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Tan BY, Yang SY, Pereira MJ, Tan CY, Lim CJ, Ng JP, Lee KT, Pua YH, Briggs AM, Hunter DJ, Skou ST, Thumboo J, Car J. Collaborative model of care between orthopaedics and allied healthcare professionals (CONNACT) in knee osteoarthritis: Effectiveness-implementation hybrid randomized controlled trial of a community-based, multidisciplinary, stratified intervention. Osteoarthritis Cartilage 2024:S1063-4584(24)01177-4. [PMID: 38710437 DOI: 10.1016/j.joca.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 05/08/2024]
Abstract
OBJECTIVE To compare the clinical and cost effectiveness of the Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT), a community-based, stratified, multidisciplinary intervention consisting of exercise, education, psychological and nutrition delivered through a chronic care model to usual hospital care in adults with knee osteoarthritis (OA). METHODS Pragmatic, parallel-arm, single-blinded superiority RCT trial. Community-dwelling, ambulant adults with knee OA (Kellgren-Lawrence grade > 1; Knee Injury and OA Outcome Score (KOOS4) ≤75) were enrolled. Primary outcome was KOOS4 at 12-months; secondary outcomes included: quality of life, physical performance measures, symptom satisfaction, psychological outcomes, dietary habits, and global perceived effect. Intention-to-treat analysis using generalized linear model (GLM) and regression modeling were conducted. Economic evaluation through a societal approach was embedded. RESULTS 110 participants (55 control, 55 intervention) were randomized. No between-group difference found for the primary outcome (MD [95%CI]: -1.86 [-9.11. 5.38]), although both groups demonstrated within-group improvement over 12-months. Among the secondary outcomes, the CONNACT group demonstrated superior dietary change (12 months) and physical performance measures (3 months), and global perceived effect (6 months). While there was no between-group difference in total cost, significant productivity gains (reduced indirect cost) were seen in the CONNACT group. CONCLUSION CONNACT was not superior to usual care at 1 year. Further efforts are needed to understand the underlying contextual and implementation factors in order to further improve and refine such community-based, stratified care models moving forward. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT03809975. Registered January 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03809975.
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Affiliation(s)
- Bryan Y Tan
- Department of Orthopaedic Surgery, Woodlands Health, Singapore; Sydney Musculoskeletal Health, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia.
| | - Su-Yin Yang
- Psychology Service, Woodlands Health, Singapore
| | | | - Chun Yue Tan
- Department of Orthopaedic Surgery, Woodlands Health, Singapore
| | - Chien Joo Lim
- Department of Orthopaedic Surgery, Woodlands Health, Singapore
| | - Julia P Ng
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Keng Thiam Lee
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - Yong Hao Pua
- Department of Physiotherapy, Singapore General Hospital, Singapore
| | - Andrew M Briggs
- Curtin School of Allied Health and Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - David J Hunter
- Sydney Musculoskeletal Health, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia
| | - Soren T Skou
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark; The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore; Duke-NUS Medical School, Singapore
| | - Josip Car
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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Höld E, Chmelar S, Aubram T, Leitner G, Nehrer S, Neubauer O, Wagner KH, Wondrasch B. Nutrition and movement to improve quality of life in patients with knee osteoarthritis: the NUMOQUA study protocol for a randomised controlled trial. Trials 2024; 25:245. [PMID: 38594710 PMCID: PMC11005166 DOI: 10.1186/s13063-024-08048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/08/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Osteoarthritis (OA) has long been considered as a degenerative disease of cartilage tissue resulting from bodily wear and tear. However, there is accumulating evidence that inflammation plays a key role in the pathogenesis of OA. In knee OA, the most common form of OA, exercise therapy as an effective component of early treatment addresses functional deficits, pain and inflammation. Since inflammation is critical for the development and progress of OA, anti-inflammatory therapies must be combined strategically. In the course of the NUMOQUA project, an anti-inflammatory therapeutic diet named 'Austrian Osteoarthritis Cuisine' was developed. It is based on the framework of the New Nordic Diet combined with the food-based dietary guidelines of Austria, the guidelines for OA, the Austrian food culture and the principles of a sustainable diet. The present study examines the implementation of the 'Austrian OA Cuisine' combined with the evidence-based training programme GLA:D® (Good Life with osteoArthritis in Denmark) in Austrian patients with knee OA and the effects on quality of life, nutritional and inflammatory status, as well as oxidative stress parameters. METHODS A total of 60 participants aged 50 to 75 with knee OA will be included and randomly assigned either to the intervention group or the control group. All participants will undergo the GLA:D® programme in the first 6 weeks. Additionally, the intervention group will receive nutritional group training and individual nutritional counselling on the 'Austrian OA Cuisine' over 9 months. The control group will receive general information about a healthy lifestyle. Measurements at baseline and at 4 follow-up dates include nutritional, inflammatory and oxidative stress markers. Furthermore, anthropometric, behavioural and clinical data will be obtained. The recruitment process lasted from autumn 2022 to January 2024, followed by the intervention until October 2024. DISCUSSION The prevalence of OA is expected to increase in the future due to ongoing demographic changes and rising obesity rates. The expected results will provide important evidence on whether this interdisciplinary therapeutic approach could be a new, cost-effective and sustainable strategy to address the disease process of OA without negative side effects. TRIAL REGISTRATION ClinicalTrials.gov NCT05955300. Date of registration: 23rd of October 2023.
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Affiliation(s)
- Elisabeth Höld
- Department of Health Sciences, St. Pölten University of Applied Sciences, St. Pölten, Austria.
| | - Sabine Chmelar
- Department of Health Sciences, St. Pölten University of Applied Sciences, St. Pölten, Austria
- Vienna Doctoral School of Pharmaceutical, Nutritional and Sport Science (PhaNuSpo), University of Vienna, Vienna, Austria
| | - Tatjana Aubram
- Institute for Innovation Systems, St. Pölten University of Applied Sciences, St. Pölten, Austria
| | - Gabriele Leitner
- Department of Health Sciences, St. Pölten University of Applied Sciences, St. Pölten, Austria
| | - Stefan Nehrer
- Faculty of Health and Medicine, University for Continuing Education Krems, Krems, Austria
| | - Oliver Neubauer
- Faculty of Health and Medicine, University for Continuing Education Krems, Krems, Austria
- Research Platform Active Ageing, University of Vienna, Vienna, Austria
| | - Karl-Heinz Wagner
- Research Platform Active Ageing, University of Vienna, Vienna, Austria
- Department of Nutritional Sciences, University of Vienna, Vienna, Austria
| | - Barbara Wondrasch
- Department of Health Sciences, St. Pölten University of Applied Sciences, St. Pölten, Austria
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Tan BY, Tan CY, Tan TL, Yang SY, Chew GLS, Tan SI, Chua YC, Yan YW, Soh DBQ, Goh TH, Ng PJ, Ng YT, Kuan SB, Teo BS, Kong KH, Pereira MJ, Ng HP. Heat and Acupuncture to Manage Osteoarthritis of the Knee (HARMOKnee): Protocol for an Effectiveness-Implementation Hybrid Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e54352. [PMID: 38568718 PMCID: PMC11024749 DOI: 10.2196/54352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Knee osteoarthritis (KOA) is one of most prevalent and fastest-growing causes of pain, impaired mobility, and poor quality of life in the rapidly aging population worldwide. There is a lack of high-quality evidence on the efficacy of traditional Chinese medicine (TCM), particularly acupuncture, and a lack of KOA practice guidelines that are tailored to unique population demographics and tropical climates. OBJECTIVE Our HARMOKnee (Heat and Acupuncture to Manage Osteoarthritis of the Knee) trial aims to address these gaps by evaluating the short- and medium-term clinical and cost-effectiveness of acupuncture with heat therapy in addition to standard care, compared to standard care alone. Through a robust process and economic evaluation, we aim to inform evidence-based practice for patients with KOA to facilitate the large-scale implementation of a comprehensive and holistic model of care that harmonizes elements of Western medicine and TCM. We hypothesize that acupuncture with heat therapy as an adjunct to standard care is clinically more effective than standard care alone. METHODS A multicenter, pragmatic, parallel-arm, single-blinded, effectiveness-implementation hybrid randomized controlled trial will be conducted. We intend to recruit 100 patients with KOA randomized to either the control arm (standard care only) or intervention arm (acupuncture with heat therapy, in addition to standard care). The inclusion criteria are being a community ambulator and having primary KOA, excluding patients with secondary arthritis or previous knee replacements. The primary outcome measure is the Knee Osteoarthritis Outcome Score at 6 weeks. Secondary outcome measures include psychological, physical, quality of life, satisfaction, and global outcome measures at 6, 12, and 26 weeks. A mixed method approach through an embedded process evaluation will facilitate large-scale implementation. An economic evaluation will be performed to assess financial sustainability. RESULTS Patient enrollment has been ongoing since August 2022. The recruitment process is anticipated to conclude by July 2024, and the findings will be analyzed and publicized as they are obtained. As of November 6, 2023, our patient enrollment stands at 65 individuals. CONCLUSIONS The findings of our HARMOKnee study will contribute substantial evidence to the current body of literature regarding the effectiveness of acupuncture treatment for KOA. Additionally, we aim to facilitate the creation of standardized national guidelines for evidence-based practice that are specifically tailored to our unique population demographics. Furthermore, we seek to promote the adoption and integration of acupuncture and heat therapy into existing treatment models. TRIAL REGISTRATION ClinicalTrials.gov NCT05507619; https://clinicaltrials.gov/study/NCT05507619. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54352.
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Affiliation(s)
- Bryan Yijia Tan
- Department of Orthopaedic Surgery, Woodlands Health, National Healthcare Group, Singapore, Singapore
| | - Chun Yue Tan
- Department of Orthopaedic Surgery, Woodlands Health, National Healthcare Group, Singapore, Singapore
| | - Tong Leng Tan
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
| | - Su-Yin Yang
- Psychology Service, Woodlands Health, Singapore, Singapore
| | - Gillian Long Szu Chew
- Department of Orthopaedic Surgery, Woodlands Health, National Healthcare Group, Singapore, Singapore
| | - Siang Ing Tan
- Complementary Integrative Medicine, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
| | - Yu Chun Chua
- Complementary Integrative Medicine, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
| | - Yew Wai Yan
- Complementary Integrative Medicine, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
| | - Derrick Bing Quan Soh
- Complementary Integrative Medicine, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
| | - Tong Hwee Goh
- Traditional Chinese Medicine Pain Management, Medical Department, Singapore Chung Hwa Medical Institution, Singapore, Singapore
- Teaching Department, Singapore College of Traditional Chinese Medicine, Singapore, Singapore
| | - Pu Jue Ng
- Traditional Chinese Medicine Pain Management, Medical Department, Singapore Chung Hwa Medical Institution, Singapore, Singapore
- Teaching Department, Singapore College of Traditional Chinese Medicine, Singapore, Singapore
| | - Yee Teck Ng
- Traditional Chinese Medicine Pain Management, Medical Department, Singapore Chung Hwa Medical Institution, Singapore, Singapore
| | - Swee Boey Kuan
- Traditional Chinese Medicine Pain Management, Medical Department, Singapore Chung Hwa Medical Institution, Singapore, Singapore
| | - Bo Siang Teo
- Traditional Chinese Medicine Pain Management, Medical Department, Singapore Chung Hwa Medical Institution, Singapore, Singapore
| | - Keng He Kong
- Rehabilitation Centre, Tan Tock Seng Hospital, National Healthcare Group, Singapore, Singapore
| | | | - Hui Ping Ng
- Traditional Chinese Medicine Pain Management, Medical Department, Singapore Chung Hwa Medical Institution, Singapore, Singapore
- Teaching Department, Singapore College of Traditional Chinese Medicine, Singapore, Singapore
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Østerås N, Aas E, Moseng T, van Bodegom-Vos L, Dziedzic K, Natvig B, Røtterud JH, Vlieland TV, Furnes O, Fenstad AM, Hagen KB. Longer-term quality of care, effectiveness, and cost-effectiveness of implementing a model of care for osteoarthritis: A cluster-randomized controlled trial. Osteoarthritis Cartilage 2024; 32:108-119. [PMID: 37839506 DOI: 10.1016/j.joca.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/07/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE To assess the quality of care, effectiveness, and cost-effectiveness over 12 months after implementing a structured model of care for hip and knee osteoarthritis (OA) in primary healthcare as compared to usual care. DESIGN In this pragmatic cluster-randomized, controlled trial with a stepped-wedge cohort design, we recruited 40 general practitioners (GPs), 37 physiotherapists (PTs), and 393 patients with symptomatic hip or knee OA from six municipalities (clusters) in Norway. The model included the delivery of a 3-hour patient education and 8-12 weeks individually tailored exercise programs, and interactive workshops for GPs and PTs. At 12 months, the patient-reported quality of care was assessed by the OsteoArthritis Quality Indicator questionnaire (16 items, pass rate 0-100%, 100%=best). Costs were obtained from patient-reported and national register data. Cost-effectiveness at the healthcare perspective was evaluated using incremental net monetary benefit (INMB). RESULTS Of 393 patients, 109 were recruited during the control periods (control group) and 284 were recruited during interventions periods (intervention group). At 12 months the intervention group reported statistically significant higher quality of care compared to the control group (59% vs. 40%; mean difference: 17.6 (95% confidence interval [CI] 11.1, 24.0)). Cost-effectiveness analyses showed that the model of care resulted in quality-adjusted life-years gained and cost-savings compared to usual care with mean INMB €2020 (95% CI 611, 3492) over 12 months. CONCLUSIONS This study showed that implementing the model of care for OA in primary healthcare, improved quality of care and showed cost-effectiveness over 12 months compared to usual care. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT02333656.
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Affiliation(s)
- Nina Østerås
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway.
| | - Eline Aas
- Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway; Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway.
| | - Tuva Moseng
- Center for Treatment of Rheumatic and Musculoskeletal Diseases (REMEDY), Diakonhjemmet Hospital, Oslo, Norway.
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.
| | - Krysia Dziedzic
- Impact Accelerator Unit, Primary Care Centre Versus Arthritis, Keele University, United Kingdom.
| | - Bård Natvig
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Jan Harald Røtterud
- Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway.
| | - Thea Vliet Vlieland
- Department of Orthopaedics, Leiden University Medical Center, Leiden, the Netherlands.
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.
| | - Kåre Birger Hagen
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway.
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Tan BY, Pereira MJ, Yang SY, Hunter DJ, Skou ST, Thumboo J, Car J. Collaborative model of care between Orthopaedics and allied healthcare professionals in knee osteoarthritis (CONNACT): study protocol for an effectiveness-implementation hybrid randomized control trial. BMC Musculoskelet Disord 2020; 21:684. [PMID: 33066746 PMCID: PMC7568411 DOI: 10.1186/s12891-020-03695-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/01/2020] [Indexed: 11/29/2022] Open
Abstract
Background Knee Osteoarthritis (OA) is a leading cause of global disability. The Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT) Model of Care (MoC) was developed by optimizing evidence-based non-surgical treatments to deliver value-based care for people with knee OA. The primary aim of this study is to determine the clinical effectiveness of the CONNACT MoC (3 months) compared to usual care. The secondary aims are: a) To determine the cost-effectiveness and b) To develop an evaluation and implementation framework to inform large scale implementation for this MoC. Methodology Type 1 Effectiveness-Implementation Hybrid Trial using an explanatory sequential mixed-method approach. The study consists of 3 components. The first component is the pragmatic, parallel-arm, single-blinded randomized control trial. Inclusion criteria are patients with knee OA based on the National Institute of Health and Care Excellence (NICE) criteria with radiographic severity of greater than Kellgren-Lawrence 1, and Knee Injury and OA Outcome Score (KOOS4) of equal or less than 75. Exclusion criteria include other forms of arthritis, history of previous knee arthroplasty or wheelchair-bound patient. KOOS4 is the primary outcome measure at 3 months, 6 months and 1 year. Secondary outcomes include KOOS individual subscales, quality of life scoring, functional performance, global, diet and psychological related outcomes. The second component is an economic evaluation of the cost-effectiveness of the CONNACT MoC using a societal perspective. The third component is an implementation and evaluation framework using process evaluation under the RE-AIM framework using a mixed-method approach. Sample size of 100 patients has been calculated. Discussion CONNACT MoC is a complex intervention. In line with the MRC guidance for developing and evaluating complex interventions, a pilot feasibility study was completed and a comprehensive approach including an RCT, economic evaluation and process evaluation is described in this study protocol. Results from this study will help clinicians, healthcare administrators and policymakers guide the sustainable and effective implementation of the CONNACT MoC for knee OA and serve as a basis for similar multidisciplinary MoC for chronic degenerative musculoskeletal conditions to be developed. Trial registration Clinicaltrials.gov Identifier: NCT03809975. Registered January 182,019.
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Affiliation(s)
- Bryan Yijia Tan
- Department of Orthopaedic Surgery, Woodlands Health Campus, National Healthcare Group, Singapore, Singapore. .,Singapore General Hospital, Singapore City, Singapore.
| | | | - Su-Yin Yang
- Department of Orthopaedic Surgery, Woodlands Health Campus, National Healthcare Group, Singapore, Singapore.,Tan Tock Seng Hospital, Singapore City, Singapore
| | - David J Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia
| | - Soren Thorgaard Skou
- Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense M, Denmark.,Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | | | - Josip Car
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore City, Singapore
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