Barriers and Facilitators Associated with Non-Surgical Treatment Use for Osteoarthritis Patients in Orthopaedic Practice

Patient and clinician perspectives of online-delivered exercise programmes for chronic musculoskeletal conditions: a mixed-methods systematic review

PURPOSE

To synthesize common or differing perceptions of patients' and clinicians' that influence uptake of online-delivered exercise programmes (ODEPs) for chronic musculoskeletal (MSK) conditions.

METHODS

Eight databases were searched from inception to April 2023 for studies including (1) patients with and/or clinicians delivering ODEPs for chronic MSK conditions, and (2) synchronous ODEPs, where information is exchanged simultaneously (mode A); asynchronous ODEPs, with at least one synchronous feature (mode B); or no ODEPs, documenting past experiences and/or likelihood of participating in an ODEP (mode C). Critical Appraisal Skills Programme checklists were used to assess study quality. Perceptions of patients' and clinicians' influencing uptake of ODEPs were extracted. Quantitative and qualitative data were synthesised and integrated.

RESULTS

Twenty-one studies were included (twelve quantitative, seven qualitative, and two mixed-methods) investigating the perceptions of 1275 patients and 534 clinicians on ODEP mode A (n = 7), mode B (n = 8), and mode C (n = 6). Sixteen of the 23 identified perceptions related to satisfaction, acceptability, usability, and effectiveness were common, with 70% of perceptions facilitating uptake and 30% hindering uptake.

CONCLUSIONS

Findings highlight the need to promote targeted education for patients and clinicians addressing interconnected perceptions, and to develop evidence-based perception-centred strategies encouraging integrated care and guideline-based management of chronic MSK conditions.

Usage of guideline-adherent core treatments for knee osteoarthritis before and after consulting an orthopaedic surgeon: A prospective cohort study

Objective

To describe 1) the proportion of patients with knee osteoarthritis (OA) undergoing guideline-adherent core treatments until six months after primary referral to an orthopaedic surgeon, 2) which specific treatment pathways these patients undertake and 3) the characteristics of patients choosing different treatment pathways.

Design

This prospective cohort study consecutively invited patients referred to an orthopaedic surgeon due to knee OA at two Danish hospitals from October 2018 to December 2020. Before and six months after consulting the surgeon, patients answered a questionnaire reporting which treatments they had received for knee OA. The proportion receiving the combination of guideline-adherent treatments (i.e., exercise, education, and dietary weight management if needed) was determined. We evaluated the specific treatment usage before and until six months after the consultation and investigated characteristics of patients undertaking different pathways.

Results

Out of 5251 eligible patients, 2574 (49%) had complete data and were included in analyses. 23% received guideline-adherent treatments, 10% had no treatment. Patients underwent 1143 unique treatment pathways, 62% including treatments not recommended/recommended against. Those who underwent guideline-adherent pathways had similar characteristics to those who did not but tended to be females, retired, had longer-lasting knee problems, have comorbidities, and higher education levels.

Conclusions

Only one in four patients with knee OA received treatment adhering to clinical guidelines before and six months after consulting the surgeon. Patients used many different treatment pathways. There is a need for a structured effort to increase the use of guideline-adherent core treatments.

Trial Identifiers

Registration: NCT03746184, Protocol: PMID: 34233992.

Barriers and facilitators for implementing lifestyle-related treatment modalities in osteoarthritis: A cross-sectional study among primary and secondary healthcare professionals

PURPOSE

To identify barriers and facilitators as perceived by primary and secondary healthcare professionals (HCPs) when implementing lifestyle-related treatment modalities (LRTMs) in patients with hip/knee osteoarthritis (OA).

METHODS

A cross-sectional study. A Dutch online survey was distributed among eight different disciplines of primary and secondary HCPs. Potential barriers and facilitators were identified based on participants' responses to 32 research-derived statements on implementing LRTMs, and presented as factors with "major agreement" (≥75%), "minor agreement" (60-75%) or "no agreement" (<60%).

RESULTS

213 participants completed the survey. Seven "barriers" and 20 "facilitators" were identified. There were three "major agreement barriers": organization of Dutch healthcare system, audits within organization, and lifestyle climate in Dutch society. The top three "major agreement facilitators" were: health effects on patients, safety of increasing physical activity, and personal attitude. The total number of "barriers" differed per HCP discipline, with the highest number (12) among orthopedic surgeons (or in-training) and the lowest number (4) among dieticians, physiotherapists, and lifestyle counselors.

CONCLUSIONS

The findings suggest that implementing LRTMs within OA care could be improved by focusing on societal rather than individual HCP factors. National preventive policies on health promotion could counteract the expected increase in healthcare demand and costs due to OA and other chronic diseases. Future research is needed to match relevant implementation strategies to all barriers identified.

Healthcare utilization patterns for knee or hip osteoarthritis before and after changes in national health insurance coverage: A data linkage study

INTRODUCTION

Medical guidelines aim to stimulate stepped care for knee and hip osteoarthritis, redirecting treatments from hospitals to primary care. In the Netherlands, this development was supported by changing health insurance coverage for physio/exercise therapy. The aim of this study was to evaluate healthcare utilization patterns before and after health changes in health insurance coverage.

METHOD

We analyzed electronic health records and claims data from patients with osteoarthritis in the knee (N = 32,091) and hip (N = 16,313). Changes between 2013 and 2019 in the proportion of patients treated by the general practitioner, physio/exercise therapist or orthopedic surgeon within 6 months after onset were assessed.

RESULTS

Joint replacement surgeries decreased for knee (OR 0.47 [0.41-0.54]) and hip (OR 0.81 [0.71-0.93]) osteoarthritis between 2013-2019. The use of physio/exercise therapy increased (knee: OR 1.38 [1.24-1.53], hip: OR 1.26 [1.08-1.47]). However, the proportion treated by a physio/exercise therapist decreased for patients that had not depleted their annual deductibles (knee: OR 0.86 [0.79 - 0.94], hip: OR 0.90 [0.79 - 1.02]). This might be affected by the inclusion of physio/exercise therapy in basic health insurance in 2018.

CONCLUSION

We have found a shift from hospitals to primary care in knee and hip osteoarthritis care. However, the use of physio/exercise therapy declined after changes in insurance coverage for patients that had not depleted their deductibles.

Osteoarthritis management care pathways are complex and inefficient: A qualitative study of physiotherapist perspectives from specialised osteoarthritis services

OBJECTIVE

Hip and knee osteoarthritis guidelines internationally provide consistent first-line care recommendations. However, uptake of these recommendations remains suboptimal. This qualitative study explores factors influencing guideline-based care from the perspectives of physiotherapists working in specialised osteoarthritis services across different models of care.

METHODS

Nineteen semi-structured interviews were conducted with physiotherapists working in specialist osteoarthritis services across three different Australian models of care (OsteoArthritis Hip and Knee Service n = 10; OsteoArthritis Chronic Care Programme n = 4; Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services n = 5). Interviews were audio recorded and transcribed verbatim. Data were coded and analysed inductively using thematic analysis.

RESULTS

The overarching theme to emerge was that accessing first-line osteoarthritis care is complex and difficult, regardless of model of care. Subthemes indicated that: (i) services are either unavailable or inadequately funded, (ii) referral pathways are labyrinthine and lengthy, (iii) patients and other health professionals often believe that surgery is the only/best option and (iv) managing patient co-morbidities is challenging.

CONCLUSION

Physiotherapists working in specialised osteoarthritis services perceive multiple and complex factors influencing adherence to first-line care. Barriers occur at various levels in all models of care, including patient and health professional beliefs, health service, and system levels. These results suggest improving healthcare for people with osteoarthritis requires urgent system reform.

Knee-extensor strength, symptoms, and need for surgery after two, four, or six exercise sessions/week using a home-based one-exercise program: a randomized dose-response trial of knee-extensor resistance exercise in patients eligible for knee replacement (the QUADX-1 trial)

OBJECTIVE

To investigate firstly the efficacy of three different dosages of one home-based, knee-extensor resistance exercise on knee-extensor strength in patients eligible for knee replacement, and secondly, the influence of exercise on symptoms, physical function and decision on surgery.

METHOD

One-hundred and forty patients eligible for knee replacement were randomized to three groups: 2, 4 or 6 home-based knee-extensor resistance exercise-sessions per week (group 2, 4 and 6 respectively) for 12 weeks.

PRIMARY OUTCOME

isometric knee-extensor strength.

SECONDARY OUTCOMES

Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score, average knee pain last week (0-10 numeric rating scale), 6-min walk test, stair climbing test, exercise adherence and "need for surgery".

RESULTS

Primary analysis: Intention-to-treat analysis of 140 patients did not find statistically significant differences between the groups from baseline to after 12 weeks of exercise in isometric knee-extensor strength: Group 2 vs 4 (0.003 Nm/kg (0.2%) [95% CI -0.15 to 0.15], P = 0.965) and group 4 vs 6 (-0.04 Nm/kg (-2.7%) [95% CI -0.15 to 0.12], P = 0.628). Secondary analysis: Intention-to-treat analyses showed statistically significant differences between the two and six sessions/week groups in favor of the two sessions/week group for Oxford Knee Score: 4.8 OKS points (15.2%) [1.3 to 8.3], P = 0.008) and avg. knee pain last week (NRS 0-10): -1.3 NRS points (-19.5%) [-2.3 to -0.2], P = 0.018. After the 12-week exercise intervention, data were available for 117 patients (N = 39/group): 38 (32.5%) patients wanted surgery and 79 (67.5%) postponed surgery. This was independent of exercise dosage.

CONCLUSION

In patients eligible for knee-replacement we found no between-group differences in isometric knee extensor strength after 2, 4 and 6 knee-extensor resistance exercise sessions per week. We saw no indication of an exercise dose-response relationship for isometric knee-extensor strength and only clinically irrelevant within group changes. For some secondary outcome (e.g., KOOS subscales) we found clinically relevant within group changes, which could help explain why only one in three patients decided to have surgery after the simple home-based exercise intervention.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02931058. Preprint: https://doi.org/10.1101/2021.04.07.21254965.

Patient and clinician perspectives of online-delivered exercise programmes for chronic musculoskeletal conditions: protocol for a systematic review

Background: Despite the growing economic and social impact of chronic musculoskeletal (MSK) conditions, there has been low uptake of clinical guidelines for management, owing partly to the negative perceptions of patients and clinicians of their appropriateness and accessibility. Online-delivered exercise programmes (ODEPs) offer an alternative that can reduce costs and offer convenience for those with mobility limitations. As such, investigating participants’ perceptions of such programmes provides insight into the complexity and interplay of factors associated with uptake and optimization of implementation strategies. Objectives: This study aims to systematically review of the literature of patients’ and clinicians’ perceptions of ODEPs for chronic MSK conditions. Methods: To ensure the likelihood of identifying all relevant published articles, the following databases will be searched from inception to end of the project: CINAHL Complete, MEDLINE, SportDiscus, AMED, APA PsycArticles, APA PsycInfo, Scopus, and Cochrane Library. Included articles will qualitatively and/or quantitatively report the perceptions of participants of ODEPs for chronic MSK conditions. ODEPs are defined as either (a) synchronous, users can exchange information simultaneously, or (b) asynchronous, with at least one synchronous feature, or (c) neither, where the authors investigate a user’s past experiences and/or likelihood of participating in such a programme. Article screening and quality assessment using the Critical Appraisal Skills Programme (CASP) checklists will be performed by two independent reviewers. All findings from included articles will be extracted and coded using a thematic synthesis approach. Discussion: It is important to offer diverse resources to address the growing public health burden of chronic MSK conditions. This study will explore patients and clinicians’ perceptions of ODEPs including needs, appropriateness and acceptability. Our findings could be used by policy makers, clinicians, and researchers to generate new models of care that could influence the uptake and long-term sustainability of ODEPs for chronic MSK conditions. PROSPERO registration: CRD42021273773.

Quality of knee osteoarthritis care in the Netherlands: a survey on the perspective of people with osteoarthritis

BACKGROUND

Quality indicators (QIs) are used to monitor quality of care and adherence to osteoarthritis (OA) standards of care. Patient reported QIs can identify the most important gaps in quality of care and the most vulnerable patient groups. The aim of this study was to capture the perspective of people with knee OA (KOA) in the Netherlands on the quality of care received, and explore determinants related to lower achievement rates.

METHODS

We sent an online survey to all members of The Dutch Knee Panel (n = 622) of the Sint Maartenskliniek Nijmegen, the Netherlands between September and October 2019. The survey consisted of a slightly adapted version of the "OsteoArthritis Quality Indicator" (OA-QI) questionnaire (18 items; yes, no, N/A); a rating of quality of KOA care on a 10-point scale; a question on whether or not one wanted to see change in the care for KOA; and an open-ended question asking recommendations for improvement of OA care. Furthermore, sociodemographic and disease related characteristics were collected. Pass rates for separate QIs and pass rates on patient level were calculated by dividing the number of times the indicator was achieved by the number of eligible persons for that particular indicator.

RESULTS

A total of 434 participants (70%) completed the survey. The mean (SD) pass rate (those answering "Yes") for separate QIs was 49% (20%); ranging from 15% for receiving referral for weight reduction to 75% for patient education on how to manage knee OA. The mean (SD) pass rate on patient level was 52% (23%). Presence of OA in other joints, comorbidities, and having a knee replacement were associated with higher pass rates. On average, a score of 6.5 (1.6) was given for the quality of care received, and the majority of respondents (59%) wanted change in the care for KOA. Of 231 recommendations made, most often mentioned were the need for tailoring of care (14%), more education (13%), and more empathy and support from healthcare providers (12%).

CONCLUSION

This study found patients are only moderately satisfied with the OA care received, and showed substantial gaps between perceived quality of care for OA and internationally accepted standards. Future research should focus on the underlying reasons and provide strategies to bridge these gaps.

Disappointing evaluation of a shared decision-making intervention for residents and orthopaedic surgeons

OBJECTIVE

To evaluate a shared decision-making (SDM) intervention in orthopaedic hip and knee osteoarthritis care.

METHODS

Using a pre- post intervention design study, we tested an intervention, that included a decision aid for patients (ptDA) and a SDM training course for residents in training and orthopaedic surgeons. The theory of planned behaviour was used for intervention development. Primary outcomes included patient reported decisional conflict, SDM, and satisfaction. Secondary outcomes were physicians' attitude and knowledge, and uptake of the ptDA.

RESULTS

317 patients were included. The intervention improved physicians' knowledge about SDM but had no effect on the primary outcomes. 19 eligible patients used the ptDA (17%). SDM was higher for middle educated patients compared to lower educated (mean difference 9.91, p=0.004), patients who saw surgeons instead of residents (mean difference 5.46, p=0.044) and when surgery was chosen and desired by patients compared to situations where surgery was desired but not chosen (mean difference 15.39, p=0.036).

CONCLUSION

Our multifaceted intervention did not improve SDM and ptDA uptake was low.

PRACTICE IMPLICATIONS

In orthopaedic hip and knee osteoarthritic care other ways should be explored to successful implement SDM. Since residents received lower SDM scores, special focus should go to this group.

Barriers and facilitators perceived by healthcare professionals for implementing lifestyle interventions in patients with osteoarthritis: a scoping review

OBJECTIVE

To provide an overview of barriers and facilitators that healthcare professionals (HCPs) perceive regarding the implementation of lifestyle interventions (LIs) in patients with hip and/or knee osteoarthritis (OA).

DESIGN

Scoping review.

DATA SOURCES

The databases PubMed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from inception up to January 2021.

ELIGIBILITY CRITERIA

Primary research articles with a quantitative, qualitative or mixed-methods design were eligible for inclusion if they reported: (1) perceptions of primary and/or secondary HCPs (population); (2) on implementing LIs with physical activity and/or weight management as key components (concept) and (3) on conservative management of hip and/or knee OA (context). Articles not published in English, German or Dutch were excluded.

DATA EXTRACTION AND SYNTHESIS

Barriers and facilitators were extracted by two researchers independently. Subsequently, the extracted factors were linked to a framework based on the Tailored Implementation for Chronic Diseases checklist.

RESULTS

Thirty-six articles were included. In total, 809 factors were extracted and subdivided into nine domains. The extracted barriers were mostly related to non-optimal interdisciplinary collaboration, patients' negative attitude towards LIs, patients' low health literacy and HCPs' lack of knowledge and skills around LIs or promoting behavioural change. The extracted facilitators were mostly related to good interdisciplinary collaboration, a positive perception of HCPs' own role in implementing LIs, the content or structure of LIs and HCPs' positive attitude towards LIs.

CONCLUSIONS

Multiple individual and environmental factors influence the implementation of LIs by HCPs in patients with hip and/or knee OA. The resulting overview of barriers and facilitators can guide future research on the implementation of LIs within OA care. To investigate whether factor frequency is related to the relevance of each domain, further research should assess the relative importance of the identified factors involving all relevant disciplines of primary and secondary HCPs.

PROSPERO REGISTRATION NUMBER

CRD42019129348.

Relationship Between Pain Beliefs and Postoperative Pain Outcomes After Total Knee and Hip Replacement Surgery

PURPOSE

The aim of this study was to investigate the relationship between pain beliefs and postoperative pain outcomes in patients who underwent total knee replacement or total hip replacement.

DESIGN

This was a descriptive, prospective, and cross-sectional study.

METHODS

The study population included all patients who met the sampling criteria and agreed to participate in the study between April 2019 and January 2020 (N = 91). Data were collected using a sociodemographic and clinical characteristics form, the Pain Beliefs Questionnaire (PBQ), and the Turkish Revised American Pain Society Patient Outcome Questionnaire (APS-POQ-R-TR). Sociodemographic and clinical data and PBQ scores were obtained preoperatively, and the APS-POQ-R-TR was applied 24 hours after surgery.

FINDINGS

In the first 24 hours, the mean lowest pain level was 2.96 ± 2.29; mean highest pain level was 8.05 ± 2.66. In the evaluation of the relationships between patients' sociodemographic characteristics and mean PBQ organic and psychological beliefs scores, statistically significant differences were observed according to income and education level. Mean PBQ organic and psychological beliefs scores were not significantly associated with APS-POQ-R-TR total scores or subscale scores for pain severity, activity interference, sleep interference, and perception of care; affective effect of pain; or adverse effects of pain treatment.

CONCLUSIONS

The results of our study indicate that education level and socioeconomic status were associated with patients' pain beliefs, but we observed no relationship between pain beliefs and perceived pain outcomes.

Non-surgical treatment before hip and knee arthroplasty remains underutilized with low satisfaction regarding performance of work, sports, and leisure activities

Background and purpose - Guidelines for managing hip and knee osteoarthritis (OA) advise extensive non-surgical treatment prior to surgery. We evaluated what percentage of hip and knee OA patients received non-surgical treatment prior to arthroplasty, and assessed patient satisfaction regarding alleviation of symptoms and performance of activities. Patients and methods - A multi-center cross-sectional study was performed in 2018 among 186 patients who were listed for hip or knee arthroplasty or had undergone surgery within the previous 6 months in the Netherlands. Questions concerned non-surgical treatments received according to the Stepped Care Strategy and were compared with utilization in 2013. Additionally, satisfaction with treatment effects for pain, swelling, stiffness, and activities of daily life, work, and sports/leisure was questioned. Results - The questionnaire was completed by 175 patients, age 66 years (range 38-84), 57% female, BMI 29 (IQR 25-33). Step 1 treatments, such as acetaminophen and lifestyle advice, were received by 79% and 60% of patients. Step 2 treatments, like exercise-based therapy and diet therapy, were received by 66% and 19%. Step 3-intra-articular injection-was received by 47%. Non-surgical treatment utilization was lower than in 2013. Nearly all treatments showed more satisfied patients regarding pain relief and fewer regarding activities of work/sports/leisure. Hip and knee OA patients were mostly satisfied with NSAIDs for all outcomes, while exercise-based therapy was rated second best. Interpretation - Despite international guideline recommendations, non-surgical treatment for hip and knee OA remains underutilized in the Netherlands. Of the patients referred for arthroplasty, more were satisfied with the effect of non-surgical treatment on pain than on work/sports/leisure participation.

"I've been to physical therapy before, but not for the knees." A qualitative study exploring barriers and facilitators to physical therapy utilization for knee osteoarthritis

BACKGROUND

Physical therapy (PT) is recommended to reduce pain and improve function. However, only 10%-15% of adults with knee osteoarthritis (OA) use PT in the United States. The purpose of this study was to explore patient-reported barriers and facilitators to PT utilization for knee OA, to understand why PT is underutilized.

METHODS

Qualitative descriptive study using semi-structured interviews was conducted, that is, one-on-one phone interviews with adults from local community centers. Participants were eligible if they were fluent in English and self-reported knee OA (1) over 45 years of age, (2) have activity-related knee pain, and (3) have no morning stiffness or morning stiffness in the knee(s) for ≤30 min. Interviews were audio-recorded and transcribed. To identify barriers and facilitators to PT utilization for knee OA, a coding framework, thematic analysis, and a constant comparative approach were used.

RESULTS

Of 22 participants with health insurance and who participated, 59% were considering PT, 23% refused PT, and 18% used PT for knee OA. Themes identified as either barriers or facilitators for participants were (1) previous experience with PT, (2) physician referral, (3) beliefs about treatment efficacy before and after knee replacement surgery, (4) insurance coverage, and (5) preference to avoid surgery.

CONCLUSION

A previous positive encounter with PT and a physician referral may facilitate PT utilization for adults with knee OA. Knowledge about and access to PT services were not identified as barriers related to PT utilization. Further research is necessary to confirm findings in a broader group of adults with knee OA.

Perceived facilitators and barriers among physical therapists and orthopedic surgeons to pre-operative home-based exercise with one exercise-only in patients eligible for knee replacement: A qualitative interview study nested in the QUADX-1 trial

AIM

Clinical guidelines recommend non-surgical treatment before surgery is considered in patients eligible for knee replacement. Surgical treatment is provided by orthopedic surgeons and exercise therapy is provided by physical therapists. The aim of this study was to identify perceived facilitators and barriers-among orthopedic surgeons and physical therapists-towards coordinated non-surgical and surgical treatment of patients eligible for knee replacement using pre-operative home-based exercise therapy with one exercise.

METHODS

This qualitative study is embedded within the QUADX-1 randomized trial that investigates a model of coordinated non-surgical and surgical treatment for patients eligible for knee replacement. Physical therapists and orthopedic surgeons working with patients with knee osteoarthritis in their daily clinical work were interviewed (one focus group and four single interviews) to explore their perceived facilitators and barriers related to pre-operative home-based exercise therapy with one exercise-only in patients eligible for knee replacement. Interviews were analyzed using thematic analysis.

RESULTS

From the thematic analysis three main themes emerged: 1) Physical therapists' dilemma with one home-based exercise, 2) Orthopedic surgeons' dilemma with exercise, and 3) Coordinated non-surgical and surgical care.

CONCLUSION

We found that the pre-operative exercise intervention created ambivalence in the professional role of both the physical therapists and orthopedic surgeons. The physical therapists were skeptical towards over-simplified exercise therapy. The orthopedic surgeons were skeptical towards the potential lack of (long-term) effect of exercise therapy in patients eligible for knee replacement. The consequence of these barriers and ambivalence in the professional role is important to consider when planning implementation of the model of coordinated non-surgical and surgical treatment.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02931058.

Outcomes of a conservative care program for knee osteoarthritis through translation of research into practice

INTRODUCTION

Evidence-based guidelines suggest a conservative, nonsurgical approach as first-line treatment for knee osteoarthritis. However, previous literature has documented underutilization of the fundamental components of condition management emphasized in the guidelines. The intervention aim is to apply organized conservative components of care for knee osteoarthritis in an evidence-based management program through the translation of research into practice with a target to observe meaningful functional improvement in a distinct population.

METHODS

The program, modeled after the nonsurgical arm of a randomized, controlled trial, was designed as a single-arm observational cohort study with a pre- and post-program comparison for participants reporting presence of knee osteoarthritis who were attributed to a specific employer's health plan in the United States. The 12-week intervention consisted of condition education, group exercise, and a dietary intervention.

RESULTS

Ninety-six participants enrolled in the program, of which 72% completed the protocol. The median change in pre- to post-program Knee Injury and Osteoarthritis Outcome Score values was 10.4 ± 0.8 (Z = 210.5, p < 0.001)-a clinically important change. Secondary outcomes were complementary to the primary outcome.

CONCLUSIONS

Results of the program indicate that the clinically significant 3-month findings in the report by Skou et al. (2015) regarding functional improvement can be replicated in an alternate setting. Organizing and offering fundamental components of condition management in a group format with provider oversight could be a feasible and logical component in the continuum of care for knee osteoarthritis, while complementing other secondary management strategies following diagnosis.

Evaluation of an educational course for primary care physiotherapists on comorbidity-adapted exercise therapy in knee osteoarthritis: an observational study

Objective

The objectives of the present study were to: (1) evaluate the effect of an educational course on competence (knowledge and clinical reasoning) of primary care physical therapists (PTs) in treating patients with knee osteoarthritis (KOA) and comorbidity according to the developed strategy; and (2) identify facilitators and barriers for usage.

Method

The present research was an observational study with a pretest‐posttest design using mixed methods. PTs were offered a postgraduate course consisting of e‐learning and two workshops (blended education) on the application of a strategy for exercise prescription in patients with KOA and comorbidity. Competences were measured by questionnaire on knowledge (administered before and 2 weeks after the course), and a patient vignette to measure clinical reasoning (administered before the course and after a 6 month period of treating patients). Facilitators and barriers for using the strategy were assessed by a questionnaire and semi‐structured interviews.

Results

Thirty‐four PTs were included. Competence (knowledge and clinical reasoning) improved significantly (p < 0.01). Fourteen out of 34 PTs had actually treated patients with KOA and comorbidity, during a 6‐month period. The strategy was found to be feasible in daily practice. The main barriers included the limited number of (self‐) referrals of patients, limited number of reimbursed treatment sessions by insurance companies and a suboptimal collaboration with (referring) physicians.

Conclusion

A blended course on exercise therapy for patients with KOA and comorbidity seems to improve PTs' competence through increasing knowledge and clinical reasoning skills. Identified barriers should be solved before large‐scale implementation of exercise therapy can take place in these complex patients.

Preferences and beliefs of Dutch orthopaedic surgeons and patients reduce the implementation of "Choosing Wisely" recommendations in degenerative knee disease

PURPOSE

The purpose of this study was to assess which factors were associated with the implementation of "Choosing Wisely" recommendations to refrain from routine MRI and arthroscopy use in degenerative knee disease.

METHODS

Cross-sectional surveys were sent to 123 patients (response rate 95%) and 413 orthopaedic surgeons (response rate 62%) fulfilling the inclusion criteria. Univariate and multivariate logistic regression analyses were used to identify factors associated with implementation of "Choosing Wisely" recommendations.

RESULTS

Factors reducing implementation of the MRI recommendation among patients included explanation of added value by an orthopaedic surgeon [OR 0.18 (95% CI 0.07-0.47)] and patient preference for MRI [OR 0.27 (95% CI 0.08-0.92)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own MRI experience than existing evidence [OR 0.41 (95% CI 0.19-0.88)] and higher estimated patients' knowledge to participate in shared decision-making [OR 0.38 (95% CI 0.17-0.88)]. Factors reducing implementation of the arthroscopy recommendation among patients were orthopaedic surgeons' preferences for an arthroscopy [OR 0.03 (95% CI 0.00-0.22)] and positive experiences with arthroscopy of friends/family [OR 0.03 (95% CI 0.00-0.39)]. Factors reducing implementation among orthopaedic surgeons were higher valuation of own arthroscopy experience than existing evidence [OR 0.17 (95% CI 0.07-0.46)] and belief in the added value [OR 0.28 (95% CI 0.10-0.81)].

CONCLUSIONS

Implementation of "Choosing Wisely" recommendations in degenerative knee disease can be improved by strategies to change clinician beliefs about the added value of MRIs and arthroscopies, and by patient-directed strategies addressing patient preferences and underlying beliefs for added value of MRI and arthroscopies resulting from experiences of people in their environment.

LEVEL OF EVIDENCE

IV.

Variation in Nonsurgical Treatment Recommendations for Common Upper Extremity Conditions

BACKGROUND

In orthopaedic surgery, there is known surgeon-to-surgeon variation in recommendations for surgery. Variation in recommendations for nonsurgical treatment of common upper extremity conditions for which surgery is discretionary remains unclear.

METHODS

One hundred eighty-three surgeons were included after completing six questions on six scenarios of upper extremity conditions regarding nonsurgical treatment recommendations. For one scenario, we measured the influence of reading a summary of preferred practice before making recommendations.

RESULTS

Variation in nonsurgical treatment recommendations was observed between surgeons and between upper extremity conditions. Surgeons that reviewed a decision support paragraph were more likely to opine that surgery would eventually be beneficial.

DISCUSSION

The notable variation in nonsurgical treatment recommendations indicates a substantial influence of surgeon bias in decision-making. To help ensure that decisions are consistent, surgeons may benefit from decision support and guidelines to help limit practice variation.

Reduction of routine radiographs in the follow-up of distal radius and ankle fractures: Barriers and facilitators perceived by orthopaedic trauma surgeons

RATIONALE, AIMS, AND OBJECTIVES

Studies suggest that routine radiographs during follow-up of distal radius and ankle fractures result in increased radiation exposure and health care costs, without influencing treatment strategies. Encouraging clinicians to omit these routine radiographs is challenging, and little is known about barriers and facilitators that influence this omission. Therefore, this study aims to identify barriers and facilitators among orthopaedic trauma surgeons that might prove valuable towards the design of a deimplementation strategy.

METHODS

A mixed-method approach was used. First, interviews were conducted with orthopaedic trauma surgeons and patients (n = 16). Subsequently, a questionnaire was developed. This questionnaire was presented to 228 orthopaedic trauma surgeons in the Netherlands. Regression analyses were performed in order to identify which variables were independently associated to the decision to stop performing routine radiographs 6 and 12 weeks after trauma if proven not effective in a large randomized controlled trial.

RESULTS

In total, 130 (57%) respondents completed the questionnaire. Of these, 71% indicated they would stop ordering routine radiographs if they were proven not effective. Three facilitators were independent predictors for the intention to omit routine radiographs: This will "lead to lower health care costs" (Odds Ratio [OR]: 5.38 and 4.38), the need for "incorporation in the regional protocol" (OR: 3.66 and 2.66), and this will "result in time savings for the patient" (OR: 4.84).

CONCLUSIONS

We identified three facilitators that could provide backing for a deimplementation strategy aimed at a reduction of routine radiographs for patients with distal radius and ankle fractures.

A lifestyle management programme focused on exercise, diet and physiotherapy support for patients with hip or knee osteoarthritis and a body mass index over 35: A qualitative study

The Lifestyle Management Programme (LMP) is an exercise and weight management programme with physiotherapy support for people with hip or knee osteoarthritis (OA) and a body mass index (BMI) over 35. This qualitative study explored views and experiences of the LMP among patients and professionals, and offers insight for future programmes. Five referring clinicians and six delivering professionals participated in focus groups. Three referring GPs and nine patients who attended the LMP took part in semi-structured interviews. Topics included: referral, reasons for taking up and continuing the programme or not, and experiences and outcomes. Framework method was used to analyse the qualitative data. Overall, patients and professionals valued the multidisciplinary nature of the LMP. However, professionals explained feeling guilty about delaying patients on the orthopaedic waiting list and believed that the programme should be redirected to those with less severe OA and a lower BMI. Referring clinicians differed in their interpretation of the referral criteria and expressed varying levels of autonomy when making referrals. Patients referred after a consultation with their general practitioner appeared to be more satisfied with the referral process. Patients were also encouraged by the opportunity to improve health, their likelihood of surgery and social benefits. However, patients were discouraged by inconvenience, cost, lack of readiness to change and embarrassment. In conclusion, shared decision-making about lifestyle management without delaying orthopaedic opinion is preferable, and more psychological support may increase participation. Importantly, the programme may be better focused on rehabilitation for patients with a lower BMI and less severe symptoms.

Exploratory Study of 6-Month Pain Trajectories in Individuals With Predominant Patellofemoral Osteoarthritis: A Cohort Study

BACKGROUND

Knowledge of patellofemoral osteoarthritis (OA) pain trajectories is vital to helping clinicians and patients make shared disease-specific decisions regarding treatment options and coping strategies.

OBJECTIVES

To describe the pain trajectories of people living with patellofemoral OA who present to a chronic care management program, and to explore baseline characteristics associated with different trajectories.

METHODS

In this prospective longitudinal cohort study, 88 participants who presented to a chronic care management program reported their worst pain over the previous week at baseline and at 6, 12, 18, and 26 weeks using a 10-cm visual analog scale. Trajectories (classes) were identified using latent class growth analysis. Demographics, pain, physical performance, strength, quality of life, mental health, and lower limb/foot structural measures obtained at baseline were assessed for association with trajectory class membership.

RESULTS

Individuals in class 1 (28%) exhibited high, persistent pain from baseline (7.8 ± 1.7 cm), which continued over time (P = .52). Class 2 (57%) displayed moderate baseline pain (4.8 ± 1.8 cm), which also remained persistent (P = .97). Individuals in class 3 (15%) showed low, improving pain (baseline pain, 2.6 ± 1.2 cm) over time (P = .017). At baseline, poor Knee injury and Osteoarthritis Outcome Score (KOOS) scores, local and proximal sensitivity to pressure, and lower knee extensor strength were associated with increased odds of following the high-pain trajectory (range [95% confidence interval], 1.03 [1.00, 1.07] to 16.24 [2.53, 104.34]).

CONCLUSION

Distinct pain trajectories appear to exist in people with patellofemoral OA presenting to a chronic care management program. Baseline variables may be useful for identifying individuals at risk of poorer prognosis. Larger studies are needed to confirm the efficacy of this finding.

LEVEL OF EVIDENCE

Prognosis, level 2b. J Orthop Sports Phys Ther 2019;49(1):5-16. Epub 12 Sep 2018. doi:10.2519/jospt.2019.8354.

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

Background

Providing relevant information on disease and self-management helps patients to seek timely contact with care providers and become actively involved in their own care process. Therefore, health professionals from primary care, multiple hospitals and health organisations jointly decided to develop an educational program on osteoarthritis (OA). The objective of the present study was to determine preliminary effects of this OA educational program on healthcare utilization and clinical outcomes.

Methods

We developed an educational group-based program consisting of 2 meetings of 1.5 h, provided by a physiotherapist, a general practitioner (GP) and orthopaedic surgeon or specialized nurse. The program included education on OA, (expectations regarding) treatment options and self-management. Patients were recruited through searching the GPs’ electronic patients records and advertisements in local newspapers. At baseline and at 3 months follow-up participating OA patients completed questionnaires. Paired-sample t-tests, McNemar’s test and Wilcoxon Signed-Rank test were used to estimate the preliminary effects of the program.

Results

A total of 146 participants in 3 districts attended the sessions, of whom 143 agreed to participate in this study; mean age 69.1 years (SD10.2).107 (75%) participants completed both baseline and follow up assessments. The proportion of participants who had visited their GP in the 3 months after the program was lower than 3 months previous to the program (40% versus 25%, p-value 0.01). Also, we observed a decrease in proportion of patients who visited the physio- and exercise therapist, (36.1% versus 25.0%, p-value 0.02). Both illness perceptions and knowledge on OA and treatment options changed positively (Δ-1.8, 95%CI:0.4–3.4, and Δ2.4, 95%CI:-3.0 - -1.6 respectively). No changes in BMI, pain, functioning and self-efficacy were found. However, a trend towards an increase in physical activity was observed.

Conclusions

Our results show that a multidisciplinary educational program may result in a decrease in healthcare utilization and has a positive effect on illness perceptions and knowledge on OA due to clear and consistent information on OA and it treatment options.

Trial registration

Netherlands Trial Register (NTR5472). Registered 22 September 2015.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0769-7) contains supplementary material, which is available to authorized users.

Patients' perceived needs of osteoarthritis health information: A systematic scoping review

BACKGROUND

Optimal management of osteoarthritis requires active patient participation. Understanding patients' perceived health information needs is important in order to optimize health service delivery and health outcomes in osteoarthritis. We aimed to review the existing literature regarding patients' perceived health information needs for OA.

METHODS

A systematic scoping review was performed of publications in MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs of osteoarthritis health information were categorized.

RESULTS

30 studies from 2876 were included: 16 qualitative, 11 quantitative and 3 mixed-methods studies. Three areas of perceived need emerged: (1) Need for clear communication: terms used were misunderstood or had unintended connotations. Patients wanted clear explanations. (2) Need for information from various sources: patients wanted accessible health professionals with specialist knowledge of arthritis. The Internet, whilst a source of information, was acknowledged to have dubious reliability. Print media, television, support groups, family and friends were utilised to fulfil diverse information needs. (3) Needs of information content: patients desired more information about diagnosis, prognosis, management and prevention.

CONCLUSIONS

Patients desire more information regarding the diagnosis of osteoarthritis, its impact on daily life and its long-term prognosis. They want more information not only about pharmacological management options, but also non-pharmacological options to help them manage their symptoms. Also, patients wanted this information to be delivered in a clear manner from multiple sources of health information. To address these gaps, more effective communication strategies are required. The use of a variety of sources and modes of delivery may enable the provision of complementary material to provide information more successfully, resulting in better patient adherence to guidelines and improved health outcomes.

Barriers and facilitators to orthopaedic surgeons' uptake of decision aids for total knee arthroplasty: a qualitative study

OBJECTIVES

The demand for total knee arthroplasty (TKA) is increasing. Differentiating who will derive a clinically meaningful improvement from TKA from others is a key challenge for orthopaedic surgeons. Decision aids can help surgeons select appropriate candidates for surgery, but their uptake has been low. The aim of this study was to explore the barriers and facilitators to decision aid uptake among orthopaedic surgeons.

DESIGN

A qualitative study involving face-to-face interviews. Questions were constructed on the Theoretical Domains Framework to systematically explore barriers and facilitators.

SETTING

One tertiary hospital in Australia.

PARTICIPANTS

Twenty orthopaedic surgeons performing TKA.

OUTCOME MEASURES

Beliefs underlying similar interview responses were identified and grouped together as themes describing relevant barriers and facilitators to uptake of decision aids.

RESULTS

While prioritising their clinical acumen, surgeons believed a decision aid could enhance communication and patient informed consent. Barriers identified included the perception that one's patient outcomes were already optimal; a perceived lack of non-operative alternatives for the management of end-stage osteoarthritis, concerns about mandatory cut-offs for patient-centred care and concerns about the medicolegal implications of using a decision aid.

CONCLUSIONS

Multifaceted implementation interventions are required to ensure that orthopaedic surgeons are ready, willing and able to use a TKA decision aid. Audit/feedback to address current decision-making biases such as overconfidence may enhance readiness to uptake. Policy changes and/or incentives may enhance willingness to uptake. Finally, the design/implementation of effective non-operative treatments may enhance ability to uptake by ensuring that surgeons have the resources they need to carry out decisions.

Development of the "Treatment beliefs in knee and hip OsteoArthritis (TOA)" questionnaire

Background

Use of conservative treatment modalities in osteoarthritis (OA) is suboptimal, which appears to be partly due to patients’ beliefs about treatments. The aim of this study was to develop a research instrument assessing patients’ beliefs about various treatment modalities of hip and knee OA: the ‘Treatment beliefs in OA (TOA) questionnaire’.

Methods

The item pool that was retrieved from interviews with patients and healthcare providers comprised beliefs regarding five treatment modalities: physical activity, pain medication, physiotherapy, injections and arthroplasty. After an extensive selection procedure, a draft questionnaire with 200 items was constructed. Descriptive analyses and exploratory factor analyses with oblique rotation were conducted for each treatment modality separately to decide upon the final questionnaire. Internal consistency and test-retest reliability were determined.

Results

The final questionnaire comprised 60 items. It was completed by 351 patients with knee or hip OA. Each of the five treatment modalities yielded a two factor solution with 37% to 51% explained variance and high face validity. Factor I included ‘positive treatment beliefs’ and factor II ‘negative treatment beliefs’. Internal consistency (Cronbach α’s from 0.72 to 0.87) and test-retest reliability (i.e. intraclass correlation coefficient from 0.66–0.88; standard error of measurement from 0.06–0.11) were satisfactory to good.

Conclusions

The TOA questionnaire is the first questionnaire assessing positive and negative treatment beliefs regarding five treatment modalities for knee and hip OA. The instrument will help to understand whether and to what extent treatment beliefs influence treatment choices.

Electronic supplementary material

The online version of this article (10.1186/s12891-017-1762-3) contains supplementary material, which is available to authorized users.