Management of Osteoarthritis
Arthritis is a chronic disease of the joints estimated to affect over five million Australians. Over two million of these have osteoarthritis (OA) which is the most common form of arthritis , though it is known that many go unreported as it is a common misguided belief that joint pain is a part of the normal process of ageing. It has been estimated that the number of people with OA in Australia will increase from 2.2 million in 2015 to 3.1 million in 2030; with the ageing population and increasing prevalence of obesity being two of the drivers of this increase. People with OA report living with chronic pain, physical disability, functional impairment, social and vocational difficulties in their daily life . Comorbidities are common with 15% of the people accessing the ACI trial of the Osteoarthritis Chronic Care Program reporting four or more comorbidities.
What clinical processes need to change?
International and national guidelines for the management of OA recommend conservative care options as first line management strategies, even with increasing pain levels and functional disability. Conservative care includes the use of simple analgesia and multidisciplinary self-management support to include risk modifying behaviour in everyday life such as exercise and healthy eating habits. Data from the trial of the ACI Osteoarthritis Chronic Care Program (OACCP), conducted from 2011 through to 2013 has revealed that in a variety of sites across NSW, almost 70% of over 6,000 people on the waitlist for elective hip or knee joint replacement had not been referred to or accessed conservative care (besides analgesia) before referred to the surgical waitlist. To achieve the following outcomes, people referred require a minimum of 12 months enrolment in the OACCP to enable behavioural change to be embedded as a normal part of OA self-management.
The outcomes include:
- more appropriate waitlists for elective surgical replacement of hip and knee joints through identification and support of between 11% and 17% - depending on the site – of those waiting for knee replacement to remove themselves from the waitlist, in consultation with their surgeon and GP. This generally happens at approximately 26 weeks participation in their local OACCP. Those considering their need for surgery at this point often feel confident to remove themselves from the waitlist. This is due to reduced pain and increased functional ability as an outcome of being supported to self-manage their OA in line with current evidence.
- approximately 4% of those attending OACCP for management of their hip OA can be supported to access earlier surgery as they and the OACCP team identified their need due to increasing pain and disability despite conservative care interventions.
- those participants proceeding to surgical joint replacement less likely to be deferred at the point of admission as they are prepared well ahead of time with co-morbidities management optimised, any home modifications attended to months in advance, and patient expectations of the hospitalisation process and outcomes realistically understood early in their waitlist time.
What will the clinical change process look like?
The OACCP is a coordinated multidisciplinary model of care that can be used for people with OA of the hip and/or knee at all stages of the disease trajectory. While the model of care was evaluated in hospital outpatient settings with people who are already on the waitlist for surgical hip or knee joint replacement, trials led by the ACI Musculoskeletal Network since have been undertaken in primary care settings with collaboration and partnership between Local Health Districts (LHD) and Primary Health Networks (PHN). This indicated that OACCP is effective in consideration of improved patient outcomes and improved health system utilisation in outpatient settings. The interventions used to attain these results can be applied and trialled in various localities across NSW.
Key to the program at sites are:
- allocation of coordinated multidisciplinary team (MDT) to work in partnership with the patient group
- determination of the setting where the OACCP will work best for your local population and resources
- a cultural change in perspective by some of the potential team members e.g. working proactively together across professional groups (true MDT effect) and clinical sites and entities; and some team members in orthopaedics and primary care being convinced of the benefits to patients and their health service of implementing the guidelines for the management of people with OA
- an acceptance that support of people with OA includes a holistic whole of person approach in a true person-centred manner. This includes assessment and support of management of any social, psychological and co-morbidity needs of individual patients – people with OA.
What are the clinical benefits of change for this cohort?
Implementing the OACCP has the potential to:
- support optimal management of OA as a chronic disease
- improve the health of people with OA (quality of life, physical functioning and work status)
- support the management of co-morbidities e.g. hypertension, obesity, psychological health, low back pain
- reduce or delay the need for surgery with early conservative care intervention
- improve access to surgical intervention for those who require joint replacement
- realistic understanding of hospital processes and surgical outcomes.
- Arthritis Australia, Counting the cost: Part 1 Healthcare costs. 2016: Sydney, Australia.
- Australian Institute of Health & Welfare. How does osteoarthritis affect quality of life? Risk factor, disease and death 2017 [cited 2017; Available from: http://www.aihw.gov.au/osteoarthritis/quality-of-life/.
See the ACI resources on the Model