A surge in imaging, persistent surgical variation, and inadequate funding for first-line treatments have exposed major shortcomings in Australian osteoarthritis care, a leading rheumatologist warns.
Australia is spending too much on unnecessary knee imaging and potentially avoidable surgery, while failing to fund treatments that could keep patients out of operating theatres, according to leading rheumatologist Professor David Hunter.
His warning follows the release of the Australian Commission on Safety and Quality in Health Care’s Atlas Focus Report: Osteoarthritis of the Knee, which revealed an 83% increase in knee CT scans and a 26% rise in ultrasounds among Australians aged 45 and over in the five years to 2023-24.
Despite longstanding evidence supporting clinical diagnosis and non-surgical management, the report also identified substantial geographical variation in surgical intervention and persistent underuse of recommended first-line care.
The Commission’s Osteoarthritis of the Knee Clinical Care Standard was first released in 2017 to improve care for knee osteoarthritis and to reduce inappropriate interventions.
The updated 2024 Standard encouraged patients to take control of their health and clinicians to avoid referring for unnecessary scans, surgical intervention, or over-reliance on pain relief medicines.
Instead, it urged greater focus on supporting patients with weight management, nutrition, physical activity, and exercise.
Professor Hunter, a rheumatologist and clinical researcher at the University of Sydney and Royal North Shore Hospital who contributed to the Commission’s latest report’s expert group, said the consequences of unnecessary imaging extended well beyond the initial investigation.
“The bigger concern I have, is that the application of imaging leads to downstream effects that I don’t think people necessarily think about when they first order a scan,” he told Rheumatology Republic.
“So patients go on and have further investigations – but probably more importantly concerning, are the inappropriate interventions these scans can lead to, like arthroscopy.
“We really need to get the message out about the downstream consequences, that people don’t necessarily think about with regards to the initial investigation.”
He said structural abnormalities, particularly degenerative meniscal lesions, were extremely common in older adults, including those without knee pain or other symptoms.
Yet imaging reports could create anxiety and reinforce the belief that structural changes required surgical correction or immediate specialist referral.
“When the patient sees that scan, they see a war zone of a report, and it’s very hard for them to unsee that report,” Professor Hunter said.
He said clinicians needed to move away from treating imaging abnormalities in isolation, and instead focus on symptoms, function, and clinical assessment.
“We need to treat the person, not the scan,” he said.
The Atlas findings showed that rates of MBS-subsidised knee CT increased from 261 to 478 services per 100,000 people between 2019-20 and 2023-24, while ultrasound rates increased from 1160 to 1461 per 100,000.
Professor Hunter suggested that restrictions introduced in 2018 on Medicare rebates for GP-requested knee MRI scans in patients aged 50 years and over could be contributing to the increased use of CT and ultrasound as alternatives.
However, he questioned the clinical value of either CT or ultrasound investigations for diagnosing osteoarthritis.
“Ultrasound is a terrible tool for assessing the joint structural integrity. It’s great for soft tissue, but you can’t see the interior of the joint,” he told RR.
He said rheumatologists were unlikely to be major contributors to the increase in these investigations, given their ability to request MRI when clinically indicated.
However, he acknowledged the difficulties facing GPs, who must manage patient expectations and explain why imaging was often unnecessary.
“It takes it takes a fair amount of counsel to tell someone why we don’t need an image to make the diagnosis. We need to explain that we are confident of the diagnosis based on what we’ve seen in a clinical examination,” Professor Hunter said.
“So it takes a bit of time and a reasonable amount of confidence.”
The report also revealed a 50% reduction in knee arthroscopy hospitalisation rates over the decade to 2023-24, consistent with recommendations against the procedure for uncomplicated osteoarthritis.
Despite the national decline, arthroscopy rates varied 12-fold between local areas in 2023-24, raising concerns about ongoing potentially inappropriate care.
Knee replacement hospitalisations, meanwhile, increased by 17% over the decade, with six-fold geographical variation.
Professor Hunter cautioned against interpreting the overall increase as necessarily inappropriate but said the geographical differences raised serious questions about equitable access to treatment.
“The geographic variation in the data on knee replacements is a huge problem,” he said.
“It suggests that the inequity is being perpetuated by virtue of some people’s ability to pay.”
The report also highlighted a major disconnect between clinical guidelines and the care patients receive before surgical referral.
An Australian study cited in the Atlas clinical commentary found that only half of patients referred for orthopaedic assessment had previously received a referral for exercise, while around one-third had been referred for weight management.
Professor Hunter said the failure to provide recommended non-surgical treatments was not simply a problem of clinician behaviour.
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“In an ideal world, everybody would be getting that as first line care in primary care. So they’d be having the exercise, the physical activity, the education and the appropriate weight management done,” he said.
“Unfortunately, it’s just not happening, and that’s not just on the GPs. I think that’s partly on the healthcare system and the reimbursement structures.”
He said multidisciplinary programs were already available, including the Osteoarthritis Chronic Care Program in NSW, Medibank’s Better Me programs, and initiatives involving Ramsay Connect.
However, fragmented referral pathways and inadequate reimbursement remained major obstacles.
Patients could access substantial public and private funding for joint replacement surgery, imaging, and other interventions, while facing significant out-of-pocket costs for physiotherapy and weight management.
“The barrier is that it’s a complex journey, with fragmented referral pathways. But the biggest barrier is the financial barrier,” said Professor Hunter.
He said the imbalance was particularly difficult to justify when evidence-based conservative management could improve pain and function and potentially delay or avoid surgery.
“I’m not suggesting that people shouldn’t get a joint replacement, but it should be the last resort,” he said.
He called for coordinated healthcare reform that would make multidisciplinary osteoarthritis care affordable and accessible, alongside education to help clinicians and patients understand the benefits of first-line treatments.
Commission medical advisor and practising GP Dr Holdenson Kimura said the challenge was not simply telling patients to exercise, but presenting non-surgical management as an effective, positive treatment option.
“It’s actually about creating a tailored plan with them about what their preferences are and where they are at the moment and what their goals are for the future,” she said.
Her central message to GPs was to have confidence in their clinical assessments, use language that encouraged patients to remain active, and strongly promote non-surgical management as the first line of treatment.
“Empowering patients to believe that it will work and to have the confidence to give it a really good crack is key,” she said.
Professor Hunter is working with Arthritis Australia and researchers at Monash University to advocate for changes to funding arrangements at state and federal levels.
One proposal involved identifying regions with high rates of potentially low-value care and targeting patients at greatest risk of requiring joint replacement within the following 12 to 24 months.
Those patients would be offered fully supported multidisciplinary treatment, allowing governments to measure improvements in outcomes and potential savings from avoided surgery.
He pointed to the experience of a NSW program as evidence that the approach could deliver substantial financial returns.
“What we did in New South Wales is basically along those lines, and for every dollar that was invested, the state government saved $5 by virtue of the number of people who weren’t getting their joints replaced,” he said.
Professor Hunter said a shared state-federal funding model could help overcome the current fragmentation, while private health insurers also had a significant role to play.
He estimated that around 70% of elective orthopaedic surgery occurred in the private sector, giving insurers a strong financial incentive to support effective non-surgical care.
Despite years of advocacy, however, he said progress on funding reform remained frustratingly slow.
“But we’ve been banging on these doors now for the better part of every three to five years, having similar conversations. The government understand that there’s important disability from this condition,” Professor Hunter said.
He said governments understood the prevalence of osteoarthritis and the potential benefits of better treatment but were yet to make it a sufficient priority.
For Professor Hunter, the solution required more than reducing unnecessary scans or discouraging inappropriate surgery.
It meant redesigning funding and referral pathways so that patients could access treatments with proven benefits before reaching the point of surgical intervention.
“In the first instance, we’ve got to be positive about this. To me, we’ve got to frame the change that is needed around education and healthcare reform,” he said.
See the full report here.
