Improving osteoarthritis management in primary healthcare: results from a quasi-experimental study

Abstract

Background: To improve quality of care for patients with hip and knee osteoarthritis (OA), general practitioners (GPs) and physiotherapists (PTs) in a Norwegian municipality initiated an intervention. The intervention aimed to increase provision of core OA treatment (information, exercise, and weight control) prior to referral for surgery, rational use of imaging for assessing OA and improve communication between healthcare professionals. This study assessed the effectiveness of this intervention.

Methods: Forty-eight PTs and one hundred one GPs were invited to the intervention that included two interactive workshops outlining best practice and an accompanying template for PT discharge reports. Using interrupted time series research design, the study period was divided into three: pre-implementation, transition (implementation) and post-implementation. Comparing the change between pre- and post-implementation, the primary outcome was patient-reported quality of OA care measured with the OsteoArthritis Quality Indicator questionnaire. Secondary outcomes were number of PT discharge reports, information included in GP referral letters to orthopaedic surgeon, the proportion of GP referral letters indicating use of core treatment, and the use of imaging within OA assessment. Analyses involved linear mixed and logistic regression models.

Results: The PT workshop had 30 attendees, and 31 PTs and 33 GPs attended the multidisciplinary workshop. Two hundred eight and one hundred twenty-five patients completed the questionnaire during pre- and post-implementation, respectively. The adjusted model showed a small, statistically non-significant, increase in mean total score for quality of OA care (mean change = 4.96, 95% CI -0.18, 10.12, p:0.057), which was mainly related to items on OA core treatment. Patients had higher odds of reporting receipt of information on treatment alternatives (odds ratio (OR) 1.9, 95% CI 1.08, 3.24) and on self-management (OR 2.4, 95% CI 1.33, 4.32) in the post-implementation phase. There was a small, statistically non-significant, increase in the proportion of GP referral letters indicating prior use of core treatment modalities. There were negligible changes in the number of PT discharge reports, in the information included in the GP referral letters, and in the use of imaging for OA assessment.

Conclusion: This study suggests that a primary care intervention including two inter-active workshops can shift the quality of care towards best practice recommendations.

Trial registration: ClinicalTrials.gov: NCT02876120 .

Keywords: Implementation; Osteoarthritis; Quality of care.

Conflict of interest statement

Not applicable.

Figures

Fig. 1

Study timeline

Fig. 2

Overview of the intervention components

Fig. 3

Patient-reported quality of osteoarthritis care. Boxplot of total mean score during the pre-implementation in 2016 (n = 208 patient responders) and the post-implementation in 2017 (n = 125 patient responders)

Fig. 4

Patient-reported quality of osteoarthritis care. Marginsplot of total mean score during 8 pre-implementation weeks in 2016 (n = 208 patient responders) and 8 post-implementation weeks in 2017 (n = 125 patient responders)

Fig. 5

Patient-reported quality of osteoarthritis care: pass rates for individual OAQI v2 items during pre-implementation (n = 208) and post-implementation (n = 125). All items have ‘Yes’, ‘No’, and ‘Not applicable’/‘Don’t remember’ as response options. Individual item pass rates were calculated as the proportion of patients reporting that the QI was passed (‘Yes’) divided by the proportion of patients who were eligible (‘Yes’ or ‘No’) for that QI item (in percentage). Pass rates range from 0 to 100, with 100 representing that all eligible patients reported pass (‘Yes’) for that QI item. OAQI v2 items wording: 1) Have you been given information about osteoarthritis from a health professional? 2) Have you been given information about different treatment alternatives? 3) Have you been given information about how you can self-manage the disease? 4) Have you been given information about the importance of physical activity and exercise? 5) Have you been referred or offered a referral to a health professional who can advise you about physical activity and exercise? 6) Have you been advised to lose weight if you are overweight? 7) Have you been referred or offered a referral to someone who can help you to lose weight, if you are overweight?8) If you have problems with daily activities, have these problems been assessed by a health professional? 9) If you have problems with walking, has your need for a walking aid been assessed? (e.g. stick, crutch or walker) 10) If you have problems related to other daily activities, has your need for appliances and aids been assessed? (e.g. splints, assistive technology for cooking or personal hygiene, a special chair) 11) If you have joint pain, has it been assessed by a health professional? 12) If you have joint pain, was paracetamol the first medication that was recommended? 13) If you have prolonged severe joint pain, which is not relieved sufficiently by paracetamol, have you been offered stronger pain killing medications? (e.g. co-codamol, codeine, tramadol, co-proxamol, co-dydramol, dihydrocodeine) 14) If you use anti-inflammatory medications, have you been given information about the effects and possible side-effects of this medication? (e.g. ibuprofen (Nurofen, Brufen), diclofenac (Voltarol), naproxen (Naprosyn), celecoxib (Celebrex)) 15) If you have experienced an acute deterioration of your symptoms, have you been given or offered a steroid injection? 16) If you are severely troubled by your osteoarthritis, and exercise and medication do not help, have you been referred or offered a referral for an assessment for operation? (e.g. joint replacement)