Implementation of a 'Joint Clinic' to resolve unmet need for orthopaedic services in patients with hip and knee osteoarthritis: a program evaluation.

BACKGROUND: Osteoarthritis is the most common form of arthritis, principally affecting the older population. Highly prevalent, disabling diseases such as osteoarthritis strain the capacity of health systems, and can result in unmet need for services. The Joint Clinic was initiated to provide secondary care consultations and access to outpatient services for people with advanced hip or knee osteoarthritis, who were referred by their general practitioner for orthopaedic consultation but not offered an orthopaedic specialist appointment. METHODS: This longitudinal programme evaluation comprised four components: a proof-of-concept evaluation; an implementation evaluation; a process evaluation; and an outcomes evaluation. Interviews and surveys of general practitioners, staff, and patients were conducted pre- and post-implementation. Interviews were transcribed, and thematic analysis was completed. In addition, Joint Clinic patient visits and outcomes were reviewed. RESULTS: One hundred and eleven primary care physicians (GPs) and 66 patients were surveyed, and 28 semi-structured interviews of hospital staff and GPs were conducted. Proof of concept was satisfied. Interim and final implementation evaluations indicated adherence to the concept model, high levels of acceptance of and confidence in the programme and its staff, and timely completion within budget. Process evaluation revealed positive impacts of the programme and positive stakeholder perceptions, with some weaknesses in communication to the outer context of primary care. The Joint Clinic saw a total of 637 patient visits during 2 years of operation. Unmet need was reduced by 90%. Patient and referring physician satisfaction was high. Hospital management confirmed that the programme will continue. CONCLUSIONS: This evaluation indicates that the Joint Clinic concept model is fit for purpose, functioned well within the organisation, and achieved its primary objective of reducing unmet need of secondary care consultation for those suffering advanced hip or knee osteoarthritis.

Essential Elements for Advancing Cultural Humility through a Community-Based Physical Therapy Practicum in a Métis Community.

Purpose: This article reveals MPT practicum participant perceptions of the impact that a community-based practicum in a Métis community had on their learning in the area of cultural humility and cultural safety. Method: The impact of this community-based practicum intervention in a Métis community on MPT student education was explored using phenomenological descriptive methodology, with data gathered via exit interviews conducted on completion of the community-based practicum. Concepts of cultural humility and safety from the literature, along with themes emerging from practicum participant interviews, informed the analysis and theme development. Results: Participants' experiences were categorized into three themes: (1) realizing Métis community strengths; (2) learning from experiences and shaping future practice; and (3) prioritizing relationships. Findings support that participants demonstrated the practice of cultural humility as a result of engaging in the community-based practicum. Conclusions: Our results highlight the importance of (1) community engagement, (2) community-informed practicum design based on strong relationships, (3) a backbone of reflective practice, and (4) a base of community and student readiness to support practicum success. These essential elements support a cultural humility approach to implementing MPT practicums in Indigenous communities, as well as a practice in reconciliation.

Objectif : le présent article révèle les perceptions d'étudiants à la maîtrise en physiothérapie sur les retombées d'un stage en communauté métisse dans leur apprentissage de l'humilité culturelle et de la sécurité culturelle. Méthodologie : les chercheurs ont exploré les retombées de ce stage en communauté métisse sur la formation d'étudiants à la maîtrise en physiothérapie au moyen d'une méthodologie phénoménologique descriptive et ont récolté leurs données lors d'entrevues à la fin du stage. Ils ont appuyé leur analyse et leurs thèmes sur les concepts d'humilité culturelle et de sécurité culturelle tirés des publications scientifiques ainsi que sur les sujets découlant des entrevues avec les participants. Résultats : Les chercheurs ont regroupé les expériences des participants en trois thèmes : 1) comprendre les forces de la communauté métisse, 2) apprendre des expériences, modeler les futures pratiques et 3) prioriser les relations. Les résultats confirment que les participants ont adopté des pratiques d'humilité culturelle après leur stage communautaire. Conclusion : les résultats démontrent l'importance a) de l'engagement communautaire, b) d'un stage communautaire axé sur de solides relations, c) d'une structure de pratique réflexive et d) d'une certaine préparation de l'étudiant et de la communauté pour soutenir la réussite du stage. Ces éléments essentiels corroborent l'approche d'humilité culturelle pour instaurer des stages d'étudiants à la maîtrise dans les communautés autochtones, de même qu'une pratique de réconciliation.

Outcomes and Factors Influencing Response to an Individualized Multidisciplinary Chronic Disease Management Program for Hip and Knee Osteoarthritis.

BACKGROUND: The objective of the study was to investigate the effectiveness of, and factors associated with, response to a chronic disease management program for patients with hip and knee osteoarthritis (OA). METHODS: Over a 2-year period (2012-2014), 218 patients (97 hip OA; 121 knee OA) were managed with an individualized program of interventions that could include education, physiotherapy, orthotics, occupational therapy, or dietitian referral. Changes in Oxford Hip Score or Oxford Knee Score and Short Form-12 (SF-12) Physical and Mental Component Summary Score (PCS, MCS) were analyzed by joint affected, both unadjusted, and gender and age adjusted. A further analysis also adjusted for body mass index. RESULTS: At mean 12-month follow-up, patients with knee OA had a statistically significant improvement in Oxford Knee Score and PCS, while patients with hip OA had a statistically significant deterioration in all 3 scores. There was evidence that these changes differed between joints for Oxford and PCS scores. Older age was associated with worse outcomes for Oxford scores. Higher body mass index was associated with worse outcomes for Oxford and PCS scores. Patients with hip OA (35%) were more likely to deteriorate to a clinically significant extent (5 points) for Oxford scores than those with knee OA. Gender was not associated with outcomes. Patients with hip OA (54%) were more likely than those with knee OA (24%) to have subsequently had surgery (P < .001). CONCLUSIONS: Patients with knee OA were more likely to improve with a chronic disease management plan than patients with hip OA and efforts should be directed to them.

The Joint Clinic: Managing Excess Demand for Hip and Knee Osteoarthritis Referrals Using a New Physiotherapy-Led Outpatient Service.

BACKGROUND: There are increasing problems with access to both outpatient assessment and joint replacement surgery for patients with hip or knee osteoarthritis. METHODS: Data were collected on all patients seen at the Joint Clinic over a 2-year period with minimum 12-month follow-up. Patients were assessed by a nurse and a physiotherapist, baseline scores and demographic details collected, and an individualized personal care plan developed. Patients could be referred for a first specialist assessment (FSA) if their severity justified surgical assessment. RESULTS: Three hundred fifty-eight patients were seen at Joint Clinic, of whom 150 (44%) had hip and 189 (56%) had knee OA. The mean age was 67.4 years and there were 152 men (45%) and 187 women (55%). The mean baseline Oxford score was 19.8 (standard deviation 8.2). Fifty-four patients were referred directly to FSA (mean Oxford score 13.0, standard deviation 6.7) and 89 after a subsequent review. The scores of patients referred for FSA were significantly worse than those managed in the Joint Clinic (P < .001). Of the 143 referred for FSA, 115 underwent or were awaiting surgery, 18 were recommended surgery but scored below prioritization threshold, and 10 were not recommended surgery. The Oxford scores of the 194 patients managed non-operatively improved from 22.0 to 25.0 (P = .0013). CONCLUSION: This study shows that the Joint Clinic was effective as a triage tool with 93% of those referred for FSA being recommended surgery. This has freed up surgeon time to see only those patients most in need of surgical assessment.

Rationing for Total Hip and Knee Arthroplasty Using the New Zealand Orthopaedic Association Score: Effectiveness and Comparison With Patient-Reported Scores.

BACKGROUND: There is increasing interest in scoring systems to prioritize patients for hip and knee arthroplasty. The purpose of this study was to determine the effectiveness of the New Zealand Orthopaedic Association (NZOA) score and compare it with patient-reported scores of patients listed for hip and knee arthroplasty. METHODS: Over a 1-year period, all patients listed for primary hip and knee arthroplasty were scored by a prioritization nurse. The NZOA score, outcome, preoperative Oxford hip or knee score (OHKS) and reduced Western Ontario McMaster osteoarthritis index (WOMAC) score (RWS) were collected. RESULTS: Overall, 608 patients were listed for hip (319) or knee (289) arthroplasty. The mean scores for knees were all better than hips (P < .001). On initial scoring, 324 patients (53%) were given certainty (mean NZOA, 80.5; OHKS, 10.0; RWS, 35.1), 90 (15%) given clinical over-ride (NZOA, 69.6; OHKS, 12.0; RWS, 33.2), and 194 (32%) returned to general practitioner (NZOA, 64; OHKS, 14.2; RWS, 30.8). Knees (38%) were more likely to be returned than hips (26%; P = .002). Fifty (26%) were re-referred during the study period (mean, 5 months) and given certainty or over-ride. The difference at final outcome between patients with certainty and clinical over-ride was NZOA, 10.3 points; Oxford, 1.6 points; and RWS, 1.4 points. The difference between clinical over-ride and returned to general practitioner was NZOA, 7.2; Oxford, 4.4; RWS, 5.3. CONCLUSION: The NZOA score is an effective tool for rationing for joint arthroplasty. Patients around the threshold score of 70 may not have a clinically important difference compared with those above threshold.

The Incremental Effects of Manual Therapy or Booster Sessions in Addition to Exercise Therapy for Knee Osteoarthritis: A Randomized Clinical Trial.

STUDY DESIGN: A factorial randomized controlled trial. OBJECTIVES: To investigate the addition of manual therapy to exercise therapy for the reduction of pain and increase of physical function in people with knee osteoarthritis (OA), and whether "booster sessions" compared to consecutive sessions may improve outcomes. BACKGROUND: The benefits of providing manual therapy in addition to exercise therapy, or of distributing treatment sessions over time using periodic booster sessions, in people with knee OA are not well established. METHODS: All participants had knee OA and were provided 12 sessions of multimodal exercise therapy supervised by a physical therapist. Participants were randomly allocated to 1 of 4 groups: exercise therapy in consecutive sessions, exercise therapy distributed over a year using booster sessions, exercise therapy plus manual therapy without booster sessions, and exercise therapy plus manual therapy with booster sessions. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC score; 0-240 scale) at 1-year follow-up. Secondary outcome measures were the numeric pain-rating scale and physical performance tests. RESULTS: Of 75 participants recruited, 66 (88%) were retained at 1-year follow-up. Factorial analysis of covariance of the main effects showed significant benefit from booster sessions (P = .009) and manual therapy (P = .023) over exercise therapy alone. Group analysis showed that exercise therapy with booster sessions (WOMAC score, -46.0 points; 95% confidence interval [CI]: -80.0, -12.0) and exercise therapy plus manual therapy (WOMAC score, -37.5 points; 95% CI: -69.7, -5.5) had superior effects compared with exercise therapy alone. The combined strategy of exercise therapy plus manual therapy with booster sessions was not superior to exercise therapy alone. CONCLUSION: Distributing 12 sessions of exercise therapy over a year in the form of booster sessions was more effective than providing 12 consecutive exercise therapy sessions. Providing manual therapy in addition to exercise therapy improved treatment effectiveness compared to providing 12 consecutive exercise therapy sessions alone. Trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000460808).

Development of a screening tool predicting the transition from acute to chronic low back pain for patients in a GP setting: protocol of a multinational prospective cohort study.

BACKGROUND: Low back pain (LBP) is by far the most prevalent and costly musculoskeletal problem in our society today. Following the recommendations of the Multinational Musculoskeletal Inception Cohort Study (MMICS) Statement, our study aims to define outcome assessment tools for patients with acute LBP and the time point at which chronic LBP becomes manifest and to identify patient characteristics which increase the risk of chronicity. METHODS: Patients with acute LBP will be recruited from clinics of general practitioners (GPs) in New Zealand (NZ) and Switzerland (CH). They will be assessed by postal survey at baseline and at 3, 6, 12 weeks and 6 months follow-up. Primary outcome will be disability as measured by the Oswestry Disability Index (ODI); key secondary endpoints will be general health as measured by the acute SF-12 and pain as measured on the Visual Analogue Scale (VAS). A subgroup analysis of different assessment instruments and baseline characteristics will be performed using multiple linear regression models. This study aims to examine: 1. Which biomedical, psychological, social, and occupational outcome assessment tools are identifiers for the transition from acute to chronic LBP and at which time point this transition becomes manifest. 2. Which psychosocial and occupational baseline characteristics like work status and period of work absenteeism influence the course from acute to chronic LBP. 3. Differences in outcome assessment tools and baseline characteristics of patients in NZ compared with CH. DISCUSSION: This study will develop a screening tool for patients with acute LBP to be used in GP clinics to access the risk of developing chronic LBP. In addition, biomedical, psychological, social, and occupational patient characteristics which influence the course from acute to chronic LBP will be identified. Furthermore, an appropriate time point for follow-ups will be given to detect this transition. The generalizability of our findings will be enhanced by the international perspective of this study. TRIAL REGISTRATION: [Clinical Trial Registration Number, ACTRN12608000520336].