Abstract
Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Despite the existence of evidence-based treatments and guidelines, substantial gaps remain in the quality of OA management. There is underutilization of behavioral and rehabilitative strategies to prevent and treat OA as well as a lack of processes to tailor treatment selection according to patient characteristics and preferences. There are emerging efforts in multiple countries to implement models of OA care, particularly focused on improving nonsurgical management. Although these programs vary in content and setting, key lessons learned include the importance of support from all stakeholders, consistent program delivery and tools, a coherent team to run the program, and a defined plan for outcome assessment. Efforts are still needed to develop, deliver, and evaluate models of care across the spectrum of OA, from prevention through end-stage disease, in order to improve care for this highly prevalent global condition.
Osteoarthritis burden and gaps in management
Symptomatic osteoarthritis (OA), defined as having persistent symptoms in addition to positive imaging findings or functional limitations, is a leading cause of chronic pain and disability among adults . It places a substantial burden at the individual level, affecting psychological well-being, sleep, work participation, social participation, management of comorbid health conditions, and health-related quality of life . OA also has a tremendous societal and public health impact. For example, the 2010 Global Burden of Disease Survey found that knee and hip OA were responsible for 17 million years lived with disability worldwide ; the burden is likely higher when other joints are considered. OA is associated with increased healthcare utilization and costs as well as higher non-healthcare-related costs including work force loss, productivity loss, and formal and informal caregiving . OA is the most rapidly growing cause of disability globally , and this rising epidemic will place increasing burden on both patients and healthcare systems. Rates of total joint replacement (TJR) surgeries are increasing dramatically in many developed countries , leading to concerns about meeting demands. Prevention and early management are critical to address the significant and increasing public health burden of OA.
Guidelines from professional societies emphasize that a combination of behavioral and clinical strategies is essential for OA management ( Fig. 1 ) . Core therapies, appropriate for all individuals with OA, include self-management education, exercise (land- or water-based structured progressed aerobic conditioning, muscle strength training, and neuromuscular exercise), lifestyle physical activity, and weight management; these first-line treatments should be maintained throughout the disease course. Other evidence-based therapies for OA include increasing joint range of motion with manual therapy and biomechanical interventions such as braces, oral and topical pharmacotherapies, intra-articular corticosteroids, and joint replacement surgery; these should be applied based on patients’ symptom severity, impairments, and risk factors.
Unfortunately, there are major gaps in both OA prevention and the use of evidence-informed therapies, illustrated internationally . For example, studies indicate that healthcare providers often do not include recommendations for exercise and weight management as part of OA management . Studies also show underutilization of biomechanical therapies (e.g., knee braces), lack of function and disability assessment, and issues related to pain medication safety. There are many potential factors underlying these gaps in care, including competing demands of comorbid health conditions in the context of clinic visits, and a perception among healthcare providers that OA is merely a part of normal aging with limited treatment options . There is a clear need to develop and implement models that promote evidence-informed OA prevention and management. This study describes the current evidence for models of care (MoCs) across the spectrum of OA. This includes models for primary prevention, nonsurgical management, surgical prioritization, and management of persistent pain. We describe the research evidence base to guide these MoCs, examples of care models currently being implemented (when available), and recommendations for advancing these efforts worldwide.
Primary OA prevention models
The need for primary OA prevention models
Any comprehensive MoC should consider the spectrum of disease, including primary prevention strategies. Two key primary prevention targets for OA are weight reduction and joint injury prevention. Population-based efforts toward weight management could have a substantial impact on prevention of OA, as even a modest amount of weight loss seems to confer a decrease in OA risk . In this section, we focus on injury prevention because of its specific relevance to OA. There is a growing public health burden related to the incidence of early-onset post-traumatic osteoarthritis (PTOA) in at-risk populations . Sport and recreation is the leading cause of injury in youth, accounting for up to 40% of the injury burden, with 50% of these being knee, ankle, and hip injuries . The estimated injury incidence proportion in youth sport is 35 injuries/100 students/year (ages 11–18) . Meta-analyses reveal a 4-fold increased knee OA risk 15 years post injury . Unfortunately, limited attention has been given to the multifactorial etiology of PTOA, with a goal of informing early diagnostics and prevention . In this section, we apply an epidemiological model of disease prevention onto the events associated with the development of PTOA to illustrate opportunities for primary (prevent joint injury) and secondary (slow down or halt the onset of PTOA following injury) prevention that should be included in a comprehensive model.
Joint injury prevention models
Evidence for the efficacy of joint injury prevention programs
Many studies show that injury prevention strategies can reduce the number and severity of injuries . In youth, meta-analysis revealed a combined preventative effect of neuromuscular training in reducing the risk of lower extremity injury [incidence rate ratio (IRR) = 0.64 (95% confidence interval (CI); 0.49–0.84)] and knee injury [IRR = 0.74 (95% CI; 0.51–1.07)] . Consistent evidence has been reported in adult athlete populations, with an emphasis on neuromuscular training components (e.g. strength, balance, and agility). However, little is known about the most effective training program components or the most efficient implementation approaches for injury prevention.
Challenges and recommendations for joint injury prevention models
Primary prevention strategies for sport injury have been based on a multifactorial model for injury risk, considered within a variable implementation context . Although the translation of injury prevention research into best practice has received a great deal of attention, its wide-scale implementation in real-life conditions is an ongoing challenge . The Translating Research into Injury Prevention Practice (TRIPP) Framework attempts to address implementation shortcomings by adding two key stages required to translate effective prevention strategies into practice to the four-staged van Mechelen injury prevention model (i.e., stage 1: establish the extent of injury burden; stage 2: identify injury risk factors and causal mechanisms; stage 3: develop and introduce preventative strategies; and stage 4: evaluate the impact of these strategies on injury burden) . The TRIPP stage 5 involves describing the context in which the intervention was developed to inform implementation strategies and successful transfer to a real-world context of sport . The TRIPP stage 6 involves implementing the intervention in a real-world context and evaluating its effectiveness . An example of a program with widespread implementation internationally is the Fédération Internationale de Football Association (FIFA) 11+ ( http://f-marc.com/11plus/home/ ) for injury prevention in soccer. This effort is based on an evidence-informed program that has resulted in significantly reduced injuries during matches and training. To facilitate implementation, there is a publically available, detailed manual describing the program and illustrating all the exercises; video demonstrations of the exercises are also available. A countrywide campaign to implement this program in Switzerland has been documented, resulting in good penetration (80% of coaches knew of the program and 57% performed all or most parts of it), and lower injury rates among teams using the program .
Practice and policy efforts related to injury prevention rely on efficient use of limited financial resources, and a greater focus on economic evaluations is important, as highlighted by the Reach Efficacy Adoption Implementation Maintenance Framework (RE-AIM), . In developing the optimal implementation strategy, it is critical to consider the multiple factors that may influence adherence to such a program across multiple levels of influence on sport safety (e.g., child, parent, coach, teacher, community, and government) .
In summary, there is consistency to support the preventative effects and economic benefits of multifaceted neuromuscular training programs including strength, balance, and agility components in reducing the risk of lower extremity injuries in sport and recreation. However, lack of uptake and maintenance of such programs is an ongoing concern. A greater focus on implementation is critical to influence knowledge, behavior change, and sustainability of evidence-informed injury prevention practice.
Injury rehabilitation models
Joint injury and development of PTOA: informing rehabilitation models
Little is known about the period between joint injury and PTOA onset, other than as it relates to return to sport after anterior cruciate ligament injury or reconstruction (which does not appear to mitigate the risk of PTOA) . A better understanding of this period could inform the development, implementation, and evaluation of early diagnostics and joint injury rehabilitation programs that focus not only on the acute injury but also on minimizing the onset of risk factors for PTOA. There is emerging evidence that 3–10 years post sport-related knee injury, young adults are more likely to become overweight/obese, less physically active, and demonstrate magnetic resonance imaging (MRI)-defined OA compared with uninjured matched controls . These findings suggest that young adults with knee injury history may compound their risk for PTOA by developing other modifiable risk factors (e.g., obesity, inactivity, and altered joint loading) that may accelerate the rate of progression to OA .
Challenges and recommendations for injury rehabilitation models
Although there are limited data based on which recommendations could be made regarding a specific MoC for injury rehabilitation that will delay or halt the onset of PTOA, current evidence suggests that these programs should include strategies aimed at (1) maintaining a healthy weight and (2) restoring strength, balance, and healthy movement patterns that facilitate recommended levels of exercise. A better understanding of the relationship between lower levels of exercise and/or inappropriate dietary intake and the psychosocial factors at play (potential loss of athletic and/or exercise identity) is required. In addition, more evidence is needed regarding the most appropriate form and timeline for acute, pre-surgical, surgical, and postsurgical care. As with injury prevention, greater attention is needed to develop and implement practical and specific models of injury rehabilitation to influence the growing burden of PTOA.
Primary OA prevention models
The need for primary OA prevention models
Any comprehensive MoC should consider the spectrum of disease, including primary prevention strategies. Two key primary prevention targets for OA are weight reduction and joint injury prevention. Population-based efforts toward weight management could have a substantial impact on prevention of OA, as even a modest amount of weight loss seems to confer a decrease in OA risk . In this section, we focus on injury prevention because of its specific relevance to OA. There is a growing public health burden related to the incidence of early-onset post-traumatic osteoarthritis (PTOA) in at-risk populations . Sport and recreation is the leading cause of injury in youth, accounting for up to 40% of the injury burden, with 50% of these being knee, ankle, and hip injuries . The estimated injury incidence proportion in youth sport is 35 injuries/100 students/year (ages 11–18) . Meta-analyses reveal a 4-fold increased knee OA risk 15 years post injury . Unfortunately, limited attention has been given to the multifactorial etiology of PTOA, with a goal of informing early diagnostics and prevention . In this section, we apply an epidemiological model of disease prevention onto the events associated with the development of PTOA to illustrate opportunities for primary (prevent joint injury) and secondary (slow down or halt the onset of PTOA following injury) prevention that should be included in a comprehensive model.
Joint injury prevention models
Evidence for the efficacy of joint injury prevention programs
Many studies show that injury prevention strategies can reduce the number and severity of injuries . In youth, meta-analysis revealed a combined preventative effect of neuromuscular training in reducing the risk of lower extremity injury [incidence rate ratio (IRR) = 0.64 (95% confidence interval (CI); 0.49–0.84)] and knee injury [IRR = 0.74 (95% CI; 0.51–1.07)] . Consistent evidence has been reported in adult athlete populations, with an emphasis on neuromuscular training components (e.g. strength, balance, and agility). However, little is known about the most effective training program components or the most efficient implementation approaches for injury prevention.
Challenges and recommendations for joint injury prevention models
Primary prevention strategies for sport injury have been based on a multifactorial model for injury risk, considered within a variable implementation context . Although the translation of injury prevention research into best practice has received a great deal of attention, its wide-scale implementation in real-life conditions is an ongoing challenge . The Translating Research into Injury Prevention Practice (TRIPP) Framework attempts to address implementation shortcomings by adding two key stages required to translate effective prevention strategies into practice to the four-staged van Mechelen injury prevention model (i.e., stage 1: establish the extent of injury burden; stage 2: identify injury risk factors and causal mechanisms; stage 3: develop and introduce preventative strategies; and stage 4: evaluate the impact of these strategies on injury burden) . The TRIPP stage 5 involves describing the context in which the intervention was developed to inform implementation strategies and successful transfer to a real-world context of sport . The TRIPP stage 6 involves implementing the intervention in a real-world context and evaluating its effectiveness . An example of a program with widespread implementation internationally is the Fédération Internationale de Football Association (FIFA) 11+ ( http://f-marc.com/11plus/home/ ) for injury prevention in soccer. This effort is based on an evidence-informed program that has resulted in significantly reduced injuries during matches and training. To facilitate implementation, there is a publically available, detailed manual describing the program and illustrating all the exercises; video demonstrations of the exercises are also available. A countrywide campaign to implement this program in Switzerland has been documented, resulting in good penetration (80% of coaches knew of the program and 57% performed all or most parts of it), and lower injury rates among teams using the program .
Practice and policy efforts related to injury prevention rely on efficient use of limited financial resources, and a greater focus on economic evaluations is important, as highlighted by the Reach Efficacy Adoption Implementation Maintenance Framework (RE-AIM), . In developing the optimal implementation strategy, it is critical to consider the multiple factors that may influence adherence to such a program across multiple levels of influence on sport safety (e.g., child, parent, coach, teacher, community, and government) .
In summary, there is consistency to support the preventative effects and economic benefits of multifaceted neuromuscular training programs including strength, balance, and agility components in reducing the risk of lower extremity injuries in sport and recreation. However, lack of uptake and maintenance of such programs is an ongoing concern. A greater focus on implementation is critical to influence knowledge, behavior change, and sustainability of evidence-informed injury prevention practice.
Injury rehabilitation models
Joint injury and development of PTOA: informing rehabilitation models
Little is known about the period between joint injury and PTOA onset, other than as it relates to return to sport after anterior cruciate ligament injury or reconstruction (which does not appear to mitigate the risk of PTOA) . A better understanding of this period could inform the development, implementation, and evaluation of early diagnostics and joint injury rehabilitation programs that focus not only on the acute injury but also on minimizing the onset of risk factors for PTOA. There is emerging evidence that 3–10 years post sport-related knee injury, young adults are more likely to become overweight/obese, less physically active, and demonstrate magnetic resonance imaging (MRI)-defined OA compared with uninjured matched controls . These findings suggest that young adults with knee injury history may compound their risk for PTOA by developing other modifiable risk factors (e.g., obesity, inactivity, and altered joint loading) that may accelerate the rate of progression to OA .
Challenges and recommendations for injury rehabilitation models
Although there are limited data based on which recommendations could be made regarding a specific MoC for injury rehabilitation that will delay or halt the onset of PTOA, current evidence suggests that these programs should include strategies aimed at (1) maintaining a healthy weight and (2) restoring strength, balance, and healthy movement patterns that facilitate recommended levels of exercise. A better understanding of the relationship between lower levels of exercise and/or inappropriate dietary intake and the psychosocial factors at play (potential loss of athletic and/or exercise identity) is required. In addition, more evidence is needed regarding the most appropriate form and timeline for acute, pre-surgical, surgical, and postsurgical care. As with injury prevention, greater attention is needed to develop and implement practical and specific models of injury rehabilitation to influence the growing burden of PTOA.
OA care pathways
Models of nonsurgical OA service delivery in developed countries
There are numerous national and international guidelines for nonsurgical OA management of , and there is broad agreement on core therapies . Internationally, however, there are wide variations in practice and gaps between current care and OA treatment recommendations . A number of programs have been designed to close the gap between OA recommendations and practice, using differing models of service delivery (e.g., specific strategies for implementing various components of recommended OA care). A selection of these programs was recently featured as part of a pre-conference workshop of the Osteoarthritis Research Society International (OARSI). In this section, we briefly describe some of these exemplar OA programs, and Table 1 provides details on the target population, eligibility criteria, targeted interventions, outcome measures being collected, and funding models.
| Name of Program and Originating Country | Target population (e.g., knee and hip OA) | Eligibility criteria | Targeted interventions (e.g., diet and exercise) | Outcome measures being collected | Number of persons enrolled/seen in the program | Duration of program for individual participants | Website for further information | Point of contact for further information (name: E-mail address) | Healthcare system, funding model |
|---|---|---|---|---|---|---|---|---|---|
| Osteoarthritis Chronic Care program (OACCP); Australia | Persons with knee and or hip OA | Pain in the affected joint most days of the past month, pain visual analog scale (VAS) ≥ 4 out of 10 and doctor diagnosed hip or knee OA | Coordinated multidisciplinary management including exercise, diet, psychological support, occupational therapy, orthotics, and medical management | Pain VAS, knee injury and osteoarthritis outcome score (KOOS)/hip disability and osteoarthritis outcome score (HOOS), Patient Global Assessment, EQ-5D/Assessment of Quality of Life, Depression, Anxiety and Stress Scale 21, Katz comorbidities, 6-min walk test, timed up-and-go, body mass index (BMI), hip/waist ratio, willingness for surgery, surgical waitlist removal/acceleration | ∼10,000 since 2012 | Up to 12 months | http://www.aci.health.nsw.gov.au/models-of-care/musculoskeletal/osteoarthritis-chronic-care-program | David Hunter: David.Hunter@sydney.edu.au | Funded through public hospital system and expanding into primary care and private hospitals. |
| Better management of patients with osteoarthritis (BOA); Sweden Digitalized version: Joint Academy | Persons with hip, knee or hand OA. (shoulder to be included 2016). | Non-traumatic pain, sufficient to seek care, and attributed by a clinician to a joint. | Physical therapist, occupational therapist, and OA-communicator (i.e., “expert patient”) delivered education, supported self-management, physical activity recommendations, optional individualized exercise program, optional supervised exercise group sessions (using individual program) | EQ-5D, pain numeric rating scale, pain frequency, desire to have surgery, level of physical activity, fear of movement, Charnley comorbidity index, use of pain medications, sick leave, previous treatments, Arthritis Self Efficacy scale, At follow-up: satisfaction and usefulness of intervention | ∼60,000 since 2010 | 3 months of intervention, postal follow-up at 12 months | www.boaregistret.se Digitalized version/e-health: www.jojntacademy.com | Carina Thorstensson: Carina.thorstensson@registercentrum.se | Physical therapy (health care) pays cost-price for 2-day course. Patients pay approximately. 12 USD per individual visit and 10 USD for group visits. Patients’ cost ceiling within a 1-year limit for medical care and medicine under the health service is 140 USD. Costs exceeding this limit, and additional costs for visits mentioned above, are paid for by healthcare system (tax). The register was initially funded as a 3-year pilot project by the national social insurance office and financial support from the Swedish government to the regional authorities (Dagmar model). BOA became a national quality register in 2010 and as such is supported financially, after annual application, by the Swedish authority of local authorities and regions. Additional support from the region of Västra Götaland. The intervention is part of primary care practice. |
| Good Life with osteoarthritis in Denmark (GLA:D); Denmark | Persons with hip and/or knee OA (same as BOA) | Non-traumatic pain, sufficient to seek care, and attributed by a clinician to hip or knee joint (same as BOA) | Two sessions of physical therapist-delivered Information, if available 1 additional session with “expert patient”, supported self-management, physical activity recommendations, 12 supervised neuromuscular exercise sessions based on the program NEuroMuscular EXercise (NEMEX). Educational part, but not exercise part, similar to BOA | Among others: EQ-5D, pain visual analog scale, physical activity, fear of movement, use of pain medications, sick leave, comorbidities, Arthritis Self Efficacy Scale, At follow-up: satisfaction and usefulness of intervention. Outcomes are similar to BOA with the addition of KOOS/HOOS quality of life, SF-12 and functional tests: 40 min walk, chair stands | ∼15,000 since Feb 2013 | Three months of intervention immediate follow-up (Internet-based and clinical visit), and additional online follow-up at 12 months | www.glaid.dk | Ewa M. Roos: eroos@health.sdu.dk Søren T. Skou: stskou@health.sdu.dk | In 2011–2013 14,000 USD have been received from Danish Rheumatism Association and 11,800 USD from Danish Physiotherapy Association, money used to start the registry. In 2015, the Danish Rheumatism gave 15,000 USD for a health economic evaluation and the Danish Physiotherapy Association gave 45,000 USD for the project manager (Dr Skou). The physiotherapists pay themselves (app. 560 USD) for the 2-day training course. This money is used to support a project manager, run the courses, and maintain the registry. Reimbursement to therapists and patient fees vary based on healthcare insurance, but in private physical therapy practice, most commonly patients pay 375 USD and physical therapists are reimbursed with 250 USD. Some patients receive the GLA:D program from the municipality, which covers the full cost. University of Southern Denmark graciously covers Dr Roos’ time and involvement and hosts the courses. |
| Osteoarthritis Healthy Weight For Life (OA HWFL); Australia | Persons with knee or hip OA | Diagnosis supported by radiological evidence AND BMI ≥ 28 AND Symptoms that have (or are likely to) necessitated referral to an orthopedic surgeon for further investigation OR Joint replacement is planned and improved fitness for surgery desirable | Weight loss (7.5–10%) and improved nutrition, muscle strengthening, land-based and range of motion exercises, pain management strategies, education, monitoring and engagement strategies | KOOS/HOOS, Short-Form 12, body weight, waist circumference, satisfaction with support and information | ∼9000 to date | 18 weeks intensive and proactive engagement, open-ended inbound support | www.HealthyWeightForLife.com.au and click on Osteoarthritis program link | Luke Lawler: luke@primahealth.com.au | 100% funded for eligible patients through private health insurers |
| Amsterdam osteoarthritis cohort (AMSOA); The Netherlands | Persons with knee and or hip OA | Non-traumatic pain, sufficient to seek care, and attributed by a clinician (rheumatologist and/or rehabilitation physician) to hip or knee joint | Coordinated multidisciplinary management including supervised exercise program according to the knee joint stabilization therapy trial (Knoop et al.), occupational therapy, psychological support, and medical management | Western Ontario and McMaster Universities Osteoarthritis Index, physical performance (timed up-and-go/stair climb), muscle strength, proprioception, physical activity, Short-Form-36, comorbidity illness rating scale, medication | 1000 to date | 3 months of multidisciplinary intervention | www.reade.nl | Martin van der Esch m.vd.esch@reade.nl | Funding is partly through the healthcare system and partly from trials. Trials are within the cohort. |
| JIGSAW Joint Implementation of Osteoarthritis guidelines in the West Midlands, UK (Based on MOSAICS study) | Knee, hip, hand, foot OA, and joint pain, presenting to a general practitioner in primary care | Aged 45 years and over, joint pain, OA in knee, hip, hand, foot; exclusion red flags | Use of an electronic OA template to record key quality indicators of OA care. PLUS A model OA consultation with a general practitioner: makes, gives, explains the OA diagnosis; gives OA guidebook; analgesia; offers referral to practice nurse. Practice nurse up to 4 sessions supporting self-management: OA guidebook; exercise/physical activity advice using Arthritis Research UK booklets; weight management; analgesia | OA quality indicators | South Shropshire, UK: Total practice population = 102,827 Total number of practices = 14 Practices agreeing to participate = 10 Number of practice teams trained by champions = 10 Number of practice nurses trained = 13 | Up to 3 months | OA e-template http://www.keele.ac.uk/pchs/disseminatingourresearch/researchtools/oae-template/ OA guidebook http://www.keele.ac.uk/media/keeleuniversity/ri/primarycare/pdfs/OA_Guidebook.pdf MOSAICS http://www.isrctn.com/ISRCTN06984617 | Krysia Dziedzic k.s.dziedzic@keele.ac.uk , Helen Duffy h.c.duffy@keele.ac.uk , | Regional Innovation Fund; Clinical Commissioning Group redesign of orthopedic pathways; NIHR Knowledge Mobilisation Research Fellowship (Dziedzic); EIT-Health |
Osteoarthritis Chronic Care Program (OACCP) Australia
OACCP ( http://www.aci.health.nsw.gov.au/resources/musculoskeletal/osteoarthritis_chronic_care_program/osteoarthritis-chronic-care-program ) is a program for individuals with doctor-diagnosed knee and or hip OA, with pain in the affected joint on most days of the past month (pain visual analog scale ≥ 4 out of 10) . Coordinated, individually tailored physiotherapy-led multidisciplinary management is offered, including exercise, diet, psychological support, occupational therapy, orthotics, and medical management. Outcome measures are pain, Patient Global Assessment, EQ-5D/Assessment of Quality of Life, Depression, Anxiety and Stress Scale 21, Katz comorbidities, 6-min walk test, timed-up-and-go test, body mass index (BMI), hip/waist ratio, willingness to have surgery, and surgical waitlist removal/acceleration.
Better management of patients with osteoarthritis (BOA) Sweden
BOA (and the Digitalized version: Joint Academy, www.jointacademy.com ) is a program for individuals with hip, knee, or hand OA, with shoulder OA to be included in 2016 ( www.boaregistret.se ) . Participants have non-traumatic pain, sufficient to seek care, and attributed by a clinician to their joint. Physiotherapists, occupational therapists, and expert patients (described as OA communicators) provide education, self-management support, exercise recommendations, an optional individualized exercise program, and optional supervised exercise group sessions (using the individual program). Patient-reported outcome measures include EQ-5D, pain (numeric rating scale, pain frequency), desire to have surgery, level of exercise, fear of movement, Charnley comorbidity index, use of pain medications, sick leave, previous treatments, and the Arthritis Self Efficacy Scale. At 3- and 12-month follow-up, satisfaction with and usefulness of the program are also measured.
Good life with arthritis in Denmark (GLA:D)
GLA:D ( www.glaid.dk ) is offered to individuals with hip and/or knee OA, defined as non-traumatic pain sufficient to seek care, and attributed by a clinician to OA of the hip or knee joint. Participants are offered two sessions of physiotherapist-delivered information, if available one additional session with an “expert patient,” supported self-management, exercise recommendations, and 12 sessions of supervised neuromuscular exercise sessions based on the NEuroMuscular EXercise (NEMEX) program . Patient-reported outcome measures significantly overlap with the BOA program, while collection of objective performance measures (40-min walk, 30-s chair stands) is specific to GLA:D . Outcomes are collected electronically at baseline after 3 and 12 months.
Osteoarthritis Healthy Weight For Life (OA HWFL) Australia
The OA HWFL program is offered to individuals with knee or hip OA diagnosed by radiological evidence, BMI ≥ 28 and symptoms that have or are likely to necessitate referral to an orthopedic surgeon or a joint replacement is planned, with improved fitness for surgery desired . The program offers weight loss (7.5–10%) and improved nutrition, muscle strengthening, land-based and range of motion exercises, pain management strategies, education, monitoring, and engagement strategies. Outcome measures include the knee injury and osteoarthritis outcome score/hip disability and osteoarthritis outcome score, Short-Form 12, body weight and waist circumference, and satisfaction with support and information.
Amsterdam osteoarthritis cohort (AMSOA) The Netherlands
Included in the AMSOA cohort, an OA management program is offered to individuals with knee and/or hip OA. Pain is non-traumatic, sufficient to seek care, and attributed by a clinician (rheumatologist and/or rehabilitation physician) to a hip or knee joint. The AMSOA management program offers coordinated multidisciplinary management including supervised exercise according to a knee joint stabilization program , occupational therapy, psychological support, and medical management. Outcome measures include the Western Ontario and McMaster Universities Osteoarthritis Index, physical performance (timed get-up-and-go, stair climb), muscle strength, proprioception, physical activity, Short-Form 36, comorbidity illness rating scale, and medication use.
Joint Implementation of Osteoarthritis guidelines in the West Midlands, UK (JIGSAW)
JIGSAW is based on the MOSAICS cluster randomized controlled trial . It is offered to individuals consulting in general practice with knee, hip, hand, and/or foot OA and joint pain. Participants are 45 years and over, with joint pain that limits function in the target joints and in the absence of “red flags.” The program is a “model OA consultation” with a general practitioner and a practice nurse. The consultation includes making, giving, and explaining the OA diagnosis; giving an OA guidebook; and offering analgesia and referral to a practice nurse. The model OA practice nurse consultation includes up to four sessions supporting self-management: the OA guidebook; exercise and physical activity advice using Arthritis Research UK booklets; weight management; and support with pain relief. Outcomes are measured using an electronic OA template to record key quality indicators of OA care.
Similarities and differences among OA programs
Tables 1 and 2 provide details that allow comparison of many aspects of these OA programs. With respect to development, all the programs have been based on research evidence and guidelines. Regarding content, the majority of programs have delivered core treatments to varying degrees, including support for self-management, patient education, and exercise. However, exercise types have varied in terms of intensity and degree of standardization, and only some programs include weight management. The healthcare professionals and patient populations targeted in these programs vary. Some programs target the whole of primary care with a complex, integrated, multidisciplinary model of OA care, both for delivering a pathway of care and delivering training (e.g., JIGSAW); others are focused on one professional group and/or one or two joint sites; and others are a hybrid of the two. With respect to measurement, clinical outcomes are considered of high importance. Although there are some differences in measures used across the programs, most assess pain, function, and quality of life. All programs also attempt to assess OA-related care received by patients before and after the program. Most of the OA programs have complex funding arrangements, including health insurance policies, academic resources, innovation funding, self-funding of healthcare professional training, arthritis charity funding, or a combination of these.
| Level 1: Description of the Program | Level 2: Implementation Factors, Facilitators, and Lessons Learned | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Name of Program | The context | Audit of current practice | Implementation Theory (ies) Used | Who Took the Initiative | Evidence of Adoption at Pace and Scale | Key Challenges/Barriers | Key Facilitators/Handling Barriers | Suitability for Developing Countries | Lessons Learned |
| Osteoarthritis Chronic Care Program (OACCP) | Public hospitals in New South Wales, Australia | Although 70% of knee replacements can be attributed to overweight & estimated that 25–50% of replacements could thus be avoided; <8% of Australians reported trying to lose weight as part of their OA treatment. Reports suggested suboptimal use of allied health practitioner interventions for OA | Chronic Care Model (CCM) , recognizing the need for a variety of interventions depending on the social, psychological, and physiological needs of individuals. OACCP team members also use behavioral change theory to guide implementation Local sites develop clinical pathways for the OACCP according to resources available at their site | David Hunter & working group of clinicians collaborated with the Agency of Clinical Innovation (Ministry of Health, New South Wales) | Started with 7 pilot sites in New South Wales. Cost–benefit analysis (2014) found OACCP saved some individual sites over $1,000,000/year in unnecessary joint arthroplasties. In summary, OACCP resulted in: i) significantly improved functionality, mobility (knee > improvement than hip) ii) significant decline in some comorbidities iii) 11% removal of patients from the waitlist for knee replacements because they no longer required surgery http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/259794/oaccp-evaluation-feb-2015.pdf OACCP has been expanded to include 16 hospitals in public and private settings across New South Wales. Many of these programs are now recurrently funded, while others are still in the pilot phase | A key challenge initially was to rally the support of orthopedic surgeons for the OACCP. Initially patients from joint arthroplasty waitlists were targeted; some did require joint arthroplasty, and those who had been waiting a long time for arthroplasty were unwilling to give up their position on the waitlist despite improvements in symptoms. Now patients are referred by any health practitioner, so some are earlier in disease course. Although OACCP prevents unnecessary arthroplasties, this is seen by health system as “cost-shifting”; when a patient is removed from the waitlist, there is always somebody to take their place. Unwillingness of local health districts to dedicate funding to the OACCP. Seen as an “additional” program despite documented good clinical outcomes and cost-savings. Once the pilot project with funding ended, some local sites failed to provide ongoing funding, or at least had funding reduced, meaning contracts of key healthcare personnel were terminated. | OACCP model of care development included input from health professionals (clinical, research & government), consumers and non-governmental stakeholders. Seven pilot sites commenced in 2011/2012 for 2 years, during which time they reported Standardized indicators for the evaluation of the program components and participant outcomes. Electronic data capture for relevant outcome data and reports on key performance and clinical indicators. Regular contact between musculoskeletal coordinators of OACCP sites, and Agency of Clinical Innovation reporting to key stakeholders. Frequent presentations to orthopedic surgeons and hospital executives providing updates on program deliverables with support from local champions driving the initiative. Release of sector-wide Model of Care for OA by Agency of Clinical Innovation. | If pre-existing healthcare professionals can be up trained to deliver appropriate chronic disease management, the model of care can be tailored to suit most poorly resourced, developing healthcare settings. Apart from healthcare personnel, the resource requirements for successful delivery of the model of care are minimal. Low health literacy in such settings would be a challenge with large proportions of the population not seeking medical care or comprehending treatment recommendations. | Coordinated data collection to enable generation of activity and outcome reports at a local level is key in securing ongoing local funding. Support from local orthopedic surgeons greatly contributes to the success of individual OACCPs. Programs such as OACCP would be better suited, likely more cost-effective and more accessible to patients in the primary care setting. Future research in Australia is focused on further refining the optimal model of care within the Australian setting. Often patients are referred to the OACCP late in their disease course, following surgical planning with an orthopedic surgeon. A recently published paper demonstrates these patients already on waitlist have twice the odds of reporting they are “worse” 26 weeks into the OACCP despite symptomatic improvement on HOOS/KOOS . It would be preferable if patients were referred to the OACCP prior to booking for joint arthroplasty. |
| Better Management of Patients with Osteoarthritis (BOA) | Primary care. Intervention given by physiotherapist and sometimes occupational therapist. Collaboration with Swedish Rheumatism Association through Osteoarthritis communicators. | A survey of 1600 patients receiving total hip replacement for OA, showing that only a minority had seen a physical therapist before surgery, and of those who had seen a physical therapist, only a minority had received treatment according to guidelines. | 10-step model to induce change in professional behavior, Stage of change, Self-determination theory, Relapse prevention model, Social learning theory . | A joint initiative by Carina Thorstensson (conclusions from thesis, review of literature, interviews with patients and development of the evidence-based intervention), Leif Dahlberg and other orthopedic surgeons (who felt the need to improve indications, expectations and patient-reported outcomes after surgery), and Göran Garellick at the Swedish Hip Arthroplasty Register. | Translation of evidence, patient perceptions, and clinical experience into a supported self-management program (2006). A pilot trial of the intervention showing potential to improve symptoms and self-efficacy (2006). Transforming evidence and rationale for program into education for healthcare professionals (2006). Defining a “minimal intervention” and a minimal set of outcomes (2007). Setting up a database to collect outcomes online, and to report results back to clinic in real time (2007). Feasibility test during a 2-year pilot, involving 10 clinics (4 hospital-based and 6 in primary care) in four geographic regions (2008–2010). Continuous education of healthcare professionals. Since 2010, the BOA is a national quality register, and all clinics using the intervention can report. In January 2016, 3000 healthcare professionals were educated to deliver and evaluate the program, 445 clinics are using the register to report and follow results, and 60,000 patients are included. | Financial compensation in primary care is focused on activity rather than quality of care. The tradition of using radiographic changes as a diagnostic criteria often causes a delay in diagnosis and consequently in adequate treatment. A large number of patients are referred to orthopedic surgeons without having tried nonsurgical treatment. Lack of routines regarding regular assessments and evaluations in health care, including rehabilitation. Lack of knowledge within rehabilitation field about how to use results to identify potential areas for improvement. Administrative burden (to register). A small practice may have waiting list before the intervention starts. | Defining a minimal intervention (i.e., information), that can be built upon allows for local adaptions. Healthcare professionals receive a ready-to-use model on a flash-disk during their education. Support is provided via e-mail or phone. No specific exercise program is used, but neuromuscular principles and quality are emphasized to be used for all types of exercises, to increase fidelity among physiotherapists. An OA communicator serves as a peer with experiences from self-management and physical activity, adding credibility to information provided by healthcare professionals. (Their participation is voluntary and free of charge.) Interactivity during theory sessions and involving participants in discussions and sharing of experiences, increase the opportunity for teach-back. Exercise and daily physical activity are emphasized and strongly recommended throughout intervention, but the initiative to participate is to be made by the participant, to increase compliance and internal motivation. Information is crucial to gain understanding of how, why, and when to be physically active. Exercises are individually adapted in accordance with personal resources and goals, and tried out during a face-to-face session. Participants can choose to perform exercises supervised at clinic, at home or where it suits them best, to facilitate compliance. Home exercises are introduced as “5 min per day” to facilitate adoption in daily life. For inactive participants, regular breaking of inactivity (by e.g., standing up during commercials on TV), can be easier to implement than an exercise program. Focus on one life style change at a time (rather than both weight reduction and exercise). | Suitable, with cultural adaptations of the minimal intervention, i.e. information. Physical activity can be emphasized with adaptation to local culture and traditions. Self-management is not only about exercise, but also about how to manage symptoms by cognitive and active coping strategies. This is relevant across contexts, with adaptations to ensure cultural relevance. | Despite several years of successful implementation, and involvement from several hundred clinics nationwide, we estimate that we reach approximately 10% of all patients in need. There are several reasons for lack of reach. The development and use of a digital version ( www.jointacademy.com ) has shown promising results of at least similar magnitude to the program presented in primary care. A digitalized health care may increase access for people with limited time (i.e., working people) or long distance to healthcare facilities. A digitalized version also has the possibility to increase long-term compliance, which still is a great challenge for the BOA program. Additional booster sessions after the 3-month follow-up might be cost-effective in the long run. Clinicians are keen on delivery of a rational, evidence–based, and time-efficient group treatment, but not on evaluation and assessment. Managers are important stakeholders to allocate time for assessment and to ask for results. Online feedback in real time is an important tool that can be used to further improve health care. This feedback needs to be developed in close collaboration with healthcare professionals, managers, and patients to be used and useful in clinic. Successful implementation requires involvement from the full team. Focus on care units who are motivated and engaged, rather than those who are negative, gives positive attention and proud colleagues who become champions for implementation. Involvement in developing national and regional guidelines, based on evidence-based international guidelines, is important, and facilitates top–down approach. Using results from follow-up data in public reporting (i.e., press release and debate articles) increases the demand from patients to receive evidence-based treatment according to the program. Together with reports from proud healthcare professionals and patient stories, this forms important bottom–up influence. Involvement from patient representatives (i.e., patients with positive experience from life style changes in OA, and education to facilitate discussions among participants) in the program facilitates interpretation of the program education among participants, and increases motivation to change. |
| Good Life with osteoArthritis in Denmark (GLA:D) | Intervention given by physical therapists, mostly in municipalities and private clinics but also at some hospitals | Results from two randomized clinical trials in patients being referred to orthopedic surgeons showed that exercise therapy had been applied in about 1 out of 20 patients before referral | A multimodal approach was applied as summarized by Grol & Grimshaw | GLA:D was initiated by Ewa M. Roos and Søren T. Skou at University of Southern Denmark in 2013. GLA:D is a not-for-profit, bottom–up approach started with limited funding and maintained by course fees. The setup, including the educational part is an adapted version of the Swedish BOA program. The Neuromuscular exercise program used is previously described and found feasible and effective. | The first course for physical therapists was held in January 2013 with 42 participants. Over 3 years, 10 additional courses have been held with up to 90 participating physical therapists in each course, and still the waiting list for courses is long. The first annual report (data until 31 December 2013) included data from 719 patients from 49 GLA:D-units, the second annual report (data until 31 December 2014) included data from 3637 patients from 137 GLA:D-units, while the third annual report (data until 31 December 2015) included data from 9827 patients from 227 GLA:D-units. Thus far, more than 13,500 patients have been included and the numbers are expected to reach around 20,000 patients by the end of 2016 due to exponential growth. | Cost: While treatment in private clinics is associated with out-of-pocket payment from the patient, it is free in the municipalities. This, however, makes it more difficult to implement in the municipalities, since the cost needs to be covered by public funding. In Denmark, most patients have to pay for physiotherapy and exercise, while surgery is free of charge. Administrative burden for physical therapists: registering data in the national GLA:D registry is currently not reimbursed by the health authorities. As a result of this, not all GLA:D units report data to the registry. Thus far, it is not a requirement that patients have nonsurgical treatment of a sufficient dose and length prior to seeing the surgeon, resulting in a large number of patients being referred to orthopedic surgeons without having tried nonsurgical treatment first. | Delivering a “tool box” for the physical therapist, consisting of all the material and training needed to initiate GLA:D in their local clinic or municipality is a key to success. Engaging the physical therapists, patients, and other stakeholders in the development and giving them ownership to the program is crucial. Conveying a clear message and informing patients about nonsurgical treatment through mass media can lead to patients demanding to have nonsurgical treatment, thereby bypassing organizational and political barriers as well as financial incentives otherwise preventing change and the uptake of clinical guidelines. Once numbers of patients and physical therapists in the treatment program allow evaluation of outcomes and feasibility of the program in clinical practice, addressing politicians and decision-makers can propel implementation. Health economic analyses are central to maintain implementation rate. | Suitable, with cultural adaptations of the course for physical therapists, the treatment of patients and the evaluation in the registry | Implementing evidence in clinical practice can profitably be done with a bottom–up approach instead of a top–down approach, since this strengthens the engagement, feeling of professional pride, and ownership among stakeholders. A bottom–up approach requires less start-up funding than a top–down approach. Some patients are willing to pay out of pocket for education and exercise although surgery is free of charge. This system may however increase inequality in access to evidence-based OA care. |
| Osteoarthritis Healthy Weight For Life | Primary care and secondary care delivered remotely | Modified version of the plan-do-study-act method of quality improvement in healthcare model. Model underpinned by comprehensive patient engagement strategies. | Prima Health Solutions in collaboration with an early adopter health insurance fund | Prima Health Solutions has specialized in research, development, and systematic remote delivery of integrated best practice chronic disease management programs for weight-related chronic diseases (OA, type 2 diabetes, CVD) since 2005. | Patient recruitment is now the biggest challenge despite the program being clinically effective, scalable, and free to eligible patients. Once patients are enrolled, the systems, processes, and central support team are in place to deliver consistent and predictable clinical outcomes irrespective of the rural, remote, or urban location of patients. | Understanding the key drivers of the program funder, and where possible capturing and reporting on outcome data can provide ongoing support for the underlying business case. | From a technical perspective, the highly refined patient resources, systems, process, and information technology would enable a quality-assured implementation without extensive local resources. However, it is likely to be cost-prohibitive for the general community in developing countries. | To deliver a program with scale that achieves consistent clinical outcomes across geographically diverse patients requires more than clinical expertise; it requires a detailed plan, systems processes, standardized resources, measurement framework, and feedback loops. | |
| Amsterdam osteoarthritis cohort (AMS-OA) | Secondary care: rehabilitation center in the Netherlands. | Patients with knee and/or hip OA seen by rheumatologists and rehabilitation physicians. | Implementation and construction of OA management program in the AMS-OA cohort was based on “Beating osteoarthritis”: development of a stepped care strategy to optimize utilization and timing of nonsurgical treatment modalities for patients with hip or knee osteoarthritis” by Smink et al. . Furthermore, the exercise program was based on the knee joint stabilization exercise trial of Knoop et al. . | The initiative for the AMS-OA cohort was taken by Joost Dekker, Willem Lems, Leo Roorda and Martin van der Esch in 2009. | Based on practicality, an inclusion of 150 patients a year was planned. Currently, a total of 1000 patients are included in the cohort. | Challenge is to implement the results of studies in daily practice in a secondary care setting and at the same time implement the findings in primary care. In primary care, a barrier is to develop an assessment system for providing research data. Engagement of primary care providers, not only to execute interventions programs but especially to deliver further research data for the development of program. | One of the key drivers for the AMS-OA cohort is the funding for clinical trials nested in the cohort. This funding makes it possible to extend research. Another key driver is the engagement of rheumatologists, rehabilitations physicians, and physiotherapists to deliver data and implement results in clinical practice. | Sufficient knowledge for the development of a cohort, monitoring of the quality of a cohort, and monitoring the OA management program is required. This knowledge is present in specialized secondary care, but it is not easy to convert it to primary health care. Maintaining a cohort has significant costs and can be a barrier for developing countries. | Monthly discussions and meetings are needed with all those involved in the design and implementation of a cohort and the consequences for the OA management program. |
| Joint Implementation of Guidelines for oSteoArthritis in the West Midlands JIGSAW Based on MOSAICS study (Dziedzic et al., 2014) | Primary Care in Clinical Commissioning Groups (CCGs) UK. Initial consultation with the general practitioner, followed by up to four sessions with a practice nurse within the general practice. | Using OA e-template endorsed by NICE, UK, in 14 practices in one CCG, UK | Implementation Theory, Behavior Change Theory, Normalization Process Theory | General Practitioner as Clinical Champion who also sat on CCG Board in the locality. Felt that this model of OA care would be beneficial in real-world practice. CCG concerns about how many patients were being referred to orthopedics from primary care | Via the Academic Health Sciences Network, West Midlands, UK ×3 CCGs. Estimated number of practices, n = 100. In one practice of 8000 patients, 7 GPs, 3 practice nurses trained to deliver the program. In one practice, the four sessions with a practice nurse (the OA “clinic”) saw 61 patients over 21 months (approximately 3 per month). Of these, 36 patients received one appointment, 19 two appointments, 6 three appointments. | Pressures of local primary care organizations, clinical time to undertake training, costs of releasing practice nurses to attend training, increased requirements for general practice with no recognition of costs/burden on practice | Dedicated implementation team with project management funded via the West Midlands Academic Health Sciences Network; National Institute of Health Research, Knowledge Mobilization Research Fellowship funded dedicated time; Clinical Champions, Patient and Public Involvement. Training made freely available with clinical champions visiting practices, practice nurse training reduced from 4 days (Research Study MOSAICS) to 2 days, worked with local CCG to develop funding model to support implementation in practice. Automated e-OA template enables practices to demonstrate compliance with NICE guidance | The practice nurse training and a “training the trainers” model could be used for core non-pharmacological approaches. | Pragmatic cluster trial with strong engagement of local stakeholders can instigate uptake of innovations produced by the research. Local general practitioners and practice nurse champions are influential. Information technology and project management needed support to deliver training. Patient involvement in the development of the program enhanced patient-facing material. Identify both strong clinical and managerial champions, understand the context (e.g., benchmarking and local pressures), allow time for training/project management, and adapt to differing circumstances (e.g., practice nurses vs. lifestyle coaches). Funding needed for both the implementation team and the stakeholder engagement. |
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