Implementing international osteoarthritis guidelines in an integrated care model – results from a cluster randomized controlled trial

Østerås, N.; Moseng, T.; van Bodegom-Vos, L.; Dziedzic, K.; Mdala, I.; Natvig, B.; Røtterud, J.; Andreassen, Ø.; Schjervheim, U.-B.; Hansen, J.; Vlieland, T.; Hagen, K.

Abstract

Purpose: Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care has been developed. The main aim of the study was to assess the effectiveness and feasibility of a tailored strategy to implement the SAMBA model for integrated OA care in Norway.

Methods: A cluster randomized controlled trial with stepped wedge cohort design was conducted in six municipalities (clusters). The SAMBA model was implemented in one municipality at the time by switching from “usual care” to the new SAMBA model. The implementation strategy was based on interactive workshops for general practitioners (GPs), physiotherapists (PTs) and orthopaedic surgeon in addition to educational material, educational outreach visits, feedback, and reminder material. The workshops included an update on current OA treatment recommendations and facilitated multidisciplinary (GP and PT) and multilevel collaboration (GP and orthopaedic surgeon). The GPs informed the patients about OA and treatment alternatives and referred the patients to PT. The PTs regularly arranged OA patient education programmes followed by twice weekly group exercise sessions for 8–12 weeks. Patient participants, people with hip and/or knee OA, completed questionnaires at baseline and at 3-, 6-, 9- and 12-months follow-ups. The primary outcome measure was patient-reported quality of care at the 6-months follow-up. It was measured with the OsteoArthritis Quality Indicator questionnaire that includes 16 quality indicators (QIs) related to OA patient education and information, regular provider assessments, referrals, and pharmacological treatment. Secondary outcomes included referrals to PT, MRI, and orthopaedic surgeon as well as patient satisfaction with care, overweight and fulfillment of physical activity recommendations (eg. >75 min hard/>150 min moderate activity per week). Register data on referrals are not yet available, so the results are based on analyses of patient-reported number of referrals. Data was analysed with longitudinal multilevel mixed-models adjusted for time and with Chi-square analyses.

Results: 40 of 79 invited GPs and 37 of 87 invited PTs attended the workshops. Of 531 patients, 393 fulfilled the inclusion criteria and were included in the control (n = 109) or the intervention group (n = 284). In total 9 multidisciplinary workshops and 27 OA patient education programmes and exercise groups were initiated. At baseline achievement of QIs for OA care for the two groups were similar (39% vs 37%), but at the 6-month follow-up, the intervention group achieved a significantly (B: 19.9 95% CI 13.7, 26.0) higher achievement rate (60% vs 41%) indicating better quality of care compared to the control group. Compared to the control group, a larger proportion in the intervention group was referred to PT (OR 2.5 95% CI 1.1, 5.7) and a smaller proportion to orthopaedic surgeon (OR 0.3 95% CI 0.1, 0.9) at the 3- and 6-month follow-ups, respectively. The proportion of patients with MRI referrals and the proportion of patients with overweight were similar across the two groups at all time points. The intervention group reported significantly higher satisfaction with care (X2: 54.1, p< 0.001) and a larger proportion (X2: 14.1, p = 0.001) met the recommendations for physical activity level compared to the control group at the 6-month follow-up.

Conclusions: The implementation strategy for the SAMBA model led to improved quality of care, higher patient satisfaction with care and higher physical activity levels among the patient participants. The implementation strategy with multidisciplinary workshops may be implemented in more municipalities and can be adjusted to fit other patient groups.

Citation

Østerås, N., Moseng, T., van Bodegom-Vos, L., Dziedzic, K., Mdala, I., Natvig, B., …Hagen, K. (2018). Implementing international osteoarthritis guidelines in an integrated care model – results from a cluster randomized controlled trial. Osteoarthritis and Cartilage, 26(S1), https://doi.org/10.1016/j.joca.2018.02.085

• Journal Article Type: Conference Paper
• Online Publication Date: Apr 16, 2018
• Publication Date: Apr 16, 2018
• Deposit Date: Jun 23, 2023
• Journal: Osteoarthritis and Cartilage
• Print ISSN: 1063-4584
• Publisher: Elsevier
• Peer Reviewed: Not Peer Reviewed
• Volume: 26
• Issue: S1
• DOI: https://doi.org/10.1016/j.joca.2018.02.085