Preliminary effects of a regional approached multidisciplinary educational program on healthcare utilization in patients with hip or knee osteoarthritis: an observational study

How Does Osteoarthritis Education Influence Knowledge, Beliefs, and Behavior in People With Knee and Hip Osteoarthritis? A Systematic Review

OBJECTIVE

Our goal was to inform the design and implementation of osteoarthritis (OA) education for people with knee and hip OA. This review investigated the impact of OA education on knowledge, beliefs, and behavior and how and why these changes occur.

METHODS

Five databases-MEDLINE, Excerpta Medica Database (Embase), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Physiotherapy Evidence Database (PEDro)-were searched in August 2023. Eligible studies were quantitative, qualitative, and mixed-methods, involving OA education interventions and assessing knowledge, beliefs, and/or behavioral outcomes. An interpretivist analytic process guided data evaluation, synthesis, and description of meta-themes.

RESULTS

Ninety-eight studies were included (80 quantitative, 12 qualitative, 6 mixed-methods). OA education was heterogeneous in content and delivery. Outcome measures varied, with poor distinction among knowledge, beliefs, and behavior constructs. Trends toward short-term knowledge improvement were observed, but there were no clear trends in beliefs or behavior change. Intrinsic factors (eg, pre-existing beliefs) and extrinsic factors (eg, socioeconomic factors) appeared to influence change. Three meta-themes described how and why changes may occur: (i) engagement: how individuals relate with education content and delivery; (ii) embodiment: the role of experiential factors in learning, and (iii) empowerment: the level of agency education generates.

CONCLUSION

Beyond the provision of information and instruction, OA education is a complex, relational process influenced by multidimensional factors. This review identifies potentially important strategies at individual, interpersonal, and community levels to support the design and delivery of engaging education that promotes holistic, embodied learning and facilitates meaningful, empowering change.

Diagnosing knee osteoarthritis in patients, differences between general practitioners and orthopedic surgeons: a retrospective cohort study

BACKGROUND

knee complaints are one of the most common reasons to consult the general practitioners in the Netherlands and contribute to the increasing burden on general practitioners. A proportion of patients that are referred to orthopedic outpatient clinics are potentially referred unnecessarily. We believe osteoarthritis is not always considered by general practitioners as the cause of atraumatic knee complaints. This may impede early recognition and timely care of osteoarthritis complaints and lead to unnecessary referrals.

METHODS

the aim of this study was to compare the frequency of (differential) diagnosis of osteoarthritis mentioned in referral letters of general practitioners with the frequency of osteoarthritis mentioned as orthopedic diagnosis at the outpatient clinic. Therefore we conducted a retrospective cohort study based on data collected from referral letters and the corresponding outpatient clinic reports of patients with atraumatic knee complaints of 45 years or older referred to a regional hospital in Nijmegen, The Netherlands in the period from 1-6-2019 until 1-01-2020.

RESULTS

a total of 292 referral letters were included. In the younger aged patients (45-54 years) osteoarthritis was mentioned less frequent and meniscal lesions were mentioned more frequent in referral letters when compared to diagnoses made at the outpatient clinic. Differences in differential diagnosis of osteoarthritis as well as meniscal lesions between orthopedic surgeon and general practitioners were found (both p < 0.001, McNemar). Matching diagnoses were present in 58.2% when all referral letters were analyzed (n = 292) and 75.2% when only referrals containing a differential diagnosis were analyzed (n = 226). Matching diagnoses were present in 31.6% in the younger age categories (45-54 years). A linear trend showing fewer matching diagnoses in younger patient categories was observed (p < 0.001).

CONCLUSIONS

Osteoarthritis was less frequently mentioned in general practitioner referral letters among the differential diagnosis then it was diagnosed at the outpatient clinic, especially in younger patients (45-54 years). Also matching diagnoses in younger patients were evidently lower than in older patients, partly explained by underdiagnosing of osteoarthritis in younger patients in this cohort. Better recognition of osteoarthritis in younger patients and changing the diagnostic approach of general practitioners might improve efficacy in knee care. Future research should focus on the effectiveness of musculoskeletal triage, the need for multidisciplinary educational programs for patients and promotion of conservative treatment modalities among general practitioners.

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 scalable 12-week exercise and education programme reduces symptoms and improves function and wellbeing in people with hip and knee osteoarthritis

Introduction

Osteoarthritis is a chronic musculoskeletal condition that impacts more than 300 million people worldwide, with 43 million people experiencing moderate to severe disability due to the disease. This service evaluation provides the results from a tailored blended model of care on joint health, physical function, and personal wellbeing.

Methods

1,593 adult participants with osteoarthritis completed the Nuffield Health Joint Pain Programme between February 2019 and May 2022. The 12-week programme included two 40-min exercise sessions per week. All exercise sessions were conducted face-to-face and were followed by 20 min of education to provide information and advice on managing osteoarthritis.

Results

The 12-week joint pain programme significantly improved Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) global scores (Week 0: 37.5 [17.2]; Week 12: 24.0 [16.6]; p < 0.001), as well as subscales for pain (Week 0: 7.6 [3.7]; Week 12: 4.9 [3.7]; p < 0.001), function (Week 0: 26.0 [13.0]; Week 12: 16.3 [12.4]; p < 0.001), and stiffness (Week 0: 3.9 [1.6]; Week 12: 2.8 [1.7]; p < 0.001). Significant improvements in health-related outcomes including systolic and diastolic blood pressure (Week 0: 139 [18] mmHg; Week 12: 134 [17] mmHg, and Week 0: 82 [11] mmHg; Week 12: 79 [19] mmHg; both p < 0.001), body mass index (Week 0: 29.0 [4.5] kg/m2; Week 12: 28.6 [4.4] kg/m2; p < 0.001), waist to hip ratio (Week 0: 0.92 [0.23]; Week 12: 0.90 [0.11], p < 0.01) and timed up and go (Week 0: 10.8 s [2.9]; Week 12: 8.1 s [2.0]; p < 0.001) were also observed. On completion of the joint pain programme, participants also reported significant improvements in all assessed aspects of self-reported wellbeing (all p < 0.001).

Discussion

With reductions in physical symptoms of osteoarthritis and improvements in personal wellbeing, the joint pain programme delivered by personal trainers in a gym-setting offers a nationally scalable, non-pharmacological treatment pathway for osteoarthritis.

Feasibility of a randomised controlled trial of two types of written information for people with knee osteoarthritis

Objective

Test the feasibility of conducting an individually randomised controlled trial recruiting people with knee osteoarthritis (OA) in community pharmacies and evaluate the impacts of a novel information booklet.

Design

People with knee OA were identified by pharmacy staff using clinical criteria and randomised to receive a novel information booklet (intervention) or the currently available written OA resource (active control). Mixed-methods process evaluation assessed participant recruitment, retention, and experience. Participant-reported outcome measures, assessing OA illness perceptions, OA knowledge, fear of movement, and pain when walking at baseline and 4-weeks, were analysed using linear regression models (adjusted for baseline).

Results

Of 72 eligible people, 64 were randomised to intervention (n ​= ​33) or control (n ​= ​31). The randomisation sequence was followed correctly and no protocol deviations identified. Mean recruitment rate was 2.7 participants per pharmacy per week. One-in-five participants had no educational qualifications and one-in-four had not received a knee OA diagnosis prior to the trial. Three meta-themes emerged from pharmacist and participant qualitative analysis: 'pleased to be asked'; 'easy process'; and 'successful process'. Three participants were lost to follow-up. At 4 weeks, intervention arm Knee Osteoarthritis Knowledge Scale scores improved (mean difference ​= ​3.6, 95%CI 0.7 to 6.5). Brief Illness Perceptions Questionnaire scores were similar between groups (mean difference 0.4, 95%CI -3.7 to 4.5).

Conclusion

It is feasible to conduct an individually randomised trial in community pharmacy, a potentially effective setting to initiate accessible OA care. A novel information booklet improved OA knowledge, but is unlikely to affect illness perceptions on its own.

Patient education improves pain and function in people with knee osteoarthritis with better effects when combined with exercise therapy: a systematic review

QUESTION

Is patient education effective as a standalone intervention or combined with other interventions for people with knee osteoarthritis?

DESIGN

Systematic review of randomised controlled trials. MEDLINE, EMBASE, SPORTDiscus, CINAHL and Web of Science were searched from inception to April 2020. The Cochrane Risk of Bias tool was used for included studies, and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to interpret certainty of results.

PARTICIPANTS

People with knee osteoarthritis.

INTERVENTION

Any patient education intervention compared with any non-pharmacological comparator.

OUTCOME MEASURES

Primary outcomes were self-reported pain and function.

RESULTS

Twenty-nine trials involving 4,107 participants were included, informing low to very-low certainty evidence. Nineteen of 28 (68%) pooled comparisons were not statistically significant. Patient education was superior to usual care for pain (SMD -0.35, 95% CI -0.56 to -0.14) and function in the short term (-0.31, 95% CI -0.62 to 0.00), but inferior to exercise therapy for pain in the short term (0.77, 95% CI 0.07 to 1.47). Combining patient education with exercise therapy produced superior outcomes compared with patient education alone for pain in the short term (0.44, 95% CI 0.19 to 0.69) and function in the short (0.81, 95% CI 0.54 to 1.08) and medium term (0.39, 95% CI 0.15 to 0.62). When using the Western Ontario and McMaster Universities Osteoarthritis Index for these comparisons, clinically important differences indicated that patient education was inferior to exercise therapy for pain in the short term (MD 1.56, 95% CI 0.14 to 2.98) and the combination of patient education and exercise therapy for function in the short term (8.94, 95% CI 6.05 to 11.82).

CONCLUSION

Although patient education produced statistically superior short-term pain and function outcomes compared with usual care, differences were small and may not be clinically important. Patient education should not be provided as a standalone treatment and should be combined with exercise therapy to provide statistically superior and clinically important short-term improvements in function compared with education alone.

REGISTRATION

PROSPERO CRD42019122004.

Does the Conservative Non-pharmacological Management of Knee Osteoarthritis in Switzerland Reflect the Clinical Guidelines? A Survey Among General Practitioners, Rheumatologists, and Orthopaedic Surgeons

Introduction: The International Guidelines recommend exercise, education and weight management (if appropriate) as the first-line conservative treatment for patients with knee osteoarthritis (OA) to enhance their self-management. The aim of this study was to investigate the current state of conservative non-pharmacological management of patients with knee OA in Switzerland and to explore the perceived barriers and facilitators to the application of the guideline recommendations.

Materials and methods: Eleven semi-structured interviews with selected general practitioners (GPs), rheumatologists and orthopaedic surgeons were performed. Based on these results, an online survey was developed and sent to the members of three scientific medical societies. Questions addressed the frequency of diagnostic measures, treatment options, reasons for referral to exercise and also barriers and facilitators.

Results: A total of 234 members responded. They indicated that patients normally present due to pain (n = 222, 98.2%) and functional limitations of the knee (n = 151, 66.8%). In addition to clinical assessment, X-ray (n = 214, 95.5%) and MRI (n = 70, 31.3%) were the most frequently used diagnostic measures. Treatment options usually involved patient education for diagnosis (n = 223, 98.6%) and suitable activities (n = 217, 96%), pharmacological treatment (n = 203, 89.8%) and referral to physiotherapy (n = 188, 83.2%). The participants estimated that they had referred 54% of their patients with knee OA for a specific exercise. The referral to exercise was driven by “patient expectation/high level of suffering” (n = 73, 37.1%) and their “own clinical experience” (n = 49, 24.9%). The specialists rated the most important barriers to referral to exercise as “disinterest of patient” (n = 88, 46.3%) and “physically active patient” (n = 59, 31.1%). As the most important facilitators, they rated “importance to mention exercise despite the short time of consultation” (n = 170, 89.4%) and “insufficiently physically active patient” (n = 165, 86.9%).

Discussion: A substantial evidence–performance gap in the management of patients with knee OA appears to exist in Switzerland. For the systematic referral to exercise as the first-line intervention, it might be useful for medical doctors to suggest a structured exercise programme to patients with knee OA, rather than just advising general exercise.

Interdisciplinary Care Networks in Rehabilitation Care for Patients with Chronic Musculoskeletal Pain: A Systematic Review

This systematic review aims to identify what rehabilitation care networks, within primary care or between primary and other health care settings, have been described for patients with chronic musculoskeletal pain, and what their impact is on the Quadruple Aim outcomes (health; health care costs; quality of care experienced by patients; work satisfaction for health care professionals). Studies published between 1 January 1994 and 11 April 2019 were identified in PubMed, CINAHL, Web of Science, and PsycInfo. Forty-nine articles represented 34 interventions: 21 within primary care; 6 between primary and secondary/tertiary care; 1 in primary care and between primary and secondary/tertiary care; 2 between primary and social care; 2 between primary, secondary/tertiary, and social care; and 2 between primary and community care. Results on impact were presented in 19 randomized trials, 12 non-randomized studies, and seven qualitative studies. In conclusion, there is a wide variety of content, collaboration, and evaluation methods of interventions. It seems that patient-centered interdisciplinary interventions are more effective than usual care. Further initiatives should be performed for interdisciplinary interventions within and across health care settings and evaluated with mixed methods on all Quadruple Aim outcomes.

A practical guide to interpreting and applying systematic reviews of qualitative studies in rheumatology

While patient-centered care is widely advocated in the management of rheumatic diseases, it can be challenging to implement, particularly for patients with complex systemic conditions. Patient-centered care involves identifying and integrating the patient's experiences, attitudes, and preferences in decision-making. Qualitative research is used to describe patient perspectives and priorities that may not always be expressed in clinical settings. Systematic reviews of qualitative studies can provide new and more comprehensive evidence of patients' beliefs and priorities across different populations and healthcare settings and are increasingly being reported across medical specialties, including rheumatology. In rheumatology, they have been used to examine topics including medication-taking and adherence, coping with systemic sclerosis and conservative management and exercise in osteoarthritis. By referencing recent examples of systematic qualitative reviews in the rheumatology literature, this article will outline the methodology and methods used, and provide an approach to guide the appraisal of reviews. We aim to give the reader a practical understanding of systematic reviews of qualitative literature and elucidate how knowledge gained from such reviews can be applied to improve the care of patients with rheumatic conditions.

Comparison of physical activity among different subsets of patients with knee or hip osteoarthritis and the general population

To compare the amount of physical activity (PA) among patients with different subsets of knee or hip osteoarthritis (OA) and the general population. Secondary analyses of data of subjects ≥ 50 years from four studies: a study on the effectiveness of an educational program for OA patients in primary care (n = 110), a RCT on the effectiveness of a multidisciplinary self-management program for patients with generalized OA in secondary care (n = 131), a survey among patients who underwent total joint arthroplasty (TJA) for end-stage OA (n = 510), and a survey among the general population in the Netherlands (n = 3374). The Short QUestionnaire to ASssess Health-enhancing physical activity (SQUASH) was used to assess PA in all 4 studies. Differences in PA were analysed by multivariable linear regression analyses, adjusted for age, body mass index and sex. In all groups, at least one-third of total time spent on PA was of at least moderate-intensity. Unadjusted mean duration (hours/week) of at least moderate-intensity PA was 15.3, 12.3, 18.1 and 17.8 for patients in primary, secondary care, post TJA, and the general population, respectively. Adjusted analyses showed that patients post TJA spent 5.6 h [95% CI: 1.5; 9.7] more time on PA of at least moderate-intensity than patients in secondary care. The reported amount of PA of at least moderate-intensity was high in different subsets of OA and the general population. Regarding the amount of PA in patients with different subsets of OA, there was a substantial difference between patients in secondary care and post TJA patients.

Development and evaluation of a tailored e-self-management intervention (dr. Bart app) for knee and/or hip osteoarthritis: study protocol

Background

This paper describes (the development of) an eHealth tool (dr. Bart app) to enhance self-management and to optimize non-surgical health care utilization in patients with knee and/or hip osteoarthritis (OA) and presents a study aiming 1) to study the effectiveness of the dr. Bart app on health care use 2) to explore differences in use, usability and the clinical outcomes of the dr. Bart app between the Netherlands and Germany.

Methods

The dr. Bart app is a fully automated eHealth application and is based on the Fogg model for behavioural change, augmented with reminders, rewards and self-monitoring to reinforce app engagement and health behaviour. The dr. Bart app propose goals to a healthier lifestyle based on machine learning techniques fed by data collected in a personal profile and choosing behaviour of the app user. Patients ≥50 years with self-reported knee and/or hip OA will be eligible to participate. Participants will be recruited in the community through advertisements in local newspapers and campaigns on social media. This protocol presents a study with three arms, aiming to include 161 patients in each arm. In the Netherlands, patients are randomly allocated to usual care or dr. Bart app and in Germany all patients receive the dr. Bart app. The primary outcome of the first research question is the number of self-reported consultations in secondary health care. The primary outcome of the second research question (comparison between the Netherlands and Germany) is self-management behaviour assessed by the patient activation measure (PAM-13) questionnaire. Secondary outcomes are costs, health-related quality of life, physical functioning and activity, pain, use and usability of the dr. Bart app. Data will be collected through three online questionnaires (at baseline and after 3 and 6 months after inclusion).

Discussion

This study will gain insight into the effectiveness of the dr. Bart app in the (conservative) treatment of patients with knee and/or hip OA and differences in the use and usability of the dr. Bart app between the Netherlands and Germany.

Trial registration

Dutch Trial Register (Trial Number NTR6693 / NL6505). Registration date: 4 September 2017.