Applying a Health Network approach to translate evidence-informed policy into practice: a review and case study on musculoskeletal health

Primary care-based models of care for osteoarthritis; a scoping review

OBJECTIVE

To identify and describe the extent, nature, characteristics, and impact of primary care-based models of care (MoCs) for osteoarthritis (OA) that have been developed and/or evaluated.

DESIGN

Six electronic databases were searched from 2010 to May 2022. Relevant data were extracted and collated for narrative synthesis.

RESULTS

Sixty-three studies pertaining to 37 discrete MoCs from 13 countries were included, of which 23 (62%) could be classified as OA management programmes (OAMPs) comprising a self-management intervention to be delivered as a discrete package. Four models (11%) focussed on enhancing the initial consultation between a patient presenting with OA at the first point of contact into a local health system and the clinician. Emphasis was placed on educational training for general practitioners (GPs) and allied healthcare professionals delivering this initial consultation. The remaining 10 MoCs (27%) detailed integrated care pathways of onward referral to specialist secondary orthopaedic and rheumatology care within local healthcare systems. The majority (35/37; 95%) were developed in high-income countries and 32/37 (87%) targeted hip/and or knee OA. Frequently identified model components included GP-led care, referral to primary care services and multidisciplinary care. The models were predominantly 'one-size fits all' and lacked individualised care approaches. A minority of MoCs, 5/37 (14%) were developed using underlying frameworks, three (8%) of which incorporated behaviour change theories, while 13/37 (35%) incorporated provider training. Thirty-four of the 37 models (92%) were evaluated. Outcome domains most frequently reported included clinical outcomes, followed by system- and provider-level outcomes. While there was evidence of improved quality of OA care associated with the models, effects on clinical outcomes were mixed.

CONCLUSION

There are emerging efforts internationally to develop evidence-based models focused on non-surgical primary care OA management. Notwithstanding variations in healthcare systems and resources, future research should focus on model development alignment with implementation science frameworks and theories, key stakeholder involvement including patient and public representation, provision of training and education for providers, treatment individualisation, integration and coordination of services across the care continuum and incorporation of behaviour change strategies to foster long-term adherence and self-management.

A scoping review of outer context constructs in dissemination and implementation science theories, models, and frameworks

Many studies have explored organizational factors that facilitate implementation. However, there is still a limited understanding of determinants external to the implementing organization and their effects on evidence-based intervention (EBI) adoption, implementation, and outcomes. The purpose of this scoping review was to assess definitions of context and identify salient determinants of outer context found in dissemination and implementation theories, models, and frameworks. We employed a compilation of dissemination and implementation frameworks from two reviews as the data source. We abstracted the following information: type of article, outcomes of the framework, presence of a context definition, presence of any outer setting definition and the definition, number and domains of outer setting mentioned, definitions of outer context constructs, and any quantitative measures of outer setting. We identified 19 definitions of outer context. Forty-seven (49%) frameworks reported one or more specific constructs of the outer setting. While the outer context domains described in the frameworks varied, the most common domains were policy (n = 24), community (n = 20), partnerships (n = 13), and communications (n = 12). Based on our review of the frameworks, more conceptualization and measurement development for outer context domains are needed. Few measures were found and definitions of domains varied across frameworks. Expanding outer context construct definitions would advance measure development for important factors external to the organizations related to EBI implementation.

Applying the behavioural change wheel to guide the implementation of a biopsychosocial approach to musculoskeletal pain care

Achieving high value, biopsychosocial pain care can be complex, involving multiple stakeholders working synergistically to support the implementation of quality care. In order to empower healthcare professionals to assess, identify and analyse biopsychosocial factors contributing to musculoskeletal pain, and describe what changes are needed in the whole-of-system to navigate this complexity, we aimed to: (1) map established barriers and enablers influencing healthcare professionals' adoption of a biopsychosocial approach to musculoskeletal pain against behaviour change frameworks; and (2) identify behaviour change techniques to facilitate and support the adoption and improve pain education. A five-step process informed by the Behaviour Change Wheel (BCW) was undertaken: (i) from a recently published qualitative evidence synthesis, barriers and enablers were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework (TDF) using "best fit" framework synthesis; (ii) relevant stakeholder groups involved in the whole-of-health were identified as audiences for potential interventions; (iii) possible intervention functions were considered based on the Affordability, Practicability, Effectiveness and Cost-effectiveness, Acceptability, Side-effects/safety, Equity criteria; (iv) a conceptual model was synthesised to understand the behavioural determinants underpinning biopsychosocial pain care; (v) behaviour change techniques (BCTs) to improve adoption were identified. Barriers and enablers mapped onto 5/6 components of the COM-B model and 12/15 domains on the TDF. Multi-stakeholder groups including healthcare professionals, educators, workplace managers, guideline developers and policymakers were identified as target audiences for behavioural interventions, specifically education, training, environmental restructuring, modelling and enablement. A framework was derived with six BCTs identified from the Behaviour Change Technique Taxonomy (version 1). Adoption of a biopsychosocial approach to musculoskeletal pain involves a complex set of behavioural determinants, relevant across multiple audiences, reflecting the importance of a whole-of-system approach to musculoskeletal health. We proposed a worked example on how to operationalise the framework and apply the BCTs. Evidence-informed strategies are recommended to empower healthcare professionals to assess, identify and analyse biopsychosocial factors, as well as targeted interventions relevant to various stakeholders. These strategies can help to strengthen a whole-of-system adoption of a biopsychosocial approach to pain care.

Multidisciplinary patient-centred model of care for osteoarthritis: scoping review protocol—an initiative by the Egyptian Academy of Bone Health

Background

There is an evidence-practice gap in osteoarthritis (OA) management which has caused several patients living with the disease are receiving suboptimal medical care. Though there are several guidelines and treatment recommendations published, there is a real need to operationalise such evidence-based guidelines and facilitate their implementation by healthcare professionals in their local health systems

Main text

This work was carried out to outline a patient-centred multidisciplinary osteoarthritis care programme for knee and hip joint osteoarthritis that is applicable in standard clinical practice. A scoping review was conducted to identify an evidence-informed osteoarthritis management strategy, which outlines the optimal manner to treat patients living with osteoarthritis and can be implemented by healthcare professionals. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) checklist was used to guide the reporting of this review. Based on this, a “Model of Care” based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including non-pharmacological, pharmacological therapies, psychotherapy, rehabilitation as well as surgery) has been developed aiming to optimise the outcomes. The goals and principles have been identified as well as the key performance indices. An algorithm for the multidisciplinary management of osteoarthritis has been developed.

Conclusion

The developed osteoarthritis care programme (OACP) provided a “Model of Care” for people living with OA which can be implemented in standard practice. The results will give insight into the features, performance, results, and outcome measures assessed. It will also guide future research towards how “Model of Care” can be patient-centred and tailored to the individual medical status.

Primary care-based models of care for osteoarthritis: a scoping review protocol

Background: The burden of osteoarthritis (OA) to individuals and health systems is substantial and is expected to increase due to population ageing and rising prevalence of obesity and multimorbidity. Primary care-based models of care (MoCs) are being increasingly developed in response to this growing burden. However, these MoCs have yet to be formally reviewed. A MoC can be defined as an ‘evidence-informed strategy, framework or pathway that outlines the optimal manner in which condition-specific care should be delivered to consumers within a local health system’.

Objective: To identify and describe the available research regarding the extent, nature and characteristics of MoCs for OA that have been developed or evaluated in primary care.

Methods: A scoping review will be conducted in accordance with the Arksey and O’Malley scoping review framework and the PRISMA-ScR guidelines. Systematic literature searches of MEDLINE, EMBASE, CINAHL, PsychINFO, Web of Science and LILACs will be conducted from 2010 to present, aligning with publication dates of recent clinical guidelines. A structured iterative search of grey literature will be conducted. Full-text original quantitative or mixed method studies which describe the development or evaluation of MoCs for OA in primary care will be considered. Data will be charted and synthesised and a narrative synthesis will be conducted.

Conclusions: This scoping review will provide a broad overview regarding the extent, nature and characteristics of the available literature on primary care based MoCs for OA. Findings will be used to identify gaps in the current evidence to identify areas for future research.

Identification of knowledge translation theories, models or frameworks suitable for health technology reassessment: a survey of international experts

OBJECTIVE

Health technology reassessment (HTR) is a field focused on managing a technology throughout its life cycle for optimal use. The process results in one of four possible recommendations: increase use, decrease use, no change or complete withdrawal of the technology. However, implementation of these recommendations has been challenging. This paper explores knowledge translation (KT) theories, models and frameworks (TMFs) and their suitability for implementation of HTR recommendations.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Purposeful sampling of international KT and HTR experts was administered between January and March 2019.

METHODS

Sixteen full-spectrum KT TMFs were rated by the experts as 'yes', 'partially yes' or 'no' on six criteria: familiarity, logical consistency/plausibility, degree of specificity, accessibility, ease of use and HTR suitability. Consensus was determined as a rating of ≥70% responding 'yes'. Descriptive statistics and manifest content analysis were conducted on open-ended comments.

RESULTS

Eleven HTR and 11 KT experts from Canada, USA, UK, Australia, Germany, Spain, Italy and Sweden participated. Of the 16 KT TMFs, none received ≥70% rating. When ratings of 'yes' and 'partially yes' were combined, the Consolidated Framework for Implementation Research was considered the most suitable KT TMF by both KT and HTR experts (86%). One additional KT TMF was selected by KT experts: Knowledge to Action framework. HTR experts selected two additional KT TMFs: Co-KT framework and Plan-Do-Study-Act cycle. Experts identified three key characteristics of a KT TMF that may be important to consider: practicality, guidance on implementation and KT TMF adaptability.

CONCLUSIONS

Despite not reaching an overall ≥70% rating on any of the KT TMFs, experts identified four KT TMFs suitable for HTR. Users may apply these KT TMFs in the implementation of HTR recommendations. In addition, KT TMF characteristics relevant to the field of HTR need to be explored further.

Primary care-based models of care for osteoarthritis: a scoping review protocol

Background: The burden of osteoarthritis (OA) to individuals and health systems is substantial and is expected to increase due to population ageing and rising prevalence of obesity and multimorbidity. Primary care-based models of care (MoCs) are being increasingly developed in response to this growing burden. However, these MoCs have yet to be formally reviewed. A MoC can be defined as an 'evidence-informed strategy, framework or pathway that outlines the optimal manner in which condition-specific care should be delivered to consumers within a local health system'. Objective: To identify and describe the available research regarding the extent, nature and characteristics of MoCs for OA that have been developed or evaluated in primary care. Methods: A scoping review will be conducted in accordance with the Arksey and O'Malley scoping review framework and the PRISMA-ScR guidelines. Systematic literature searches of MEDLINE, EMBASE, CINAHL, PsychINFO, Web of Science and LILACs will be conducted from 2010 to present, aligning with publication dates of recent clinical guidelines. A structured iterative search of grey literature will be conducted. Full-text original quantitative or mixed method studies which describe the development or evaluation of MoCs for OA in primary care will be considered. Data will be charted and synthesised and a narrative synthesis will be conducted. Conclusions: This scoping review will provide a broad overview regarding the extent, nature and characteristics of the available literature on primary care based MoCs for OA. Findings will be used to identify gaps in the current evidence to identify areas for future research.

What Are Models of Care? A Systematic Search and Narrative Review to Guide Development of Care Models for Premature Ovarian Insufficiency

No specific model of care (MoC) is recommended for premature ovarian insufficiency (POI), despite awareness that POI is associated with comorbidities requiring multidisciplinary care. This article aims to explore the definitions and central components of MoC in health settings, so that care models for POI can be developed. A systematic search was performed on Ovid Medline and Embase, and including gray literature. Unique definitions of MoC were identified, and thematic analysis was used to summarize the key component of MoC. Of 2,477 articles identified, 8 provided unique definitions of MoC, and 11 described components of MoC. Definitions differ in scope, focusing on disease, service, or system level, but a key feature is that MoC is operational, describing how care is delivered, as well as what that care is. Thematic analysis identified 42 components of MoC, summarized into 6 themes-stakeholder engagement, supporting integrated care, evidence-based care, defined outcomes and evaluation, behavior change methodology, and adaptability. Stakeholder engagement was central to all other themes. MoCs operationalize how best practice care can be delivered at a disease, service, or systems level. Specific MoC should be developed for POI, to improve clinical and process outcomes, translate evidence into practice, and use resources more efficiently.

Knowledge mobilization in bridging patient-practitioner-researcher boundaries: A systematic integrative review

AIM

To review when, how, and in what context knowledge mobilization (KMb) has crossed patient-practitioner-researcher boundaries.

BACKGROUND

KMb is essential in contemporary health care, yet little is known about how patients are engaged.

DESIGN

Integrative review.

DATA SOURCES

Ten academic databases and grey literature.

REVIEW METHODS

We followed integrative review methodology to identify publications from 2006-2019 which contributed to understanding of cross-boundary KMb. We extracted data using a bespoke spreadsheet and the Template for Intervention Description and Replication (TIDieR) framework. We used meta-summary to organize key findings.

RESULTS

Thirty-three papers collectively provide new insights into 'when' and 'how' KMb has crossed patient-researcher-practitioner boundaries and the impact this has achieved. Knowledge is mobilized to improve care, promote health, or prevent ill health. Most studies focus on creating or re-shaping knowledge to make it more useful. Knowledge is mobilized in small community groups, in larger networks, and intervention studies. Finding the right people to engage in activities is crucial, as activities can be demanding and time-consuming. Devolving power to communities and using local people to move knowledge can be effective. Few studies report definitive outcomes of KMb.

CONCLUSION

Cross-boundary KMb can and does produce new and shared knowledge for health care. Positive outcomes can be achieved using diverse public engagement strategies. KMb process and theory is an emerging discipline, further research is needed on effective cross-boundary working and on measuring the impact of KMb.

IMPACT

This review provides new and nuanced understandings of how KMb theory has been used to bridge patient-researcher-practitioner boundaries. We have assessed 'how', 'when', and in what context patients, practitioners and researchers have attempted to mobilize knowledge and identified impact. We have developed a knowledge base about good practice and what can and potentially should be avoided in cross-boundary KMb.

Implementing models of care for musculoskeletal conditions in health systems to support value-based care

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

Global health policy in the 21st century: Challenges and opportunities to arrest the global disability burden from musculoskeletal health conditions

The profound burden of disease associated with musculoskeletal health conditions is well established. Despite the unequivocal disability burden and personal and societal consequences, relative to other non-communicable diseases (NCDs), system-level responses for musculoskeletal conditions that are commensurate with their burden have been lacking nationally and globally. Health policy priorities and responses in the 21st century have evolved significantly from the 20th century, with health systems now challenged by an increasing prevalence and impact of NCDs and an unprecedented rate of global population ageing. Further, health policy priorities are now strongly aligned to the 2030 Sustainable Development Goals. With this background, what are the challenges and opportunities available to influence global health policy to support high-value care for musculoskeletal health conditions and persistent pain? This paper explores these issues by considering the current global health policy landscape, the role of global health networks, and progress and opportunities since the 2000-2010 Bone and Joint Decade for health policy to support improved musculoskeletal health and high-value musculoskeletal health care.

Evaluation of Digital Technologies Tailored to Support Young People's Self-Management of Musculoskeletal Pain: Mixed Methods Study

BACKGROUND

Digital technologies connect young people with health services and resources that support their self-care. The lack of accessible, reliable digital resources tailored to young people with persistent musculoskeletal pain is a significant gap in the health services in Australia. Recognizing the intense resourcing required to develop and implement effective electronic health (eHealth) interventions, the adaptation of extant, proven digital technologies may improve access to pain care with cost and time efficiencies.

OBJECTIVE

This study aimed to test the acceptability and need for adaptation of extant digital technologies, the painHEALTH website and the iCanCope with Pain app, for use by young Australians with musculoskeletal pain.

METHODS

A 3-phased, mixed methods evaluation was undertaken from May 2019 to August 2019 in Australia. Young people aged 15 to 25 years with musculoskeletal pain for >3 months were recruited. Phases were sequential: (1) phase 1, participant testing (3 groups, each of n=5) of co-designed website prototypes compared with a control website (painHEALTH), with user tasks mapped to eHealth quality and engagement criteria; (2) phase 2, participants' week-long use of the iCanCope with Pain app with engagement data captured using a real-time analytic platform (daily check-ins for pain, interference, sleep, mood, physical activity, and energy levels; goal setting; and accessing resources); and (3) phase 3, semistructured interviews were conducted to gain insights into participants' experiences of using these digital technologies.

RESULTS

Fifteen young people (12/15, 80% female; mean age 20.5 [SD 3.3] years; range 15-25 years) participated in all 3 phases. The phase 1 aggregated group data informed the recommendations used to guide 3 rapid cycles of prototype iteration. Adaptations included optimizing navigation, improving usability (functionality), and enhancing content to promote user engagement and acceptability. In phase 2, all participants checked in, with the highest frequency of full check-ins attributed to pain intensity (183/183, 100.0%), pain interference (175/183, 95.6%), and mood (152/183, 83.1%), respectively. Individual variability was evident for monitoring progress with the highest frequency of history views for pain intensity (51/183, 32.3%), followed by pain interference (24/183, 15.2%). For the goals set feature, 87% (13/15) of participants set a total of 42 goals covering 5 areas, most frequently for activity (35/42, 83%). For phase 3, metasynthesis of qualitative data highlighted that these digital tools were perceived as youth-focused and acceptable. A total of 4 metathemes emerged: (1) importance of user-centered design to leverage user engagement; (2) website design (features) promoting user acceptability and engagement; (3) app functionality supporting self-management; and (4) the role of wider promotion, health professional digital prescriptions, and strategies to ensure longer-term engagement.

CONCLUSIONS

Leveraging extant digital tools, with appropriate user-informed adaptations, can help to build capacity tailored to support young people's self-management of musculoskeletal pain.

A common framework of steps and criteria for prioritizing topics for evidence syntheses: a systematic review

OBJECTIVE

The objective of the study was to systematically review the literature for proposed approaches and exercises conducted to prioritize topics or questions for systematic reviews and other types of evidence syntheses in any health-related area.

STUDY DESIGN AND SETTING

A systematic review. We searched Medline and CINAHL databases in addition to Cochrane website and Google Scholar. Teams of two reviewers independently screened the studies and extracted data.

RESULTS

We included 31 articles reporting on 29 studies: seven proposed approaches for prioritization and 25 conducted prioritization exercises (three studies did both). The included studies addressed the following fields: clinical (n = 19; 66%), public health (n = 10; 34%), and health policy and systems (n = 8; 28%), with six studies (21%) addressing more than one field. We categorized prioritization into 11 steps clustered in 3 phases (preprioritization, prioritization, and postprioritization). Twenty-eight studies (97%) involved or proposed involving stakeholders in the priority-setting process. These 28 studies referred to twelve stakeholder categories, most frequently to health care providers (n = 24; 86%) and researchers (n = 21; 75%). A common framework of 25 prioritization criteria was derived, clustered in 10 domains.

CONCLUSION

We identified literature that addresses different aspects of prioritizing topics or questions for evidence syntheses, including prioritization steps and criteria. The identified steps and criteria can serve as a menu of options to select from, as judged appropriate to the context.

A scoping review of full-spectrum knowledge translation theories, models, and frameworks

Background

Application of knowledge translation (KT) theories, models, and frameworks (TMFs) is one method for successfully incorporating evidence into clinical care. However, there are multiple KT TMFs and little guidance on which to select. This study sought to identify and describe available full-spectrum KT TMFs to subsequently guide users.

Methods

A scoping review was completed. Articles were identified through searches within electronic databases, previous reviews, grey literature, and consultation with KT experts. Search terms included combinations of KT terms and theory-related terms. Included citations had to describe full-spectrum KT TMFs that had been applied or tested. Titles/abstracts and full-text articles were screened independently by two investigators. Each KT TMF was described by its characteristics including name, context, key components, how it was used, primary target audience, levels of use, and study outcomes. Each KT TMF was also categorized into theoretical approaches as process models, determinant frameworks, classic theories, implementation theories, and evaluation frameworks. Within each category, KT TMFs were compared and contrasted to identify similarities and unique characteristics.

Results

Electronic searches yielded 7160 citations. Additional citations were identified from previous reviews (n = 41) and bibliographies of included full-text articles (n = 6). Thirty-six citations describing 36 full-spectrum were identified. In 24 KT TMFs, the primary target audience was multi-level including patients/public, professionals, organizational, and financial/regulatory. The majority of the KT TMFs were used within public health, followed by research (organizational, translation, health), or in multiple contexts. Twenty-six could be used at the individual, organization, or policy levels, five at the individual/organization levels, three at the individual level only, and two at the organizational/policy level. Categorization of the KT TMFs resulted in 18 process models, eight classic theories, three determinant frameworks, three evaluation frameworks, and four that fit more than one category. There were no KT TMFs that fit the implementation theory category. Within each category, similarities and unique characteristics emerged through comparison.

Conclusions

A systematic compilation of existing full-spectrum KT TMFs, categorization into different approaches, and comparison has been provided in a user-friendly way. This list provides options for users to select from when designing KT projects and interventions.

Trial registration

A protocol outlining the methodology of this scoping review was developed and registered with PROSPERO (CRD42018088564).

Scoping review of priority setting of research topics for musculoskeletal conditions

OBJECTIVE

Describe research methods used in priority-setting exercises for musculoskeletal conditions and synthesise the priorities identified.

DESIGN

Scoping review.

SETTING AND POPULATION

Studies that elicited the research priorities of patients/consumers, clinicians, researchers, policy-makers and/or funders for any musculoskeletal condition were included.

METHODS AND ANALYSIS

We searched MEDLINE and EMBASE from inception to November 2017 and the James Lind Alliance top 10 priorities, Cochrane Priority Setting Methods Group, and Cochrane Musculoskeletal and Back Groups review priority lists. The reported methods and research topics/questions identified were extracted, and a descriptive synthesis conducted.

RESULTS

Forty-nine articles fulfilled our inclusion criteria. Methodologies and stakeholders varied widely (26 included a mix of clinicians, consumers and others, 16 included only clinicians, 6 included only consumers or patients and in 1 participants were unclear). Only two (4%) reported any explicit inclusion criteria for priorities. We identified 294 broad research priorities from 37 articles and 246 specific research questions from 17 articles, although only four (24%) of the latter listed questions in an actionable format. Research priorities for osteoarthritis were identified most often (n=7), followed by rheumatoid arthritis (n=4), osteoporosis (n=4) and back pain (n=4). Nearly half of both broad and specific research priorities were focused on treatment interventions (n=116 and 111, respectively), while few were economic (n=8, 2.7% broad and n=1, 0.4% specific), implementation (n=6, 2% broad and n=4, 1.6% specific) or health services and systems research (n=15, 5.1% broad and n=9, 3.7% specific) priorities.

CONCLUSIONS

While many research priority-setting studies in the musculoskeletal field have been performed, methodological limitations and lack of actionable research questions limit their usefulness. Future studies should ensure they conform to good priority-setting practice to ensure that the generated priorities are of maximum value.

PROSPERO REGISTRATION NUMBER

CRD42017059250.

Patients' perceived needs for medical services for non-specific low back pain: A systematic scoping review

BACKGROUND

An improved understanding of patients' perceived needs for medical services for low back pain (LBP) will enable healthcare providers to better align service provision with patient expectations, thus improving patient and health care system outcomes. Thus, we aimed to identify the existing literature regarding patients' perceived needs for medical services for LBP.

METHODS

A systematic scoping review was performed of publications identified from MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding each study, its design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs for medical services for LBP were categorised.

RESULTS

50 studies (35 qualitative, 14 quantitative and 1 mixed-methods study) from 1829 were relevant. Four areas of perceived need emerged: (1) Patients with LBP sought healthcare from medical practitioners to obtain a diagnosis, receive management options, sickness certification and legitimation for their LBP. However, there was dissatisfaction with the cursory and superficial approach of care. (2) Patients had concerns about pharmacotherapy, with few studies reporting on patients' preferences for medications. (3) Of the few studies which examined the patients' perceived need of invasive therapies, these found that patients avoided injections and surgeries (4) Patients desired spinal imaging for diagnostic purposes and legitimation of symptoms.

CONCLUSIONS

Across many different patient populations with data obtained from a variety of study designs, common themes emerged which highlighted areas of patient dissatisfaction with the medical management of LBP, in particular, the superficial approach to care perceived by patients and concerns regarding pharmacotherapy. Patients perceive unmet needs from medical services, including the need to obtain a diagnosis, the desire for pain control and the preference for spinal imaging. These issues need to be considered in developing approaches for the management of LBP in order to improve patient outcomes.

Building multidisciplinary health workforce capacity to support the implementation of integrated, people-centred Models of Care for musculoskeletal health

To address the burden of musculoskeletal (MSK) conditions, a competent health workforce is required to support the implementation of MSK models of care. Funding is required to create employment positions with resources for service delivery and training a fit-for-purpose workforce. Training should be aligned to define "entrustable professional activities", and include collaborative skills appropriate to integrated and people-centred care and supported by shared education resources. Greater emphasis on educating MSK healthcare workers as effective trainers of peers, students and patients is required. For quality, efficiency and sustainability of service delivery, education and research capabilities must be integrated across disciplines and within the workforce, with funding models developed based on measured performance indicators from all three domains. Greater awareness of the societal and economic burden of MSK conditions is required to ensure that solutions are prioritised and integrated within healthcare policies from local to regional to international levels. These healthcare policies require consumer engagement and alignment to social, economic, educational and infrastructure policies to optimise effectiveness and efficiency of implementation.

Supporting the Evaluation and Implementation of Musculoskeletal Models of Care: A Globally Informed Framework for Judging Readiness and Success

OBJECTIVE

To develop a globally informed framework to evaluate readiness for implementation and success after implementation of musculoskeletal models of care (MOCs).

METHODS

Three phases were undertaken: 1) a qualitative study with 27 Australian subject matter experts (SMEs) to develop a draft framework; 2) an eDelphi study with an international panel of 93 SMEs across 30 nations to evaluate face validity, and refine and establish consensus on the framework components; and 3) translation of the framework into a user-focused resource and evaluation of its acceptability with the eDelphi panel.

RESULTS

A comprehensive evaluation framework was developed for judging the readiness and success of musculoskeletal MOCs. The framework consists of 9 domains, with each domain containing a number of themes underpinned by detailed elements. In the first Delphi round, scores of "partly agree" or "completely agree" with the draft framework ranged 96.7%-100%. In the second round, "essential" scores ranged 58.6%-98.9%, resulting in 14 of 34 themes being classified as essential. SMEs strongly agreed or agreed that the final framework was useful (98.8%), usable (95.1%), credible (100%) and appealing (93.9%). Overall, 96.3% strongly supported or supported the final structure of the framework as it was presented, while 100%, 96.3%, and 100% strongly supported or supported the content within the readiness, initiating implementation, and success streams, respectively.

CONCLUSION

An empirically derived framework to evaluate the readiness and success of musculoskeletal MOCs was strongly supported by an international panel of SMEs. The framework provides an important internationally applicable benchmark for the development, implementation, and evaluation of musculoskeletal MOCs.

Musculoskeletal Health Conditions Represent a Global Threat to Healthy Aging: A Report for the 2015 World Health Organization World Report on Ageing and Health

Persistent pain, impaired mobility and function, and reduced quality of life and mental well-being are the most common experiences associated with musculoskeletal conditions, of which there are more than 150 types. The prevalence and impact of musculoskeletal conditions increase with aging. A profound burden of musculoskeletal disease exists in developed and developing nations. Notably, this burden far exceeds service capacity. Population growth, aging, and sedentary lifestyles, particularly in developing countries, will create a crisis for population health that requires a multisystem response with musculoskeletal health services as a critical component. Globally, there is an emphasis on maintaining an active lifestyle to reduce the impacts of obesity, cardiovascular conditions, cancer, osteoporosis, and diabetes in older people. Painful musculoskeletal conditions, however, profoundly limit the ability of people to make these lifestyle changes. A strong relationship exists between painful musculoskeletal conditions and a reduced capacity to engage in physical activity resulting in functional decline, frailty, reduced well-being, and loss of independence. Multilevel strategies and approaches to care that adopt a whole person approach are needed to address the impact of impaired musculoskeletal health and its sequelae. Effective strategies are available to address the impact of musculoskeletal conditions; some are of low cost (e.g., primary care-based interventions) but others are expensive and, as such, are usually only feasible for developed nations. In developing nations, it is crucial that any reform or development initiatives, including research, must adhere to the principles of development effectiveness to avoid doing harm to the health systems in these settings.

Spaces of knowing: an Australian case study of capacity building across boundaries in a health promotion learning network

This article explores the potential for health promotion capacity building across boundaries in a place-based health promotion learning network generated as part of a recent Australian Research Council-funded project in Queensland, Australia. We emphasise in particular the potential of creating new 'at the boundary' spaces of knowing that encourage and enable health promotion workers to work in interdisciplinary and intersectoral ways. The article discusses the way that diverse health promotion workers from different disciplines and government and non-government organisations came together to learn 'how to do' in new or re-invigorated ways. For many network participants, this cross-boundary space of knowing and capacity building provided a welcome respite from their daily contexts of practice which may be limited by institutional, disciplinary or other boundaries.

Models of care for musculoskeletal health: a cross-sectional qualitative study of Australian stakeholders' perspectives on relevance and standardised evaluation

BACKGROUND

The prevalence and impact of musculoskeletal conditions are predicted to rapidly escalate in the coming decades. Effective strategies are required to minimise 'evidence-practice', 'burden-policy' and 'burden-service' gaps and optimise health system responsiveness for sustainable, best-practice healthcare. One mechanism by which evidence can be translated into practice and policy is through Models of Care (MoCs), which provide a blueprint for health services planning and delivery. While evidence supports the effectiveness of musculoskeletal MoCs for improving health outcomes and system efficiencies, no standardised national approach to evaluation in terms of their 'readiness' for implementation and 'success' after implementation, is yet available. Further, the value assigned to MoCs by end users is uncertain. This qualitative study aimed to explore end users' views on the relevance of musculoskeletal MoCs to their work and value of a standardised evaluation approach.

METHODS

A cross-sectional qualitative study was undertaken. Subject matter experts (SMEs) with health, policy and administration and consumer backgrounds were drawn from three Australian states. A semi-structured interview schedule was developed and piloted to explore perceptions about musculoskeletal MoCs including: i) aspects important to their work (or life, for consumers) ii) usefulness of standardised evaluation frameworks to judge 'readiness' and 'success' and iii) challenges associated with standardised evaluation. Verbatim transcripts were analysed by two researchers using a grounded theory approach to derive key themes.

RESULTS

Twenty-seven SMEs (n = 19; 70.4 % female) including five (18.5 %) consumers participated in the study. MoCs were perceived as critical for influencing and initiating changes to best-practice healthcare planning and delivery and providing practical guidance on how to implement and evaluate services. A 'readiness' evaluation framework assessing whether critical components across the health system had been considered prior to implementation was strongly supported, while 'success' was perceived as an already familiar evaluation concept. Perceived challenges associated with standardised evaluation included identifying, defining and measuring key 'readiness' and 'success' indicators; impacts of systems and context changes; cost; meaningful stakeholder consultation and developing a widely applicable framework.

CONCLUSIONS

A standardised evaluation framework that includes a strong focus on 'readiness' is important to ensure successful and sustainable implementation of musculoskeletal MoCs.

Evidence-informed health policy making in Canada: past, present, and future

Evidence-informed health policy making (EIHP) is becoming a necessary means to achieving health system reform. Although Canada has a rich and well documented history in the field of evidence-based medicine, a concerted effort to capture Canada's efforts to support EIHP in particular has yet to be realized. This paper reports on the development of EIHP in Canada, including promising approaches being used to support the use of evidence in policy making about complex health systems issues. In light of Canada's contributions, this paper suggests that scholars in Canada will continue engaging in the field of EIHP through further study of interventions underway, as well as by sharing knowledge within and beyond Canada's borders about approaches that support EIHP.

Implementing evidence-informed policy into practice for health care professionals managing people with low back pain in Australian rural settings: a preliminary prospective single-cohort study

OBJECTIVE

To provide access to professional development opportunities for health care professionals, especially in rural Australian regions, consistent with recommendations in the Australian National Pain Strategy and state government policy.

DESIGN AND SETTING

A preliminary prospective, single-cohort study design, which aligned health policy with evidence-informed clinical practice, evaluated the implementation and effectiveness of an interprofessional, health care provider pain education program (hPEP) for management of nonspecific low back pain (nsLBP) in rural Western Australia.

INTERVENTION

The 6.5-hour hPEP intervention was delivered to 60 care providers (caseload nsLBP 19.8% ± 22.5) at four rural WA regions.

OUTCOME MEASURES

Outcomes were recorded at baseline and 2 months post-intervention regarding attitudes, beliefs (modified Health Care Providers Pain and Impairment Relationship Scale [HC-PAIRS]), Back Pain Beliefs Questionnaire [BBQ]), and self-reported evidence-based clinical practice (knowledge and skills regarding nsLBP, rated on a 5-point Likert scale with 1 = nil and 5 = excellent).

RESULTS

hPEP was feasible to implement. At 2 months post-hPEP, responders' (response rate 53%) improved evidence-based beliefs were indicated by HC-PAIRS scores: baseline mean (SD) [43.2 (9.3)]; mean difference (95% CI) [-5.9 (-8.6 to -3.1)]; and BBQ baseline [34.3 (6.8)]; mean difference [2.1 (0.5 to 3.6)]. Positive shifts were observed for all measures of clinical knowledge and skills (P < 0.001) and increased assistance with planning lifestyle changes (P < 0.001), advice on self-management (P = 0.010), and for decreased referrals for spinal imaging (P = 0.03).

CONCLUSIONS

This policy-into-practice educational program is feasible to implement in rural Western Australia (WA). While preliminary data are encouraging, a further randomized controlled trial is recommended.

Models of care for musculoskeletal health in Australia: now more than ever to drive evidence into health policy and practice

Musculoskeletal health conditions such as arthritis, osteoporosis and pain syndromes impart a profound socioeconomic burden worldwide, particularly in developed nations such as Australia. Despite the identified burden, substantial evidence-practice and care disparity gaps remain in service delivery and access that limit the potential for improved consumer outcomes and system efficiencies. Addressing these gaps requires a whole-of-sector response, supported by evidence-informed health policy. Models of care (MoCs) serve as a policy vehicle to embed evidence into health policy and guide practice through changes in service delivery systems and clinician behaviour. In Australia, MoCs for musculoskeletal health have been developed by networks of multidisciplinary stakeholders and are incrementally being implemented across health services, facilitated by dedicated policy units and clinical champions. A web of evidence is now emerging to support this approach to driving evidence into health policy and practice. Understanding the vernacular of MoCs and the development and implementation of MoCs is important to embracing this approach to health policy. What is known about the topic? The impact of musculoskeletal health conditions is profound. As the awareness around the magnitude of the impact of these conditions increases, the importance of system-wide policy responses and platforms for health service improvements is now recognised. The term ‘models of care’ is not new. It has been used for many years, mainly at the hospital level, for planning and delivering clinical services. However, over the past 8 years an alternative approach using health networks has been adopted for the development and implementation of models of care to achieve broad engagement and a wider and more sustainable scope for implementation. What does this paper add? Here, we provide a rationale for the development of models of care for musculoskeletal health and draw on experience in their development and implementation using a health network model, referring to an emerging web of evidence to support this approach. We describe what models of care are, how they are developed and question whether they make a difference and what the future may hold. What are the implications for practitioners? All indications suggest that models of care are here to stay. Therefore, this paper provides practitioners with a contemporary overview of models of care in Australia, their relevance to musculoskeletal healthcare, particularly related to closing evidence-practice gaps, and opportunities for sector engagement.

Translating evidence for low back pain management into a consumer-focussed resource for use in community pharmacies: a cluster-randomised controlled trial

Background

This cluster-randomised controlled trial determined the effectiveness of an evidence-based, pamphlet intervention in improving low back pain (LBP)-related beliefs among pharmacy consumers.

Methods

Thirty five community pharmacies were randomised to three groups: pamphlet+education intervention [n = 11]; pamphlet only intervention [n = 11]; control: usual care [n = 13]. Eligibility requirements for clusters included: community-based pharmacies and proprietor participation consent. Pharmacy consumers (N = 317) aged 18–65 years currently experiencing LBP participated. Intervention group allocation depended on the pharmacy attended. Individual-level outcomes were measured at pre-intervention (T0), at two (T1) and eight (T2) weeks post-intervention and included beliefs about LBP [Back Pain Beliefs Questionnaire (BBQ); Fear Avoidance Beliefs Questionnaire (FABQ)]. Secondary outcomes included pain severity, activity impairment and pamphlet perceived usefulness. Blinding to group allocation included primary investigators, outcome assessors and the statistician. Pharmacy staff and consumers were un-blinded.

Results

Of 35 pharmacies recruited (317 consumers), no clusters were lost to follow-up. Follow-up was available for n = 24 at 2 weeks only; n = 38 at 8 weeks only; n = 148 at both time points, with n = 148+24+38 = 210 analysed (107 excluded: no follow up). Adjusting for baseline scores demonstrated no significant differences in beliefs (2 or at 8 weeks) between pamphlet (with or without education) versus control, or between ‘pamphlet with’ versus ‘without’ education. Work-related fear (FABQ) was significantly lower in consumers receiving pamphlet (with or without education) versus control (difference −2.3, 95%CI: −4.4 to −0.2). There was no significant difference between “pamphlet with” versus “pamphlet without” groups. Consumers receiving the “pamphlet with” reported greater perceived usefulness than consumers receiving the “pamphlet without” (difference 0.9 (95%CI: 0.0 to 1.8)).

Conclusion

Community pharmacies provided a feasible primary care portal for implementing evidence-based information. The associated improvement in work-related LBP-beliefs for consumers receiving the pamphlet suggests this simple intervention may be a useful component of care.

Trial Registration

ACTR.org.au ACTRN12611000053921