Collaborative model of care between orthopaedics and allied healthcare professionals (CONNACT) in knee osteoarthritis: Effectiveness-implementation hybrid randomized controlled trial of a community-based, multidisciplinary, stratified intervention.

OBJECTIVE: To compare the clinical and cost effectiveness of the Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT), a community-based, stratified, multidisciplinary intervention consisting of exercise, education, psychological and nutrition delivered through a chronic care model to usual hospital care in adults with knee osteoarthritis (OA). METHODS: Pragmatic, parallel-arm, single-blinded superiority RCT trial. Community-dwelling, ambulant adults with knee OA (Kellgren-Lawrence grade > 1; Knee Injury and OA Outcome Score (KOOS4) ≤75) were enrolled. Primary outcome was KOOS4 at 12-months; secondary outcomes included: quality of life, physical performance measures, symptom satisfaction, psychological outcomes, dietary habits, and global perceived effect. Intention-to-treat analysis using generalized linear model (GLM) and regression modeling were conducted. Economic evaluation through a societal approach was embedded. RESULTS: 110 participants (55 control, 55 intervention) were randomized. No between-group difference found for the primary outcome (MD [95%CI]: -1.86 [-9.11. 5.38]), although both groups demonstrated within-group improvement over 12-months. Among the secondary outcomes, the CONNACT group demonstrated superior dietary change (12 months) and physical performance measures (3 months), and global perceived effect (6 months). While there was no between-group difference in total cost, significant productivity gains (reduced indirect cost) were seen in the CONNACT group. CONCLUSION: CONNACT was not superior to usual care at 1 year. Further efforts are needed to understand the underlying contextual and implementation factors in order to further improve and refine such community-based, stratified care models moving forward. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03809975. Registered January 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03809975.

Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus.

OBJECTIVE: Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations. DESIGN: Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed. DATA SOURCES: MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021. ELIGIBILITY: Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury. RESULTS: Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2-14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2-5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (-1.5 (-2.9 to -0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL). CONCLUSION: There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.

Implementation of clinical guidelines for osteoarthritis together (IMPACT): protocol for a participatory health research approach to implementing high value care.

BACKGROUND: The evidence-based interventions of exercise and education have been strongly recommended as part of prominent clinical guidelines for hip and knee osteoarthritis (OA) for more than ten years. Despite the wealth of strong evidence that exists, implementation in practice is sub-optimal. This paper describes the key methodologies used in the co-design, tailoring, and evaluation of the IMPACT project implementation strategies, to confront this problem across multiple levels (micro, meso, macro) in public and private healthcare settings in Ireland. METHODS: Using a type III hybrid implementation-effectiveness design, a participatory, dynamic and iterative process will be used to tailor and evaluate multi-level implementation strategies using the following stages: 1) Co-design the implementation strategies with key stakeholders using best evidence, a theory-driven implementation framework (Consolidated Framework for Implementation Research), local context and expert consensus; 2) Pilot and evaluate the implementation strategies by training physiotherapists to deliver the evidence-based Good Life with osteoArthritis Denmark (GLA:D®) education and exercise programme using the implementation strategies, and conduct a mixed-methods process evaluation; 3) Adapt the implementation strategies based on implementation process evaluation indicators from stage two. The adapted strategies will be used for scale-up and sustainability in subsequent GLA:D® Ireland training programmes that will be rolled out nationally. Evaluation of effectiveness on patient and cost outcomes will continue up to 12 months post-programme delivery, using an online patient registry and pre-post design. DISCUSSION: This implementation science project aims to use participatory health research to address a gap in management of OA across public and private healthcare settings. This research has the potential to change practice and promote a policy of exercise and physical activity referral for chronic musculoskeletal disease that utilises community engagement effectively and enacts change 'together', with involvement of researchers, decision-makers, clinicians and patients.

Cost-effectiveness of an 8-week supervised education and exercise therapy programme for knee and hip osteoarthritis: a pre-post analysis of 16 255 patients participating in Good Life with osteoArthritis in Denmark (GLA:D).

OBJECTIVES: To evaluate 1-year cost-effectiveness of an 8-week supervised education and exercise programme delivered in primary care to patients with symptomatic knee or hip osteoarthritis (OA). DESIGN: A registry-based pre-post study linking patient-level data from the Good Life with osteoArthritis in Denmark (GLA:D) registry to national registries in Denmark. SETTING AND PARTICIPANTS: 16 255 patients with symptomatic knee or hip OA attending GLA:D. INTERVENTION: GLA:D is a structured supervised patient education and exercise programme delivered by certified physiotherapists and implemented in Denmark. OUTCOME MEASURES: Adjusted healthcare costs per Quality-Adjusted Life Year (QALY) gained from baseline to 1 year (ratio of change in healthcare costs to change in EuroQoL 5-Dimensions 5-Level questionnaire (EQ-5D)). All adjusted measures were estimated using a generalised estimating equation gamma regression model for repeated measures. Missing data on EQ-5D were imputed with Multiple Imputations (3 months: 23%; 1 year: 39 %). RESULTS: Adjusted change in healthcare cost was 298€ (95% CI: 206 to 419) and 640€ (95% CI: 400 to 1009) and change in EQ-5D was 0.035 (95% CI: 0.033 to 0.037) and 0.028 (95% CI: 0.025 to 0.032) for knee and hip patients, respectively. Hence estimated adjusted healthcare costs per QALY gained was 8497€ (95% CI: 6242 to 11 324) for knee and 22 568€ (95% CI: 16 000 to 31 531) for hip patients. In patients with high compliance, the adjusted healthcare costs per QALY gained was 5438€ (95% CI: 2758 to 9231) for knee and 17 330€ (95% CI: 10 041 to 29 364) for hip patients. Healthcare costs per QALY were below conventional thresholds for willingness-to-pay at 22 804€ (20 000£) and 43 979€ (US$50 000), except the upper limit of the 95% CI for hip patients which was in between the two thresholds. CONCLUSIONS: A structured 8-week supervised education and exercise programme delivered in primary care was cost-effective at 1 year in patients with knee or hip OA supporting large-scale implementation in clinical practice.

Feasibility assessment of an occupational therapy lifestyle intervention added to multidisciplinary chronic pain treatment at a Danish pain centre: a qualitative evaluation from the perspectives of patients and clinicians.

Purpose: As part of intervention feasibility evaluation before conducting a clinical trial, this study aimed to investigate perspectives of patients and clinicians involved in the occupational therapy lifestyle-oriented programme REVEAL(OT) [Redesign your EVEveryday Activities and Lifestyle with Occupational Therapy] which was added to multidisciplinary chronic pain treatment.Methods: We conducted three focus group interviews, two with eight voluntarily selected patients and one with four clinicians. Data were analysed using Braun & Clarke's semantic data-driven analysis.Results: Patients reported satisfaction with the intervention and a greater acceptance of living with chronic pain through increased understanding of pain mechanisms, more effective daily planning and improved social interaction. Patients felt empowered to change lifestyle habits by restarting habitual interests, prioritizing joyful occupations for improved occupational balance, and lifestyle modifications. Contact to occupational therapists and peer support were important empowering factors for working with lifestyle goals. Patients and clinicians expressed their views on further improvement of the REVEAL(OT).Conclusions: Patients and clinicians found the lifestyle-oriented occupational therapy programme relevant as an add-on to the multidisciplinary chronic pain treatment. A need was expressed for a reduced information and treatment load and a higher degree of communication and cooperation among the clinicians involved in the intervention.

Risk-stratified and stepped models of care for back pain and osteoarthritis: are we heading towards a common model?

The overall quality of care for musculoskeletal pain conditions is suboptimal, partly due to a considerable evidence-practice gap. In osteoarthritis and low back pain, structured models of care exist to help overcome that challenge. In osteoarthritis, focus is on stepped care models, where treatment decisions are guided by response to treatment, and increasingly comprehensive interventions are only offered to people with inadequate response to more simple care. In low back pain, the most widely known approach is based on risk stratification, where patients with higher predicted risk of poor outcome are offered more comprehensive care. For both conditions, the recommended interventions and models of care share many commonalities and there is no evidence that one model of care is more effective than the other. Limitations of existing models of care include a lack of integrated information on social factors, comorbid conditions, and previous treatment experience, and they do not support an interplay between health care, self-management, and community-based activities. Moving forwards, a common model across musculoskeletal conditions seems realistic, which points to an opportunity for reducing the complexity of implementation. We foresee this development will use big data sources and machine-learning methods to combine stepped and risk-stratified care and to integrate self-management support and patient-centred care to a greater extent in future models of care.

Implementing a national first-line management program for moderate-severe knee osteoarthritis in Australia: A budget impact analysis focusing on knee replacement avoidance.

Objective: To model potential cost savings associated with implementing a first-line management program for moderate-severe knee osteoarthritis (OA) at a national level in Australia. Methods: A budget impact analysis was undertaken using published trial data and publically available data. Australian population projections and OA prevalence data were used to forecast likely need for total knee replacement (TKR) surgery for 2019-2029. Published data were sourced on TKR avoidance following a 12-week non-surgical knee OA management program (exercise therapy, education, insoles, dietary advice, analgesia) and cost per TKR in Australia. The cost of providing the first-line program was estimated on a sliding scale ($AUD750-$3000), with a base case of $AUD1,500. These inputs were used to model potential annual savings associated with national implementation of the program. Results: The number of people in Australia with moderate-severe knee OA requiring TKR was estimated to be 56,007 in 2019, rising to 69,038 by 2029. Avoidance of TKR by 34%-68% of people after the first-line management program could translate to savings of $AUD303million-690 million in 2019. Successively lowering the proportion of people who avoided TKR demonstrated that only 1 in 12 program recipients would need to avoid surgery for the program to generate savings. Conclusions: National implementation of a first-line OA management program as an alternative to TKR could produce substantial cost savings for the Australian healthcare system. Longer term data on TKR avoidance is needed to establish whether cost savings are realised or simply shifted to later years.

Ultrasonographic assessment of patellar tendon thickness at 16 clinically relevant measurement sites - A study of intra- and interrater reliability.

OBJECTIVES: To determine intra- and interrater reliability of ultrasonographic imaging (USI) measurements of patellar tendon (PT) thickness using 16 measurement sites covering the entire tendon. DESIGN: Reliability study. SETTING: Physiotherapy outpatient clinic. PARTICIPANTS: Twenty healthy and physically active volunteers (9 women). Mean age: 24 years (SD ±â€¯2.73). Mean body mass: 75.8 kg (SD ±â€¯11.8). MAIN OUTCOME MEASURES: Intraclass correlation coefficient (ICC) and 95% limits of agreement (LOA) in cm and in percentage relative to the mean PT thickness. RESULTS: Intrarater reliability ranged from 0.59 to 0.87 and 0.59 to 0.93 for examiners I and II, respectively. Interrater reliability ranged from 0.37 to 0.89. Measurement precision for examiner I ranged from 0.05 to 0.09 cm (17.5%-26.7%) while ranging from 0.04 to 0.13 cm (13.3%-38.7%) for examiner II. Interrater measurement precision ranged from 0.07 to 0.15 cm (19.1%-42.5%). CONCLUSION: In an attempt to replicate daily clinical USI practice, this was the first study extensively assessing reliability throughout the full range of the patellar tendon - revealing a considerable variation in intra- and interrater reliability as well as measurement precision throughout the 16 individual PT sites. In a clinical context, the low interrater reliability and precision found at the proximal tendon insertion site may have implications for USI of the symptomatic PT, as this is the site mainly associated with underlying pathologic changes. Further reliability studies are needed to clarify the region-specific reliability of the full length PT.

The value of routine radiography in patients with knee osteoarthritis consulting primary health care: a study of agreement.

BACKGROUND: Radiography is often used routinely by the general practitioner (GP) in knee osteoarthritis (KOA), even though the diagnosis can be made based on clinical findings. However, radiography may also be requested when serious pathology is suspected. The agreement between the radiographic and the GPs clinical diagnosis and the ability of radiography to rule out serious pathology in clinical KOA is unknown, despite that this is important to evaluate the clinical value of radiography. OBJECTIVES: The objectives were to evaluate agreement between the radiographic and clinical diagnosis in KOA; and to describe radiographic features in patients referred from their GP with clinical KOA. METHODS: Referral forms from GPs and radiographs of 1 334 consecutive patients above 40 years not previously diagnosed with KOA were evaluated. The agreement between primary indication for radiographic referral (± clinical KOA; according to the recommendations from the European League Against Rheumatism) and the radiographic diagnosis (± radiographic KOA; Kellgren and Lawrence score ≥ 1) was estimated using Cohen's Κ statistics. Furthermore, an evaluation of radiographic features was carried out in patients with clinical KOA (n = 997). RESULTS: The strength of the agreement was 0.106 to 0.298 with the lowest agreement in the youngest patients and the highest in the oldest patients. Five radiographs (0.5%) revealed conditions needing further investigation or specific treatment (osteonecrosis, osteochondral lesion, fracture and subluxation). CONCLUSION: In patients with clinical KOA, the radiography seems only indicated if the clinical assessment cannot rule out other diagnoses or serious pathology.