Abstract
With musculoskeletal conditions now identified as the second highest cause of the morbidity-related global burden of disease, models of care for the prevention and management of disability related to musculoskeletal conditions are an imperative. Musculoskeletal models of care aim to describe how to operationalise evidence-based guidelines for musculoskeletal conditions and thus support implementation by clinical teams and their health systems. This review of models of care for musculoskeletal pain conditions, osteoarthritis, rheumatoid arthritis, osteoporosis and musculoskeletal injuries and trauma outlines health system and local implementation strategies to improve consumer outcomes, including supporting access to multidisciplinary teams, improving access for vulnerable populations and levering digital technologies to support access and self-management. However, the challenge remains of how to inform health system decision-makers and policy about the human and fiscal benefits for broad implementation across health services. Recommendations are made for potential solutions, as well as highlighting where further evidence is required.
Introduction
The perceived burden of disease attributed to chronic musculoskeletal conditions and the sequelae from musculoskeletal injury and trauma have been lower relative to other diseases more closely associated with mortality, such as cancer, kidney disease and ischaemic heart disease. However, the emerging evidence now unequivocally and consistently identifies the profound prevalence, socio-economic impact and burden of disease imposed by chronic musculoskeletal conditions and their associated pain burden and functional impairments. These outcomes are particularly relevant in conditions such as osteoarthritis (OA), rheumatoid arthritis (RA), osteoporosis (OP) and pain of musculoskeletal origin, especially low back pain .
In the most recent Global Burden of Disease Study, musculoskeletal conditions including RA, hip and knee OA, low back and neck pain, gout and other musculoskeletal disorders represented the second highest burden of disease globally, when expressed as years lived with disability – an index representing morbidity. At the condition level, low back pain was the leading global cause of years lived with disability across all 289 diseases and injuries examined . Even when mortality was considered with morbidity (expressed as disability-adjusted life years), the burden of disease for musculoskeletal conditions was still substantial, representing the fifth highest condition group . In developed nations, however, this ranking is substantially higher owing to a greater disease burden attributed to morbidity rather than mortality. Even more striking are the projections for the future burden of disease associated with musculoskeletal conditions. For example, a recent Australian socio-economic impact report based on Australian Health Survey data conservatively estimated that the prevalence of cases of musculoskeletal conditions will soar by 43% by 2032 . Population modelling suggests that although the steepest trajectory will be in cases of OA (58%), the greatest absolute number of people will live with chronic back problems. More recent estimates of the projection of osteopenia and OP in Australia highlight a striking 31% increase in the number of Australians affected by these conditions by 2022 .
Despite the identified burden of musculoskeletal conditions, a substantial burden–service gap persists in most developed nations. Not only is the access to care variable according to geography, ethnicity and socio-economic status, thus creating care disparities , but also the delivery of care from practitioners and health systems inadequately aligns with the best available evidence for what works . The burden–service gap is not easily solved as it is driven by a myriad of complex interdependencies at multiple levels: macro (health systems, organisations, health policy and socio-economic factors), meso (delivery systems, infrastructure and the volume and competencies and training of health practitioners) and micro (participation by consumers in co-care of their conditions). Access to, and delivery of, care is further complicated by the chronicity of musculoskeletal conditions. Health-care systems in developed nations are oriented towards acute care services and respond to mortality risk rather than long-term morbidity associated with musculoskeletal conditions and their co-morbidities, which stymies opportunities for service development. A fundamental change in the manner in which health-care systems and services are planned, implemented, delivered and evaluated is therefore needed to address disability associated with musculoskeletal ill health.
Models of Care (MoCs) can help to address the burden–service gap in musculoskeletal health . A MoC is an evidence-informed strategy, framework or pathway that outlines the optimal manner in which care for specific types or groups of conditions should be made available and delivered to consumers. A MoC aims to include contemporary evidence with a framework to meet the current and projected community need, in the context of local operational requirements . Importantly, a MoC is not a clinical practice guideline. While a high level of evidence, such as that contained in clinical practice guidelines, should underpin a MoC, the fundamental purpose of a MoC is to operationalise ‘what works’ into practice, rather than to appraise and to grade evidence and develop specific clinical practice recommendations . MoCs may address service planning, implementation, delivery and evaluation at multiple levels, according to the contextual factors associated with the condition and with the intended implementation environment. While MoCs are increasingly accepted as a contemporary vehicle to drive evidence into practice; for example, in Australia , a review of MoCs for musculoskeletal health conditions and injury and trauma has not been undertaken at an international level. Therefore, the aim of this chapter was to convene a multidisciplinary, international team to analyse this knowledge gap for specific musculoskeletal conditions including chronic pain of musculoskeletal origin, OA, RA, OP and musculoskeletal injury and trauma. We sought to provide an overview of current MoCs for these specific conditions across care settings and to offer recommendations for future policy and practice initiatives that reduce the burden–service gap for consumers with, or at risk of, musculoskeletal conditions.
Methods
A narrative review was undertaken of peer-reviewed published literature and relevant grey literature relating to MoCs for the suite of relevant musculoskeletal conditions and injuries. Search terms relevant to each of the specific conditions (chronic pain of musculoskeletal origin, OA, RA and OP) and musculoskeletal injury and trauma were developed and used in scholarly databases to identify published literature. Relevant grey literature was identified through Internet searches and knowledge of the international team. Writing groups followed a structured approach to review and synthesise literature relating to MoCs, and these findings are presented in Section C.
Methods
A narrative review was undertaken of peer-reviewed published literature and relevant grey literature relating to MoCs for the suite of relevant musculoskeletal conditions and injuries. Search terms relevant to each of the specific conditions (chronic pain of musculoskeletal origin, OA, RA and OP) and musculoskeletal injury and trauma were developed and used in scholarly databases to identify published literature. Relevant grey literature was identified through Internet searches and knowledge of the international team. Writing groups followed a structured approach to review and synthesise literature relating to MoCs, and these findings are presented in Section C.
MoCs for musculoskeletal conditions
Chronic musculoskeletal pain
Epidemiology and impact
Chronic musculoskeletal pain (CMP) is one of the most common reasons that people seek medical help, is costly, and yet still goes under-recognised and under-treated. The health and economic burdens associated with CMP are substantial for health consumers and for society . The scale of chronic pain is enormous, affecting the lives of one in five people globally including children and adolescents, with CMP contributing a significant proportion of this burden . People living with CMP face a constant daily struggle to affirm their self, confront stigma, reconstruct a sense of self through time, find an explanation, navigate the health-care system and prove legitimacy. The impact of CMP on the individual consumer is further exacerbated by an increase in prevalence of co-morbidities such as anxiety, depression and decreased physical and mental functioning .
Management of CMP
Although not everyone with musculoskeletal conditions experiences CMP, it is those with chronic pain and high disability who consume the most resources and who carry the most substantial burden . In this population, the management of pain and disability is less than optimal. Chronic pain, defined as “pain without apparent biological value that has persisted beyond the normal tissue healing time (usually taken to be three months),” is a multidimensional process not only affecting sensory and emotional processing but also producing an altered brain state considered by some as representing a chronic degenerative disease. The mechanisms underlying chronic pain include a complex interaction of physiological, emotional, cognitive, social and environmental factors highlighting the need for integrated care delivered through MoCs that address these multidimensional aspects of the lived experience of pain.
Overall, the present treatment options for CMP result in modest improvements at best , highlighting the crucial need for assessment of the effectiveness of combination (multimodal) treatments appropriate to the individual. These include early intervention, identification of indicators of treatment response and the use of risk classification strategies . Further, as the complexity of CMP is poorly understood across the community, and by educators, researchers and trainee and trained health professionals alike, obtaining timely, integrated, effective, evidence-informed care is challenging. Care disparities result, but these may be amenable to policy shifts that promote team management, support consumers with the knowledge and skills to take an active role in their care and implement digital technologies to overcome access difficulties attributed to geography .
The burden of chronic pain associated with musculoskeletal disorders can, however, be substantially reduced when available evidence-based management is implemented . Health and economic benefits of best-practice care have been highlighted by the Societal Impact of Pain Group Report on Pan-European health policy initiatives , innovative Australian models and systematic reviews such as that by Lin and colleagues . In this context, the adoption of a biopsychosocial approach using evidence-informed interventions is consistently recommended . This approach provides a useful clinical framework for addressing the multidimensional nature of CMP and making sense of the variable and often incongruent relationship between pain severity, physical pathology findings and disability. Multidimensional domains are addressed using multimodal approaches tailored to the individual, including self-management support strategies, psycho-education (neurophysiology of pain), use of active strategies such as pacing (time-contingent graded activity), behavioural approaches to pain (e.g., addressing catastrophising, distress, unhelpful beliefs and fear-avoidance behaviours), and active movement-based strategies. These may need to be combined with pharmacologic and interventional procedural options, as appropriate . The integrative biopsychosocial approach is ideally delivered by an inter-professional team with the consumer being a key team member .
MoCs for CMP
Given the breadth of CMP and its relevance to other condition-specific foci in this chapter, here we address the development and implementation of MoCs from a health systems’ perspective. Developing innovative MoCs based on a contemporary perspective of CMP and aligning these MoCs with a skilled workforce, and building capacity for co-management by consumers, are widely acknowledged as being essential to the sustainable delivery of best-practice musculoskeletal pain management . Cross-sector engagement and collaboration is critical for the implementation of best-practice MoCs for CMP. The frameworks for the implementation of MoCs range from health networks to regionally coordinated hub and spoke models (British Colombia Pain Initiative, Canada) and province-wide networks (Nova Scotia Chronic Pain Collaborative Network ( http://communitypainnetwork.com/ )) ( Table 1 ). Frameworks that align evidence, policy and practice can facilitate the implementation of integrated, high-quality services by multidisciplinary and multi-agency teams as a standard feature of care . For example, in Australia, Health Networks in Western Australia and New South Wales have provided a sustainable mechanism to engage consumers, carers, clinicians and other stakeholders; provided a forum to exchange ideas, information and evidence; and collaboratively plan and deliver evidence-based and contextually appropriate health system improvements for consumers with musculoskeletal pain . The Western Australian Spinal Pain MoC has been developed, implemented and evaluated using this framework across care settings .
QoL: quality of life; ED: emergency department; QALY: quality-adjusted life year
| Pain MoC | Where | What (components of model) | Who | How | Outcome (where reported) |
|---|---|---|---|---|---|
| Kaiser Permanente, USA: Oregon and Washington a | Initially 14 primary care sites (GP clinics) |
| Pain management team (social worker trained in mental health, physiotherapist, pharmacist, nurse) | Specialist nurse triage: pathways to: primary care medical care tertiary care |
|
| Calgary Health Region Chronic Pain Program a | Regionally coordinated hub and spoke model; Primary care (max 6 months before on-referral to tertiary) Tertiary care |
| Comprehensive inter-professional team (medical, allied health): Primary care: nurse-led, physiotherapist, pharmacist, behavioural health consultant | Referral by GP; The Chronic Pain Centre has joined the Calgary Zone: Central Access and Triage project | No data available |
| Nova Scotia, Canada Chronic Pain Collaborative Care Network a | Province wide network Primary care (collaborative emergency centres collaborative care clinics, and community health centres) Secondary care Tertiary care |
| Collaborative interdisciplinary team (different in different communities): doctors, nurse practitioners, family practice nurses, paramedics, midwives and/or mental health workers. | Triage system |
|
| British Colombia Pain Initiative, Canada a | Regionally coordinated hub and spoke model; Alignment of pain services with integrated primary care networks |
| Inter-professional | Organised referral system | No data available |
| Pain Collaboration and Exchange initiative, South Hampton, United Kingdom a | Primary care based with service redesign based on chronic disease management principles |
| Inter-professional | Triage strategy (stratification done by non-medical members of team) Aim: clinically appropriate specialist-led care within 18 weeks from initial referral |
|
| Sheffield Back Pain, United Kingdom b | Primary care based |
| Inter-professional | 1. Referral process (Primary care physician) 2. Risk stratification (STarT tool: 1-min self-check) 3. Simplified two item screen for other musculoskeletal problems (hip, knee, foot and ankle, hand and elbow, shoulder) | No data available |
| Chronic Pain Scotland Service Model c | Primary care-based Community settings |
| Integrated multidisciplinary teams in community settings carry protocol-led triage with onward referral to most appropriate service | Self-referral; centralised referral management system to expert physiotherapy advice to reduce primary care physician consultation rates and speed up referral for orthopaedic surgery | No data available |
| Hunter Integrated Pain Service, New South Wales, Australia d | Regional city; tertiary and primary care |
| Interdisciplinary | Referral and triage with standardised screening questionnaire; | No data available |
| The STEPS model Perth, Western Australia | Metropolitan tertiary initially; now many other sites including in primary care |
| Interdisciplinary | Referral from any health professional to service Triage with capture of standardised data across all pain dimensions |
|
| Pain Management Research Institute, Royal North Shore Hospital, Sydney Australia | Tertiary |
| Multidisciplinary | Referral and triage | Data are collected. Average levels of depression pre intervention were moderate to severe and fell to mild levels at post intervention. No other data accessible. |
| Integrated Managed Care Company, Germany e [Collaboration with German Pain Association and National Compulsory Health Insurer] | Multi centres |
| Interdisciplinary | Referral from specialised case managers | 7627 patients were allocated to 36 centres; 5751 patients participated in the treatment period; 52.6% were back to full-time work after 4 weeks; non-responders underwent another 4-week programme with a success rate of 81.1%. The one-year-follow-up of the QoL showed good sustainability |
| Swedish National Rehabilitation Guarantee e | The programme is generating opportunities for closer collaboration between Swedish Country Councils, primary health care centres, and universities. |
| Interdisciplinary | Patients with mental illnesses and pain in neck and back, who were already off sick or were at risk of sick leave. | Currently, 24 projects are running all over Sweden. Results will be available early 2015. |
| Netherlands e | University-based comprehensive multispecialty spine centre |
| Interdisciplinary team of medical and non-medical specialists derived from 7 departments | Referral to the centre | On referral to the spine centre, 35% worked, at discharge 60% and at 3 months follow-up 77% were working again. The mean cost per patient in this centre is € 1123, with a cost/benefit estimate of € 0.22 (cost/added QALY € 1123/€ 5000). |
a Adapted from National Pain Strategy and Cousins 2009, ‘Australian National Pain Summit: Fact finding visits to USA, Canada, UK – Report on key findings and associated resource materials’, available at www.painsummit.org.au/news .
b http://www.sheffieldbackpain.com/ .
c The Scottish Government Health Delivery Directorate, Improvement and Support Team, Long Term Conditions Collaborative Improving Care Pathways, The Scottish Government, Edinburgh 2010 (appendix 3) http://chronicpainscotland.org/patients-area/living-well-with-chronic-pain/ .
d http://www.hnehealth.nsw.gov.au/pain .
Service delivery inversion for CMP
A further example of opportunity afforded through a network model is the initiation of a system inversion in service delivery for pain (including CMP) management in Western Australia. In this model, inter-professional consumer group education sessions are delivered prior to individual practitioner appointments. The MoC has delivered reduced wait times and costs at public pain medicine units and increased use of active pain management strategies by consumers with fewer requiring individual consultations . Given the alignment with policy, this MoC has recurrent resourcing and has now been adopted in a number of primary care sites throughout Australia.
Risk identification in primary care settings and articulation with tertiary and specialist care
Primary care-based MoCs that articulate with tertiary centres are becoming more common and most involve triage systems with risk stratification and tiered management. For example, The Sheffield Back Pain model ( http://www.sheffieldbackpain.com/ ) focuses on early recognition of the risk of progression to chronicity by using a validated risk stratification tool (the STarTBack screening tool ). Intervention approaches are matched to the complexity of an individual’s symptoms with tools for primary care practitioners to manage low-risk back pain, while there are also triggers for referrals to multidisciplinary care for high-risk consumers. The Chronic Pain Scotland Service Model ( http://www.knowledge.scot.nhs.uk/pain/scottish-service-model.aspx ) ( Table 1 ) has also implemented a similar primary care-based approach.
Other initiatives include system redesigns with implementation of a MoC based on chronic disease management principles, such as the Southampton Pain Clinic. Here, primary care practitioners have been upskilled with resources to manage the majority of consumers and only a minority are taken into specialist care for treatment with clear end points . Treatment and referral guidelines for primary care physicians, a care pathway bridging primary and secondary care, effective triage of referrals and an increased focus on a self-management programme in the community, along with effective cross-sector communication, have resulted in reduced wait times, reduced use of medications and cost savings of £204 per consumer .
Building consumer capacity in musculoskeletal pain
Care disparities (e.g., due to geographic barriers, financial or health literacy) may be moderated through MoCs that use information and communications technologies such as telehealth ( Table 1 ), online media and smart devices to lever the dissemination of consumer-oriented evidence. For example, the painHEALTH policy-into-practice initiative funded by the Western Australian government ( http://painhealth.csse.uwa.edu.au/index.html ) is a web-based platform providing inter-professional, evidence-based consumer information and integrated pain management modules; the National Health Service (NHS)-supported website Sheffield, UK, https://www.sheffieldpersistentpain.com/ ; and in Scotland a site for consumers and health professionals, http://chronicpainscotland.org/ , and for teenagers with chronic pain: http://chronicpainscotland.org/teenagers-living-with-pain/ . The Chronic Pain Scotland Service Model ( http://www.knowledge.scot.nhs.uk/pain/scottish-service-model.aspx ) is supplemented by population-based pain education (including media campaigns and phone support) with parallel pain workforce competency frameworks. These platforms are sustainable and widely accessible, although standardised data to inform health and economic benefit as a component of co-care need to be collected and published.
Building primary care workforce capacity in musculoskeletal pain
The Nova Scotia Chronic Pain Collaborative Network has tackled the issue of inadequate professional skills in pain management by implementing a collaborative (generalist–specialist) learning community of practice as part of the total MoC. Primary care physicians and pain specialists develop shared clinical solutions that acknowledge the complexities of integrated care with up to 16 primary care physicians trained each year . Shared solutions can help to strengthen clinical pathways and facilitate a more seamless transition of care while moderating tension between the generalist–specialist interface. Similar community-based MoCs with upskilled health professionals working in partnership with primary care physicians have demonstrated promising outcomes such as faster, local and evidence-based care for consumers with improved efficiencies and positive health outcomes ( Table 1 ).
Barriers to implementation of MoCs for CMP
Despite progress in the implementation of best practice for CMP management, system barriers often fail to enable integrated care across health sectors. Further, access to pain management services is inconsistent both within and across nations, and available health services differ markedly in the type of care they offer and MoCs by which they are delivered . The result is fragmented care for consumers, and variable outcomes and significant avoidable health-care costs for governments . Primary care consultation and funding models do not consistently align with treatment pathways, highlighting the imperative for MoCs to enable effective, streamlined participation from all service providers, which a centralised (e.g., tertiary pain clinic) model often fails to do. Many practising and emerging health professionals have little or no training to help them address the complex nature of pain and disability , and training is often delivered within a discipline-specific (e.g., medical) curriculum model, thereby failing to capture the multidimensional aspects of pain, including frequent co- or multi-morbidities that require cross-discipline attention.
So, what can be done? A systems approach is required with a focus on solutions that are implementable, flexible, sustainable and practically oriented to support and strongly encourage adoption by clinicians working at the coalface ( Table 2 ). Systems that recognise the fundamentally different work patterns and demands of general practice and specialist teams and that are consumer centred, rather than disease or symptom oriented, are needed and will help to moderate friction at the specialist–generalist interface. MoCs also need to be flexible in order to meet contextual requirements such as the local needs of developing/developed nations, address care disparities and bridge the lifespan. MoCs need to identify clear care pathways; facilitate timely assessment and management; ensure training is adequate and consistent; and provide practical strategies, remain sustainable and address prevention and rehabilitation to reduce disease burden and lost productivity. The use of e-health technologies can help to bridge the primary care–tertiary care gap and provide an efficient use of resources. Standardised data on CMP must be captured, monitored and evaluated.
| Target areas | What needs changing | How to change |
|---|---|---|
| Education about chronic musculoskeletal pain |
|
|
| Health policy |
|
|
| Appropriate pain management |
|
|
| Service delivery – provision of person-centred integrated pain management |
|
|
| Health outcomes and economic data |
|
|
| Prevention |
|
|
To effectively manage the scope of MoCs, agreements across jurisdictions are an obvious implementation mechanism. For example, the Societal Impact of Pain Group is a multi-stakeholder platform in Europe that aims to exchange information and share best practices and solutions across all member states of the European Union. Further, together they have developed and fostered European-wide strategies and activities for improved pain care in Europe ( http://www.sip-platform.eu/sip-mission.html ) . Within such frameworks, new MoCs that are underpinned by high-quality evidence are required, for example, randomised controlled trials where available and practical and pragmatic trials allowing real-world practices to be investigated and incorporated into these models , and evaluation of health and economic benefits.
Osteoarthritis
Epidemiology and impact
OA is the most common form of arthritis and represents the most substantial public health issue in developed nations, highlighting the urgency for system reform to support the implementation of effective MoCs to optimise management approaches and consumer outcomes . In the United States of America, knee OA is the leading cause of impaired mobility-related activities of daily living in older adults . The worldwide prevalence and incidence of OA have been increasing, largely attributed to ageing populations and rising obesity rates. For example, Lawrence et al. reported that the prevalence of symptomatic OA in the United States of America increased by 30% from 1995 to 2005, from 21 to 27 million people . Current Australian modelling predicts an increase in cases of OA of 58% by 2032 . These trajectories will have substantial implications for health-care services, particularly orthopaedic surgery and conservative care specialists. Importantly, OA is not just a disease of ageing. Established risk factors for OA including joint trauma, obesity, physical inactivity and occupational joint loading commonly occur in younger age. A recent United States of America-based study identified that the incidence of knee OA using the 2007–2008 population health data was greatest for ages 55–64 years, with the mean age of diagnosis at 53 years . Australian data support this observation, where a peak in the number of people with OA was evident at age 55–64 years . These data also explain an increased proportion of arthroplasties being performed in younger age groups .
Similar to other chronic musculoskeletal conditions discussed in this chapter, the psychosocial burden associated with OA is profound, particularly in advanced OA where pain and impaired function become substantial barriers to physical and mental well-being. For example, people with knee or hip joint OA waiting for joint replacement surgery in Australia reported profound psychological distress and a quality of life worse than death . Importantly, many people with OA also live with physical and mental co-morbid conditions which have important implications for management approaches and consumers’ responses to them.
Management of OA
The rising health and economic burden of OA reinforces the need for timely, effective management strategies. The current goal of treatment is to reduce the impact of OA on the individual and society, by reducing symptoms (mainly pain), improving function and preventing and reducing functional and work disability; hence, pain management is mostly considered within a biopsychosocial framework. Although pain can be associated with an increasing severity of radiographic OA changes, there is also evidence for central sensitisation which helps to explain the inconsistent pain–pathology relationship . Current guidelines for the treatment of OA recommend a combination of pharmacologic and non-pharmacologic treatments . For example, in the United Kingdom, Porcheret et al. developed a four-step MoC for managing older adults (aged >50 years) with knee pain and OA based on a systematic review of treatments and recommendations from a nominal group consensus panel . This model provides recommendations for primary care physicians to escalate treatment based on symptom control, from Step 1 (exercise, weight management, analgesic and written information about OA) to Step 4 (surgery such as arthroplasty).
Currently, there are no effective therapies that modify structural progression in OA; hence, pharmacologic treatments are recommended for pain relief with good to excellent levels of evidence, including simple analgesia with paracetamol and oral non-steroidal anti-inflammatory drugs (NSAIDs). Corticosteroid injections and opioids (for severe pain) are recommended in the short term . Non-pharmacologic treatments with good to excellent levels of evidence include weight loss and land-based exercise. Interventions with satisfactory levels of evidence include multimodal physiotherapy, aquatic exercise, tai chi, thermotherapy, transcutaneous electrical nerve stimulation and acupuncture . Self-management programmes appear to be effective in reducing pain and several have demonstrated modest and sustainable improvements in self-efficacy and function . Nevertheless, there are disparities in the management of OA, with suboptimal use of evidence-based guidelines , inappropriate use of arthroscopy as well as medication safety concerns for the elderly . Arthroplasties are indicated for advanced symptomatic OA and their rates have risen significantly .
MoCs for OA
With current evidence demonstrating that conservative care options are effective for many people with OA, and concerns about the appropriateness of surgical intervention in people without severe radiologic OA, this section will discuss MoCs that primarily focus on conservative care and those that incorporate surgical intervention where clinically indicated .
As a complex chronic disease often associated with other co-morbidities, the delivery of care for people with OA is ideally provided using the principles of chronic care as described by Wagner, including care coordination, multidisciplinary team interventions and collaborative care planning with the person who has OA as an equal partner in its development and implementation, and underpinned with the philosophies of self-management support . These principles are appropriate across care settings and the OA disease continuum . Established MoCs that embrace these principles are summarised below.
Multidisciplinary teams across care settings
Care settings in many countries such as the United Kingdom, Canada, Australia and the United States of America have demonstrated the benefits of access to multidisciplinary teams for OA management, especially teams working in an interdisciplinary manner . Through these MoCs, consumers gain on-site access to the expertise of several professional groups that each address important aspects of OA and its co-morbidities. Specific to OA, these components of care include weight loss, pain management, psychosocial health support strategies, and supporting improvements in functional capacity . However, globally, there are challenges in the availability of skilled team members. For example, in hospital settings, those available are often fully engaged in acute care services, while in non-hospital care settings, team members are rarely co-located, making interdisciplinary care and communication more difficult. Other barriers to implementing this MoC include the volume of specific health professionals available, discrepancies in funding models to support multi-professional care, service sites in rural and remote settings and outer urban fringes being less attractive for practitioners and the need to support health professionals to appreciate the benefits of team care for people with OA. Schofield et al. described their experiences in supporting interdisciplinary health-care providers in a rural setting. Their work resulted in better outcomes for their cohort, health system advantages and better supported team members as evidenced by skill development and reduced feelings of isolation .
Extended scope of practice MoCs
In efforts to address the complex nature of management approaches for people with OA and improve access to, and coordination of, best-practice care, some health systems and service sites have developed MoCs with extended scope of practice . In these MoCs, a team member, often a nurse or physiotherapist, is supported to expand their knowledge and skills to deliver and coordinate best-practice care for people with OA. Extended scope of practice roles include determining a care pathway after cross-discipline assessments are completed, ordering of investigations, prescribing from an agreed formulary of medications and referrals to medical specialists. Outcomes for consumers include increased and earlier access to care usually provided in a setting convenient to the consumer, for example, in their home or in a community setting away from hospitals, improved understanding of their disease and a high level of satisfaction with the care provided .
Pharmacist-initiated care
Pharmacists have played an active role in identifying consumers who are not seeking necessary physician attention for managing chronic diseases, including OA. Observational data have suggested that knowledge of having OA, as determined by pharmacist screening, might be a motivation for individuals to seek help and adopt a healthy lifestyle . A recent randomised controlled trial evaluated a pharmacist-initiated intervention involving the use of an OA screening questionnaire, education on pain medication, physiotherapy-guided exercise and communication with the primary care physician. Compared to the control group, which only received an education pamphlet, participants in the intervention group received more appropriate care (as measured by OA quality indicators) and demonstrated greater improvement in function, pain and quality of life . The promising results suggest that non-physician health professionals can play a key role in improving OA care.
System-level MoCs for OA
While guidelines for the management of OA in consideration of both non-surgical and surgical care are available in many areas of the globe (e.g., Refs. ), there are few descriptions of how to implement these guidelines in order to ensure chronic disease care principles and quality processes are followed. However, examples of how MoCs have been successfully implemented across a health system include the Osteoarthritis Hip and Knee Service (OAHKS) in Victoria, which was the first Australian system-level MoC for OA. The OAHKS provides multidisciplinary care for people with OA, including surgical and conservative care . Latterly, the Osteoarthritis Chronic Care Program was introduced in New South Wales , and the MoC for Elective Joint Replacement in Western Australia with its complementary model on how to implement musculoskeletal health care in community-based settings .
MoCs for OA in the digital age
Access to care is often impeded by the distances some people live from health-care services. People living in rural and remote areas are often those who need access to health care the most . Telephone, video conferencing and other web-based modes are proving to be successful in the delivery of OA care, especially in consideration of self-management support. In one example, Sperber et al. conducted a randomised controlled trial using telephone-based self-management support compared to usual care in a cohort of United States of America veterans with OA attending a primary care service . Monthly phone calls from a health educator were supplemented with mailed educational tools, and the participants were supported to set goals and develop action plans. In another study, Lorig and colleagues reported on their randomised controlled trial that utilised an Internet-based self-management support programme . Self-management support content included appropriate OA management to be read online by participants at least three times a week for the first 6 weeks. After reading each week’s information, the participants would develop and log their action plans for the next week. After 12 months, both studies found that participants reported clinically meaningful improvements in symptoms and general well-being when compared to their matched control study participants.
In Australia, the national consumer organisation for people with arthritis has developed a website, MyJointPain ( https://www.myjointpain.org.au/ ), to provide education and support of people with OA. Other examples of OA MoCs that are site specific or involve particular health professional groups are summarised in Table 3 .
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