The burden of disease of musculoskeletal (MSK) conditions is a global priority

The burden of disease of musculoskeletal (MSK) conditions at a global level is well established, evidenced most recently through the Global Burden of Disease (GBD) studies where the disability burden attributed to MSK conditions was observed to be enormous; exceeding all non-communicable diseases (NCDs) other than mental health and behavioural disorders . These data point to the upward trajectory of prevalence and escalating personal and societal impacts of MSK conditions and persistent pain across the life course, further reinforced by recent nation-specific whitepapers and seminal reports . Against a background of significantly reduced quality of life, function and mental wellbeing, a major human capital consequence of impaired MSK health is reduced workforce participation and early retirement . Reduced participation has significant downstream consequences for retirement wealth for the individual, and upstream consequences for government, such as reduced taxation revenue and increased welfare payments in many nations . In the context of low- and middle-income economies and subsistence communities, MSK-related disability results in reduced capacity for work participation and therefore a critical threat to livelihoods. Importantly, while communicable diseases remain a large driver to disability-adjusted life years in low- and middle-income economies, the recent GBD data point to an increasing burden of NCDs, particularly MSK conditions, in low- and middle-income economies . In this context, addressing the burden of disease for MSK conditions across economies and across the life course, and their unifying feature of persistent or recurrent pain, is indeed an urgent global priority . Lim et al. (Chapter 3) explore the burden of disease challenges in low- and middle-income Asian economies. Approaching pain from a contemporary pain science perspective is also a priority for improving pain care.

The scale of the MSK burden and its sequelae present major challenges to which nations need to adequately respond. Although the World Health Organisation (WHO) has developed a guide for nations to assess their policy and programme capacity to respond to NCDs, the guide considers only cancer, lung diseases, diabetes and cardiovascular disease . Similarly, the WHO 2013–2020 Global Action Plan for the Prevention and Control of Non-Communicable Diseases focuses on cardiovascular diseases, cancer, chronic respiratory diseases and diabetes, although MSK conditions remain within its scope. Recently, the European Region of the WHO released an action plan for the prevention and control of NCDs in the WHO European Region. For the first time, this Plan included musculoskeletal health as a priority intervention area . Support for nations to develop and sustainably implement system response capacity is needed. This issue of the journal tackles these challenges across different economic and care settings to provide readers with evidence-informed, practical guidance.

Big problems need big solutions

MSK health outcomes are influenced by a range of factors: health system and public health factors ( macro level), service delivery factors ( meso level) and clinician and consumer behaviours ( micro level) ( Table 1 ). These factors are discussed further in detail across the various chapters in this issue of the journal. Despite a large volume of evidence for ‘what works’ to address MSK health impairments and their sequelae, these evidence-based strategies are inadequately applied in practice by health providers , inadequately integrated into lifestyle behaviours by health consumers and featured in health policy and health service delivery objectives at a level grossly incommensurate with the burden of disease . To effectively and sustainably address the burden of disease of MSK conditions, a multi-level response is required, where macro-, meso-, and micro-level factors need to be considered in an integrated manner . As outlined in the various chapters in this issue of the journal, a multi-level response is necessarily a complex intervention that demands a cross-sector, multi-disciplinary and a partnership-driven approach, supported, where feasible, by governments. Here, Models of Care (MoCs) provide one possible vehicle to drive effective change .

What are they?

An MoC is an evidence-informed policy or framework that outlines the optimal manner in which condition-specific care should be made available and delivered to consumers at a system level. An MoC aims to describe the principles of care for a given condition (the ‘what’) as well as guidance on how those principles could be implemented in a local setting (the ‘how’). MoCs aim to address current and projected community needs in the context of local operational requirements. The guidance provided is coined as “the right care , delivered at the right time , by the right team , in the right place , with the right resources ” . MoCs are used as a facilitator to bridge the gap between evidence for what works (or does not work) in care delivery and practice, by describing not only what to do but critically also how to do it within a health system, considering the macro, meso and micro levels. Here, an important distinction is that an MoC is not a clinical practice guideline. Rather, MoCs complement clinical practice guidelines by serving as a guide to describe how best evidence for the delivery of MSK care can be implemented as a sector-wide Model of Service Delivery by clinicians, consumers and health systems across the disease continuum, while considering practicalities of the local environment. A Model of Service Delivery is not the same as an MoC. A Model of Service Delivery operationalises the MoC and describes in detail how a given MoC is to be implemented in a local setting or health service at the operational level. A Model of Service Delivery is therefore the next step in the implementation continuum ( Fig. 1 ).

Schematic of the continuum between identifying a complex health problem and implementing best practice care within a local setting. The MoC provides principle-level guidance on what care and how to implement it, while the Model of Service Delivery operationalises these principles into local operational activity, informed by an implementation plan.

How are MoCs developed?

The approach to develop an MoC will necessarily vary between sociocultural settings – what is appropriate and feasible in low-income Asian economies, for example, will not be the same as high-income European economies. These issues are considered in detail in Chapters 2 and 3. Consistent with contemporary principles of implementation science , MoCs are ideally developed using multi-stakeholder input, and importantly, meaningful involvement of consumers and carers, as highlighted in Chapter 4. These principles apply not only to developing strategies for MSK care but also to all NCDs and apply across sociocultural and economic settings . The diversity and scope of the stakeholders involved will vary according to the clinical issue being addressed, and will be further informed by how the local health system operates and related political considerations. In Australia, for example, a centrally coordinated health network model is used in some jurisdictions , with established effectiveness . Critically, given the increasing global attention towards the development and implementation of MoCs, there is a need to apply some level of standardisation to the development, implementation and evaluation of MoCs to enable benchmarking and accumulation of a comparable web of evidence regarding effectiveness. Indeed, this is one of the priorities of the Global Alliance for Musculoskeletal Health of the Bone and Joint Decade ( http://bjdonline.org/ ). In this regard, an internationally informed framework to support the development, implementation and evaluation of MoCs has recently been developed with relevant representation from high-, middle- and low-income economies .

How are MoCs used in practice?

MoCs can be used to improve MSK care outcomes at macro, meso and micro levels by influencing policy and health strategy priorities, resourcing and health governance decisions (macro factors); service design and workforce capacity building initiatives (meso factors); and consumers’ participation in care and clinicians’ practice behaviours (micro factors). In this regard, the Australian experience has been positive, where a number of MoCs and service frameworks have been developed collaboratively , and continue to be developed, monitored and iterated across jurisdictions. These MoCs have been instrumental in advocating for and initiating service improvement programmes for a range of conditions, for example, persistent pain , rheumatoid arthritis , osteoarthritis and secondary osteoporotic fracture prevention . At the international level, we have recently reviewed MoCs for persistent pain, rheumatoid arthritis, osteoarthritis, osteoporosis and MSK injury and trauma , while Hoy et al. have considered the application of MoCs in practice in low- and middle-income economies . Unlike in high-income settings, they and other authors , recommend approaching policy and programme initiatives for MSK health in an integrated health manner that is not condition specific. Rather than a disease-specific or ‘vertical’ approach taken in high-income settings (e.g., Chapters 2, 8 and 9), this integrated approach better supports whole-of-system strengthening and minimises threats of fragmentation and short-lived initiatives. Nonetheless, some condition-specific initiatives such as the World Spine Care (WSC) programme (discussed further in Chapter 10), appear to have potential but are notably supported by resources from high-income economies , and therefore in some contexts may not align optimally with the principles of development effectiveness for long-term sustainability .

What are they?

An MoC is an evidence-informed policy or framework that outlines the optimal manner in which condition-specific care should be made available and delivered to consumers at a system level. An MoC aims to describe the principles of care for a given condition (the ‘what’) as well as guidance on how those principles could be implemented in a local setting (the ‘how’). MoCs aim to address current and projected community needs in the context of local operational requirements. The guidance provided is coined as “the right care , delivered at the right time , by the right team , in the right place , with the right resources ” . MoCs are used as a facilitator to bridge the gap between evidence for what works (or does not work) in care delivery and practice, by describing not only what to do but critically also how to do it within a health system, considering the macro, meso and micro levels. Here, an important distinction is that an MoC is not a clinical practice guideline. Rather, MoCs complement clinical practice guidelines by serving as a guide to describe how best evidence for the delivery of MSK care can be implemented as a sector-wide Model of Service Delivery by clinicians, consumers and health systems across the disease continuum, while considering practicalities of the local environment. A Model of Service Delivery is not the same as an MoC. A Model of Service Delivery operationalises the MoC and describes in detail how a given MoC is to be implemented in a local setting or health service at the operational level. A Model of Service Delivery is therefore the next step in the implementation continuum ( Fig. 1 ).

Schematic of the continuum between identifying a complex health problem and implementing best practice care within a local setting. The MoC provides principle-level guidance on what care and how to implement it, while the Model of Service Delivery operationalises these principles into local operational activity, informed by an implementation plan.

How are MoCs developed?

The approach to develop an MoC will necessarily vary between sociocultural settings – what is appropriate and feasible in low-income Asian economies, for example, will not be the same as high-income European economies. These issues are considered in detail in Chapters 2 and 3. Consistent with contemporary principles of implementation science , MoCs are ideally developed using multi-stakeholder input, and importantly, meaningful involvement of consumers and carers, as highlighted in Chapter 4. These principles apply not only to developing strategies for MSK care but also to all NCDs and apply across sociocultural and economic settings . The diversity and scope of the stakeholders involved will vary according to the clinical issue being addressed, and will be further informed by how the local health system operates and related political considerations. In Australia, for example, a centrally coordinated health network model is used in some jurisdictions , with established effectiveness . Critically, given the increasing global attention towards the development and implementation of MoCs, there is a need to apply some level of standardisation to the development, implementation and evaluation of MoCs to enable benchmarking and accumulation of a comparable web of evidence regarding effectiveness. Indeed, this is one of the priorities of the Global Alliance for Musculoskeletal Health of the Bone and Joint Decade ( http://bjdonline.org/ ). In this regard, an internationally informed framework to support the development, implementation and evaluation of MoCs has recently been developed with relevant representation from high-, middle- and low-income economies .

How are MoCs used in practice?

MoCs can be used to improve MSK care outcomes at macro, meso and micro levels by influencing policy and health strategy priorities, resourcing and health governance decisions (macro factors); service design and workforce capacity building initiatives (meso factors); and consumers’ participation in care and clinicians’ practice behaviours (micro factors). In this regard, the Australian experience has been positive, where a number of MoCs and service frameworks have been developed collaboratively , and continue to be developed, monitored and iterated across jurisdictions. These MoCs have been instrumental in advocating for and initiating service improvement programmes for a range of conditions, for example, persistent pain , rheumatoid arthritis , osteoarthritis and secondary osteoporotic fracture prevention . At the international level, we have recently reviewed MoCs for persistent pain, rheumatoid arthritis, osteoarthritis, osteoporosis and MSK injury and trauma , while Hoy et al. have considered the application of MoCs in practice in low- and middle-income economies . Unlike in high-income settings, they and other authors , recommend approaching policy and programme initiatives for MSK health in an integrated health manner that is not condition specific. Rather than a disease-specific or ‘vertical’ approach taken in high-income settings (e.g., Chapters 2, 8 and 9), this integrated approach better supports whole-of-system strengthening and minimises threats of fragmentation and short-lived initiatives. Nonetheless, some condition-specific initiatives such as the World Spine Care (WSC) programme (discussed further in Chapter 10), appear to have potential but are notably supported by resources from high-income economies , and therefore in some contexts may not align optimally with the principles of development effectiveness for long-term sustainability .

Implementation approaches across high-income economies

Implementation approaches will, necessarily, vary according to setting or context . The chapters within this themed issue of the journal demonstrate this well, particularly the differences in approaches adopted in high-income economies compared with low- and middle-income economies (Chapters 2, 3, 8 and 9) and the nuances of the compensation environment (Chapter 5). High-income economies tend to have a greater capacity to plan and execute health reform at a system level because of greater resourcing, more stable governance arrangements and delineation across components of the health systems, population health surveillance capabilities, and more human capacity to undertake policy development and implementation within relatively stable political systems. This greater capacity, however, is sometimes offset with less agility to enact change at a local level, particularly in highly regulated care settings such as the compensation environment, as discussed in detail by Beales et al. (Chapter 5). Key drivers of implementation successes of MoCs in high-income economies seem to be based on a foundation of health policy that articulates with the MoC, thereby providing a platform for coordinated action by government and other organisations. Such policies might include chronic disease management frameworks, primary prevention frameworks, care integration strategies, workforce capacity building and role delineation plans and so on, and directly enable implementation of components of MoCs. Mitchell et al. (Chapter 9) provide a comprehensive commentary on these issues as they relate to fracture liaison services for secondary osteoporotic fracture management and orthogeriatric services, while Allen et al. (Chapter 8) provide a comprehensive commentary as it relates to osteoarthritis care. On a background of this system-based policy, high-income economies often have capacity to establish pilot studies or undertake formative evaluations of MoCs. Often, these health service, pragmatic evaluations of implementation stem from primary efficacy studies such as randomised controlled trials (RCTs). Translation of RCT findings into an upscaled, real-world, health service implementation initiative appears to be an effective approach to implementation of MoCs in high-income settings. Dziedzic et al. (Chapter 2) provide examples of this approach as they relate to osteoarthritis and low back pain care in the United Kingdom. Such upscaling, however, demands a theory-driven approach to implementation or behaviour change, such as that captured by the Consolidated Framework for Implementation Research (CFIR) or the Behaviour Change Wheel . Beales et al. (Chapter 5) describe the application of the CFIR in practice in a compensable environment.

A critical aspect of implementation in these settings is purposeful and thorough cross-sector engagement consultation of a range of stakeholders (e.g., clinicians, consumers, carers, policymakers, insurers and non-government organisations) and the support of clinician and administrative champions. The latter support may be provided through non-government organisations, research groups, government bodies or professional bodies. Regardless of the support mode, coordination and support from a central agency are critical . This concept of central agency support extends beyond single jurisdictions. For example, the highly successful and global approach to fragility fracture care, Capture the Fracture ^® , has been facilitated through the development and promotion of a Best Practice Framework, which articulates standards for fracture liaison services and benchmarks international services . The International Osteoporosis Foundation supports the programmes, such as the Best Practice Framework and an international programme committee, to evaluate health services and support implementation of care standards (refer to Chapter 9 for further detail).

Implementation approaches in high-income settings must be coupled with evaluation, ensuring that outcomes are meaningful to system administrators and consumers, which requires measurement of both system-based (e.g., economic) and patient-reported (e.g., function) outcomes. At a service delivery level in high-income settings, MSK disease MoCs need to better align with a contemporary understanding of pain biology and better articulate the need for care integration given the common co-morbidities associated with MSK pain, including mental health conditions such as depression and anxiety . Mostly, these components of care are considered disparately (for example, in osteoarthritis care), rather than integrated, leaving the service fragmented and consumers failing to receive holistic, best-practice care that addresses the biological, psychological and social components of their health state. Both Beales et al. (Chapter 5) and Allen et al. (Chapter 8) discuss this barrier to best-practice pain co-care in the contexts of compensable MSK injuries and osteoarthritis care, respectively.

Implementation approaches in low- and middle-income settings in Asia

Care of MSK conditions in Asian low- and middle-income countries is severely limited by significant lack of funding resources and specialty-trained workforce capacity. Prioritisation of government healthcare funding is generally directed towards communicable diseases and other NCDs associated with higher mortality, such as cardiovascular diseases, diabetes mellitus and cancer. MSK conditions represent a low healthcare priority, and there is a lack of awareness of the increasing disease burden and cost to the economy. Scarce resources have resulted in government policies focussing on primary care and prevention of these diseases, often with little or no integration with specialist care. Through the Community Oriented Program for Control of Rheumatic Disease (COPCORD) project, epidemiological data have been gathered on the burden of pain, arthritis and disability in developing economies, through community surveys in rural areas (see http://copcord.org/publications.asp and Chapter 3). The COPCORD project, in particular, has helped to identify the magnitude of the burden for MSK conditions in these countries. In the Philippines, a low-income country, the Applied Rheumatology Made Simple (ARMS) programme is an educational programme developed by local specialist societies and funded by non-government organisations (an international specialist society and a pharmaceutical company) that has successfully built medical workforce capacity. This was achieved through education of primary care providers on MSK conditions and developing a shared-care model together with specialists from local clinical networks. The programme has also added workforce capacity through training of patients to be educators of their own diseases. More detail is provided in Chapter 3. In Malaysia, a middle-income country, a different approach to workforce capacity building has been taken through partnership of the Ministry of Health with specialist societies. For example, the osteoarthritis clinical practice guidelines were developed by the Malaysian Society of Rheumatology and workshops to upskill regional and rural medical staff are conducted with active support from the Ministry of Health through endorsement, logistical support and funding. Both the Filipino ARMS programme and the Malaysian osteoarthritis clinical practice guideline workshops highlight the critical importance of partnerships between government, private funders and other special interest groups to improve care for MSK conditions. Furthermore, government recognition and prioritisation of MSK conditions are key factors for developing appropriate MoCs. However, the evaluation of the efficacy of these programmes in improving patient outcomes is limited to participants’ pre- and post-course knowledge. A system-wide evaluation of clinical practice standards would require further resources, which may not be feasible in low-to middle-income countries. Hoy et al. advocate a multi-pronged approach to the development of MSK MoCs to ensure effectiveness of these initiatives . This approach involves:

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  active ownership and participation by local communities ;

  
  
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  alignment of MSK MoC initiatives with existing priorities and policies such as national health strategies;

  
  
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  harnessing research, information and evidence to inform MoC development and implementation;

  
  
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  inclusion of performance indicators to monitor and evaluate the MoCs ;

  
  
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  integration of MoCs across existing health systems;

  
  
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  financial transparency and accountability related to development and implementation of MoCs with organisational and funding partners;

  
  
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  informing and engaging policymakers and leaders to develop and implement policies and legislation for the prevention of and management of MSK conditions and injuries; and

  
  
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  appropriate resource allocation for MSK MoCs (development, implementation and evaluation components) .

To ensure sustainability of these initiatives, local “champions” of MSK MoC implementation are required, consistent with the approach in high-income settings. These could include individuals involved in the education and mentoring of trainees, as well as those involved in research to develop a research agenda appropriate to local conditions.