Osteoarthritis: Models for appropriate care across the disease continuum

Osteoarthritis: Models for appropriate care across the disease continuum

Best Practice & Research Clinical Rheumatology 30 (2016) 503e535 Contents lists available at ScienceDirect Best Practice & Research Clinical Rheumat...

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Best Practice & Research Clinical Rheumatology 30 (2016) 503e535

Contents lists available at ScienceDirect

Best Practice & Research Clinical Rheumatology journal homepage: www.elsevierhealth.com/berh

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Osteoarthritis: Models for appropriate care across the disease continuum Kelli D. Allen a, b, *, Peter F. Choong c, d, Aileen M. Davis e, f, g, h, Michelle M. Dowsey c, d, Krysia S. Dziedzic i, Carolyn Emery j, k, David J. Hunter l, m, Elena Losina n, o, Alexandra E. Page p, Ewa M. Roos q, Søren T. Skou r, s, t, Carina A. Thorstensson u, v, Martin van der Esch w, Jackie L. Whittaker x a

Department of Medicine, Thurston Arthritis Research Center, University of North Carolina, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599-7280, USA b Center for Health Services Research in Primary Care, Department of Veterans Affairs Medical Center, Durham, NC, USA c Department of Orthopaedics and The University of Melbourne, Level 2, Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065, Victoria, Australia d Department of Surgery, St. Vincent's Hospital Melbourne, Level 2, Clinical Sciences Building, 29 Regent Street, Fitzroy, 3065, Victoria, Australia e Division of Health Care and Outcomes Research, Krembil Research Institute, University Health Network, MP11-322, 399 Bathurst Street, Toronto, ON, M5T2S8, Canada f Institute of Health Policy, Management and Evaluation, University of Toronto, MP11-322, 399 Bathurst Street, Toronto, ON, M5T2S8, Canada g Institute of Rehabilitation Science, Canada h Departments of Physical Therapy and Surgery, University of Toronto, MP11-322, 399 Bathurst Street, Toronto, ON, M5T2S8, Canada i Institute of Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Keele University, Keele, ST5 5BG, UK j Sport Injury Prevention Research Centre, University of Calgary, Canada k Faculty of Kinesiology, Cumming School of Medicine, University of Calgary, Canada l Institute of Bone and Joint Research, The Kolling Institute, The University of Sydney, Sydney, Australia m Rheumatology Department, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia n Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham & Women's Hospital & Boston University School of Public Health e US, 75 Francis Street, BC-4-4016, Boston, MA, 02115, USA o Policy and Innovation eValuations in Orthopedic Treatment (PIVOT) Research Center, Department of Orthopedic Surgery, Brigham & Women's Hospital & Boston University School of Public Health e US, 75 Francis Street, BC-4-4016, Boston, MA, 02115, USA p San Diego Musculoskeletal and Joint Research Foundation, Private Practice, American Academy of Orthopaedic Surgeons Health Care Systems Committee, San Diego, CA, USA q Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, DK-5230, Odense M, Denmark

* Corresponding author. Department of Medicine, Thurston Arthritis Research Center, University of North Carolina, 3300 Thurston Bldg., CB# 7280, Chapel Hill, NC, 27599-7280, USA. Tel.: þ1 919 966 0558; fax: þ1 919 966 1739. E-mail address: [email protected] (K.D. Allen). http://dx.doi.org/10.1016/j.berh.2016.09.003 1521-6942/Published by Elsevier Ltd.

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r Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, 5230, Odense, Denmark s Clinical Nursing Research Unit, Aalborg University Hospital, 9000, Aalborg, Denmark t Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Region Zealand, 4200, Slagelse, Denmark u Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation. The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden v €stra Go €stra Go €taland, Centre of Registers Va €taland, 41345, The BOA-registry, Center of Registers Va Gothenburg, Sweden w Reade Centre for Rehabilitation and Rheumatology, Rehabilitation Research Centre, Dr. J. van Breemenstraat 2, 1056 AB Amsterdam, P.O. Box 58271, 1040 HG, Amsterdam, The Netherlands x Department of Physical Therapy, Faculty of Rehabilitation Medicine and Glen Sather Sports Medicine Clinic, University of Alberta, 2-50 Corbett Hall, 8205-114 Street, Edmonton, AL, T6G 2G4, Canada

a b s t r a c t Keywords: Osteoarthritis Quality of healthcare Implementation Health services

Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Despite the existence of evidence-based treatments and guidelines, substantial gaps remain in the quality of OA management. There is underutilization of behavioral and rehabilitative strategies to prevent and treat OA as well as a lack of processes to tailor treatment selection according to patient characteristics and preferences. There are emerging efforts in multiple countries to implement models of OA care, particularly focused on improving nonsurgical management. Although these programs vary in content and setting, key lessons learned include the importance of support from all stakeholders, consistent program delivery and tools, a coherent team to run the program, and a defined plan for outcome assessment. Efforts are still needed to develop, deliver, and evaluate models of care across the spectrum of OA, from prevention through end-stage disease, in order to improve care for this highly prevalent global condition. Published by Elsevier Ltd.

Osteoarthritis burden and gaps in management Symptomatic osteoarthritis (OA), defined as having persistent symptoms in addition to positive imaging findings or functional limitations, is a leading cause of chronic pain and disability among adults [1]. It places a substantial burden at the individual level, affecting psychological well-being, sleep, work participation, social participation, management of comorbid health conditions, and health-related quality of life [2]. OA also has a tremendous societal and public health impact. For example, the 2010 Global Burden of Disease Survey found that knee and hip OA were responsible for 17 million years lived with disability worldwide [1]; the burden is likely higher when other joints are considered. OA is associated with increased healthcare utilization and costs as well as higher nonhealthcare-related costs including work force loss, productivity loss, and formal and informal caregiving [2]. OA is the most rapidly growing cause of disability globally [3], and this rising epidemic will place increasing burden on both patients and healthcare systems. Rates of total joint replacement (TJR) surgeries are increasing dramatically in many developed countries [4], leading to concerns about meeting demands. Prevention and early management are critical to address the significant and increasing public health burden of OA. Guidelines from professional societies emphasize that a combination of behavioral and clinical strategies is essential for OA management (Fig. 1) [5]. Core therapies, appropriate for all individuals with OA, include self-management education, exercise (land- or water-based structured progressed

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Fig. 1. Summary of OA Treatment Components from Review of Treatment Guidelines.

aerobic conditioning, muscle strength training, and neuromuscular exercise), lifestyle physical activity, and weight management; these first-line treatments should be maintained throughout the disease course. Other evidence-based therapies for OA include increasing joint range of motion with manual therapy and biomechanical interventions such as braces, oral and topical pharmacotherapies, intraarticular corticosteroids, and joint replacement surgery; these should be applied based on patients' symptom severity, impairments, and risk factors. Unfortunately, there are major gaps in both OA prevention and the use of evidence-informed therapies, illustrated internationally [6e10]. For example, studies indicate that healthcare providers often do not include recommendations for exercise and weight management as part of OA management [8]. Studies also show underutilization of biomechanical therapies (e.g., knee braces), lack of function and disability assessment, and issues related to pain medication safety. There are many potential factors underlying these gaps in care, including competing demands of comorbid health conditions in the context of clinic visits, and a perception among healthcare providers that OA is merely a part of normal aging with limited treatment options [11,12]. There is a clear need to develop and implement models that promote evidence-informed OA prevention and management. This study describes the current evidence for models of care (MoCs) across the spectrum of OA. This includes models for primary prevention, nonsurgical management, surgical prioritization, and management of

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persistent pain. We describe the research evidence base to guide these MoCs, examples of care models currently being implemented (when available), and recommendations for advancing these efforts worldwide. Primary OA prevention models The need for primary OA prevention models Any comprehensive MoC should consider the spectrum of disease, including primary prevention strategies. Two key primary prevention targets for OA are weight reduction and joint injury prevention. Population-based efforts toward weight management could have a substantial impact on prevention of OA, as even a modest amount of weight loss seems to confer a decrease in OA risk [13]. In this section, we focus on injury prevention because of its specific relevance to OA. There is a growing public health burden related to the incidence of early-onset post-traumatic osteoarthritis (PTOA) in at-risk populations [14]. Sport and recreation is the leading cause of injury in youth, accounting for up to 40% of the injury burden, with 50% of these being knee, ankle, and hip injuries [15,16]. The estimated injury incidence proportion in youth sport is 35 injuries/100 students/year (ages 11e18) [15,17]. Meta-analyses reveal a 4-fold increased knee OA risk 15 years post injury [18,19]. Unfortunately, limited attention has been given to the multifactorial etiology of PTOA, with a goal of informing early diagnostics and prevention [19,20]. In this section, we apply an epidemiological model of disease prevention onto the events associated with the development of PTOA to illustrate opportunities for primary (prevent joint injury) and secondary (slow down or halt the onset of PTOA following injury) prevention that should be included in a comprehensive model. Joint injury prevention models Evidence for the efficacy of joint injury prevention programs Many studies show that injury prevention strategies can reduce the number and severity of injuries [21,22]. In youth, meta-analysis revealed a combined preventative effect of neuromuscular training in reducing the risk of lower extremity injury [incidence rate ratio (IRR) ¼ 0.64 (95% confidence interval (CI); 0.49e0.84)] and knee injury [IRR ¼ 0.74 (95% CI; 0.51e1.07)] [21]. Consistent evidence has been reported in adult athlete populations, with an emphasis on neuromuscular training components (e.g. strength, balance, and agility). However, little is known about the most effective training program components or the most efficient implementation approaches for injury prevention. Challenges and recommendations for joint injury prevention models Primary prevention strategies for sport injury have been based on a multifactorial model for injury risk, considered within a variable implementation context [23]. Although the translation of injury prevention research into best practice has received a great deal of attention, its wide-scale implementation in real-life conditions is an ongoing challenge [10]. The Translating Research into Injury Prevention Practice (TRIPP) Framework attempts to address implementation shortcomings by adding two key stages required to translate effective prevention strategies into practice [24] to the four-staged van Mechelen injury prevention model (i.e., stage 1: establish the extent of injury burden; stage 2: identify injury risk factors and causal mechanisms; stage 3: develop and introduce preventative strategies; and stage 4: evaluate the impact of these strategies on injury burden) [25]. The TRIPP stage 5 involves describing the context in which the intervention was developed to inform implementation strategies and successful transfer to a real-world context of sport [24]. The TRIPP stage 6 involves implementing the intervention in a real-world context and evaluating its effectiveness [24]. An  de ration Interexample of a program with widespread implementation internationally is the Fe nationale de Football Association (FIFA) 11þ (http://f-marc.com/11plus/home/) for injury prevention in soccer. This effort is based on an evidence-informed program that has resulted in significantly reduced injuries during matches and training. To facilitate implementation, there is a publically available, detailed manual describing the program and illustrating all the exercises; video demonstrations of the

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exercises are also available. A countrywide campaign to implement this program in Switzerland has been documented, resulting in good penetration (80% of coaches knew of the program and 57% performed all or most parts of it), and lower injury rates among teams using the program [26]. Practice and policy efforts related to injury prevention rely on efficient use of limited financial resources, and a greater focus on economic evaluations is important, as highlighted by the Reach Efficacy Adoption Implementation Maintenance Framework (RE-AIM), [27]. In developing the optimal implementation strategy, it is critical to consider the multiple factors that may influence adherence to such a program across multiple levels of influence on sport safety (e.g., child, parent, coach, teacher, community, and government) [28]. In summary, there is consistency to support the preventative effects and economic benefits of multifaceted neuromuscular training programs including strength, balance, and agility components in reducing the risk of lower extremity injuries in sport and recreation. However, lack of uptake and maintenance of such programs is an ongoing concern. A greater focus on implementation is critical to influence knowledge, behavior change, and sustainability of evidence-informed injury prevention practice. Injury rehabilitation models Joint injury and development of PTOA: informing rehabilitation models Little is known about the period between joint injury and PTOA onset, other than as it relates to return to sport after anterior cruciate ligament injury or reconstruction (which does not appear to mitigate the risk of PTOA) [29]. A better understanding of this period could inform the development, implementation, and evaluation of early diagnostics and joint injury rehabilitation programs that focus not only on the acute injury but also on minimizing the onset of risk factors for PTOA. There is emerging evidence that 3e10 years post sport-related knee injury, young adults are more likely to become overweight/obese, less physically active, and demonstrate magnetic resonance imaging (MRI)-defined OA compared with uninjured matched controls [20,30]. These findings suggest that young adults with knee injury history may compound their risk for PTOA by developing other modifiable risk factors (e.g., obesity, inactivity, and altered joint loading) that may accelerate the rate of progression to OA [20]. Challenges and recommendations for injury rehabilitation models Although there are limited data based on which recommendations could be made regarding a specific MoC for injury rehabilitation that will delay or halt the onset of PTOA, current evidence suggests that these programs should include strategies aimed at (1) maintaining a healthy weight and (2) restoring strength, balance, and healthy movement patterns that facilitate recommended levels of exercise. A better understanding of the relationship between lower levels of exercise and/or inappropriate dietary intake and the psychosocial factors at play (potential loss of athletic and/or exercise identity) is required. In addition, more evidence is needed regarding the most appropriate form and timeline for acute, pre-surgical, surgical, and postsurgical care. As with injury prevention, greater attention is needed to develop and implement practical and specific models of injury rehabilitation to influence the growing burden of PTOA. OA care pathways Models of nonsurgical OA service delivery in developed countries There are numerous national and international guidelines for nonsurgical OA management of [5,31], and there is broad agreement on core therapies [5]. Internationally, however, there are wide variations in practice [9] and gaps between current care and OA treatment recommendations [32,33]. A number of programs have been designed to close the gap between OA recommendations and practice, using differing models of service delivery (e.g., specific strategies for implementing various components of recommended OA care). A selection of these programs was recently featured as part of a pre-conference workshop of the Osteoarthritis Research Society International (OARSI). In this section, we briefly describe some of these exemplar OA programs, and Table 1 provides details on the target population, eligibility criteria, targeted interventions, outcome measures being collected, and funding models.

Target population Eligibility criteria (e.g., knee and hip OA)

Targeted interventions (e.g., diet and exercise)

Osteoarthritis Chronic Care program (OACCP); Australia

Persons with knee Pain in the affected and or hip OA joint most days of the past month, pain visual analog scale (VAS)  4 out of 10 and doctor diagnosed hip or knee OA

Coordinated multidisciplinary management including exercise, diet, psychological support, occupational therapy, orthotics, and medical management

Better management of patients with osteoarthritis (BOA); Sweden Digitalized version: Joint Academy

Persons with hip, knee or hand OA. (shoulder to be included 2016).

Non-traumatic pain, sufficient to seek care, and attributed by a clinician to a joint.

Outcome measures being collected

Pain VAS, knee injury and osteoarthritis outcome score (KOOS)/hip disability and osteoarthritis outcome score (HOOS), Patient Global Assessment, EQ-5D/Assessment of Quality of Life, Depression, Anxiety and Stress Scale 21, Katz comorbidities, 6-min walk test, timed up-and-go, body mass index (BMI), hip/waist ratio, willingness for surgery, surgical waitlist removal/ acceleration Physical therapist, EQ-5D, pain numeric occupational rating scale, pain therapist, and OAfrequency, desire to communicator (i.e., have surgery, level of “expert patient”) physical activity, fear delivered education, of movement, supported selfCharnley management, physical comorbidity index, activity use of pain recommendations, medications, sick optional leave, previous individualized treatments, Arthritis exercise program, Self Efficacy scale, At optional supervised follow-up: exercise group satisfaction and sessions (using usefulness of individual program) intervention

Number of Duration of program Website for further persons for individual information enrolled/seen in participants the program

Point of contact for further information (name: E-mail address)

~10,000 since 2012

Up to 12 months

http://www.aci. health.nsw.gov.au/ models-of-care/ musculoskeletal/ osteoarthritischronic-careprogram

David Hunter: David. Funded through [email protected] public hospital au system and expanding into primary care and private hospitals.

~60,000 since 2010

3 months of intervention, postal follow-up at 12 months

www.boaregistret.se Digitalized version/ e-health: www.jojntacademy. com

Carina Thorstensson: Carina. [email protected] registercentrum.se

Healthcare system, funding model

Physical therapy (health care) pays cost-price for 2-day course. Patients pay approximately. 12 USD per individual visit and 10 USD for group visits. Patients' cost ceiling within a 1year limit for medical care and medicine under the health service is 140 USD. Costs exceeding this limit, and additional costs for visits mentioned above, are paid for by healthcare

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Name of Program and Originating Country

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Table 1 Featured OA Management Programs in the Osteoarthritis Research Society International (OARSI) Repository.

Non-traumatic pain, sufficient to seek care, and attributed by a clinician to hip or knee joint (same as BOA)

Two sessions of physical therapistdelivered Information, if available 1 additional session with “expert patient”, supported selfmanagement, physical activity recommendations, 12 supervised neuromuscular exercise sessions based on the program NEuroMuscular EXercise (NEMEX). Educational part, but not exercise part, similar to BOA

Among others: EQ- ~15,000 since 5D, pain visual Feb 2013 analog scale, physical activity, fear of movement, use of pain medications, sick leave, comorbidities, Arthritis Self Efficacy Scale, At follow-up: satisfaction and usefulness of intervention. Outcomes are similar to BOA with the addition of KOOS/ HOOS quality of life, SF-12 and functional tests: 40 min walk, chair stands

www.glaid.dk Three months of intervention immediate follow-up (Internet-based and clinical visit), and additional online follow-up at 12 months

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Good Life with Persons with hip osteoarthritis in and/or knee OA Denmark (same as BOA) (GLA:D); Denmark

system (tax). The register was initially funded as a 3-year pilot project by the national social insurance office and financial support from the Swedish government to the regional authorities (Dagmar model). BOA became a national quality register in 2010 and as such is supported financially, after annual application, by the Swedish authority of local authorities and regions. Additional support from the €stra region of Va € taland. The Go intervention is part of primary care practice. Ewa M. Roos: [email protected] In 2011e2013 health.sdu.dk 14,000 USD have Søren T. Skou: been received from [email protected] Danish dk Rheumatism Association and 11,800 USD from Danish Physiotherapy Association, money used to start the registry. In 2015, the Danish Rheumatism gave 15,000 USD for a health economic evaluation and the Danish Physiotherapy Association gave

Name of Program and Originating Country

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Table 1 (continued ) Target population Eligibility criteria (e.g., knee and hip OA)

Weight loss (7.5e10%) and improved nutrition, muscle strengthening, land-

Outcome measures being collected

KOOS/HOOS, ShortForm 12, body weight, waist circumference,

Number of Duration of program Website for further persons for individual information enrolled/seen in participants the program

~9000 to date

18 weeks intensive and proactive engagement, open-

www. HealthyWeight ForLife.com.au and click on

Point of contact for further information (name: E-mail address)

Luke Lawler: [email protected] com.au

Healthcare system, funding model

45,000 USD for the project manager (Dr Skou). The physiotherapists pay themselves (app. 560 USD) for the 2-day training course. This money is used to support a project manager, run the courses, and maintain the registry. Reimbursement to therapists and patient fees vary based on healthcare insurance, but in private physical therapy practice, most commonly patients pay 375 USD and physical therapists are reimbursed with 250 USD. Some patients receive the GLA:D program from the municipality, which covers the full cost. University of Southern Denmark graciously covers Dr Roos' time and involvement and hosts the courses. 100% funded for eligible patients through private health insurers

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Osteoarthritis Persons with knee Diagnosis supported by Healthy Weight or hip OA radiological evidence For Life (OA AND BMI  28 AND Symptoms that have

Targeted interventions (e.g., diet and exercise)

HWFL); Australia

satisfaction with based and range of motion exercises, pain support and information management strategies, education, monitoring and engagement strategies

Western Ontario and 1000 to date McMaster Universities Osteoarthritis Index, physical performance (timed up-and-go/stair climb), muscle strength, proprioception, physical activity, Short-Form-36, comorbidity illness rating scale, medication JIGSAW Knee, hip, hand, Aged 45 years and over, Use of an electronic OA quality indicators South Joint foot OA, and joint joint pain, OA in knee, OA template to record Shropshire, UK: key quality indicators Implementation pain, presenting to hip, hand, foot; Total practice of OA care. of Osteoarthritis a general exclusion red flags population ¼ PLUS guidelines in practitioner in 102,827 A model OA the West primary care Total number of consultation with a Midlands, UK practices ¼ 14 general practitioner: (Based on MOSAICS Practices makes, gives, explains study) agreeing to the OA diagnosis; participate ¼ 10 gives OA guidebook; Number of analgesia; offers practice teams referral to practice trained by nurse. Practice nurse champions ¼ 10 up to 4 sessions Number of supporting selfpractice nurses management: OA trained ¼ 13 guidebook; exercise/ physical activity advice using Arthritis Research UK booklets; weight management; analgesia Amsterdam osteoarthritis cohort (AMSOA); The Netherlands

Coordinated multidisciplinary management including supervised exercise program according to the knee joint stabilization therapy trial (Knoop et al.), occupational therapy, psychological support, and medical management

ended inbound support

Osteoarthritis program link

3 months of multidisciplinary intervention

www.reade.nl

Martin van der Esch Funding is partly [email protected] through the healthcare system and partly from trials. Trials are within the cohort.

Up to 3 months

OA e-template http://www.keele.ac. uk/ pchs/dissem inatingourr esearch/resear chtools/oaetemplate/ OA guidebook http://www.keele.ac. uk/ media/keele university/ri/ primarycare/pdfs/ OA_Guidebook.pdf MOSAICS http://www.isrctn. com/ISRCTN 06984617

Krysia Dziedzic [email protected] ac.uk, Helen Duffy [email protected] uk,

Regional Innovation Fund; Clinical Commissioning Group redesign of orthopedic pathways; NIHR Knowledge Mobilisation Research Fellowship (Dziedzic); EIT-Health

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(or are likely to) necessitated referral to an orthopedic surgeon for further investigation OR Joint replacement is planned and improved fitness for surgery desirable Persons with knee Non-traumatic pain, and or hip OA sufficient to seek care, and attributed by a clinician (rheumatologist and/or rehabilitation physician) to hip or knee joint

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Osteoarthritis Chronic Care Program (OACCP) Australia OACCP (http://www.aci.health.nsw.gov.au/resources/musculoskeletal/osteoarthritis_chronic_care_ program/osteoarthritis-chronic-care-program) is a program for individuals with doctor-diagnosed knee and or hip OA, with pain in the affected joint on most days of the past month (pain visual analog scale  4 out of 10) [34,35]. Coordinated, individually tailored physiotherapy-led multidisciplinary management is offered, including exercise, diet, psychological support, occupational therapy, orthotics, and medical management. Outcome measures are pain, Patient Global Assessment, EQ-5D/ Assessment of Quality of Life, Depression, Anxiety and Stress Scale 21, Katz comorbidities, 6-min walk test, timed-up-and-go test, body mass index (BMI), hip/waist ratio, willingness to have surgery, and surgical waitlist removal/acceleration. Better management of patients with osteoarthritis (BOA) Sweden BOA (and the Digitalized version: Joint Academy, www.jointacademy.com) is a program for individuals with hip, knee, or hand OA, with shoulder OA to be included in 2016 (www. boaregistret.se) [7]. Participants have non-traumatic pain, sufficient to seek care, and attributed by a clinician to their joint. Physiotherapists, occupational therapists, and expert patients (described as OA communicators) provide education, self-management support, exercise recommendations, an optional individualized exercise program, and optional supervised exercise group sessions (using the individual program). Patient-reported outcome measures include EQ-5D, pain (numeric rating scale, pain frequency), desire to have surgery, level of exercise, fear of movement, Charnley comorbidity index, use of pain medications, sick leave, previous treatments, and the Arthritis Self Efficacy Scale. At 3- and 12-month follow-up, satisfaction with and usefulness of the program are also measured. Good life with arthritis in Denmark (GLA:D) GLA:D (www.glaid.dk) is offered to individuals with hip and/or knee OA, defined as non-traumatic pain sufficient to seek care, and attributed by a clinician to OA of the hip or knee joint. Participants are offered two sessions of physiotherapist-delivered information, if available one additional session with an “expert patient,” supported self-management, exercise recommendations, and 12 sessions of supervised neuromuscular exercise sessions based on the NEuroMuscular EXercise (NEMEX) program [36]. Patient-reported outcome measures significantly overlap with the BOA program, while collection of objective performance measures (40-min walk, 30-s chair stands) is specific to GLA:D [37]. Outcomes are collected electronically at baseline after 3 and 12 months. Osteoarthritis Healthy Weight For Life (OA HWFL) Australia The OA HWFL program is offered to individuals with knee or hip OA diagnosed by radiological evidence, BMI  28 and symptoms that have or are likely to necessitate referral to an orthopedic surgeon or a joint replacement is planned, with improved fitness for surgery desired [38]. The program offers weight loss (7.5e10%) and improved nutrition, muscle strengthening, land-based and range of motion exercises, pain management strategies, education, monitoring, and engagement strategies. Outcome measures include the knee injury and osteoarthritis outcome score/hip disability and osteoarthritis outcome score, Short-Form 12, body weight and waist circumference, and satisfaction with support and information. Amsterdam osteoarthritis cohort (AMSOA) The Netherlands Included in the AMSOA cohort, an OA management program is offered to individuals with knee and/or hip OA. Pain is non-traumatic, sufficient to seek care, and attributed by a clinician (rheumatologist and/or rehabilitation physician) to a hip or knee joint. The AMSOA management program offers coordinated multidisciplinary management including supervised exercise according to a knee joint stabilization program [39], occupational therapy, psychological support, and medical management. Outcome measures include the Western Ontario and McMaster Universities Osteoarthritis Index, physical performance (timed get-up-and-go, stair climb), muscle strength, proprioception, physical activity, Short-Form 36, comorbidity illness rating scale, and medication use.

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Joint Implementation of Osteoarthritis guidelines in the West Midlands, UK (JIGSAW) JIGSAW is based on the MOSAICS cluster randomized controlled trial [40]. It is offered to individuals consulting in general practice with knee, hip, hand, and/or foot OA and joint pain. Participants are 45 years and over, with joint pain that limits function in the target joints and in the absence of “red flags.” The program is a “model OA consultation” with a general practitioner and a practice nurse. The consultation includes making, giving, and explaining the OA diagnosis; giving an OA guidebook; and offering analgesia and referral to a practice nurse. The model OA practice nurse consultation includes up to four sessions supporting self-management: the OA guidebook; exercise and physical activity advice using Arthritis Research UK booklets; weight management; and support with pain relief. Outcomes are measured using an electronic OA template to record key quality indicators of OA care. Similarities and differences among OA programs Tables 1 and 2 provide details that allow comparison of many aspects of these OA programs. With respect to development, all the programs have been based on research evidence and guidelines. Regarding content, the majority of programs have delivered core treatments to varying degrees, including support for self-management, patient education, and exercise. However, exercise types have varied in terms of intensity and degree of standardization, and only some programs include weight management. The healthcare professionals and patient populations targeted in these programs vary. Some programs target the whole of primary care with a complex, integrated, multidisciplinary model of OA care, both for delivering a pathway of care and delivering training (e.g., JIGSAW); others are focused on one professional group and/or one or two joint sites; and others are a hybrid of the two. With respect to measurement, clinical outcomes are considered of high importance. Although there are some differences in measures used across the programs, most assess pain, function, and quality of life. All programs also attempt to assess OA-related care received by patients before and after the program. Most of the OA programs have complex funding arrangements, including health insurance policies, academic resources, innovation funding, self-funding of healthcare professional training, arthritis charity funding, or a combination of these. Use of implementation theory to support the programs The majority of selected programs have used implementation theories in their development (Table 2) (see Chapter 2 for a further description of theories of implementation). Other theories relate to selfmanagement, chronic care, stepped care, and patient engagement. It is difficult to judge whether one approach or a combination of approaches is superior, as implementation fidelity appears to be contextspecific; nevertheless, the use of theory is fundamental to the development and implementation of programs. Comparison of OA management programs with guideline implementation The programs shown in Tables 1 and 2 have been compared against recognized criteria for guideline implementation (Appendix Table 1) [41]. These programs meet many of the criteria, including use of evidence-based guidelines in the implementation effort. Yet there are also gaps in meeting some criteria, including the use of implementation tools, computer decision aids, costing tools, podcasts, webinars, and endorsement by professional societies. The latter may be an important next step, to further promote this work nationally and internationally for maximum impact. Lessons learned from nonsurgical OA management programs There are emerging key messages from these programs (Table 2) [1]: Support from key stakeholders is necessary, whether they are healthcare professional groups such as orthopedic surgeons, general practitioners, physiotherapists, or selected clinical champions [2]; Programs should be delivered with as much consistency as possible, considering local resources and structures [3]; Consistent evaluation and collection of outcome data are critical [4]; A coherent team is needed to run and deliver the program; and [5] Funding to support implementation and sustainability often requires creative approaches and leveraging opportunities. Some strategies to boost the likelihood of sustained funding include: piloting the implementation model before scaling up, aligning the intervention with health system policies and priorities, and articulating the benefits of the program to health system leaders.

Level 1: Description of the Program

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Table 2 Description of the Featured Programs in the Osteoarthritis Research Society International (OARSI) Repository and Lessons From Their Implementation. Level 2: Implementation Factors, Facilitators, and Lessons Learned

The context

Audit of current practice

Implementation Theory (ies) Used

Who Took the Initiative

Evidence of Adoption at Pace and Scale

Key Challenges/ Barriers

Key Facilitators/ Handling Barriers

Suitability for Developing Countries

Lessons Learned

Osteoarthritis Chronic Care Program (OACCP)

Public hospitals in New South Wales, Australia

Although 70% of knee replacements can be attributed to overweight & estimated that 25e50% of replacements could thus be avoided; <8% of Australians reported trying to lose weight as part of their OA treatment. Reports suggested suboptimal use of allied health practitioner interventions for OA

Chronic Care Model (CCM) [98], recognizing the need for a variety of interventions depending on the social, psychological, and physiological needs of individuals. OACCP team members also use behavioral change theory to guide implementation Local sites develop clinical pathways for the OACCP according to resources available at their site

David Hunter & working group of clinicians collaborated with the Agency of Clinical Innovation (Ministry of Health, New South Wales)

Started with 7 pilot sites in New South Wales. Costebenefit analysis (2014) found OACCP saved some individual sites over $1,000,000/year in unnecessary joint arthroplasties. In summary, OACCP resulted in: i) significantly improved functionality, mobility (knee > improvement than hip) ii) significant decline in some comorbidities iii) 11% removal of patients from the waitlist for knee replacements because they no longer required surgery http://www. aci.health.nsw.gov. au/__data/assets/pdf_ file/0009/259794/ oaccp-evaluation-feb2015.pdf OACCP has been expanded to include 16 hospitals in public and private settings across New South Wales. Many of these programs are now recurrently funded, while others are still in the pilot phase

A key challenge initially was to rally the support of orthopedic surgeons for the OACCP. Initially patients from joint arthroplasty waitlists were targeted; some did require joint arthroplasty, and those who had been waiting a long time for arthroplasty were unwilling to give up their position on the waitlist despite improvements in symptoms. Now patients are referred by any health practitioner, so some are earlier in disease course. Although OACCP prevents unnecessary arthroplasties, this is seen by health system as “costshifting”; when a patient is removed from the waitlist, there is always somebody to take their place.

OACCP model of care development included input from health professionals (clinical, research & government), consumers and non-governmental stakeholders. Seven pilot sites commenced in 2011/2012 for 2 years, during which time they reported Standardized indicators for the evaluation of the program components and participant outcomes. Electronic data capture for relevant outcome data and reports on key performance and clinical indicators. Regular contact between musculoskeletal coordinators of OACCP sites, and Agency of Clinical Innovation reporting to key stakeholders. Frequent presentations to

If pre-existing healthcare professionals can be up trained to deliver appropriate chronic disease management, the model of care can be tailored to suit most poorly resourced, developing healthcare settings. Apart from healthcare personnel, the resource requirements for successful delivery of the model of care are minimal. Low health literacy in such settings would be a challenge with large proportions of the population not seeking medical care or comprehending treatment recommendations.

Coordinated data collection to enable generation of activity and outcome reports at a local level is key in securing ongoing local funding. Support from local orthopedic surgeons greatly contributes to the success of individual OACCPs. Programs such as OACCP would be better suited, likely more costeffective and more accessible to patients in the primary care setting. Future research in Australia is focused on further refining the optimal model of care within the Australian setting. Often patients are referred to the OACCP late in their disease course, following surgical planning with an orthopedic surgeon. A recently published

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Name of Program

Primary care. Intervention given by physiotherapist and sometimes occupational therapist. Collaboration with Swedish Rheumatism Association through Osteoarthritis communicators.

A survey of 1600 patients receiving total hip replacement for OA, showing that only a minority had seen a physical therapist before surgery, and of those who had seen a physical therapist, only a minority had received treatment according to guidelines.

10-step model to induce change in professional behavior, Stage of change, Selfdetermination theory, Relapse prevention model, Social learning theory [99e103].

A joint initiative by Carina Thorstensson (conclusions from thesis, review of literature, interviews with patients and development of the evidencebased intervention), Leif Dahlberg and other orthopedic surgeons (who felt the need to improve indications, expectations and patient-reported outcomes after surgery), and € ran Garellick at Go the Swedish Hip

Translation of evidence, patient perceptions, and clinical experience into a supported selfmanagement program (2006). A pilot trial of the intervention showing potential to improve symptoms and self-efficacy (2006). Transforming evidence and rationale for program into education for healthcare professionals (2006). Defining a “minimal intervention” and a minimal set of outcomes (2007). Setting up a database to collect outcomes online, and to report

orthopedic surgeons and hospital executives providing updates on program deliverables with support from local champions driving the initiative. Release of sectorwide Model of Care for OA by Agency of Clinical Innovation.

Defining a minimal intervention (i.e., information), that can be built upon allows for local adaptions. Healthcare professionals receive a ready-touse model on a flash-disk during their education. Support is provided via email or phone. No specific exercise program is used, but neuromuscular principles and quality are emphasized to be used for all types

paper demonstrates these patients already on waitlist have twice the odds of reporting they are “worse” 26 weeks into the OACCP despite symptomatic improvement on HOOS/KOOS [35]. It would be preferable if patients were referred to the OACCP prior to booking for joint arthroplasty.

Suitable, with cultural adaptations of the minimal intervention, i.e. information. Physical activity can be emphasized with adaptation to local culture and traditions. Self-management is not only about exercise, but also about how to manage symptoms by cognitive and active coping strategies. This is relevant across contexts, with adaptations to

Despite several years of successful implementation, and involvement from several hundred clinics nationwide, we estimate that we reach approximately 10% of all patients in need. There are several reasons for lack of reach. The development and use of a digital version (www. jointacademy. com) has shown promising results of at least similar magnitude to the program presented in

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Better Management of Patients with Osteoarthritis (BOA)

Unwillingness of local health districts to dedicate funding to the OACCP. Seen as an “additional” program despite documented good clinical outcomes and cost-savings. Once the pilot project with funding ended, some local sites failed to provide ongoing funding, or at least had funding reduced, meaning contracts of key healthcare personnel were terminated. Financial compensation in primary care is focused on activity rather than quality of care. The tradition of using radiographic changes as a diagnostic criteria often causes a delay in diagnosis and consequently in adequate treatment. A large number of patients are referred to orthopedic surgeons without having tried nonsurgical treatment. Lack of routines

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Table 2 (continued ) Level 1: Description of the Program Name of Program

The context

Audit of current practice

Level 2: Implementation Factors, Facilitators, and Lessons Learned Implementation Theory (ies) Used

Evidence of Adoption at Pace and Scale

Key Challenges/ Barriers

Key Facilitators/ Handling Barriers

Suitability for Developing Countries

Lessons Learned

Arthroplasty Register.

results back to clinic in real time (2007). Feasibility test during a 2-year pilot, involving 10 clinics (4 hospitalbased and 6 in primary care) in four geographic regions (2008e2010). Continuous education of healthcare professionals. Since 2010, the BOA is a national quality register, and all clinics using the intervention can report. In January 2016, 3000 healthcare professionals were educated to deliver and evaluate the program, 445 clinics are using the register to report and follow results, and 60,000 patients are included.

regarding regular assessments and evaluations in health care, including rehabilitation. Lack of knowledge within rehabilitation field about how to use results to identify potential areas for improvement. Administrative burden (to register). A small practice may have waiting list before the intervention starts.

of exercises, to increase fidelity among physiotherapists. An OA communicator serves as a peer with experiences from selfmanagement and physical activity, adding credibility to information provided by healthcare professionals. (Their participation is voluntary and free of charge.) Interactivity during theory sessions and involving participants in discussions and sharing of experiences, increase the opportunity for teach-back. Exercise and daily physical activity are emphasized and strongly recommended throughout intervention, but the initiative to participate is to be made by the

ensure cultural relevance.

primary care. A digitalized health care may increase access for people with limited time (i.e., working people) or long distance to healthcare facilities. A digitalized version also has the possibility to increase longterm compliance, which still is a great challenge for the BOA program. Additional booster sessions after the 3-month followup might be costeffective in the long run. Clinicians are keen on delivery of a rational, evidence ebased, and timeefficient group treatment, but not on evaluation and assessment. Managers are important stakeholders to allocate time for assessment and to ask for results. Online feedback in real time is an important tool

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Who Took the Initiative

that can be used to further improve health care. This feedback needs to be developed in close collaboration with healthcare professionals, managers, and patients to be used and useful in clinic. Successful implementation requires involvement from the full team. Focus on care units who are motivated and engaged, rather than those who are negative, gives positive attention and proud colleagues who become champions for implementation. Involvement in developing national and regional guidelines, based on evidence-based international guidelines, is important, and facilitates top edown approach. Using results from follow-up data in public reporting (i.e., press release and debate articles) increases the demand from

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participant, to increase compliance and internal motivation. Information is crucial to gain understanding of how, why, and when to be physically active. Exercises are individually adapted in accordance with personal resources and goals, and tried out during a face-to-face session. Participants can choose to perform exercises supervised at clinic, at home or where it suits them best, to facilitate compliance. Home exercises are introduced as “5 min per day” to facilitate adoption in daily life. For inactive participants, regular breaking of inactivity (by e.g., standing up during commercials on TV), can be easier to implement than an exercise program. Focus on one life

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Table 2 (continued ) Level 1: Description of the Program Name of Program

The context

Audit of current practice

Level 2: Implementation Factors, Facilitators, and Lessons Learned Implementation Theory (ies) Used

Who Took the Initiative

Evidence of Adoption at Pace and Scale

Key Challenges/ Barriers

Key Facilitators/ Handling Barriers

Suitability for Developing Countries

Good Life with osteoArthritis in Denmark (GLA:D)

Intervention given by physical therapists, mostly in municipalities and private clinics but also at some hospitals

Results from two randomized clinical trials [37,104] in patients being referred to orthopedic surgeons showed that

A multimodal approach was applied as summarized by Grol & Grimshaw [105]

GLA:D was initiated by Ewa M. Roos and Søren T. Skou at University of Southern Denmark in 2013. GLA:D is a not-forprofit, bottomeup

The first course for physical therapists was held in January 2013 with 42 participants. Over 3 years, 10 additional courses have been held with up to 90 participating physical therapists in each

Cost: While treatment in private clinics is associated with out-of-pocket payment from the patient, it is free in the municipalities. This, however,

Delivering a “tool box” for the physical therapist, consisting of all the material and training needed to initiate GLA:D in their local clinic or municipality is a

Suitable, with cultural adaptations of the course for physical therapists, the treatment of patients and the evaluation in the registry

patients to receive evidence-based treatment according to the program. Together with reports from proud healthcare professionals and patient stories, this forms important bottom eup influence. Involvement from patient representatives (i.e., patients with positive experience from life style changes in OA, and education to facilitate discussions among participants) in the program facilitates interpretation of the program education among participants, and increases motivation to change. Implementing evidence in clinical practice can profitably be done with a bottomeup approach instead of a topedown approach, since

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style change at a time (rather than both weight reduction and exercise).

Lessons Learned

exercise therapy had been applied in about 1 out of 20 patients before referral

course, and still the waiting list for courses is long. The first annual report (data until 31 December 2013) included data from 719 patients from 49 GLA:D-units, the second annual report (data until 31 December 2014) included data from 3637 patients from 137 GLA:D-units, while the third annual report (data until 31 December 2015) included data from 9827 patients from 227 GLA:D-units. Thus far, more than 13,500 patients have been included and the numbers are expected to reach around 20,000 patients by the end of 2016 due to exponential growth.

makes it more difficult to implement in the municipalities, since the cost needs to be covered by public funding. In Denmark, most patients have to pay for physiotherapy and exercise, while surgery is free of charge. Administrative burden for physical therapists: registering data in the national GLA:D registry is currently not reimbursed by the health authorities. As a result of this, not all GLA:D units report data to the registry. Thus far, it is not a requirement that patients have nonsurgical treatment of a sufficient dose and length prior to seeing the surgeon, resulting in a large number of patients being referred to orthopedic surgeons without having tried nonsurgical treatment first.

key to success. Engaging the physical therapists, patients, and other stakeholders in the development and giving them ownership to the program is crucial. Conveying a clear message and informing patients about nonsurgical treatment through mass media can lead to patients demanding to have nonsurgical treatment, thereby bypassing organizational and political barriers as well as financial incentives otherwise preventing change and the uptake of clinical guidelines. Once numbers of patients and physical therapists in the treatment program allow evaluation of outcomes and feasibility of the program in clinical practice, addressing politicians and decision-makers can propel implementation. Health economic analyses are central to

this strengthens the engagement, feeling of professional pride, and ownership among stakeholders. A bottomeup approach requires less start-up funding than a top edown approach. Some patients are willing to pay out of pocket for education and exercise although surgery is free of charge. This system may however increase inequality in access to evidence-based OA care.

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approach started with limited funding and maintained by course fees. The setup, including the educational part is an adapted version of the Swedish BOA program. The Neuromuscular exercise program used is previously described and found feasible and effective.

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Table 2 (continued ) Level 1: Description of the Program Name of Program

The context

Primary care and secondary care delivered remotely

Amsterdam osteoarthritis cohort (AMSOA)

Secondary care: rehabilitation center in the Netherlands.

Patients with knee and/or hip OA seen by rheumatologists and rehabilitation physicians.

Level 2: Implementation Factors, Facilitators, and Lessons Learned Implementation Theory (ies) Used

Who Took the Initiative

Evidence of Adoption at Pace and Scale

Modified version of the plan-do-studyact method of quality improvement in healthcare model. Model underpinned by comprehensive patient engagement strategies.

Prima Health Solutions in collaboration with an early adopter health insurance fund

Prima Health Solutions has specialized in research, development, and systematic remote delivery of integrated best practice chronic disease management programs for weightrelated chronic diseases (OA, type 2 diabetes, CVD) since 2005.

Implementation and construction of OA management program in the AMS-OA cohort was based on “Beating osteoarthritis”: development of a stepped care strategy to optimize utilization and timing of

The initiative for the AMS-OA cohort was taken by Joost Dekker, Willem Lems, Leo Roorda and Martin van der Esch in 2009.

Based on practicality, an inclusion of 150 patients a year was planned. Currently, a total of 1000 patients are included in the cohort.

Key Challenges/ Barriers

Patient recruitment is now the biggest challenge despite the program being clinically effective, scalable, and free to eligible patients. Once patients are enrolled, the systems, processes, and central support team are in place to deliver consistent and predictable clinical outcomes irrespective of the rural, remote, or urban location of patients. Challenge is to implement the results of studies in daily practice in a secondary care setting and at the same time implement the findings in primary care. In primary care, a barrier is to develop an assessment system for providing research

Key Facilitators/ Handling Barriers

maintain implementation rate. Understanding the key drivers of the program funder, and where possible capturing and reporting on outcome data can provide ongoing support for the underlying business case.

One of the key drivers for the AMS-OA cohort is the funding for clinical trials nested in the cohort. This funding makes it possible to extend research. Another key driver is the engagement of rheumatologists, rehabilitations physicians, and physiotherapists

Suitability for Developing Countries

Lessons Learned

From a technical perspective, the highly refined patient resources, systems, process, and information technology would enable a qualityassured implementation without extensive local resources. However, it is likely to be costprohibitive for the general community in developing countries.

To deliver a program with scale that achieves consistent clinical outcomes across geographically diverse patients requires more than clinical expertise; it requires a detailed plan, systems processes, standardized resources, measurement framework, and feedback loops.

Sufficient knowledge for the development of a cohort, monitoring of the quality of a cohort, and monitoring the OA management program is required. This knowledge is present in specialized secondary care, but it is not easy to convert it to

Monthly discussions and meetings are needed with all those involved in the design and implementation of a cohort and the consequences for the OA management program.

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Osteoarthritis Healthy Weight For Life

Audit of current practice

Primary Care in Clinical Commissioning Groups (CCGs) UK. Initial consultation with the general practitioner, followed by up to four sessions with a practice nurse within the general practice.

Using OA etemplate endorsed by NICE, UK, in 14 practices in one CCG, UK

General Practitioner as Clinical Champion who also sat on CCG Board in the locality. Felt that this model of OA care would be beneficial in realworld practice. CCG concerns about how many patients were being referred to orthopedics from primary care

Via the Academic Health Sciences Network, West Midlands, UK 3 CCGs. Estimated number of practices, n ¼ 100. In one practice of 8000 patients, 7 GPs, 3 practice nurses trained to deliver the program. In one practice, the four sessions with a practice nurse (the OA “clinic”) saw 61 patients over 21 months (approximately 3 per month). Of these, 36 patients received one appointment, 19 two appointments, 6 three appointments.

data. Engagement of primary care providers, not only to execute interventions programs but especially to deliver further research data for the development of program.

to deliver data and implement results in clinical practice.

primary health care. Maintaining a cohort has significant costs and can be a barrier for developing countries.

Pressures of local primary care organizations, clinical time to undertake training, costs of releasing practice nurses to attend training, increased requirements for general practice with no recognition of costs/burden on practice

Dedicated implementation team with project management funded via the West Midlands Academic Health Sciences Network; National Institute of Health Research, Knowledge Mobilization Research Fellowship funded dedicated time; Clinical Champions, Patient and Public Involvement. Training made freely available with clinical champions visiting practices, practice nurse training reduced from 4 days (Research Study MOSAICS) to 2 days, worked with local CCG to

The practice nurse training and a “training the trainers” model could be used for core nonpharmacological approaches.

Pragmatic cluster trial with strong engagement of local stakeholders can instigate uptake of innovations produced by the research. Local general practitioners and practice nurse champions are influential. Information technology and project management needed support to deliver training. Patient involvement in the development of the program enhanced patientfacing material. Identify both strong clinical and managerial champions, understand the

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Joint Implementation of Guidelines for oSteoArthritis in the West Midlands JIGSAW Based on MOSAICS study (Dziedzic et al., 2014)

nonsurgical treatment modalities for patients with hip or knee osteoarthritis” by Smink et al. [31]. Furthermore, the exercise program was based on the knee joint stabilization exercise trial of Knoop et al. [39]. Implementation Theory, Behavior Change Theory, Normalization Process Theory [33,106e110]

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Table 2 (continued ) Level 1: Description of the Program Name of Program

The context

Audit of current practice

Level 2: Implementation Factors, Facilitators, and Lessons Learned Implementation Theory (ies) Used

Who Took the Initiative

Evidence of Adoption at Pace and Scale

Key Challenges/ Barriers

Key Facilitators/ Handling Barriers

Lessons Learned

context (e.g., benchmarking and local pressures), allow time for training/project management, and adapt to differing circumstances (e.g., practice nurses vs. lifestyle coaches). Funding needed for both the implementation team and the stakeholder engagement.

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develop funding model to support implementation in practice. Automated e-OA template enables practices to demonstrate compliance with NICE guidance

Suitability for Developing Countries

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Surgical prioritization and selection for optimal TJR outcomes The role of TJR in OA TJR can profoundly reduce pain and improve function for individuals severely affected by OA [42]. It is generally indicated when other interventions are no longer providing adequate pain relief [5]. When delivered to patients with end-stage OA, TJR is regarded as the most cost-effective solution [43]. However, there remain challenges to TJR delivery, and there is still a need for evidence-based MoCs that maximize efficiency and outcomes of TJR. In this section, we describe these challenges, together with recommendations for developing and implementing these models. Challenges and controversies facing TJR Increasing demand. Physicians and many patients now consider TJR so successful and predictable that demand regularly dominates surgical waiting lists, with national joint replacement registries reporting sustained growth [44,45]. Projected increases in TJR across countries depend on not only need but also the number of surgeons and availability. The current largest market is in North America, where TJR is projected to rise 300e600% by 2030 [46], but demand is also increasing worldwide. This underscores the importance of efficient, effective care models. As an example, growing demand for TJR led Western Australia to develop their Elective Joint Replacement Service Model of Care. Through standardized patient pathways starting in the primary care setting, the model utilizes a multidisciplinary team for conservative treatment as well as prioritization of patients for surgical treatment. Pathways and teams facilitate optimal surgical outcomes from preoperative assessment through recovery and discharge [47]. Increasing cost. Increases in total costs of TJR have raised concern about the sustainability of current practices. For example, in the Australian private sector in 2013, the direct costs of total knee and hip TJR were $414 million and $522 million, respectively [48], representing a rise in cost of 20% and 25%, respectively, from the previous year. In the United States, the 2011 estimated costs of TJR was $66 billion US$ [45]. Effective care models have the capability of controlling these costs. Complications. Complications contribute significantly to poor outcomes and escalating costs of TJR. For example, postoperative complications such as anemia, delirium, and sepsis can increase costs up to 20% [49]. Yet, even in the absence of a clear complication, TJR does not always provide relief: up to 25% of TJR patients remain dissatisfied with their surgical result [50,51]. In countries where TJR is an established surgical procedure, higher volume hospitals and surgeons have fewer complications and better outcomes [52,53]. Compilation of large-scale data such as national registries can facilitate earlier recognition of complications and guide best practices. Opportunities for improving TJR outcomes Appropriate patient selection for TJR can lower risks and may identify up to 15% of patients who would not benefit from this procedure [54,55]. This would reduce the fruitless expenditure and utilization of this valuable resource, avoid unnecessary suffering for the patient, and create more timely opportunities for others deemed suitable for TJR. Indeed, these reasons align with the priorities of contemporary MoCs that promote the right care at the right time. However, there is a dearth of instruments and care models to guide patient selection and timing of surgery. The following are three approaches that could improve MoCs surrounding TJR delivery: Development of care pathways to optimize nonsurgical alternatives for end-stage OA. Alternative nonsurgical treatment pathways for all surgical candidates would ensure an equitable approach to end-stage OA, including patients who are either deemed inappropriate for TJR or those who choose not to undergo TJR. Studies provide evidence that multimodal nonsurgical treatment, as well as neuromuscular exercise, can improve outcomes among patients with severe knee or hip OA who are eligible or

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scheduled for TJR [42,56,57]. However, these strategies are not routinely utilized among patients with end-stage OA [6], and standard care pathways are needed to ensure these treatments are included even when patients are eligible for TJR. This is consistent with OA treatment guidelines, which emphasize the use of all nonsurgical approaches prior to offering surgery [5]. Patients with severe symptoms often face challenges to engagement in behaviors such as exercise and may benefit from specific guidance from a physiotherapist or other clinician to address these barriers. Stratified MoCs may also be beneficial for targeting specific nonsurgical treatments to subgroups of patients with severe OA. These models have proven efficacious and cost effective in the treatment of chronic, complex conditions such as chronic low back pain [58], but it is not known whether this approach is applicable to people with end-stage OA. Shared decision-making. Shared decision-making (SDM) is a process of eliciting the values and expectations of the patient and communicating how treatment options can best align. The process can be done between the patient and a clinician or even a nonmedical mentor. SDM can improve the rapidity of decision-making [59], reduce costs [60], and decrease disparities in access to TJR [61]. Decision tools are available and have shown efficacy in the research context [60,62], but there has been little attention to best practices or models for incorporating the broader SDM process regarding TJR into the clinical context. Identifying nonresponders to TJR preoperatively. Tools to identify patients who are likely to benefit from interventions have been useful in a variety of clinical conditions, but until recently, such tools have been lacking with respect to TJR outcomes. A nomogram for predicting the probability of nonresponse to knee TJR has recently been developed [54]. Key parameters that were shown to be independently prognostic for poor outcome were used to construct the nomogram, including BMI  40 kg/m2, KellgreneLawrence grade <4, Total Western Ontario and McMaster Universities Osteoarthritis Index preoperative score, and Short-Form 12 Mental Component Summary score. Using this Responder Tool, the authors reported a nonresponder rate of 15% following TJR. A preliminary comparative study of 1419 patients conducted with the Swedish Knee Registry (personal communication) confirmed a similar nonresponder rate (14.2%), suggesting external validity and translatability. Given the importance of identifying likely nonresponders to TJR, there is an urgent need for additional research on the validity of the tool as well as processes for incorporating it in the process of care for OA in different settings, including developing countries. In summary, TJR is a safe and effective procedure for end-stage OA in the majority of patients, but not all. Developing resources to identify patients most likely to benefit from TJR offers one way to address access to the surgery in an era of limited resources. For those with end-stage OA where surgery may not be safe or desirable, system-wide service delivery pathways are needed as components to MoCs to ensure provision of other effective management strategies. Techniques such as SDM, combined with assessment of risks and use of responder tools, can help referring providers and surgeons identify the right patient for the right procedure at the right time.

Management of persistent pain in osteoarthritis Pain is a hallmark symptom of OA, and activity-limiting pain is typically the reason patients seek care. Although chronic pain is ubiquitous among individuals with symptomatic OA, there are some patients for whom significant and activity-limiting pain persists despite the use of common therapies [50], which we define as “persistent pain.” OA-related pain is a complex phenomenon involving multiple mechanisms, and alterations in nociceptive processing play a key role in a subset of patients with OA [63]. These alterations can include both peripheral sensitization, where the nociceptors become sensitized by inflammation or other tissue damage, and central pain sensitization, where central nervous system neurons become hyperexcitable [64]. Peripheral pain input and sensitization have been suggested to be important for the development and persistence of

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widespread sensitization [65,66]. Although clinical measures like quantitative sensory testing are the gold standard for evaluating pain sensitization, recent studies have supported the ability of selfreport measures to identify this syndrome [67,68]. This is important, since patient reported measures can help guide appropriate treatments in clinical settings. In addition, sleep problems and psychological factors (e.g., depression, anxiety, and pain catastrophizing) are often unrecognized health issues that can contribute to be root causes of persistent pain. On the basis of this, models of OA care could benefit from systematically integrating pain science and therapies, as well including screening for pain sensitization, sleep problems, and psychological health factors, particularly when patients exhibit significant ongoing pain that does not respond adequately to common evidence-based therapies [69]. Both non-pharmacological and pharmacological strategies are important components of any MoC for managing persistent pain in OA [70]. Although there has been little formal evaluation of care models specifically focusing on persistent OA-related pain in real-world clinical settings, recent research provides guidance on recommended approaches. Because pain sensitization and psychological factors are common reasons for persistent pain in OA, we focus the remainder of this section on intervention approaches aimed at affecting these mechanisms. Nonpharmacological and integrative interventions for persistent OA pain Cognitive behavioral therapy (CBT) for pain has been one of the most widely studied psychological interventions for OA and other chronic pain conditions; it can improve outcomes including pain severity, pain interference, pain catastrophizing, depression, anxiety, and sleep disturbance [71]. Given its effectiveness, recent research has sought to identify models for more widely disseminating and implementing CBT among patients with OA, including physiotherapist-delivered and nurse-delivered CBT [72,73]. Another study showed the efficacy of an automated, online CBT program for patients with OA [74]. These studies illustrate strategies that healthcare systems can use to implement pain CBT in comprehensive MoCs for OA. Mindfulness training (MT), or mindfulness-based stress reduction, is another intervention with a growing body of evidence for improving pain-related and psychological outcomes. Although there has been limited research of this therapy for patients with OA specifically [75], it has demonstrated effectiveness in patients with chronic pain [76], and the effects seem to be comparable to CBT [75]. Most studies show low attrition (15%) [77] and sustained improvements (particularly in functioning) at up to 3-year follow-up [78]. Emerging research suggests that MT also may be feasible to deliver through an online format, but additional studies are needed in this area [79,80]. Exercise-based interventions, important and effective for patients with OA overall [81], may be particularly important for individuals with persistent pain. There is some evidence that exercise-based interventions may improve pain sensitization, but the results have varied and additional trials are needed. However, there is strong evidence that exercise improves mental health outcomes such as depression and anxiety [82]; therefore, OA MoCs should strongly support engagement in exercise programs for patients with persistent pain. Pharmacological interventions for persistent OA pain Previous reviews have comprehensively described pharmacological options for treating central pain sensitization [70,83]. Here we summarize centrally acting medications to be considered as part of a comprehensive MoC for persistent OA-related pain. Weak opioids and narcotic analgesics are included in some OA treatment guidelines, particularly when nonsteroidal anti-inflammatory drugs are contraindicated or not effective [5]. Antidepressants, including tricyclics and serotonin/norepinephrine receptor inhibitors (SNRIs), have been used in various chronic pain conditions, with effects that seem to be independent of their antidepressant actions [84]. Although there has been limited study of these medications in the context of OA specifically, there is growing evidence in particular for the role of SNRIs in OA [85]. There is still a need for guidance on best practices for incorporating these medications into the broader context of OA management.

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Persistent pain following TJR TJR is performed on the premise that removing diseased, nociceptive-generating tissues will resolve pain and disability. As noted above, the majority of patients experience significant improvements in pain following TJR. A recent study found that total knee replacement, in addition to nonsurgical treatment, was more effective in reducing pain sensitization than nonsurgical treatment alone [86]. However, a proportion of patients continue to experience persistent disabling pain at 12 months [87]. The cause of persistent postsurgical knee pain is unclear for the majority of cases, and without a clear causal mechanism, revision surgery is not recommended. However, pain sensitization and psychological factors are common reasons for persistent pain post knee replacement [88]. Therefore, similar to persistent pain in OA more generally, MoCs should address these potential mechanisms. No trials of multidisciplinary interventions or individualized treatments for persistent post-TJR pain have been published [89], and there is a pressing need for further research in this area. There are ongoing trials of CBT and MT in patients scheduled for TJR [90,91].

Frameworks for evaluating OA MoCs: strengthening the case for policy change and implementation Evidence for policy change and implementation requires more than clinical effectiveness data; patient-centered, organizational, and service delivery-level outcomes are also critical. The RE-AIM framework provides guidance for implementation research outcomes [92]. Further conceptualization and evaluation considerations for implementation research were presented in 2011 by Proctor et al. [93]. Fig. 2 presents the concepts of these frameworks, applied to implement and evaluate an OA MoC. Reach refers to the number of people in the target population who actually receive the intervention from among those who are eligible. Understanding any differences between those receiving the intervention compared with those eligible is critical to understanding how well the population is represented. This is particularly important in the context of the continuum of pre-OA through to the

Fig. 2. Implementation Evaluation Framework for OA Models of Care adapted from RE-AIM (Glasgow 1999) and Proctor et al. (2011).

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most severe signs and symptoms. One of the biggest challenges in providing care is matching patient needs with intensity of care. There is currently a lack of evidence for streamlining people with OA to the most effective model/level of care to optimize their outcomes. Effectiveness and efficacy are evaluated at the individual level. These outcomes need to be targeted to the intervention and include reliable, valid, and responsive measures that are meaningful to people with OA, such as patient-reported symptoms, function, mobility, and health-related quality of life; performance measures; biomechanical and neuromuscular outcomes; and imaging outcomes that are designed to evaluate structural outcomes. In addition to evaluating clinical outcomes, it is critical to evaluate direct medical and nonmedical costs as well as productivity costs associated with an OA MoC. Different cost components will help to provide a comprehensive view on the entire MoC, with direct medical costs describing the costs of treatment per se and direct nonmedical costs providing insight into the time that patients need to allocate to receive medical care. Time or productivity costs depict the impact of presenteeism and absenteeism attributed to OA before and after an intervention. The value of specific OA MoCs can be established by conducting a formal cost-effectiveness analysis. A key factor defining the costeffectiveness of an OA MoC is related to the time frame of the analysis. As OA is a chronic disease, lasting 26 years on average [94], cost-effectiveness analyses should be conducted over the remaining life span of a person entering OA care. In evaluating the costs accrued by persons affected by OA, it is important to distinguish the costs attributable to OA versus all costs; overall costs are likely to encompass the costs related to comorbidities that are often present in persons with OA. As we are living in an era of limited resources, the impact of an MoC on the budget or affordability should also be evaluated. Adoption is evaluated with system-level outcomes and measures the proportion and representativeness of organizations adopting the program/intervention. Understanding facilitators or barriers to adoption is critical in implementation research. These may include feasibility and acceptability issues related to health professional expertise and resource requirements, costs, similarity to current practice, and provider satisfaction. Implementation outcomes are evaluated at the organizational level and are designed to capture the quality and consistency of intervention delivery in the real world. Evaluation of treatment fidelity [95] addresses whether OA interventions are delivered as intended. Implementation failure through poor fidelity may result in failed patient outcomes. As with adoption, health professional expertise, resource requirements, and costs may affect implementation. Maintenance is evaluated through both individual and organizational outcomes. OA is a chronic condition and, at an individual level, maintenance outcomes include longer-term benefits demonstrating sustained behavior change. Glasgow suggests that outcomes should be maintained for at least 6 months [92]. However, given the fluctuating nature of OA symptoms, even longer-duration outcomes should be considered. At the organizational level, maintenance outcomes reflect the extent to which the intervention has become routine care as reflected in care pathways, access, and quality indicators. The Global Alliance for Musculoskeletal Health has recently published an internationally informed framework to guide the development of and assess the outcomes of musculoskeletal MoC implementation [96]. This framework outlines principles for three key phases of a musculoskeletal MoC development and implementation: readiness (what should be included in the MoC, how it should be presented, and the development process), initiating implementation (guidance to optimize success and develop an implementation plan), and success (formative and impact evaluation of the MoC). Because this framework was developed with specific consideration of musculoskeletal conditions like OA and provides detailed guidance and practical tools, it can be used to complement more general frameworks like RE-AIM. Because OA care spans over decades, it is unlikely that a single study could provide insight into implementation challenges of multiple components of an OA MoC. Modeling studies, combining the data from multiple sources, could overcome limited time horizons and samples that often constrain traditional observational and implementation studies. Modeling studies can complement the traditional study designs, providing efficient evaluation of the data uncertainty and its impact for the evaluation of OA [97].

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Practice points  Primary prevention of joint injury is key to reduce the public health burden of PTOA. Evidenced-informed neuromuscular training prevention strategies should be consistently implemented in all settings associated with increased risk.  Injury rehabilitation programs should include maintenance of a healthy weight and restoring strength, balance, and healthy movement patterns that facilitate exercise.  Evidence-based behavioral and rehabilitative strategies for OA are effective but underutilized. These should be routinely incorporated in care for patients with knee and hip OA.  Non-pharmacological approaches to pain management (e.g., CBT, mindfulness, and exercise) should be integrated into the OA care plan early in the disease continuum, rather than as a last resort.  OA care should include screening for pain sensitization, sleep problems, and psychological health factors, particularly when patients exhibit significant ongoing pain that does not respond to evidence-based therapies.  SDM is important in the TJR process. Decision tools need to be more regularly incorporated into clinical practice.

Research agenda  Despite consistent research evidence demonstrating the effectiveness of injury prevention and rehabilitation strategies, there is a need to further evaluate widespread implementation of these programs to optimize adherence and ongoing maintenance.  Although there is strong evidence that weight reduction improves outcomes among individuals with OA, there is still a need for more studies on weight management as a primary prevention strategy.  There is a need to systematically examine, over time, the outcomes and impacts of various nonsurgical OA management programs worldwide. This would facilitate spread of effective models.  There is also a need to explore how existing OA programs can be successfully adapted and implemented to the local context, including in developing countries.  OA management involves a number of behavioral strategies that are also essential for other chronic conditions. There is a need to develop and examine strategies for integrating OA care models in the larger primary care context to foster coordinated, patient-centered care.  Long-term treatment adherence and behavior change remain challenges for OA management, and there is a need to identify and examine care models to promote healthy behaviors throughout the disease course.  OA treatment guidelines and care models tend to be one-size-fits-all, largely due to the lack of information on characteristics that predict treatment response. There is a need to develop and test evidence-based care pathways that can flexibly optimize care for individual patients, incorporating SDM.

Conflicts of interest Dr Roos and Dr Skou are the founders of GLA:D, which is a non-for-profit initiative hosted at University of Southern Denmark. Dr Roos is Deputy Editor of Osteoarthritis and Cartilage. Dr Skou is Associate Editor for Journal of Orthopaedic & Sports Physical Therapy. Dr Thorstensson is one of the €stra Go €talands Regionen, and director of founders of BOA, which is a nonprofit initiative hosted at Va the BOA-register, which is a national quality register. Dr Thorstensson is one of the founders of Joint Academy and stock owner in Arthro Therapeutics. Dr Hunter is an Associate Editor for Arthritis and Rheumatology and consultant to Flexion, Nestle and Merck Serono. Dr Davis and Dr Roos are Associate Editors and Dr Allen is on the Editorial Board of Osteoarthritis and Cartilage. Drs Allen and Davis are

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Editorial Board members of Arthritis Care and Research. Dr Dziedzic was a National Institute of Health and Care Excellence (NICE) Fellow (2013e2016); member of the Guideline Development Group for Guidelines CG59 and CG177 NICE Care and Management of Osteoarthritis Guidelines; and Principal Investigator for the MOSAICS study. Acknowledgements Dr Dowsey holds an NHMRC Early Career Australian Clinical Fellowship (APP1035810). David Hunter is supported by an NHMRC Practitioner Fellowship (Grant Number APP1079777). Dr Emery holds a Chair in Pediatric Rehabilitation (Alberta Children's Hospital Foundation). The MOSAICS study was funded by the National Institute for Health Research (NIHR) Programme Grant (RP-PG-0407-10386). This research was also funded by the Arthritis Research UK Centre in Primary Care grant (Grant Number 18139). The JIGSAW-E study was funded by an EIT-Health grant (Grant Number 16016). Dr Dziedzic is part-funded by a Knowledge Mobilisation Research Fellowship (KMRF-2014-03-002) from the NIHR. The views expressed in this study are those of the author(s) and not necessarily those of the UK NHS, the NIHR, or the Department of Health. Appendix. Table: Implementation Strategies of the OA Management Programmes and Alignment with Guideline Implementation Criteria. Adapted from Gagliardi et al., Implementation Science, 2015

Strategy/tactic/step

BOA Y ¼ yes N ¼ no

JIGSAW Y ¼ yes N ¼ no

GLA:D Y ¼ yes N ¼ no

AMS-OA Y ¼ yes N ¼ no

Implementation Planning e instructions for when and how to plan and prepare for implementation Implementation considered Y Y Y Y at the beginning and throughout the development process Y (apart from Y Y (apart from N An implementation team knowledge knowledge (implementation formed from the start translation translation team was formed that included stakeholders (patient experts) experts) by experts; stakeholders were groups, end users, not included) champions, relevant organizations and agencies, policy-makers) and one or more knowledge translation experts Resources for Y Y Y Y implementation identified/assembled Current practice audited as a Y Y Y Y baseline needs assessment Y Y Y Y Barriers to implementation and use considered/ identified (e.g., patient, professional, organizational, system, economic, political, and social/cultural), and stakeholder needs and preferences captured through (e.g., literature review, observation, focus groups, interviews, and surveys)

OACCP Y ¼ yes N ¼ no

OA HWFL Y ¼ yes N ¼ no

Y

Y

Y (apart from knowledge translation experts)

Y

Y

Y

Y

Y

Y

Y

(continued on next page)

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(continued ) Strategy/tactic/step

BOA Y ¼ yes N ¼ no

JIGSAW Y ¼ yes N ¼ no

Implementation on a Y Y (core NICE recommendation-byrecommendations) recommendation basis rather than for entire guideline Effective and targeted Y Y dissemination and implementation strategies used to address identified needs and barriers Implementation tools N Y (OA Quality developed for specific Indicators -Edwards element(s) e.g., guideline et al., 2015; GP scope; guideline Training - Porcheret recommendations; et al., 2014) identified knowledge gaps; baseline audit; and interviews or focus groups with users Implementation plan Y Y describing dissemination and implementation strategies and tools, roles and responsibilities, milestones, time frames, and implementation measures Pilot testing of the Y Y implementation strategy and adjusted as needed after the pilot test and on an ongoing basis Y Y Stakeholders engaged with outreach and education throughout the guideline development process Resource planning guide in Y Y place (human, infrastructure, technological capacity needed to implement and apply the recommendations) Guideline N Y (OA e-template) recommendations integrated in computer decision support systems Implementation Tools e instructions for developing content, versions, or Designs for type(s) of tools N Y studied Resources for use of tools Y Y identified Draft tool prior to final tool Y Y Several iterations of tools Y Y Tool(s) usability tested with Y Y GPs and practice clinician or patient nurses (interviews or focus groups) Feedback is used to refine Y Y the tool Final version is reviewed Y Y

Implementation tools are published Potential Implementation Tools Versions in different languages

Y Include: Y (digitalized version)

GLA:D Y ¼ yes N ¼ no

AMS-OA Y ¼ yes N ¼ no

OACCP Y ¼ yes N ¼ no

OA HWFL Y ¼ yes N ¼ no

Y

Y

Y

Y

Y

N

Y

Y

N

N

Y Model of care published on ACI website Site manual published on ACI website

Y

Y

N

Y

Y

Y

N (in progress)

Y

Y

Y

N

Y

N

Y

N

Y

Y

N

N

N

Y

Y

Y

tools that support implementation N N Y

Y

Y

Y

Y Y Y

Y Y Y (rheumatologists and rehabilitation physicians) Y

Y Y Y

Y Y Y

Y

Y

Y

Y

Y

N

N

N

Y Y

Y

Y

N (final version is under construction) N

In progress

Y (English)

N

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(continued ) Strategy/tactic/step

BOA Y ¼ yes N ¼ no

JIGSAW Y ¼ yes N ¼ no

GLA:D Y ¼ yes N ¼ no

AMS-OA Y ¼ yes N ¼ no

OACCP Y ¼ yes N ¼ no

OA HWFL Y ¼ yes N ¼ no

Versions in different formats (mobile devices, pocket guide, wall poster) Summary versions (short version, recommendations only, evidence only) Patient or plain language version Point-of-care tools (algorithms, checklists, decision aids) Electronic medical record/ computer decision support system integration Implementation plan (recommended strategies, barriers specific to the guideline and its recommendations, instructions) Teaching aids (slide set, case examples, meeting agenda) Patient and caregiver resources

Y

Y patient self-report quality indicators

Y

N

N

Y

N

Y

Y

N

N

Y

Y

Y

Y

N

N

Y

Y

Y

Y

N

N

Y

Y (digitalized version)

Y

Y

N

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

Y OA Guidebook

Y

Y (OA leaflet, information booklet)

Y (Exercise diary, care plan and OA information booklets) Y

Y

Y Y Y N Resource planning guide (human, infrastructure, technological capacity needed to implement and apply the recommendations) Costing tools in place N N N N N (spreadsheet, report templates) Evaluation plan in place Y Y Y Y Y (instructions, measures, data collection instruments) Dissemination and Implementation: strategies for distributing, sharing, and applying guidelines recommendations Dissemination Options Include: Web site (guideline, Y Y Royal College of Y N Y implementation tools, General Practitioners accredited CPD modules) and Arthritis Research UK Journal publications (which Y N Y Y Y can link to online material) Press releases Y N Y N Y Mass media campaigns Y N Y N Y E-mail distributions Y N Y N N Podcasts or webinars N N Y N N Registered with OARSI Y OARSI Y OARSI Y OARSI N Y OARSI Repository/AHRQ Guideline Clearinghouse/ G-I-N (Guidelines International) Library Partnerships with national Y Y Y Y N organizations/networks Endorsement by specialty N Y OA e-template N N N society e.g., OARSI, EULAR, and NICE Marketing strategies Y N Y N N

Y

N

Y

Y

Y

Y Y Y N N

N N

Y

(continued on next page)

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(continued ) Strategy/tactic/step

BOA Y ¼ yes N ¼ no

JIGSAW Y ¼ yes N ¼ no

GLA:D Y ¼ yes N ¼ no

AMS-OA Y ¼ yes N ¼ no

OACCP Y ¼ yes N ¼ no

OA HWFL Y ¼ yes N ¼ no

Traditional arts

N

Y original art work used in PowerPoint presentations only

N

N

N

N

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

Y

Y

Y

Y

Y

Y

Y

Y Y Y Y

Y Y Y Y

N N Y N

Y Y Y Y

Y Y Y Y

Y

Y

N

Y

Y

Y

Y

N

N

N

Y

Y

N

Y

Y

Y

Y

N

N

N

Implementation Options Include: Printed educational Y material Y Educational meetings (conferences, workshops, CPD) Educational outreach/ Y Academic detailing Local/national/international Y opinion leaders Audit and feedback Y Reminders Y Multi-faceted interventions Y Patient-mediated Y interventions (educational material, decision support tools, mass media campaign, reminders) Organizational Y interventions (revision of professional roles or teams, leadership engagement) Financial incentives or Y penalties Computer decision support Y systems; health informatics Regulatory interventions/ Y accreditation

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