Background to COPCORD and APLAR

The Philippines: the applied rheumatology made simple (ARMS) educational programme

The Philippines is a low-income country with a population of 101 million spread over a large series of islands with a land area of 300,000 square kilometres. Infrastructure is ranked in the low to mid-levels, and gross domestic product (GDP) per capita is about US $7000 . The government spends 4.4% of GDP on healthcare, and thus, the provision of basic healthcare remains a challenge; moreover, there is a lack of good healthcare intervention programmes. MSK specialist capacity also remains a challenge, with only 120 rheumatologists in the country, effectively amounting to 1 rheumatologist per 1 million population (in contrast to 1 per 50,000 in USA).

The ARMS programme began in 2009 and was developed under the auspices of the Arthritis Care and Research Foundation of the Philippines (ArthritisCare), in partnership with Continuing Medical Education (CME) providers, including the Philippine Medical Association, Philippine College of Physicians, and Philippine Academy of Family Physicians. Funding for the programme was provided by a single unrestricted educational grant from ILAR. A major pharmaceutical company also provided funding on an arm’s-length basis for meals and venues for ARMS activities as well as logistics assistance by inviting and promoting primary care doctors. Honoraria for ARMS speakers were provided by ArthritisCare, which is in turn funded by a few wealthy benefactors.

The ARMS Project facilitates implementation of a shared-care MoC for MSK diseases by targeting workforce capacity building. Specifically, the ARMS approach streamlines the management of MSK diseases in the Philippines by empowering the primary care practitioner (PCP), through clinical education and development of a clinical network or community of clinical practice, to effectively manage simple, ‘straightforward’ MSK diseases; recognise disease activity; and monitor drug side-effects in patients with inflammatory arthritis and to recognise ‘warning signs’ in order to refer patients with potentially serious diseases to the rheumatologist or specialist . Thus, an effective network providing easy access for patients to appropriate MSK care is established between the rheumatologist and the PCP, which is especially important for people living in remote geographical areas .

The components of the ARMS educational programme comprise:

• 1.
  

  Workforce – this include the ARMS lecturer-coordinator who is a rheumatologist trained in the conduct of the programme (preferably practising within the area of the participating PCPs) and the ARMS participants consisting of PCPs or non-rheumatology specialists (e.g. internists) . The ARMS module further integrates the participation of ‘patient partners’, usually with deforming RA who have been trained and certified in the conduct and teaching of MSK physical examination. Although their involvement in the programme is optional, their training has been well received . A ‘living well’ patient support group session occasionally follows the ARMS activity, where patients with various MSK and autoimmune conditions share coping strategies, facilitated by the patient partners and consistent with contemporary MSK MoCs in high-income economies .

  
  
• 2.
  

  Educational content – this is grouped into four categories on the basis of relevance to primary care practice and the need for referral to the rheumatologist or other specialist. Examples of diseases in each category are as follows:

  
  
  
  
  • (1)
    

    Ambulatory Rheumatology (soft tissue rheumatism, OA and uncomplicated gout): These diseases require minimal tests and can usually be managed by a PCP. Patient education and self-management are emphasised for OA and gout, particularly regarding advice on lifestyle issues such as diet, weight loss, exercise and avoidance of smoking and alcohol – as part of the co-care between the PCP and the patient.

    
    
  • (2)
    

    Arthritis with extra-articular features (e.g. reactive arthritis and psoriatic arthritis): History-taking and physical examination are emphasised in order to reach a diagnosis. Essential information that can be derived from basic inexpensive tests such as complete blood count and urinalysis is reviewed.

    
    
  • (3)
    

    Autoimmune diseases (e.g. rheumatoid arthritis (RA), ankylosing spondylitis and systemic lupus erythematosus (SLE)): Emphasis is placed on continuity of care and close coordination of the PCP with the rheumatologist with respect to monitoring for disease activity and side effects to medications.

    
    
  • (4)
    

    Potentially serious conditions (e.g. infection, malignancy and vasculitis): The PCP learns to recognise ‘warning signs’ of a potentially serious situation, initiates acute management measures if necessary, and refers these patients to the rheumatologist, other specialists and ‘help-lines’.

  
  

A simplified algorithmic approach to the rheumatic diseases and interactive evaluation is provided towards the end of the module.

Current status and continuing challenges

The ARMS Programme is an example of a successfully implemented shared-care model in the context of scarce government funding and limited workforce capacity (volume and skills) resources to manage MSK conditions. Since the launch of the ARMS programme in 2009, an average of 10 programmes have been conducted annually throughout the country, with approximately 1200 PCPs certified in the programme to date. The feedback from PCPs has been encouraging, with the highest ratings garnered in terms of ‘relevance to clinical practice’ and ‘positive impact on diagnosis and treatment’ . Challenges and action items to enable sustainability of the programme include: ARMS re-certification of PCPs, long-term evaluation of the programme in terms of outcomes achievement, updating of the ARMS educational materials, procuring an effective mandate from public health officials and continuing logistical support without commercial bias. Attention should be given to developing patient-focused education by taking advantage of the information technology resources. Recurrent funding of the programme is also difficult to obtain.

Summary

The ARMS programme represents a local implementation enabler to a shared-care MoC for MSK conditions in the Philippines. It facilitates access to competent MSK healthcare through focused education of the PCP, establishment of effective networking systems between the PCPs and rheumatologist-specialists within the same geographical location and reinforcement of patient self-help programmes . These enablers are consistent with those of contemporary musculoskeletal MoCs in other nations .

Implementation practice points

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  Wide-scale implementation of a shared-care MoC for MSK diseases in the Philippines can be facilitated by an education programme that enables:

  
  
  
  
  • ○
    

    workforce skills and knowledge building in MSK disease management by targeting PCPs

    
    
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    development of a community of practice between PCPs and medical specialists

  
  

Malaysia: a national approach focussed on specific common conditions

Malaysia is a middle-income (GDP per capita of US$26,600) developing nation with a diverse mix of cultures and religions. It has a relatively small population of 30 million spread over a land area of 331,000 square kilometres ( Table 1 ). Malaysian healthcare system consists of a dual public and private system: a nationalised free public health service for all residents and a private health system comprising the majority of PCPs and several private hospital hubs in major cities. The Malaysian public health system is divided into six geographical zones: Central, South, North, West, East, and East Malaysia (Sabah and Sarawak). Each health zone serves approximately 4 million people and basic healthcare is generally adequate. Whilst out-of-pocket expenses for patients within the public sector are minimal, many Malaysians opt for private healthcare.

The Malaysian MoH has recognised a need for consistent management standards for common medical conditions throughout the country. Together with the Academy of Medicine, Malaysia, and local Specialty Societies, it has produced a set of clinical practice guidelines (CPGs) mainly to inform the practice of private PCPs and medical officers based in rural areas . The Malaysian Society of Rheumatology (MSR) and the Malaysian Osteoporosis Society developed the CPGs for OA and gout, and osteoporosis respectively. The OA CPG is the basis for this case study on supporting the implementation of MSK MoCs in Malaysia.

The MSR produced the first OA CPGs in 2002. The CPGs were made available as a booklet and online through funding by MoH. The OA CPGs were subsequently revised in 2013 . The document comprises evidence-based practice recommendations and consensus-based statements similar to other published OA guidelines , with adaptations to suit local conditions. For example, advice about squatting had to be tampered with sensitivity about the nature of toilet facilities in the rural community, and about prayer habits amongst Muslims.

The MSR was also tasked by MoH with launching and promoting the CPGs and upgrading the skills of PCPs and hospital medical officers on OA management through workshops conducted in each health zone at least once a year. Participants are given pre- and post-course assessments to evaluate their knowledge and are provided with educational resources for their local communities, and they are enrolled into a database for ongoing contact. The courses are generally well received and attended by a significant number of participants. For example, in the South zone, about one-third of some 300 doctors in the region have attended the courses. With endorsement and funding support from MoH for education on MSK management, it is hoped that medical practitioners who have not attended the workshops will be aware of the MSK CPGs and will apply them in their daily practice. There are plans to produce more MSK CPGs.

Current status and continuing challenges

The Malaysian example highlights the value of partnerships between groups of healthcare providers to deliver important interventions. Together with tacit support from the government, funding and logistical support from the MoH and the work of ‘champions’ from the Malaysian Society of Rheumatology, guidelines for the management of major MSK conditions are developed through broad consensus and then systematically disseminated to frontline PCPs for implementation to benefit the people affected. One attractive aspect of this is that each individual group developing a CPG has ownership of the programme for a common condition that is important to their patients.

Although CME programmes for medical practitioners have been established, there are no evaluation processes at the workplace to determine whether knowledge gained is translated into practice and whether recommended practice standards are met. A survey of participants at the end of a gout CPG workshop showed improvement in participants’ knowledge about gout management; however, it is unknown whether this knowledge is retained or applied . Building workforce capacity of appropriately trained clinical nurses and allied healthcare professionals in Malaysia should also be a priority, as this would potentially strengthen interdisciplinary care—a key recommendation of contemporary MoCs for chronic MSK care . Initiatives for the primary prevention of MSK disorders would be very useful for dealing with the growing burden of MSK conditions. Education about risk factors and lifestyle measures like diet, weight loss, exercise and smoking are key self-management strategies as a component of MSK care.

Implementation practice points

Implementation of a national MoC for OA in Malaysia has been enabled through:

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  Commitment from a central national agency (MoH) to prioritise and support initiatives to improve management of common health conditions in Malaysia

  
  
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  A partnership approach to develop solutions to OA care (e.g. development of CPGs, as a component of a system-wide model of best practice care) between the government and a clinical speciality organization (MSR)

  
  
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  Dissemination of MoH-endorsed information to the healthcare workforce, coupled with clinical education

Singapore – the high-income city-state with an evolving integrated healthcare system

Singapore is an island city-state with a population of 5.54 million that has grown exponentially in the past decade, mainly through immigration. It has developed rapidly from a low-income economy at its independence in 1965 into a high-income economy that is ranked number two in the world, with a GDP of US $53,000 per capita ( Table 1 ) .

Since independence, the Singaporean healthcare system has developed to a high standard, with low infant mortality (2.5 per 1000 live births) and high life expectancy (85 years) . As an urban society with a relatively small population, Singapore has not faced the problems of the Philippines or Malaysia with providing specialist healthcare to remote or rural areas. In line with other rapidly developing nations, Singapore has a rapidly ageing population and an increasing NCD burden, including MSK conditions .

In the Singapore Burden of Disease Study 2010 , MSK conditions accounted for 6% of disease burden and were ranked the fifth leading cause of disability, similar to other developed regions in the world. Between 2004 and 2010, there was a 28.5% increase in MSK disease burden, with an associated 29.8% increase in disability burden and 7.1% increase in premature mortality burden. The 12th and 16th leading causes of overall disease burden in Singapore were RA and OA respectively. Unlike other countries, LBP and NP were not major contributors to disability. This is most likely due to under-reporting. Many physically demanding occupations are taken up by foreign workers rather than by Singaporean nationals, and as the healthcare of these foreign workers is often provided by the private sector, their health data may not be captured by the MoH.

Government expenditure on national healthcare is about 4.6% of GDP , which is low among developed countries. Financing of the public health system is based on a means-tested co-payment scheme, in which patients pay for their medical costs using cash payments or funds from Medisave, a mandatory medical savings programme, together with government subsidies. Singaporean patients also have access to Medishield, a medical insurance scheme that assists in payments for high-cost inpatient medical bills . Government healthcare centres (polyclinics) provide 20% of primary care and manage nearly half the load of chronic conditions . The remaining 80% of primary healthcare is provided by general practitioners (GPs) from the private sector.

During Singapore’s national development, government health policies and financial investments were mainly directed at the management of acute conditions including communicable diseases, by supporting the growth of public hospitals and national specialist centres that are largely independent of primary care. This resulted in a healthcare landscape favouring specialist and tertiary care, such that many patients’ medical conditions (e.g. inflammatory arthritis and other comorbid conditions) are managed solely by specialist outpatient clinics (SOCs) within public hospitals, with little or no integration with primary care . However, Singapore’s rapidly ageing population and increasing prevalence of NCDs, together with its recent rapid population growth, has resulted in current strained public sector resources, with long SOC waiting lists and frequently full inpatient bed occupancy levels.

In recent years, the Singaporean government has recognised the need for a paradigm shift from tertiary centre-based specialist care to community-based, person-centred healthcare, with integration of healthcare services across the disease continuum. The principle of ‘right-siting’ was adopted through the Chronic Disease Management Programme (CDMP), which aims to manage patients with stable chronic NCDs in primary care , consistent with health policy in other high-income economies. MSK conditions covered by this scheme are currently restricted to OA, RA, psoriatic arthritis (PsA) and osteoporosis. Funding is provided through the Community Health Assist Scheme (CHAS), which includes government subsidies that are portable to the private sector and allows patients to draw a capped amount per annum from their Medisave funds to assist with their outpatient attendance costs. Participating healthcare providers are expected to provide care to patients in line with current local CPGs and/or best available evidence-based practice and to monitor patient clinical outcomes. For some NCDs such as hypertension and diabetes mellitus, relevant clinical indicators are required to be reported to the MoH.

In order to develop an integrated healthcare system that remains cost-effective for government financing, Regional Health Systems (RHSs) were established, comprising partnerships between the public and private sector and involving tertiary hospitals, specialist centres, PCPs (GPs and polyclinics), acute and step-down care facilities (including community hospitals), nursing homes, home care providers, hospices and other social service providers.

The Singaporean MoH has enabled implementation of integrated healthcare services through a multi-pronged approach:

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  Controlling public service costs through linkage of public hospital services with other public and private sector (including NGO) healthcare services, including step-down inpatient rehabilitation care, day care centres and community health services

  
  
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  Improving coordination of healthcare by different providers through sharing of information tools such as the National Electronic Health Record (NEHR), a nationwide electronic integrated patient health record from all public hospitals and polyclinics; CPGs and clinical pathways developed in consultation with relevant Colleges from the Singaporean Academy of Medicine, and health promotion mobile applications for patients

  
  
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  Health surveillance of NCDs through national disease registries

  
  
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  Mandatory reporting by service providers of clinical indicators for certain NCDs to MoH to facilitate audits of clinical practice standards

Table 3 summarises the models of MSK service delivery that have been implemented within the Singaporean health system, including barriers and enablers .

Table 3

Singaporean MSK Models of Service Delivery.

Programme	Description	Implementation details
National University Health System (NUHS) RHS Shared Care Programme	Public-private sector shared care model – Shared care between rheumatologists NUH (public hospital) and GPs in private sector – Initiation of shared care by rheumatologist with GP for stable MSK diseases MSK conditions – RA – Gout – SpA (including PsA) – Sjögren’s syndrome – Systemic lupus erythematosus (SLE)	Enablers – Participation by willing rheumatologists, GPs and patients – Upgrading of the skills of GPs in MSK disease management through attendance at NUH Rheumatology Clinics – Patient access to subsidised medications at NUH – Workflow processes and care coordination by dedicated case manager – Funding of GP visits through CHAS subsidies & CDMP – Endorsement by NUHS RHS management – Guidance in clinical management by rheumatologist and easy access to rheumatologists for GPs in programme – RA and PsA GP programme evaluation using CDMP clinical indicators Barriers – Poor participation by PCPs in public sector (polyclinics) due to heavy workloads and unfamiliarity with disease-modifying drugs – Limited CHAS/CDMP funding and limited patient access to Medisave funds – Restricted MSK conditions claimable for government subsidies – i.e. RA & PsA – Patient reluctance to transfer to shared care model – Lack of clinical indicators and GP programme evaluation for MSK conditions other than RA and PsA
National Healthcare Group (NHG) Community Right-Siting Programme (CRiSP)	Public-private sector partnership model – Partnership between specialists at TTSH (public hospital) and GPs in private sector – GP access to government-subsidised medications and investigations at TTSH MSK conditions – Knee OA – Osteoporosis	Enablers – GP access to subsidised medications, investigations and patient electronic health records at TTSH – Funding of GP visits by CHAS and CDMP – OA Programme evaluation using CDMP clinical indicators – Care co-ordination by dedicated case managers – Endorsement by NHG RHS management Barriers – Limited GP interest in programme – Insufficient CHAS/CDMP funding and limited patient access to Medisave funds – Lack of direct GP access to subsidised allied health professional services at TTSH e.g. physiotherapy and dietetic services
SingHealth Rheumatology Monitoring Clinic (RMC)	Public sector MSK multidisciplinary model – APN and pharmacist-led clinics within the SGH Rheumatology Department – DMARD monitoring for patients with stable disease MSK conditions – RA – SpA	Enablers – Participation by willing rheumatologists and patients – Continuity of care – patient review by rheumatologists on alternate visits – Clinical treatment algorithm for DMARDs – Regular supervision of APN and pharmacist by rheumatologist – Endorsement by SingHealth RHS management – Accreditation by SGH Clinical Governance Board for prescribing privileges – Research opportunities for APN and pharmacist – Internal department audit of RMC work processes Barriers – Lack of APNs and pharmacists
The Good Life Cooperative OA Knee Programme	Public-private sector partnership primary prevention model – Partnership between private preventive healthcare group, and local public housing estate community services – Knee OA screening programme comprising public education lectures and identification of potential participants through questionnaires MSK condition Knee OA	Enablers – Endorsement by local town council and Member of Parliament – Volunteer services by local physiotherapists for exercise programmes – Volunteer services of local grassroots organisations to bring local residents to attend programme – Conducting screening programme as part of community public forum for other conditions – Low cost model Barriers – Lack of funding support – Reliance on volunteer services for logistics and intervention programmes – Lack of suitably trained volunteer healthcare professionals at other housing estates – Requirement for endorsement by local town councils and other community services

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