treatment.\u003c/p\u003e\n\u003cp\u003eLinear regression\u0026nbsp;modelling\u0026nbsp;was used to explore the factors associated with the per-person and per-item OA-QI achievement rates. Simple linear regression was used to screen the variables, and variables with p\u0026lt;0.200\u0026nbsp;were\u0026nbsp;included\u0026nbsp;in\u0026nbsp;the variable selection process\u0026nbsp;via the\u0026nbsp;stepwise variable selection method.\u0026nbsp;The multicollinearity\u0026nbsp;and interaction of the final model were checked, and heteroskedasticity was checked\u0026nbsp;via the\u0026nbsp;Bruesch-Pegan/Cook-Weisberg test.\u003c/p\u003e\n\u003cp\u003eOn the other hand, multiple linear regression was used to explore the ability of the per-person OA-QI achievement rate and per-item OA-QI achievement rate to predict the 1-year change in functional outcomes, adjusting for baseline age, sex, BMI and KOOS total scores. All the tests were two sided, and statistical significance was denoted by p\u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe retrieved data for 314 participants. The majority of participants (83.1%, n\u0026thinsp;=\u0026thinsp;261/314) were recruited at orthopedic consultations. Participant characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In summary, mean age of participants was 63.38 (SD 8.13), mean BMI was 26.05 (SD 5.98) and KOOS-12 was 64.63 (SD 15.85). Most participants were female (66.6%, n\u0026thinsp;=\u0026thinsp;209/314), of Chinese ethnicity (78.7%, n\u0026thinsp;=\u0026thinsp;247/314), employed (58.2%, n\u0026thinsp;=\u0026thinsp;182/314), had attained at least high school education (47.8%, n\u0026thinsp;=\u0026thinsp;150/314), lived in public housing (83.4%, n\u0026thinsp;=\u0026thinsp;261/314) and reported bilateral knee osteoarthritis symptoms (42.4%, n\u0026thinsp;=\u0026thinsp;133/214).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003e\u0026ndash;\u003c/b\u003e Participant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic or outcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.38 (8.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.05 (5.98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal KOOS-12 score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.63 (15.85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubsections:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.82 (17.84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunction in daily living (ADL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.14 (19.37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnee-related quality of life (QOL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.85 (18.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e209 (66.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (33.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e247 (78.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupational Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182 (58.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHomemaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (10.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (26.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (14.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (47.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma holder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (16.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDegree holder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (12.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic housing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e261 (83.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondominium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (7.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerrace house\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (7.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (1.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocalization of knee osteoarthritis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e181 (57.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133 (42.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime since OA diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (14.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (32.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 to 6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70 (22.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (22.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emore than 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eBMI \u0026ndash; Body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePer-item and overall mean per-item and per-person OA-QI achievement rates\u003c/h2\u003e \u003cp\u003eThe per-item and overall mean per-item OA-QI achievement rates are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In summary, large variation was observed between each indicator (ranging from 15.68% \u0026minus;\u0026thinsp;87.50%). The highest per-item achievement rates were for referrals for physical activity (mean [95% CI] 87.50%, [83.31, 90.96]), physical activity education (mean [95% CI] 82.74% [78.03, 86.79]) and pain assessment (mean [95% CI] 80.97% [75.96, 85.33]). The lowest per-item achievement rates were for referrals to daily activity aid assessment (mean [95% CI] 15.68% [7.02, 28.59]), referrals to walking aid assessment (mean [95% CI] 25.61% [16.60, 35.1]) and weight reduction referrals (mean [95% CI] 27.41% [21.31, 34.20]). Overall, the mean per-item OA-QI achievement rate was 62.21% (95% CI: 59.71, 64.71).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003e\u0026ndash;\u003c/b\u003e Per-item and overall mean per-item OA-QI achievement rates\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnswered Yes or No\u003c/p\u003e \u003cp\u003en=/314\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnswered Yes\u003c/p\u003e \u003cp\u003en=\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAchievement rate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOA-QI indicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePer- item\u003c/p\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003cp\u003eLower, Upper\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Have you been given information about how the disease usually develops over time?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e59.33, 70.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Have you been given information about different treatment alternatives?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e305\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e60.96, 71.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Have you been given information about how you can live with the disease?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e48.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42.70, 54.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Have you been given information about how you can change your lifestyle?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49.02, 60.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Have you been given information about the importance of physical activity and exercise?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e254\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e82.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e78.03, 86.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Have you been referred to someone who can advise you about physical activity and exercise? (e.g. a physiotherapist)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e83.31, 90.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. If you are overweight, have you been advised to lose weight?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e76.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e69.42, 81.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. If you are overweight, have you been referred to someone who can help you to lose weight?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21.31, 34.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. If you have had problems related to daily activities, have these problems been assessed by health personnel in the past year?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42.18, 62.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. If you have problems with walking, has your need for a walking aid been assessed? (e.g. stick, crutch or walker)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.60, 35.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. If you have problems related to other daily activities, has your need for different appliances and aids been assessed? (e.g. splints, assistive technology for cooking or personal hygiene, a special chair)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.02, 28.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. If you have pain, has it been assessed in the past year?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e289\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e234\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e80.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e75.96, 85.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. If you have pain, was paracetamol the first medicine that was recommended for your osteoarthritic pain?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e280\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e208\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e68.75, 79.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. If you have prolonged severe pain, which is not relieved sufficiently by paracetamol, have you been offered stronger pain killers? (e.g. Co-proxamol, Co-dydramol, Tramadol, Co-codamol, Dihydrocodeine, Codeine)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44.52, 59.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. If you are taking anti-inflammatory drugs, have you been given information about the effects and possible side-effects of this medicine? (e.g. Ibuprofen, Nurofen, Brufen, Diclofenac, Voltarol, Naproxen, Naprosyn, Celebrex)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e38.31, 53.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. If you have experienced an acute deterioration of your symptoms, has a corticosteroid injection been considered?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41.57, 56.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. If you are severely troubled by your osteoarthritis, and exercise and medicine do not help, have you been referred and assessed for an operation (e.g. joint replacement)?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42.37, 60.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean overall OA-QI achievement rate\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e62.21\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e59.71, 64.71\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eAssociations of per-person OA-QI achievement rates with participant characteristics\u003c/h2\u003e \u003cp\u003eDifferences in mean per-person achievement rates between categorical outcomes are presented, and the relationships between demographics and the OA-QI achievement rate are explored in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Three significant relationships were observed: i) those who were identified as Indian ethnicity had higher mean per-person OA-QI achievement rates than those who were identified as Chinese (adj. coef [95% CI], 10.94 [2.70, 19.17], p\u0026thinsp;=\u0026thinsp;0.009); ii) those who lived in public housing had higher mean per-person OA-QI achievement rates than those who resided in condominiums did (adj. coef [95% CI], -12.02 [-21.64, -2.41], p\u0026thinsp;=\u0026thinsp;0.014); and iii) those who had had osteoarthritis for less than 1 year had lower mean per-person OA-QI achievement rates than those who had been living with osteoarthritis for 1\u0026ndash;3 years (adjusted coefficient [95% CI], 9.37 [1.60, 17.15], p\u0026thinsp;=\u0026thinsp;0.018), 4\u0026ndash;6 years (adjusted coefficient [95% CI], 11.27 [2.99, 19.55], p\u0026thinsp;=\u0026thinsp;0.008), 7\u0026ndash;10 years (adjusted coefficient [95% CI], 10.26 [1.92, 18.60], p\u0026thinsp;=\u0026thinsp;0.016) and 10\u0026thinsp;+\u0026thinsp;years (adjusted coefficient [95% CI], 13.70 [3.01, 24.38], p\u0026thinsp;=\u0026thinsp;0.012), respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Comparison of the mean per-person OA-QI achievement rate with demographic outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOA-QI achievement rate, mean (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCoef\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdj. coef\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.26 (-0.57, 0.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e-\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.00 (57.37, 66.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.31 (59.33, 65.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31 (-5.00, 5.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.908\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChinese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.14 (58.30, 63.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.30 (51.76, 66.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.84 (-10.34, 6.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.60 (63.20, 80.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.47 (2.08, 18.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.94 (2.70, 19.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.24 (56.39, 88.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.11 (-7.07, 29.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.21 (-0.63, 0.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccupational Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.55 (60.23, 66.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.20 (49.30, 79.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.65 (-11.65, 12.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHomemaker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.42 (56.07, 70.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.12 (-8.41, 8.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.38 (53.52, 63.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-5.16 (-11.04, 0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.93 (45.43, 64.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.03 (57.20,68.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.10 (-5.90, 22.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.79 (58.99, 66.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.86 (-5.03, 20.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma holder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.14 (54.57, 67.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.21 (-7.58, 20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGCE A level, IB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.52 (55.47, 69.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.58 (-6.64, 21.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.29 (47.90, 78.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.35 (-9.49, 26.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.358\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic housing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.58 (59.82, 65.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondominium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.81 (42.96, 60.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-10.77 (-20.36, -1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-12.02 (-21.64, -2.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTerrace house\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65.61 (56.04, 75.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.03 (-6.56, 2.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.79 (49.70, 89.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.21 (-11.01, 25.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLocalization of knee osteoarthritis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.01 (58.64, 65.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.48 (58.71, 66.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.47 (-4.60, 5.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.857\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTime since OA diagnosis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.03 (46.42, 61.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 to 3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.92 (57.78, 66.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.89 (0.02, 15.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.37 (1.60, 17.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4 to 6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.69 (59.57, 69.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.67 (2.25, 19.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.27 (2.99, 19.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63.44 (57.81, 69.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.42 (0.97, 17.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10.26 (1.92, 18.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emore than 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.93 (58.42, 75.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.91 (205, 23.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.70 (3.01, 24.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKOOS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.12 (-0. 27, 0.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.02 (-0.16, 0.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.774\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eADL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.12 (-0.24, 0.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQoL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.11 (-0.24, 0.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI\u0026thinsp;=\u0026thinsp;Body Mass Index, ADL\u0026thinsp;=\u0026thinsp;Activities of Daily Living, QoL\u0026thinsp;=\u0026thinsp;Quality of Life\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eRelationships of per-item and per-person OA-QI achievement rates with functional outcomes at 1 yea\u003c/em\u003er\u003c/p\u003e \u003cp\u003eOne-year follow-up data were available for 202 participants. The relationships between the per-item OA-QI achievement rate and functional outcomes at 1 year are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In summary, those who indicated that they had walking issues and indicated that they did not receive a walking aid assessment had poorer outcomes after 1 year (adjusted coefficient [95% CI]: -9.89 (-19.63, -0.15); p\u0026thinsp;=\u0026thinsp;0.047). In addition, those who were not informed about injection or surgical options had greater improvements in the KOOS-12 score at 1 year than did those who received information about injections (adjusted coefficient [95% CI]: 7.23 [1.42\u0026ndash;13.04]; p\u0026thinsp;=\u0026thinsp;0.015) or surgery (adjusted coefficient [95% CI]: 12.65 [5.89\u0026ndash;19.40]; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), respectively. The relationships between the per-person achievement rate and functional outcomes at 1 year are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. In summary, no significant associations were observed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Relationships between the per-item OA-QI achievement rate and changes in functional outcomes (total KOOS-12) at 1 year\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOA-QI item number and summarized topic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAchieved?\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean change in KOOS-12\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdj Coeff\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Disease development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.98\u0026thinsp;\u0026plusmn;\u0026thinsp;16.96\u003c/p\u003e \u003cp\u003e4.61\u0026thinsp;\u0026plusmn;\u0026thinsp;15.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e-0.83 (-6.03, 4.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.754\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.52\u0026thinsp;\u0026plusmn;\u0026thinsp;17.07\u003c/p\u003e \u003cp\u003e5.44\u0026thinsp;\u0026plusmn;\u0026thinsp;15.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e1.78 (-3.21, 6.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Self-management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.32\u0026thinsp;\u0026plusmn;\u0026thinsp;16.58\u003c/p\u003e \u003cp\u003e5.71\u0026thinsp;\u0026plusmn;\u0026thinsp;16.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e3.16 (-1.39, 7.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Lifestyle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.97\u0026thinsp;\u0026plusmn;\u0026thinsp;16.24\u003c/p\u003e \u003cp\u003e4.25\u0026thinsp;\u0026plusmn;\u0026thinsp;16.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e-0.33 (-5.11, 4.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.892\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Physical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.91\u0026thinsp;\u0026plusmn;\u0026thinsp;17.00\u003c/p\u003e \u003cp\u003e4.70\u0026thinsp;\u0026plusmn;\u0026thinsp;13.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e0.73 (-5.16, 6.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.806\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Referral physical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.54\u0026thinsp;\u0026plusmn;\u0026thinsp;16.52\u003c/p\u003e \u003cp\u003e-0.45\u0026thinsp;\u0026plusmn;\u0026thinsp;14.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e-2.54 (-9.44, 4.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Weight reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.27\u0026thinsp;\u0026plusmn;\u0026thinsp;17.35\u003c/p\u003e \u003cp\u003e5.73\u0026thinsp;\u0026plusmn;\u0026thinsp;12.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e0.37 (-6.47, 7.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.915\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Referral weight reduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.23\u0026thinsp;\u0026plusmn;\u0026thinsp;17.13\u003c/p\u003e \u003cp\u003e2.20\u0026thinsp;\u0026plusmn;\u0026thinsp;16.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e-4.69 (-10.71, 1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.125\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Functional assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.27\u0026thinsp;\u0026plusmn;\u0026thinsp;17.87\u003c/p\u003e \u003cp\u003e0.77\u0026thinsp;\u0026plusmn;\u0026thinsp;16.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e-2.53 (-10.10, 5.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.510\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Walking aid assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.26\u0026thinsp;\u0026plusmn;\u0026thinsp;14.46\u003c/p\u003e \u003cp\u003e3.99\u0026thinsp;\u0026plusmn;\u0026thinsp;18.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e-9.89 (-19.63, -0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Other aids assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.60\u0026thinsp;\u0026plusmn;\u0026thinsp;18.70\u003c/p\u003e \u003cp\u003e-3.49\u0026thinsp;\u0026plusmn;\u0026thinsp;17.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e-6.52 (21.13, 8.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.380\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Pain assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.84\u0026thinsp;\u0026plusmn;\u0026thinsp;16.09\u003c/p\u003e \u003cp\u003e6.03\u0026thinsp;\u0026plusmn;\u0026thinsp;17.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e2.36 (-3.39, 8.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.420\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. Paracetamol\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.29\u0026thinsp;\u0026plusmn;\u0026thinsp;16.94\u003c/p\u003e \u003cp\u003e6.25\u0026thinsp;\u0026plusmn;\u0026thinsp;15.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e4.37 (-0.97, 9.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Stronger pain killers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.28\u0026thinsp;\u0026plusmn;\u0026thinsp;17.71\u003c/p\u003e \u003cp\u003e5.65\u0026thinsp;\u0026plusmn;\u0026thinsp;14.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e4.18 (-1.39, 9.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. NSAIDS information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.73\u0026thinsp;\u0026plusmn;\u0026thinsp;18.66\u003c/p\u003e \u003cp\u003e6.89\u0026thinsp;\u0026plusmn;\u0026thinsp;14.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e4.93 (-0.80, 10.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Joint injection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.65\u0026thinsp;\u0026plusmn;\u0026thinsp;17.24\u003c/p\u003e \u003cp\u003e6.19\u0026thinsp;\u0026plusmn;\u0026thinsp;17.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e7.23 (1.42, 13.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. Surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-4.98\u0026thinsp;\u0026plusmn;\u0026thinsp;18.24\u003c/p\u003e \u003cp\u003e8.39\u0026thinsp;\u0026plusmn;\u0026thinsp;16.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRef\u003c/p\u003e \u003cp\u003e12.65 (5.89, 19.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdjusted for age, sex, BMI and total KOOS score at baseline\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Relationships between the per-person OA-QI achievement rate and changes in functional outcomes at 1 year\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdj. Coeff\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKOOS Total\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.16 0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKOOS Pain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.19, 0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKOOS ADL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.14, 0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.757\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKOOS QoL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.21, 0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.313\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAdjusted for age, sex, BMI and total KOOS score at baseline.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn general, the quality indicator achievement rates were underwhelming but were similar to those reported in previous research from outside Asia\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Encouragingly, participants frequently reported being provided with information about first-line interventions, namely, physical activity, exercise, and weight loss. However, information about self-management and coping strategies is infrequently provided, and referrals to specialist weight loss or supportive services (e.g., walking aids and splints) are rarely provided when indicated. The overall quality of care provided was associated with participant ethnicity, housing type, and time since diagnosis, suggesting that care is provided inconsistently. Furthermore, the provision of information about certain topics (i.e., walking aids, injections or surgery) was associated with functional outcomes at 1 year. Overall, our findings can be used to inform initiatives to improve the quality of care that is being provided to people with knee osteoarthritis in Singapore.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImproving the quality of osteoarthritis care in Singapore\u003c/h2\u003e \u003cp\u003eEncouragingly, most participants reported being provided information about, and referred to, an appropriate service for, physical activity and exercise, considering that three-quarters of people with knee osteoarthritis in Singapore reported low levels of physical activity \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Physical activity and exercise should be encouraged in this population, as they are inexpensive and effective guidelines that recommend first-line interventions that are suitable for all people regardless of age, sex, ethnicity or severity of the disease \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However, other important information that may facilitate becoming more physically active, such as lifestyle changes or coping strategies, is often not provided. Encouragingly, weight management was reported as being discussed with the majority of individuals for whom it was appropriate. However, disappointingly, only one in two people were referred to appropriate weight loss services. Considering that weight management is an integral part of guideline-adherent care\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, the reasons for the lack of referrals should be investigated further. Improving knowledge about, and access to, weight management services, among other services for which referral rates are low (i.e., walking and daily mobility aids) available in Singapore, has great potential to improve patient outcomes for patients with knee osteoarthritis and its associated comorbidities.\u003c/p\u003e \u003cp\u003eAn investigation of the relationship of the per-item OA-QI achievement rate with 1-year KOOS-12 outcomes revealed that participants who experienced acute deterioration of symptoms and who were engaged in a discussion about corticosteroid injections had worse 1-year KOOS-12 outcomes than those who also experienced an acute exacerbation but did not engage in a discussion about corticosteroid injections. However, we are unable to tell if an injection was actually offered or received. Injections are widely perceived as a treatment option to provide immediate symptom relief during an acute exacerbation\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. It is possible that discussion about injections may have put people off engaging in other long-term management strategies, such as physical therapy or lifestyle modifications, which provides a more sustainable solution for behavioral change\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe also observed that participants who experienced walking difficulties but were not assessed for walking aids demonstrated a greater improvement in their 1-year KOOS than did those whose need for walking aids was evaluated. This observation suggests a potential benefit of walking aid assessment in knee osteoarthritis patients experiencing mobility challenges. The assessment and subsequent use of walking aids might contribute to better outcomes by improving mobility, reducing pain, and enhancing overall quality of life\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. This aligns with the literature emphasizing the importance of addressing mobility issues in osteoarthritis management\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eGoing beyond quality of care to achieve good outcomes\u003c/h2\u003e \u003cp\u003eWe did not identify any significant relationships between age, sex, BMI, education, or severity of knee symptoms and the per-person OA-QI achievement rate. However, we did observe that individuals of Indian ethnicity and those residing in public housing had higher per-person OA-QI achievement rates (indicating more comprehensive care) than those who were of Chinese ethnicity or who were residing in condominiums, respectively. These findings were unexpected, and the reasons behind these associations are not immediately clear. It is possible that socioeconomic factors, cultural attitudes towards healthcare, or accessibility to healthcare resources could play a role. However, without further research specifically targeting these demographics, it is challenging to draw definitive conclusions. Importantly, these findings should also be interpreted with caution because of the lower sample sizes in the comparator groups. Further research is encouraged to understand the complex interplay of ethnicity, living conditions, and healthcare quality in the context of knee osteoarthritis treatment.\u003c/p\u003e \u003cp\u003eWe did not identify any relationship between the comprehensiveness of care (i.e., per-person OA-QI achievement rate) at baseline and 1-year KOOS-12 outcomes. One potential explanation for this finding is the multifactorial nature of health outcomes in patients with knee osteoarthritis. The quality of clinical care contributes to only 20% of the social determinants of health. Other factors, such as socioeconomic status (40%), the physical environment (10%), and health behaviors (30%), play greater roles in determining and improving health. These findings suggest that factors other than the quality of care might have a more significant impact on KOOS outcomes than the comprehensiveness of osteoarthritis care alone\u003csup\u003e\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. This underscores the complexity of healthcare outcomes and the necessity of adopting a holistic approach for managing knee osteoarthritis, which takes into account the wide array of factors influencing patient health and well-being. Our findings suggest that while comprehensiveness or quality of care is undoubtedly important, it is just one of many components that contributes to overall health outcomes in patients with knee osteoarthritis. Much of osteoarthritis care needs to be targeted at behavioral changes, and one session of information might not be sufficient to provide the necessary push to lead to such changes\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eIt is important to consider the limitations of our study when interpreting our findings. Specifically, our findings may not be fully generalizable to all individuals with knee osteoarthritis in Singapore. Furthermore, Singapore is a unique country in Asia with a diverse ethnicity mix and relatively high average income rates compared with other Asian countries; therefore, the findings of our study may not represent the wider Asian region. Notably, the majority of participants in our study were recruited through orthopedic surgeons. Evidence from around the world suggests that relatively few people with knee osteoarthritis are referred beyond primary care; therefore, investigations of care provided by first-contact practitioners in Singapore (i.e., general practitioners) are warranted. Additionally, as mentioned above, relying on self-reported data carries a risk of bias and difficulty in determining how accurate the patient\u0026rsquo;s responses are. This challenge underscores the need for more robust methods to assess patient-reported data, such as qualitative interviews and documentation reviews. Nonetheless, the depth and breadth of our analysis contribute significantly to advancing our understanding and enhancing the quality of osteoarthritis care.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study provides valuable insights into the quality of osteoarthritis care in Singapore, which appears to be suboptimal. Notably, the high achievement rates in areas such as physical activity referrals and education and pain assessment strongly align with international care standards. However, the study also highlights several areas needing attention, particularly in referrals for daily activity aids and walking aid assessments, as well as in comprehensive support for weight management. The OA-QI appears to be a poor indicator of 1-year outcomes for people with knee osteoarthritis, suggesting that the determinants of outcomes in patients with knee OA are multifaceted and extend beyond the scope of quality indicators traditionally used. Future research should aim to unravel these multifactorial influences in greater depth, contributing to more effective and nuanced treatment strategies for knee OA patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from National Healthcare group, Domain Specific Review Board, Ref no. WHC/2020-0076 and patient consent was taken prior to taking part in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManuscript does not contain data from a single individual.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy design \u0026ndash; including conceptualization and methodology: BTY, LCJ.\u003c/p\u003e\n\u003cp\u003eData collection and data analysis: LTR, AJG, BTY, LCJ.\u003c/p\u003e\n\u003cp\u003eData interpretation: LTR, AJG, BTY, LCJ.\u003c/p\u003e\n\u003cp\u003eGeneration of figures: LCJ\u003c/p\u003e\n\u003cp\u003eAll authors were involved in writing the paper and had final approval of the submitted and published versions\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Pearl Koh Yuan Zhen and Koong Mun Ee for their initial work on this project.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVos T, Lim SS, Abbafati C, et al. 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Patient-reported quality of care for osteoarthritis: development and testing of the osteoarthritis quality indicator questionnaire. \u003cem\u003eArthritis Care Res\u003c/em\u003e. 2013;65. doi:10.1002/acr.21976\u003c/li\u003e\n\u003cli\u003eIngelsrud LH, Roos EM, Gromov K, Jensen SS, Troelsen A. Patients report inferior quality of care for knee osteoarthritis prior to assessment for knee replacement surgery\u0026ndash;a cross-sectional study of 517 patients in Denmark. \u003cem\u003eActa Orthop\u003c/em\u003e. 2020;91(1):82-87.\u003c/li\u003e\n\u003cli\u003eBlackburn S, Higginbottom A, Taylor R, et al. Patient-reported quality indicators for osteoarthritis: a patient and public generated self-report measure for primary care. \u003cem\u003eRes Involv Engagem\u003c/em\u003e. 2016;2(1):1-20.\u003c/li\u003e\n\u003cli\u003eGr\u0026oslash;nhaug G, \u0026Oslash;ster\u0026aring;s N, Hagen KB. Quality of hip and knee osteoarthritis management in primary health care in a Norwegian county: a cross-sectional survey. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2014;14(1):1-7.\u003c/li\u003e\n\u003cli\u003eLarmer PJ, Bennett K, Baldwin JN, Bassett S, O\u0026rsquo;Brien DW. Quality indicators for hip and knee osteoarthritis management in New Zealand: A patient survey. \u003cem\u003eN Z J Physiother\u003c/em\u003e. Published online 2019:47 3.\u003c/li\u003e\n\u003cli\u003eTan BY, Goh ZZS, Lim CJ, et al. Singapore KneE osTeoarthritis CoHort (SKETCH): protocol for a multi-centre prospective cohort study. \u003cem\u003eBMC Musculoskelet Disord\u003c/em\u003e. 2023;24(1):104. doi:10.1186/s12891-023-06207-1\u003c/li\u003e\n\u003cli\u003eElm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. \u003cem\u003eAnn Intern Med\u003c/em\u003e. 2007;147(8):573-577.\u003c/li\u003e\n\u003cli\u003eRoos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)\u0026ndash;development of a self-administered outcome measure. \u003cem\u003eJ Orthop Sports Phys Ther\u003c/em\u003e. 1998;28(2):88-96.\u003c/li\u003e\n\u003cli\u003eGandek B, Roos EM, Franklin PD, Ware JE. A 12-item short form of the Knee injury and Osteoarthritis Outcome Score (KOOS-12): tests of reliability, validity and responsiveness. \u003cem\u003eOsteoarthritis Cartilage\u003c/em\u003e. 2019;27. doi:10.1016/j.joca.2019.01.011\u003c/li\u003e\n\u003cli\u003e\u0026Oslash;ster\u0026aring;s N, Hagen K, Garratt A, et al. Quality of osteoarthritis care: test-retest reliability and feasibility of the osteoarthritis quality indicator questionnaire. \u003cem\u003eOsteoarthritis Cartilage\u003c/em\u003e. 2012;20:185-186.\u003c/li\u003e\n\u003cli\u003eGoff AJ, Jones LE, Lim CJ, Tan BY. A cross sectional study exploring the relationship of self-reported physical activity with function, kinesiophobia, self-efficacy and quality of life in an Asian population seeking care for knee osteoarthritis. \u003cem\u003eBMC Musculoskelet Disord\u003c/em\u003e. 2024;25(1):74. doi:10.1186/s12891-024-07181-y\u003c/li\u003e\n\u003cli\u003eAyub S, Kaur J, Hui M, et al. Efficacy and safety of multiple intra-articular corticosteroid injections for osteoarthritis-a systematic review and meta-analysis of randomized controlled trials and observational studies. \u003cem\u003eRheumatol Oxf Engl\u003c/em\u003e. 2021;60(4):1629-1639. doi:10.1093/rheumatology/keaa808\u003c/li\u003e\n\u003cli\u003eWillett M, Duda J, Fenton S, Gautrey C, Greig C, Rushton A. Effectiveness of behaviour change techniques in physiotherapy interventions to promote physical activity adherence in lower limb osteoarthritis patients: A systematic review. \u003cem\u003ePloS One\u003c/em\u003e. 2019;14(7):e0219482. doi:10.1371/journal.pone.0219482\u003c/li\u003e\n\u003cli\u003eAllen KD, Golightly YM. State of the evidence. \u003cem\u003eCurr Opin Rheumatol\u003c/em\u003e. 2015;27(3). https://journals.lww.com/co-rheumatology/fulltext/2015/05000/state_of_the_evidence.12.aspx\u003c/li\u003e\n\u003cli\u003eReyes C, Garcia-Gil M, Elorza JM, et al. Socio-economic status and the risk of developing hand, hip or knee osteoarthritis: a region-wide ecological study. \u003cem\u003eOsteoarthritis Cartilage\u003c/em\u003e. 2015;23(8):1323-1329. doi:10.1016/j.joca.2015.03.020\u003c/li\u003e\n\u003cli\u003eFelson DT, Niu J, Clancy M, Sack B, Aliabadi P, Zhang Y. Effect of recreational physical activities on the development of knee osteoarthritis in older adults of different weights: the Framingham Study. \u003cem\u003eArthritis Rheum\u003c/em\u003e. 2007;57(1):6-12. doi:10.1002/art.22464\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4963107/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4963107/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to assess the self-reported quality of care for people with knee osteoarthritis in Singapore and to explore the associations between participant characteristics and functional outcomes at 1 year in relation to the reported quality of care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with knee osteoarthritis completed the osteoarthritis quality indicator (OA-QI) questionnaire between June 2021 and February 2022. The OA-QI includes 17 indicators, with \"achievement\" defined as a 'Yes' response for each. We calculated individual per-item, overall per-item mean, and per-person achievement rates (%) and explored associations between participant characteristics, achievement rates, and function at 1 year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 314 participants completed the OA-QI. Referral for physical activity (87.5%) and referral for daily activity aid assessment (15.7%) had the highest and lowest per-item achievement rates, respectively. The overall mean per-item and per-person achievement rates were both 62.2%. Participants educated about steroid injections (adjusted coefficient [95% CI]: 7.23 [1.42–13.04]; p= 0.015) or surgery (adjusted coefficient [95% CI]: 12.65 [5.89–19.40]; p\u0026lt; 0.001) had worse functional outcomes at one year than those who were eligible but not informed. Those not assessed for walking aids and indicating walking issues had poorer outcomes one year later (adjusted coefficient [95% CI]: -9.89 (-19.63, -0.15); p= 0.0470). However, no significant associations were found between per-person achievement rates and 1-year functional outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe quality of care in Singapore for people with knee osteoarthritis is suboptimal, especially for those needing walking aids and weight loss assistance. However, the quality of care alone does not fully account for long-term outcomes, suggesting that other factors need to be considered.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u0026nbsp;\u003c/strong\u003eclinicaltrials.gov registry (Identifier: NCT04942236)\u003c/p\u003e\n\u003cp\u003eTrial registration date: 25\u003csup\u003eth\u003c/sup\u003e\u0026nbsp;June 2021\u003c/p\u003e","manuscriptTitle":"Assessing the Quality of Care for Knee Osteoarthritis in Singapore: A Cross-sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-03 16:18:08","doi":"10.21203/rs.3.rs-4963107/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-02-10T05:43:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-13T20:02:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246826286285924147400641905986101033560","date":"2024-11-11T18:24:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-19T20:51:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203040765996288001135034100752922673429","date":"2024-10-11T12:17:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-09T03:33:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-03T03:03:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-03T02:33:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-08-23T09:21:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f81325ec-84c9-4441-8059-55d328a18c36","owner":[],"postedDate":"October 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T16:08:59+00:00","versionOfRecord":{"articleIdentity":"rs-4963107","link":"https://doi.org/10.1186/s12891-025-08524-z","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-03-26 15:57:54","publishedOnDateReadable":"March 26th, 2025"},"versionCreatedAt":"2024-10-03 16:18:08","video":"","vorDoi":"10.1186/s12891-025-08524-z","vorDoiUrl":"https://doi.org/10.1186/s12891-025-08524-z","workflowStages":[]},"version":"v1","identity":"rs-4963107","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4963107","identity":"rs-4963107","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}