Development of a core capability framework for qualified health professionals to optimise care for people with osteoarthritis: an OARSI initiative.

OBJECTIVE: Develop a generic trans-disciplinary, skills-based capability framework for health professionals providing care for people with OA. DESIGN: e-Delphi survey. An international inter-professional Delphi Panel (researchers; clinicians; consumer representatives) considered a draft framework (adapted from elsewhere) of 131 specific capabilities mapped to 14 broader capability areas across four domains (A: person-centred approaches; B: assessment, investigation and diagnosis; C: management, interventions and prevention; D: service and professional development). Over three rounds, the Panel rated their agreement (Likert or numerical rating scales) on whether each specific capability in Domains B and C was essential (core) for all health professionals when providing care for all people with OA. Those achieving consensus (≥80% of Panel) rating of ≥ seven out of ten (Round 3) were retained. Generic domains (A and D) were included in the final framework and amended based on Panel comments. RESULTS: 173 people from 31 countries, spanning 18 disciplines and including 26 consumer representatives, participated. The final framework comprised 70 specific capabilities across 13 broad areas i) communication; ii) person-centred care; iii) history-taking; iv) physical assessment; v) investigations and diagnosis; vi) interventions and care planning; vii) prevention and lifestyle interventions; viii) self-management and behaviour change; ix) rehabilitative interventions; x) pharmacotherapy; xi) surgical interventions; xii) referrals and collaborative working; and xiii) evidence-based practice and service development). CONCLUSION: Experts agree that health professionals require an array of skills in person-centred approaches; assessment, investigation and diagnosis; management, interventions and prevention; and service and professional development to provide optimal care for people with OA.

Health professionals and students encounter multi-level barriers to implementing high-value osteoarthritis care: a multi-national study.

OBJECTIVE: Consistent evidence-practice gaps in osteoarthritis (OA) care are observed in primary care settings globally. Building workforce capacity to deliver high-value care requires a contemporary understanding of barriers to care delivery. We aimed to explore barriers to OA care delivery among clinicians and students. DESIGN: A cross-sectional, multinational study sampling clinicians (physiotherapists, primary care nurses, general practitioners (GPs), GP registrars; total possible denominator: n = 119,735) and final-year physiotherapy and medical students (denominator: n = 2,215) across Australia, New Zealand and Canada. Respondents answered a survey, aligned to contemporary implementation science domains, which measured barriers to OA care using categorical and free-text responses. RESULTS: 1886 clinicians and 1611 students responded. Items within the domains 'health system' and 'patient-related factors' represented the most applicable barriers experienced by clinicians (25-42% and 20-36%, respectively), whereas for students, 'knowledge and skills' and 'patient-related factors' (16-24% and 19-28%, respectively) were the most applicable domains. Meta-synthesis of qualitative data highlighted skills gaps in specific components of OA care (tailoring exercise, nutritional/overweight management and supporting positive behaviour change); assessment, measurement and monitoring; tailoring care; managing case complexity; and translating knowledge to practice (especially among students). Other barriers included general infrastructure limitations (particularly related to community facilities); patient-related factors (e.g., beliefs and compliance); workforce-related factors such as inconsistent care and a general knowledge gap in high-value care; and system and service-level factors relating to financing and time pressures, respectively. CONCLUSIONS: Clinicians and students encounter barriers to delivery of high-value OA care in clinical practice/training (micro-level); within service environments (meso-level); and within the health system (macro-level).

Correction to: Effectiveness of a new model of primary care management on knee pain and function in patients with knee osteoarthritis: Protocol for THE PARTNER STUDY.

After the publication of this protocol [1], our collaborator Prima Health solutions advised us of their intent to withdraw from the study.

Implementation of the Western Australian Osteoporosis Model of Care: a fracture liaison service utilising emergency department information systems to identify patients with fragility fracture to improve current practice and reduce re-fracture rates: a 12-month analysis.

Fracture liaison service linked to an emergency department database effectively identifies patients with OP, improves best practice care, reduces recurrent fractures, and improves quality of life (QoL). The next step is to establish cost-effectiveness. This should be seen as the standard model of care. INTRODUCTION: The Western Australian Osteoporosis Model of Care recommends implementation of a fracture liaison service (FLS) to manage patients with minimal trauma fractures (MTFs). This study evaluates the efficacy of a FLS linked to a tertiary hospital emergency department information system (EDIS) in reducing recurrent fractures. METHODS: Patients aged ≥ 50 years with MTF identified from EDIS were invited to the FLS. Patient outcomes were compared to routine care (retrospective group-same hospital, and prospective group-other hospital) at 3- and 12-month follow-up. RESULTS: Two hundred forty-one of 376 (64.1%) eligible patients participated in the FLS with 12 months of follow-up. Absolute risk of recurrent MTF at 12 months was reduced by 9.2 and 10.2% compared with the prospective and retrospective controls, respectively. After age/sex adjustment, FLS participants had less MTF at 12 months vs. the retrospective controls, OR 0.38 (95%CI 0.18-0.79), but not the prospective controls, OR 0.40 (95%CI 0.16-1.01). FLS patients were more likely to receive the 'best practice' care, i.e. awareness of osteoporosis, investigations, and treatment (all p < 0.05). 'Fallers' (OR 0.48 (95%CI 0.24, 0.96)) and fall rates were lower in the FLS (p = 0.001) compared to the prospective control. FLS experienced the largest improvement in QoL from 3 to 12 months as measured by the EuroQoL 5-domain (EQ-5D) UK weighted score (+ 15 vs. - 11 vs. - 16%, p < 0.001) and EQ-5D Health State visual analogue scale (+ 29 vs. - 2 vs. + 1%, p < 0.001). CONCLUSION: Patients managed in a linked EDIS-FLS were more likely to receive the 'best practice' care and had lower recurrent MTF and improved QoL.

Systematic scoping review of patients' perceived needs of health services for osteoporosis.

Health service planners, administrators and providers need to understand the patients' perspective of health services related to osteoporosis to optimise health outcomes. The aims of this study were to systematically identify and review the literature regarding patients' perceived health service needs relating to osteoporosis and osteopenia. A systematic scoping review was performed of publications in MEDLINE, EMBASE, CINAHL and PsycINFO (1990-2016). Descriptive data regarding study design and methodology were extracted and risk of bias assessed. Aggregates of patients' perceived needs of osteoporosis health services were categorised. Thirty-three studies (19 quantitative and 14 qualitative) from 1027 were relevant. The following areas of perceived need emerged: (1) patients sought healthcare from doctors to obtain information and initiate management. They were dissatisfied with poor communication, lack of time and poor continuity of care. (2) Patients perceived a role for osteoporosis pharmacotherapy but were concerned about medication administration and adverse effects. (3) Patients believed that exercise and vitamin supplementation were important, but there is a lack of data examining the needs for other non-pharmacological measures such as smoking cessation and alcohol. (4) Patients wanted diagnostic evaluation and ongoing surveillance of their bone health. This review identified patients' needs for better communication with their healthcare providers. It also showed that a number of important cornerstones of therapy for osteoporosis, such as pharmacotherapy and exercise, are identified as important by patients, as well as ongoing surveillance of bone health. Understanding patients' perceived needs and aligning them with responsive and evidence-informed service models are likely to optimise patient outcomes.

Patients' perceived health service needs for osteoarthritis (OA) care: a scoping systematic review.

OBJECTIVE: To identify and synthesise evidence regarding patients' perceived health service needs related to osteoarthritis (OA). DESIGN: A comprehensive systematic scoping review of MEDLINE, PsycINFO, EMBASE and CINAHL (1990-2016) was performed to capture information regarding patient perceived health service needs related to OA. Risk of bias and quality of included articles were assessed. Relevant data were extracted and collated to provide a systematic review of the existing literature. RESULTS: Of the 1384 identified manuscripts, 21 were relevant to areas of patient perceived need, including needs related to medical care, pharmacologic therapy, physiotherapy and exercise therapy and alternative medicine. Key findings included (1) Symptom control drove the need for both conventional and complementary services. (2) An individualized relationship was sought with a practitioner knowledgeable in OA care and who adopted a holistic approach, whether providing conventional or alternative therapies. (3) Medications were required to obtain symptomatic relief, with use tempered by recognition of potential side effects and financial cost. (4) The need for allied health services was recognised, although patient and system issues were barriers to uptake. (5) Patient's attitudes towards joint replacement, orthoses and physical aids were influenced by patient preferences and previous healthcare experiences. CONCLUSION: Patient perceived needs are similar to those suggested by clinical guideline recommendations. Better aligning patient perceived needs with healthcare requirements may improve OA outcomes and optimise healthcare system utilisation.

Gender differences in the relationships between lean body mass, fat mass and peak bone mass in young adults.

UNLABELLED: The relationships between fat mass and bone mass in young adults are unclear. In 1,183 young Australians, lean body mass had a strong positive relationship with total body bone mass in both genders. Fat mass was a positive predictor of total body bone mass in females, with weaker association in males. INTRODUCTION: Body weight and lean body mass are established as major determinants of bone mass, but the relationships between fat mass (including visceral fat) and peak bone mass in young adults are unclear. The aim of this study was to evaluate the associations between bone mass in young adults and three body composition measurements: lean body mass, fat mass and trunk-to-limb fat mass ratio (a surrogate measure of visceral fat). METHODS: Study participants were 574 women and 609 men aged 19-22 years from the Raine study. Body composition, total body bone mineral content (TBBMC), bone area and areal bone mineral density (TBBMD) were measured using DXA. RESULTS: In multivariate linear regression models with height, lean body mass, fat mass and trunk-to-limb fat mass ratio as predictor variables, lean mass was uniquely associated with the largest proportion of variance of TBBMC and TBBMD in males (semi-partial R(2) 0.275 and 0.345, respectively) and TBBMC in females (semi-partial R(2) 0.183). Fat mass was a more important predictor of TBBMC and TBBMD in females (semi-partial R(2) 0.126 and 0.039, respectively) than males (semi-partial R(2) 0.006 and 0.018, respectively). Trunk-to-limb fat mass ratio had a weak, negative association with TBBMC and bone area in both genders (semi-partial R(2) 0.004 to 0.034). CONCLUSIONS: Lean body mass has strong positive relationship with total body bone mass in both genders. Fat mass may play a positive role in peak bone mass attainment in women but the association was weaker in men; different fat compartments may have different effects.

Low back pain-related beliefs and likely practice behaviours among final-year cross-discipline health students.

BACKGROUND: Evidence points to clinicians' beliefs and practice behaviours related to low back pain (LBP), which are discordant with contemporary evidence. While interventions to align beliefs and behaviours with evidence among clinicians have demonstrated effectiveness, a more sustainable and cost-effective approach to positively developing workforce capacity in this area may be to target the emerging workforce. The aim of this study was to investigate beliefs and clinical recommendations for LBP, and their alignment to evidence, in Australian university allied health and medical students. METHODS: Final-year students in chiropractic, medicine, occupational therapy, pharmacy and physiotherapy disciplines in three Western Australian universities responded to a survey. Demographic data, LBP-related beliefs data [modified Health Care Providers Pain and Impact Relationship Scale (HC-PAIRS) and the Back Pain Beliefs Questionnaire (BBQ)] and activity, rest and work clinical recommendations for an acute LBP clinical vignette were collected. RESULTS: Six hundred two students completed the survey (response rate 74.6%). Cross-discipline differences in beliefs and clinical recommendations were observed (p > 0.001). Physiotherapy and chiropractic students reported significantly more helpful beliefs compared with the other disciplines, while pharmacy students reported the least helpful beliefs. A greater proportion of chiropractic and physiotherapy students reported guideline-consistent recommendations compared with other disciplines. HC-PAIRS and BBQ scores were strongly associated with clinical recommendations, independent to the discipline of study and prior experience of LBP. CONCLUSIONS: Aligning cross-discipline university curricula with current evidence may provide an opportunity to facilitate translation of this evidence into practice with a focus on a consistent, cross-discipline approach to LBP management.

Bone health and back pain: what do we know and where should we go?

Bone health is generally not considered in patients who present with chronic back pain. Nonetheless, bone health and back pain share common genetic and environmental correlates suggesting a co-dependence. Evidence exists for a relationship between back pain and impaired bone health. Here we present the evidence, theoretic framework and clinical relevance. Bone health and back pain are important determinants of musculoskeletal health. Back pain experienced in youth is a risk factor for future back pain, while suboptimal bone health during development increases the risk of skeletal fragility in later life. Generally, bone health is not considered in patients with chronic back pain who do not demonstrate other well-recognised bone health risk factors or associated conditions. Nonetheless, evidence suggests that back pain and impaired bone health share common environmental and genetic correlates, indicating that bone health ought to be considered in the context of back pain in otherwise healthy individuals. This review describes the likely mechanisms explaining the relationship between back pain and impaired bone health, evidence concerning the relationship and suggestions for future research. A narrative literature search was conducted using CINAHL, Medline, PubMed and Web of Science electronic databases. A history of back pain is associated with decreased bone mineral density in adults, yet this tends to be site-specific. No studies were identified examining this association in youth, yet the negative effects of childhood skeletal trauma and obesity on bone and spinal health provide indirect evidence for an association. Further research is required to clarify the impact of back pain on bone health at different lifespan stages using prospective cohort designs.

Effect of treatment with biological agents for arthritis in Australia: the Australian Rheumatology Association Database.

BACKGROUND: The Australian Rheumatology Association Database (ARAD), a voluntary national registry, has been established to collect health information from Australian patients with inflammatory arthritis for the purpose of monitoring the benefits and safety of new treatments, in particular the biological disease-modifying anti-rheumatic drugs (bDMARDs). These drugs are proving to be very effective, yet little is known of their long-term effectiveness or safety. Patient registries that systematically gather data on large cohorts of unselected patients are increasingly believed to be an essential means of answering questions of the long-term effectiveness and safety of new drugs. The aim of this report is to describe the role, development and structure of ARAD and provide some preliminary data. METHODS: As of 1 August 2006, 563 patients with rheumatoid arthritis prescribed a bDMARD have been enrolled in ARAD, involving 105 rheumatologists from across Australia. RESULTS: The data collected will enable examination of multiple domains of patient responses to bDMARDs, including quality of life, health-care utilization, incidence of adverse events and the effects of therapy switching. CONCLUSION: Evidence-based information about the long-term outcome of bDMARD therapy is essential for clinicians, consumers, policy-makers, drug development companies and approval agencies, to enable better care and improved outcomes for patients with inflammatory arthritis.

Radiographic measures of thoracic kyphosis in osteoporosis: Cobb and vertebral centroid angles.

OBJECTIVE: Several measures can quantify thoracic kyphosis from radiographs, yet their suitability for people with osteoporosis remains uncertain. The aim of this study was to examine the validity and reliability of the vertebral centroid and Cobb angles in people with osteoporosis. DESIGN AND PATIENTS: Lateral radiographs of the thoracic spine were captured in 31 elderly women with osteoporosis. Thoracic kyphosis was measured globally (T1-T12) and regionally (T4-T9) using Cobb and vertebral centroid angles. Multisegmental curvature was also measured by fitting polynomial functions to the thoracic curvature profile. Canonical and Pearson correlations were used to examine correspondence; agreement between measures was examined with linear regression. RESULTS: Moderate to high intra- and inter-rater reliability was achieved (SEM = 0.9-4.0 degrees ). Concurrent validity of the simple measures was established against multisegmental curvature (r = 0.88-0.98). Strong association was observed between the Cobb and centroid angles globally (r = 0.84) and regionally (r = 0.83). Correspondence between measures was moderate for the Cobb method r = 0.72), yet stronger for the centroid method (r = 0.80). The Cobb angle was 20% greater for regional measures due to the influence of endplate tilt. CONCLUSIONS: Regional Cobb and centroid angles are valid and reliable measures of thoracic kyphosis in people with osteoporosis. However, the Cobb angle is biased by endplate tilt, suggesting that the centroid angle is more appropriate for this population.

The vertebral fracture cascade in osteoporosis: a review of aetiopathogenesis.

Once an initial vertebral fracture is sustained, the risk of subsequent vertebral fracture increases significantly. This phenomenon has been termed the "vertebral fracture cascade". Mechanisms underlying this fracture cascade are inadequately understood, creating uncertainty in the clinical environment regarding prevention of further fractures. The cascade cannot be explained by low bone mass alone, suggesting that factors independent of this parameter contribute to its aetiopathogenesis. This review explores physiologic properties that may help to explain the vertebral fracture cascade. Differences in bone properties, including bone mineral density and bone quality, between individuals with and those without osteoporotic vertebral fractures are discussed. Evidence suggests that non-bone parameters differ between individuals with and those without osteoporotic vertebral fractures. Spinal properties, including vertebral macroarchitecture, intervertebral disc integrity, spinal curvature and spinal loading are compared in these groups of individuals. Cross-sectional studies also indicate that neurophysiologic properties, particularly trunk control and balance, are affected by the presence of a vertebral fracture. This review provides a synthesis of the literature to highlight the multi-factorial aetiopathogenesis of the vertebral fracture cascade. With a more comprehensive understanding of the mechanisms underlying this clinical problem, more effective preventative strategies may be developed to offset the fracture cascade.

Balance impairment is related to vertebral fracture rather than thoracic kyphosis in individuals with osteoporosis.

INTRODUCTION: Balance impairments have been identified in people with osteoporosis. Although an association between thoracic kyphosis and impaired balance has been reported, the specific role of vertebral fractures has not been considered. This study aimed to investigate the independent effects of osteoporotic vertebral fracture and thoracic kyphosis on balance characteristics in an osteoporotic population. METHODS: Twenty-two individuals with osteoporosis were divided into groups with (n=10) and without (n=12) radiologically diagnosed fracture, and into groups with low (n=11) and high (n=11) thoracic kyphosis. Force-plate-derived balance parameters were recorded during three static standing tasks of 70-s duration. Balance measures were compared between fracture and kyphosis groups, and significant differences were further explored through subgroup analyses, to tease out the relationships between confounded independent variables (fracture and kyphosis) and balance measures. RESULTS: In the anterior-posterior direction, the range and root mean square of shear forces (p=0.048 and p=0.032, respectively), and range of displacement of the centre of pressure (p=0.049) were greater in the fracture group. There were no differences between groups when comparison was based on the magnitude of thoracic kyphosis (all p>or=0.264). Analyses of subgroups supported these findings. DISCUSSION: Vertebral fracture but not thoracic kyphosis is associated with impaired balance characteristics in the osteoporosis population. This finding has important implications for fracture prevention and conservative management regimes.