Implementing a structured model for osteoarthritis care in primary healthcare: A stepped-wedge cluster-randomised trial

Abstract

Background: To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international recommendations. The objective of this study was to assess the effectiveness of this model in primary care.

Methods and findings: We conducted a cluster-randomised controlled trial with stepped-wedge cohort design in 6 Norwegian municipalities (clusters) between January 2015 and October 2017. The randomised order was concealed to the clusters until the time of crossover from the control to the intervention phase. The intervention was implementation of the SAMBA model, facilitated by interactive workshops for general practitioners and physiotherapists with an update on OA treatment recommendations. Patients in the intervention group attended a physiotherapist-led OA education and individually tailored exercise programme for 8-12 weeks. The primary outcome was patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire; 0-100, 100 = optimal quality) at 6 months. Secondary outcomes included patient-reported referrals to physiotherapy, magnetic resonance imaging (MRI), and orthopaedic surgeon consultation; patients' satisfaction with care; physical activity level; and proportion of patients who were overweight or obese (body mass index ≥ 25 kg/m2). In all, 40 of 80 general practitioners (mean age [SD] 50 [12] years, 42% females) and 37 of 64 physiotherapists (mean age [SD] 42 [8] years, 65% females) participated. They identified 531 patients, of which 393 patients (mean age [SD] 64 [10] years, 71% females) with symptomatic hip or knee OA were included. Among these, 109 patients were recruited during the control periods (control group), and 284 patients were recruited during interventions periods (intervention group). The patients in the intervention group reported significantly higher quality of care (score of 60 versus 41, mean difference 18.9; 95% CI 12.7, 25.1; p < 0.001) and higher satisfaction with OA care (odds ratio [OR] 12.1; 95% CI 6.44, 22.72; p < 0.001) compared to patients in the control group. The increase in quality of care was close to, but below, the pre-specified minimal important change. In the intervention group, a higher proportion was referred to physiotherapy (OR 2.5; 95% CI 1.08, 5.73; p = 0.03), a higher proportion fulfilled physical activity recommendations (OR 9.3; 95% CI 2.87, 30.37; p < 0.001), and a lower proportion was referred to an orthopaedic surgeon (OR 0.3; 95% CI 0.08, 0.80; p = 0.02), as compared to the control group. There were no significant group differences regarding referral to MRI (OR 0.6; 95% CI 0.13, 2.38; p = 0.42) and proportion of patients who were overweight or obese (OR 1.3; 95% CI 0.70, 2.51; p = 0.34). Study limitations include the imbalance in patient group size, which may have been due to an increased attention to OA patients among the health professionals during the intervention phase, and a potential recruitment bias as the patient participants were identified by their health professionals.

Conclusions: In this study, a structured model in primary care resulted in higher quality of OA care as compared to usual care. Future studies should explore ways to implement the structured model for integrated OA care on a larger scale.

Trial registration: ClinicalTrials.gov NCT02333656.

Fig 1. Stepped-wedge design, timeline, and patient recruitment rate.

All 6 municipalities (clusters) started the trial simultaneously with a control phase (general practitioners and physiotherapists providing usual care). At predefined time points about every second month, one by one the municipalities crossed from the control to the intervention phase (use of the SAMBA model) in a randomised order. Light cells in the figure represent control periods, and dark cells represent intervention periods. The asterisks indicate the timing of the interactive workshops before switching to the intervention phase. Patients recruited to the study during the control phase in any cluster constituted the control group, whereas patients recruited during the intervention phase constituted the intervention group. All patients responded to the baseline questionnaire and follow-up questionnaires at 3, 6, 9, and 12 months post-baseline. ^aLarge municipalities (clusters) had >20,000 inhabitants.

Fig 2. The SAMBA model for integrated osteoarthritis care.

GP, general practitioner; OA, osteoarthritis; PT, physiotherapist.

Fig 3. CONSORT patient flow diagram.

ITT, intention to treat; OA, osteoarthritis.

Fig 4. Mean patient-reported quality of care in the control group (n = 109) and intervention group (n = 284) at baseline and 3 and 6 months of follow-up.

Mean patient-reported quality of care with 95% confidence interval. Patient-reported quality of care captured by OsteoArthritis Quality Indicator questionnaire version 2 (0–100, 100 = best score).