Getting a Grip on Arthritis Online: Responses of rural/remote primary care providers to a web-based continuing medical education programme.

INTRODUCTION: Physicians are often challenged with accessing relevant up-to-date arthritis information to enable the delivery of optimal care. An online continuing medical education programme to disseminate arthritis clinical practice guidelines (CPGs) was developed to address this issue. METHODS: Online learning modules were developed for osteoarthritis (OA) and rheumatoid arthritis (RA) using published CPGs adapted for primary care (best practices), input from subject matter experts and a needs assessment. The programme was piloted in two rural/remote areas of Canada. Knowledge of best practice guidelines was measured before, immediately after completion of the modules and at 3-month follow-up by assigning one point for each appropriate best practice applied to a hypothetical case scenario. Points were then summed into a total best practice score. RESULTS: Participants represented various professions in primary care, including family physicians, physiotherapists, occupational therapists and nurses (n = 89) and demonstrated significant improvements in total best practice scores immediately following completion of the modules (OA pre = 2.8/10, post = 3.8/10, P < 0.01; RA pre = 3.9/12, post = 4.6/12, P < 0.01). The response rate at 3 months was too small for analysis. CONCLUSIONS: With knowledge gained from the online modules, participants were able to apply a greater number of best practices to OA and RA hypothetical case scenarios. The online programme has demonstrated that it can provide some of the information rural/remote primary care providers need to deliver optimal care; however, further research is needed to determine whether these results translate into changes in practice.

Introduction: Il est souvent difficile pour les médecins d'accéder à de l'information pertinente et à jour sur l'arthrite dans le but de dispenser des soins optimaux. Un programme en ligne de formation médicale continue visant à disséminer les lignes directrices de pratique clinique sur l'arthrite a été créé pour résoudre ce problème. Méthodes: Des modules d'apprentissage en ligne sur l'arthrose et la polyarthrite rhumatoïde (PR) ont été élaborés à l'aide des lignes directrices de pratique clinique publiées ayant été adaptées pour les soins de première ligne (pratiques exemplaires), des commentaires des spécialistes en la matière et d'une évaluation des besoins. Le programme a été mis à l'essai dans deux régions rurales et éloignées du Canada. La connaissance des lignes directrices de pratique exemplaire a été mesurée avant, immédiatement après avoir terminé les modules et au suivi de trois mois en accordant un point à chaque pratique exemplaire appropriée appliquée à un scénario de cas hypothétique. La somme des points indiquait le score de pratique exemplaire. Résultats: Les participants représentaient diverses professions de première ligne, dont médecins de famille, physiothérapeutes, ergothérapeutes et infirmières (n = 89) et ont affiché une amélioration significative des scores totaux de pratique exemplaire immédiatement après avoir terminé les modules (arthrose avant = 2,8/10, après = 3,8/10, P < 0,01; PR avant = 3,9/12, après = 4,6/12, P < 0,01). Le taux de réponse à trois mois était trop faible pour l'analyse. Conclusions: Grâce aux connaissances acquises dans les modules en ligne, les participants ont pu appliquer un plus grand nombre de pratiques exemplaires aux scénarios de cas hypothétiques d'arthrose et de PR. Le programme en ligne a montré pouvoir fournir une part de l'information que les fournisseurs de soins en région rurale et éloignée ont besoin pour dispenser des soins optimaux, cependant des recherches plus poussées sont nécessaires pour déterminer si ces résultats se traduisent par des changements de la pratique. Mots-clés: Polyarthrite rhumatoïde, arthrose, lignes directrices de pratique clinique, système en ligne, évaluation des besoins.

Management of early- and late-stage rheumatoid arthritis: are physiotherapy students' intended behaviours consistent with canadian best practice guidelines?

PURPOSE: This study examined whether physiotherapy students in a problem-based learning (PBL) curriculum intend to implement best practices for management of clients with rheumatoid arthritis (RA). METHOD: Physiotherapy students (n=49) completed a subsection of the ACREU Primary Care Survey to evaluate the concordance between intended behaviours and Canadian best practices for early- and late-stage RA, before and after completing the relevant PBL content. Changes in scores were assessed using McNemar's test for dependent proportions. RESULTS: Most students indicated that they would recommend treatments or referrals for physiotherapy/exercise, education, and occupational therapy or joint protection pre- and post-PBL (>83% and >95%, respectively). Post-PBL, more students recommended referral to a rheumatologist and disease-modifying anti-rheumatic drugs (DMARDs) for both early and late RA; however, the increase was significant only for early RA (p=0.013 and 0.031 for referral to rheumatologist and DMARDs, respectively). More students recommended psychosocial support at both stages of RA post-PBL (early RA: p<0.001; late RA: p=0.031). Although more students recommended DMARDs post-PBL, only 8 students in total made this recommendation (16%), and fewer students considered use of non-steroidal anti-inflammatory drugs. Most students (94%) did not recommend referral to a surgeon for early or late RA. CONCLUSION: Intended behaviour of physiotherapy students was more consistent with Canadian best practice guidelines for managing clients with early- and late-stage RA following the PBL curriculum. Further study is required to determine whether the students were less aware of best practices related to pharmacologic interventions and timely referral to appropriate specialists, or whether they considered these issues to be outside their scope of practice.

Objectif : Avec cette étude, on souhaitait voir si les étudiants en physiothérapie, dans le cadre de cours qui font appel à une méthode d'apprentissage axée sur les problèmes, tentaient de mettre en pratique les pratiques exemplaires pour la gestion des clients aux prises avec la polyarthrite rhumatoïde. Méthode : Des étudiants en physiothérapie (n=49) ont rempli une sous-section du sondage de l'ACREU sur les soins de santé primaires en vue d'évaluer la concordance entre les comportements recherchés et les pratiques exemplaires canadiennes pour les patients en stade précoce et avancé de polyarthrite rhumatoïde avant et après avoir complété le contenu de la formation axée sur les problèmes. Les variations dans les pointages obtenus ont été évaluées à l'aide du test de McNemar sur les proportions dépendantes. Résultats : La plupart des étudiants ont indiqué qu'ils recommanderaient des traitements ou une consultation en physiothérapie pour des exercices, de l'éducation et de l'ergothérapie ou une protection des articulations, avant et après leur apprentissage axé sur les problèmes (>83 % et >95 %, respectivement). Pour la polyarthrite en stade précoce ou avancé, plus d'étudiants ont recommandé une consultation auprès d'un rhumatologue et de DMARD (disease-modifying anti-rheumatic drugs ; médicaments antirhumatismaux) à la suite de leur formation ; toutefois, l'augmentation était considérable uniquement pour les cas de polyarthrite précoce (p=0,013 et 0,031 pour les consultations chez un rhumatologue et les DMARD, respectivement). Après leur formation, plus d'étudiants ont recommandé un soutien psychosocial aux deux stades de la maladie (PA précoce : p<0,001 ; PA avancée : p=0,031). Même si plus d'étudiants ont recommandé le recours à des DMARD après leur apprentissage axé sur les problèmes, 8 étudiants seulement ont formulé cette recommandation (16 %) et encore moins d'étudiants ont envisagé le recours à des anti-inflammatoires non stéroïdiens. La plupart des étudiants (94 %) n'ont pas recommandé une consultation par un chirurgien pour la PA précoce ou avancée. Conclusion : Les comportements recherchés chez les étudiants en physiothérapie étaient plus fidèles aux lignes directrices canadiennes sur les pratiques exemplaires pour la gestion de clients avec PR en stade précoce ou avancé une fois qu'ils avaient reçu la formation axée sur les problèmes. Des études supplémentaires seront nécessaires pour déterminer si les étudiants étaient moins bien informés des pratiques exemplaires touchant les interventions pharmacologiques et le renvoi en consultation chez les spécialistes appropriés, ou s'ils considèrent ces tâches comme étant hors de la portée de leur pratique.

Influence of discipline of provider and model of care on an arthritis educational intervention in primary care.

OBJECTIVE: To identify both provider and organizational characteristics that predicted outcomes following an educational intervention (9-hour workshop and followup reinforcement activities) developed to improve the management of arthritis in primary care. METHODS: Providers completed a survey at baseline and at 6 months postworkshop, including a case scenario for early rheumatoid arthritis. Providers were asked how they would manage the case and their responses were coded to calculate a best practice score, ranging from 0-7. Two-level hierarchical linear modeling was used to determine which of the measured provider and organizational factors predicted best practice scores at followup. RESULTS: A total of 275 multidisciplinary providers from 131 organizations completed both baseline and followup surveys. Best practice scores increased by 17% (P < 0.01); however, the mean score at 6-month followup remained relatively low (2.68). Significant predictors of best practice scores at followup were discipline of provider and model of primary care in which they worked (P < 0.05), adjusting for baseline practice scores and clustering of providers within organizations. Physicians, nurse practitioners, and rehabilitation therapists scored higher than nurses, students, and other health care providers (P < 0.01). Physician networks scored significantly lower than providers from multidisciplinary-oriented models of care (P = 0.02). CONCLUSION: These results have implications for the education of health professionals and the design of models of care to enhance arthritis care delivery.

Evaluation of an inter-professional educational intervention to improve the use of arthritis best practices in primary care.

OBJECTIVE: To describe the evaluation of a community-based continuing health education program designed to improve the management of rheumatoid arthritis (RA) and osteoarthritis (OA), and to examine the results by discipline. METHODS: The Getting a Grip on Arthritis(©) program was based on clinical practice guidelines adapted for the primary care environment (best practices). The program consisted of an accredited inter-professional workshop and 6 months of activities to reinforce the learning. Analyses compared best practice scores derived from responses to 3 standardized case scenarios (early and late RA; moderate knee OA) at baseline and 6 months post-workshop using the ACREU Primary Care Survey. RESULTS: In total, 553 primary care providers (nurses/licensed practical nurses 30.9%, rehabilitation professionals 22.5%, physicians 22.5%, nurse practitioners 10.9%, other healthcare providers/non-clinical staff/students 13.1%) attended one of 27 workshops across Canada; 275 (49.7%) completed followup surveys. Best practice scores varied by discipline at baseline (p < 0.05) and improved for all 3 case scenarios, with nurse practitioners and rehabilitation therapists improving the most (p ≤ 0.05). CONCLUSION: Results suggest that inter-professional education may be an effective method for dissemination of guidelines and has potential to improve the delivery of arthritis care, particularly when nurse practitioners and rehabilitation therapists are involved in the care of patients.

Arthritis extended-role practitioners: impact on community practice (an exploratory study).

PURPOSE: We compared practice of extended role practitioners and experienced therapists without extended practice training to determine differences in assessment and management of clients with inflammatory arthritis, in preparation for a randomized controlled trial. METHODS: Retrospective review of randomly selected charts of extended-role trained occupational therapists or physiotherapists and from experienced therapists matched on therapist discipline, geographical location, and time of referral. Three trained reviewers used standardized forms to extract data independently. RESULTS: We reviewed 58 charts of adult clients with inflammatory arthritis. Compared with experienced therapists, extended-role practitioners were more likely to receive referrals specifically for assessments (52% vs. 14%); to treat clients with undifferentiated arthritis (48% vs. 10%); to document comorbidities (90% vs. 66%); to advocate on behalf of the client with the client's family, physician, or specialist (52% vs. 21%); to recommend or provide exercise or physical activity (86% vs. 62%); to educate clients about pain management (41% vs. 28%), energy conservation (24% vs. 14%), and posture (21% vs. 7%); to recommend splints (41% vs. 31%); and to refer for or recommend radiologic or laboratory assessments (14% vs. 3%). Experienced therapists were more likely to provide education about joint protection (41% vs. 31%), community resources (31% vs. 7%), and assistive devices (45% vs. 21%). CONCLUSIONS: We identified possible differences in practice between extended-role practitioners and experienced therapists without training for extended practice. Capturing these details in future studies evaluating the efficacy of extended role practitioner interventions will be important.

Educational interventions for implementation of arthritis clinical practice guidelines in primary care: effects on health professional behavior.

OBJECTIVE: The dissemination and adoption of clinical practice guidelines (CPG) has been suggested as one method for improving arthritis care delivery. This article provides a review and synthesis of studies evaluating the influence of educational programs designed to implement CPG for osteoarthritis (OA) and rheumatoid arthritis (RA) in primary care. METHODS: A systematic literature search was conducted to identify relevant educational interventions that reported behavioral outcomes that ensured actual knowledge utilization in primary care. A standardized approach was used to assess the quality of the individual studies and a modified version of the Philadelphia Panel methodology allowed for grading of studies based on strength of design, clinical relevance, and statistical significance. RESULTS: The search identified 485 articles; 7 studies were selected for review. In OA, peer facilitated workshops with nurse case-management support for patients decreased the number of referrals to orthopedics by 23%, and educational outreach by trained physicians improved prescribing of analgesics. Interprofessional peer facilitated workshops were successful in increasing referrals to rehabilitation services for people with OA and RA. CONCLUSION: There was sparse literature on educational programs for the implementation of arthritis CPG in the primary care environment. Future studies are needed to evaluate which specific organizational, provider, patient, and system level factors influence the uptake of arthritis CPG in primary care.

Implementing arthritis clinical practice guidelines in primary care.

BACKGROUND: Multi-faceted interventions are among the strongest methods for changing provider behavior. AIMS: This paper reports the design, implementation and process evaluation of an educational program to disseminate clinical practice guidelines (CPGs) on the management of rheumatoid arthritis (RA) and osteoarthritis (OA) in primary care. METHODS: Organizations were invited to participate in inter-professional workshops on OA and RA followed by six months of activities to support the delivery of care in the community. Confidence in ability to manage arthritis was assessed at baseline using a 10 point numerical rating scale. Qualitative assessments were done immediately and 3-12 months post workshop. RESULTS: 646 multidisciplinary providers from 216 organizations attended one of 30 workshops. Providers (n = 584) reported moderate confidence in managing arthritis: family physicians: mean: SD = 7.46(1.42), n = 145; nurse practitioners: 6.10(1.84), n = 73; other health care professionals: 5.23(2.83), n = 389. Participants identified team learning, the opportunity to network and the involvement of trained patient educators as strong features of the workshops. At follow-up, participants indicated the greatest impact of the program was on collaborative care (83%) and patient self-management (79%). CONCLUSIONS: Qualitative results suggest that inter-professional learning may be a successful strategy for improving the delivery of collaborative arthritis care and supporting patient self-management.

Primary therapist model for patients referred for rheumatoid arthritis rehabilitation: a cost-effectiveness analysis.

OBJECTIVE: To estimate the incremental cost-effectiveness (ICE) of services from a primary therapist compared with traditional physical therapists and/or occupational therapists for managing rheumatoid arthritis (RA), from the societal perspective. METHODS: Patients with RA were randomly assigned to the primary therapist model (PTM) or traditional treatment model (TTM) for approximately 6 weeks of rehabilitation treatment. Health outcomes were expressed in terms of quality-adjusted life years (QALYs), measured with the EuroQol instrument at baseline, 6 weeks, and 6 months. Direct and indirect costs, including visits to health professionals, use of investigative tests, hospital visits, use of medications, purchases of adaptive aids, and productivity losses incurred by patients and their caregivers, were collected monthly. RESULTS: Of 144 consenting patients, 111 remained in the study after the baseline assessment: 63 PTM (87.3% women, mean age 54.2 years, disease duration 10.6 years) and 48 TTM (79.2% women, mean age 56.8 years, disease duration 13.2 years). From a societal perspective, PTM generated higher QALYs (mean +/- SD 0.068 +/- 0.22) and resulted in a higher mean cost ($6,848 Canadian, interquartile range [IQR] $1,984-$9,320) compared with TTM (mean +/- SD QALY -0.017 +/- 0.24; mean costs $6,266, IQR $1,938-$10,194) in 6 months, although differences were not statistically significant. The estimated ICE ratio was $13,700 per QALY gained (95% nonparametric confidence interval -$73,500, $230,000). CONCLUSION: The PTM has potential to be an alternative to traditional physical/occupational therapy, although it is premature to recommend widespread use of this model in other regions. Further research should focus on strategies to reduce costs of the model and assess the long-term economic consequences in managing RA and other rheumatologic conditions.

Effectiveness of the primary therapist model for rheumatoid arthritis rehabilitation: a randomized controlled trial.

OBJECTIVE: To compare the primary therapist model (PTM), provided by a single rheumatology-trained primary therapist, with the traditional treatment model (TTM), provided by a physical therapy (PT) and/or occupational therapy (OT) generalist, for treating patients with rheumatoid arthritis (RA). METHODS: Eligible patients were adults requiring rehabilitation treatment who had not received PT/OT in the past 2 years. Participants were randomized to the PTM or TTM group. The primary outcome was defined as the proportion of clinical responders who experienced a > or =20% improvement in 2 of the following measures from baseline to 6 months: Health Assessment Questionnaire, pain visual analog scale, and Arthritis Community Research and Evaluation Unit RA Knowledge Questionnaire. RESULTS: Of 144 consenting patients, 33 (10 PTM participants, 23 TTM participants) dropped out without completing any followup assessment, leaving 111 for analysis (63 PTM participants, 48 TTM participants). The majority were women (PTM 87.3%, TTM 79.2%), with a mean age of 54.2 years and 56.8 years for the PTM and TTM groups, respectively. Average disease duration was 10.6 years and 13.2 years for each group, respectively. At 6 months, 44.4% of patients in the PTM group were clinical responders versus 18.8% in the TTM group (chi(2) = 8.09, P = 0.004). CONCLUSION: Compared with the TTM, the PTM was associated with better outcomes in patients with RA. The results, however, should be interpreted with caution due to the high dropout rate in the TTM group.

Getting a Grip on Arthritis: an educational intervention for the diagnosis and treatment of arthritis in primary care.

OBJECTIVE: To evaluate a community-based educational intervention designed to improve the diagnosis and treatment of arthritis in primary care. METHODS: The educational intervention, entitled "Getting a Grip on Arthritis", consisted of a 2-day workshop and followup reinforcement activities for healthcare providers (providers) and was supported by a toolkit of written materials for providers and clients. The content of the intervention was designed around 10 arthritis best practices derived from published arthritis guidelines. Five community health centers (CHC) participated as intervention sites and 2 as control sites. Intervention impact was determined through a mailed survey to clients with arthritis. Primary outcome analysis compared responses to questions about arthritis best practices between intervention and control sites at baseline and followup. RESULTS: The workshop was attended by 21 multidisciplinary providers from intervention CHC. At baseline, 423 of 624 eligible and consenting clients completed the survey and 376 of 593 completed the followup survey. At followup clients in the intervention group reported significantly higher referrals to The Arthritis Society therapy program, and were more often provided information on type of arthritis, medications and their side effects, disease management strategies, and arthritis community resources. CONCLUSION: This demonstration project is one of the first to show changes in the management of arthritis in a primary care setting. This project has recently received funding from Health Canada's Primary Health Care Transition Fund for implementation across Canada and is expected to provide a template for use in other chronic diseases.