The role of self-management in designing care for people with osteoarthritis of the hip and knee

Deaths due to non-communicable disease, including chronic conditions, are projected to rise from 59% in 2002 to 69% in 2030.1 In response, the Australian Government developed the National Chronic Disease Strategy (NCDS).2 The NCDS provides an overarching framework to drive the general direction for chronic disease management and National Service Improvement Frameworks for five National Health Priority Areas, including osteoarthritis (Box 1).

Patient self-management is one component of chronic disease management. Other important service components are that care is team-based, tailored to the level of individual risk, coordinated between health care provider and health care setting, and provided within a culture of continuous quality improvement.

In this article, I discuss the needs of people with osteoarthritis of the hip and knee, current gaps in meeting these needs, the current role of osteoarthritis self-management support, and provide reasons for repositioning osteoarthritis self-management support within a broader chronic disease management model in order to implement NCDS policy.

Worldwide, about 9.6% of men and 18% of women aged 60 years or older experience symptomatic osteoarthritis.3 These rates are rising concurrently with population ageing and increasing incidence of obesity and trauma.4 About 3.5 million Australians have arthritis, and osteoarthritis is the most prevalent form.5 It is also one of the most common reasons for visiting a general practitioner, with reported rates rising between 1999 to 2006.6

The measurable impacts of osteoarthritis include pain, loss of function, and physical and psychosocial disability. The financial impact is also significant, as increasing rates of joint replacement surgery — a cost-effective intervention for severe osteoarthritis — are a major contributor to rising direct costs of health care.5,7

Many older patients with osteoarthritis require comprehensive assessment because of chronic comorbidities such as obesity, hypertension, cardiac disease, polypharmacy, and use of risk medications such as non-steroidal anti-inflammatory drugs (NSAIDs).8 As with other chronic conditions, symptoms often fluctuate and management can involve multiple health care providers.

Reflecting international guidelines, Australian evidence-based clinical practice guidelines recommend non-pharmacological lifestyle interventions, including physical therapy and weight optimisation, as first-line therapy for osteoarthritis of the hip and knee (Box 2).9,11-13

Use of evidence-based interventions for osteoarthritis results in improved quality of wellbeing, reduced depressed mood,14 improved survival in vulnerable older people,15 and is cost-effective.16 However, despite clinical guidelines, a number of overseas studies report underutilisation of non-pharmacological therapies, inter-professional variation in prescription of non-pharmacological interventions, and use of physical therapies with little evidence of effectiveness.8,17-19 Multidisciplinary care, including physical therapy, increases the likelihood of being prescribed comprehensive therapy.18

In Australia, there are insufficient data about guideline implementation for osteoarthritis. In a baseline assessment of 27 medical records of new patients attending a public hospital’s osteoarthritis hip and knee clinic, there was poor documentation of NSAID risk assessment (1/12), blood pressure (3/12 taking NSAIDs) and emotional state (3/27). Only three of 27 patients reported having previously had exercise program prescription, and none had had nutrition assessment, although the median body mass index was 32.5 kg/m2 (interquartile range, 29.2–37.9 kg/m2) (unpublished data; available from the author). Although documentary inadequacies may have underestimated adherence to recommendations, these findings are in keeping with a recent report.8 Further qualitative data identified gaps in meeting perceived needs for medication management and continuity of care.20

Some patients with chronic conditions do not continue to adhere to therapeutic recommendations after 6 months,23 and osteoarthritis patients are among those with the highest non-adherence rates.24 Long-term adoption of non-pharmacological recommendations is more likely if interventions are perceived to be efficacious and to positively affect outcomes.25 Self-management programs aim to support patient self-management, which has been defined as “active participation by people in their own health care”.2 In Australia, two programs are well defined:

• The Arthritis Self-Management Program, a formal, structured group model led by health professionals or trained peers and run over a 6-week period, incorporates educational and behavioural strategies designed to improve patient self-efficacy or the “confidence to do”.26 However, recent evidence suggests that benefits are minimal and limited to psychological endpoints, especially if provided in isolation from physical therapy.27,28

• The Flinders Model is a “one-on-one” service model that focuses on supporting behaviour change using goal-setting care plans.29

The comparative reach, applicability and cost-effectiveness of different self-management programs for osteoarthritis is unknown.30

In addition to self-management support, additional chronic disease management components are required to support health care professionals to apply best practice, thereby helping patients manage all aspects of their condition in relation to their daily lives.31

The challenge of addressing behaviour change was highlighted in a systematic review of interventions to enhance medication adherence.32 Although not specific for patients with osteoarthritis, the review reported that interventions that were effective for long-term care were complex and included combinations of interventions such as information, reminders, self-monitoring, reinforcement, counselling, family therapy, psychological therapy, crisis intervention, telephone follow-up and supportive care.32

Therefore, an ideal chronic disease management model would include practical service delivery components such as evidence-based clinician and consumer decision aids, health care providers with communication skills,33 and condition monitoring systems. To achieve this, we need to better understand the “black box” of chronic disease management — the elements that form the construct of self-management, how these are tailored to individual need, and how this influences service design and delivery (Box 3). It is difficult to predict how many patients will be incapable of participating, or will choose not to participate in active decision making. However, such patients are likely to be part of the most disenfranchised populations, which are at the greatest health risk.34

We need to use robust research methods to investigate innovative service delivery models such as telephone support35 and coaching programs,36 as an individual with osteoarthritis might prioritise and adopt interventions differently to people with other chronic conditions.

Although chronic disease management taxonomy is not yet standardised, common structural service components have been described. These include an organised system with a culture of quality and safety,37 evidence-based care supported by clinical decision support tools, continuous care supported by clinical information systems, program participation focused at a community level, and supported patient self-management.38 In this primary care model of chronic disease management, the GP provides leadership and works with allied health professionals, pharmacists and medical specialists.38

This model is ideal for osteoarthritis, where acute care intervention is limited to patients with severe disease (for whom joint replacement surgery is indicated). However, although there is high-level evidence of a positive association between chronic disease management models and adherence to best-practice guidelines and patient health outcomes for other chronic conditions, the evidence for osteoarthritis is lacking.39 This may reflect an absence of chronic disease management components, other than self-management support, in reported osteoarthritis service models.39,40

There remain a number of generic and specific barriers to implementation of chronic disease management models for osteoarthritis management in Australia. Clinical information systems, which can support effective integration of decision support for guideline implementation, are well developed in general practice but are poorly integrated with other health care providers.41 Further, we have no national infrastructure comparable to the Scottish Intercollegiate Guidelines Network to support update of knowledge resources. Meeting the information needs of a diverse range of patients with osteoarthritis is also a challenge.

Service delivery is inhibited by workforce constraints in all professions. As a result, role redefinition using innovative service delivery models — such as those led by musculoskeletal coordinators who, using mutually agreed-upon protocols to comprehensively assess patients, coordinate care and provide self-management support — needs to be further investigated.42

Finally, funding models must support chronic care delivery. Integrated acute and community setting chronic disease management models for chronic heart failure and chronic obstructive pulmonary disease, driven by the need to address rising admissions, are supported by jurisdictional funding mechanisms such as the Hospital Admission Risk Program in Victoria.43 Recent Enhanced Primary Care44 funding initiatives to support primary care chronic disease management items through the Medicare Benefits Schedule (item numbers 721–731) provide limited access to allied health professionals, but do not address all the barriers to implementing chronic care service components. Therefore, the degree to which NCDS policy will be effectively implemented for conditions managed primarily in community settings, such as osteoarthritis, is uncertain.

3 A “black box” model of osteoarthritis self-management