Developing and embedding an advanced practice musculoskeletal physiotherapy service in public specialist outpatient services in Queensland: A health service masterclass.

INTRODUCTION: The Musculoskeletal Physiotherapy Screening Clinic and Multi-disciplinary Service (MPSC&MDS) is an advanced practice physiotherapist-led model of care developed initially to address overburdened specialist orthopaedic outpatient public hospital services across Queensland, Australia. PURPOSE: This Masterclass explores the experiences and success of embedding the MPSC&MDS state-wide across the Queensland public health system and its expansion in scale and reach to other specialist services. Key characteristics and development strategies are described that have collectively underpinned the expansion and sustainability of the service, using relevant stream sections and themes from a recommended musculoskeletal model of care framework. IMPLICATIONS: The aim of this masterclass is to be informative for readers involved in the future development or refinement of similar models of care.

Pre-operative pain pressure threshold association with patient satisfaction following Total Knee Arthroplasty.

Background: Total knee arthroplasty (TKA) is commonly performed for the treatment of knee osteoarthritis (KOA). Poor satisfaction continues to be seen after TKA. Whilst reasons for poor patient satisfaction are multifactorial, there is a strong correlation with persistent pain following TKA. Studies have shown an association between local and remote mechanical hypersensitivity, measured using pressure pain thresholds (PPTs), and severity of knee osteoarthritis and functional status. We aimed to determine if the pre-operative PPTs were associated with patient satisfaction following TKA. Methods: A prospective longitudinal study of 77 individuals was undertaken. Regression modelling assessed the relationship between Patient Satisfaction using the Knee Society Score (satisfaction subscale) following TKA for KOA, and PPTs recorded pre-operatively locally and remote to the affected knee, while accounting for potentially confounding patient demographic and psychosocial factors. Results: Lower PPTs (indicating increased mechanical hypersensitivity) locally and remote to the operative knee were modestly associated with lower patient satisfaction in the short-term (six weeks) following TKA (ß 0.25-0.28, adjR2 = 0.14-0.15), independent of demographic or psychosocial influences. However, this relationship progressively diminished in the intermediate and long-term post TKA. Conclusion: While pre-operative PPT measures may provide some foresight to patient satisfaction post TKA in the short term, these measures appear to provide little insight to patient satisfaction in the intermediate and longer term.

Exploring equity of care for Aboriginal and Torres Strait Islander peoples within the state-wide Musculoskeletal Physiotherapy Screening Clinic and Multi-disciplinary Service in Queensland Health.

ObjectiveThis study aimed to explore equity of care for Aboriginal and Torres Strait Islander peoples compared to non-Indigenous Australians within a Queensland-wide musculoskeletal service.MethodThe service database was analysed between July 2018 and April 2022 across 18 Queensland Health facilities. Representation of Aboriginal and Torres Strait Islander peoples within the service's patient population was first explored. Second, service and patient-related characteristics and outcomes between Aboriginal and Torres Strait Islander patients and non-Indigenous patients undergoing an episode of care in the service were compared using analysis of variance and chi-squared tests.ResultsA greater proportion of Aboriginal and Torres Strait Islander peoples (4.34%) were represented within the service's patient population than in the general population (3.61%) state-wide. Aboriginal and Torres Strait Islander patients presented with a generally higher severity of clinical presentation across measures at initial consult. Very similar proportions of Aboriginal and Torres Strait Islander (63.2%) and non-Indigenous (64.3%) patients reported clinically meaningful treatment benefits. While a higher proportion of Aboriginal and Torres Strait Islander patients (69.7%) were discharged from the service without requiring specialist review compared to non-Indigenous patients (65.6%), Aboriginal and Torres Strait Islander patients had higher rates of discharge due to non-attendance (20.8%) when compared to non-Indigenous (10.6%) patients (P<0.01).ConclusionsDisparity in care retention for Aboriginal and Torres Strait Islander patients compared to non-Indigenous patients was observed within the musculoskeletal service. Consultation with Aboriginal and Torres Strait Islander communities is needed to address access barriers once in the service to guide service improvement.

Reinforcing informed medication prescription for low back pain in the emergency department (RIME): a controlled interrupted time series implementation study protocol.

INTRODUCTION: Management guidelines for low back pain (LBP) recommend exclusion of serious pathology, followed by simple analgesics, superficial heat therapy, early mobilisation and patient education. An audit in a large metropolitan hospital emergency department (ED) revealed high rates of non-recommended medication prescription for LBP (65% of patients prescribed opioids, 17% prescribed benzodiazepines), high inpatient admission rates (20% of ED LBP patients), delayed patient mobilisation (on average 6 hours) and inadequate patient education (48% of patients). This study aims to improve medication prescription for LBP in this ED by implementing an intervention shown previously to improve guideline-based management of LBP in other Australian EDs. METHODS AND ANALYSIS: A controlled interrupted time series study will evaluate the intervention in the ED before (24 weeks; 20 March 2023-3 September 2023) and after (24 weeks; 27 November 2024-12 May 2024) implementation (12 weeks; 4 September 2023-26 November 2023), additionally comparing findings with another ED in the same health service. The multicomponent implementation strategy uses a formalised clinical flow chart to support clinical decision-making and aims to change clinician behaviour, through clinician education, provision of alternative treatments, educational resources, audit and feedback, supported by implementation champions. The primary outcome is the percentage of LBP patients prescribed non-recommended medications (opioids, benzodiazepines and/or gabapentinoids), assessed via routinely collected ED data. Anticipated sample size is 2000 patients (n=1000 intervention, n=1000 control) based on average monthly admissions of LBP presentations in the EDs. Secondary outcomes include inpatient admission rate, time to mobilisation, provision of patient education, imaging requests, representation to the ED within 6 months and healthcare costs. In nested qualitative research, we will study ED clinicians' perceptions of the implementation and identify how benefits can be sustained over time. ETHICS AND DISSEMINATION: This study received ethical approval from the Metro North Human Research Ethics Committee (HREC/2022/MNHA/87995). Study findings will be published in peer-reviewed journals and presented at international conferences and educational workshops. TRIAL REGISTRATION NUMBER: ACTRN12622001536752.

Prospective validity of a clinical prediction rule for response to non-surgical multidisciplinary management of knee osteoarthritis in tertiary care: a multisite prospective longitudinal study.

OBJECTIVES: We tested a previously developed clinical prediction tool-a nomogram consisting of four patient measures (lower patient-expected benefit, lower patient-reported knee function, greater knee varus angle and severe medial knee radiological degeneration) that were related to poor response to non-surgical management of knee osteoarthritis. This study sought to prospectively evaluate the predictive validity of this nomogram to identify patients most likely to respond poorly to non-surgical management of knee osteoarthritis. DESIGN: Multisite prospective longitudinal study. SETTING: Advanced practice physiotherapist-led multidisciplinary service across six tertiary hospitals. PARTICIPANTS: Participants with knee osteoarthritis deemed appropriate for trial of non-surgical management following an initial assessment from an advanced practice physiotherapist were eligible for inclusion. INTERVENTIONS: Baseline clinical nomogram scores were collected before a trial of individualised non-surgical management commenced. PRIMARY OUTCOME MEASURE: Clinical outcome (Global Rating of Change) was collected 6 months following commencement of non-surgical management and dichotomised to responder (a little better to a very great deal better) or poor responder (almost the same to a very great deal worse). Clinical nomogram accuracy was evaluated from receiver operating characteristics curve analysis and area under the curve, and sensitivity/specificity and positive/negative likelihood ratios were calculated. RESULTS: A total of 242 participants enrolled. Follow-up scores were obtained from 210 participants (87% response rate). The clinical nomogram demonstrated an area under the curve of 0.70 (p<0.001), with greatest combined sensitivity 0.65 and specificity 0.64. The positive likelihood ratio was 1.81 (95% CI 1.32 to 2.36) and negative likelihood ratio 0.55 (95% CI 0.41 to 0.75). CONCLUSIONS: The knee osteoarthritis clinical nomogram prediction tool may have capacity to identify patients at risk of poor response to non-surgical management. Further work is required to determine the implications for service delivery, feasibility and impact of implementing the nomogram in clinical practice.

Implementing good life with osteoArthritis from Denmark (GLA:D®) in Australian public hospitals. Part 2: Service providers' perceptions.

BACKGROUND: Previous literature has reported the successful implementation of the Good Life with osteoArthritis in Denmark (GLA:D®) program into predominantly private practice settings. There may be unique challenges present within the public hospital setting that influence GLA:D® implementation in public health. OBJECTIVE: Explore the attitudes and experiences of service providers directly involved in implementing GLA:D® in Australian public tertiary hospitals. DESIGN: Qualitative descriptive study design. METHOD: Service providers (n = 14) from three participating hospitals took part in semi-structured focus groups at the completion of the 6-month implementation period. Inductive thematic analysis was employed to identify primary domains across all facilities. RESULTS: Four broad domains were identified. Factors that influenced uptake included GLA:D® being a recognisable, evidence-based product requiring minimal development or adaptation. The fidelity of the GLA:D® Australia program was challenged by referral of patients with multiple/complex medical comorbidities, and patient preference to complete registry data via paper rather than online. Several operational considerations are required when delivering GLA:D® in a public hospital setting, including adequate numbers of GLA:D®-trained staff, additional screening requirements, obtaining appropriate clinical space, and persisting patient barriers to attending the service. GLA:D® provided benefits beyond improvement in pain and function, including social interactivity, high attendance and promotion of long-term self-management, while also maximising service efficiencies. CONCLUSIONS: Implementing GLA:D® in Australian public hospitals was supported by service providers. Specific operational and administrative factors, including staff training, patient complexity, and registry requirements should be considered when attempting to embed and sustain GLA:D® in large Australian public tertiary hospitals.

Implementing good life with osteoArthritis from Denmark (GLA:D®) in australian public hospitals. Part 1: Feasibility.

BACKGROUND: Literature reporting positive outcomes from the Good Life with osteoArthritis in Denmark (GLA:D®) program in Australia mainly involves patients attending private physiotherapy services. OBJECTIVE: Evaluate the feasibility of implementing GLA:D® in Australian public hospitals. DESIGN: Implementation study in three metropolitan tertiary public hospitals over six months. METHOD: Patients aged ≥18 years with knee or hip joint-related problems deemed appropriate for non-surgical care were invited to participate in GLA:D®. Feasibility was evaluated using RE-AIM framework components (Implementation, Effectiveness, Maintenance) using service-level metrics, patient-level data, and program fidelity assessment. Findings of qualitative interviews with service providers are presented in Part 2. RESULTS: Implementation: 70 patients (69 with knee osteoarthritis) participated (13 cohorts). 55 (79%) patients attended both education sessions, and 49 patients (70%) attended 10-12 exercises sessions. Fidelity was met based on environmental, therapist, participant- and program-related criteria. EFFECTIVENESS: At 3 months, patients reported lower average pain (visual analogue scale [0-100 mm]: effect size -0.56, 95% CI -0.88 to -0.23) and disability (HOOS/KOOS-12 [100-0]: 0.67, 0.28 to 1.05), and improved quality of life (EQ-5D overall score: 0.46, 0.11 to 0.80). No adverse events were reported. All patients who completed 3-month assessment (n = 52) would recommend GLA:D®. Maintenance: All participating services elected to continue delivering GLA:D® beyond the study. CONCLUSIONS: Implementing GLA:D® in Australian public hospitals is feasible, safe, and acceptable to patients with knee osteoarthritis. Public hospital patients with knee osteoarthritis reported improvements in pain, disability, and quality of life similar to previous GLA:D® cohorts.