Optimising primary care management of knee osteoarthritis: the PARTNER project

PARTNER Model of Service Delivery: The intervention targets both General Practitioners (GPs) and their patients, recruited from the practice’s patient list. GPs in the intervention arm will be provided with training and support to facilitate increased use of effective non-surgical management for their patients with knee osteoarthritis (OA). The enrolled patients are involved in the study for 12-months. Patients of the intervention GPs will receive personalised advice and support to effectively self-manage their knee OA via a centralised service; the PARTNER Care Support Team (PARTNER CST). The patients will have an initial 10 minute visit to their GP for a knee OA focused consultation. Their GP will confirm their OA diagnosis, discuss management options around weight loss, exercise and medications and refer them to the PARTNER CST for ongoing support to manage their knee OA. The PARTNER CST will be comprised of a multidisciplinary allied health team, sought from a wide range of professions (e.g. physiotherapists, occupational therapists, exercise physiologists, pharmacists, and/or dieticians), who have an interest in supporting effective chronic disease self-management and lifestyle behaviour change. The PARTNER CST staff will receive three days of face-to-face workshops in behaviour change support by HealthChange Australia, and will be required to complete four practice phone calls. Formal feedback will be provided on two of the calls. CST members will be required to complete additional training in evidence-based knee OA management provided by the investigators. Independent learning will be facilitated via an e-learning management system, and include information on evidence based treatments, and a 1-hour webinar practice on how to best explain osteoarthritis to participants. The PARTNER CST will prioritise exercise, weight loss, pain management and other self-management behaviours, and have ongoing support from the trial staff and experts on the research team. GPs in the control group will receive no intervention and their patients will not have access to the PARTNER CST and thus receive ‘usual care’. GP intervention details: GPs in the intervention group will be asked to undertake a range of professional development activities related to best practice management of knee OA prior to seeing patients enrolled in the study. The professional development activities will include: • A self-audit and feedback activity that asks GPs to reflect on their recent management of patients with knee OA and identify areas for improvement. The self-audit and feedback activity will take approximately 2 hours. It will be administered by the University of Sydney through an online survey and data management system (REDCap) and we will seek accreditation from the Royal Australian College of General Practitioners (RACGP) for professional development. • An on-line professional development module on evidence-based knee OA diagnosis and treatment developed in collaboration with the RACGP (1 hour). • An on-line PARTNER specific module that describes the trial (20 min), and offers training on health literacy and motivational interviewing topics (1-2 hours). These educational activities are based on the NICE Clinical Guidelines for the management of OA, and the Osteoarthritis Research Society International (OARSI) Guidelines. All GPs allocated to the intervention group will be provided with cdmNet software and training by the software developer during a 45 minute video conference or face-to-face workshop. cdmNet is a network of on-line computing services and infrastructure designed to help GPs manage chronic disease. Patient intervention details: Once patients are referred to the PARTNER CST, they will be followed up for the remainder of their 12-month study involvement. The PARTNER CST intervention will be delivered remotely via phone, video call, email, post and/or SMS contact as per the patient’s preference. The intervention for the patients will occur with contact at a frequency that suits their needs and preferences (estimated 2-12 contacts per patient). The PARTNER CST will discuss the role of the team, different non-surgical OA management options, and the patient’s priorities and goals. The patient will also be provided with additional OA educational resources developed by the study team and our partner organisations, including a handbook on management of osteoarthritis of the knee, a physiotherapists developed leg strengthening program, links to Arthritis Australia’s OA consumer website ‘myjointpain.org.au’, and a range of other self-monitoring tools. The CST will provide ongoing self-management advice and support, and tailor a care plan aligned to the patient’s individual needs. The patient will be encouraged and supported to undertake the study’s priority activities of leg strengthening, physical activity and weight loss. Eligible patients (BMI 27 or above) will also be given the option to undertake the CSIRO Total Wellbeing Diet (TWD) program which is a 12-week online program, involving tutorials around a healthy diet, two online coaching sessions with an accredited practicing dietitian, unlimited phone support and relevant educational materials . Patients undertaking the TWD program will also continue to be supported by the PARTNER CST throughout their involvement in the weight management program. Secondary issues and additional goals may also be discussed and set if the patient chooses. Referral to online cognitive behavioural therapy (CBT) programs or other external services will be offered if the patient meets pre-determined criteria for stepping up care and/or has identified an issue as a priority for action. These optional CBT programs and services may include pain coping skills (PainCoach), dealing with depression and anxiety (This Way Up), sleep and fatigue management (Shuti), a work productivity consultation with a rehabilitation councillor, or referral to a local health professional to address specific issues. Process evaluation: We will undertake a process and feasibility evaluation using mixed methods to assess the consistency of the trial’s implementation (fidelity), and how these processes affected the interpretation of the study’s main outcomes. The feasibility evaluations will enable us to formulate recommendations and guidance for any future implementation and scaling of the model across the broader Australia healthcare network. We will utilise a mixed methods approach based on the UK Medical Research Council Framework for undertaking a process evaluation of complex interventions and the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) frameworks. Behaviour change interventions for the GPs, patients, and the CST will be assessed using self-report questionnaires, qualitative interviews and information collected from our partner organisations who are providing training. Data collected from GPs will include GP consultation behaviours (via surveys at baseline, 6 and 12 months), readiness to implement the proposed treatment and completion of training activities. Patient data will include the Osteoarthritis Quality Indicator Questionnaire (OA-QI), information on referrals and services used (6 and 12 months). Fidelity for the PARTNER CST will involve treatment records audit, consultation behaviours (via surveys). Evaluation of the number and length of CST contacts, treatments recommended and services used will be undertaken at the end of the intervention. A sub-sample of participants from all groups (GPs, PARTNER CST, staff and patients) will be interviewed for qualitative purposes by members of the study team, and affiliated post-graduate students. The studies will primarily focus on factors affecting implementation, knowledge translation and ongoing stakeholder engagement, scaling up and long-term sustainability of the model. We will use purposive sampling to gain perspectives from different regional and practice-related contexts. Semi-structured interviews will be conducted using thematic and content analysis. They will be conducted over the telephone, audio-recorded and transcribed verbatim by researchers trained in qualitative techniques.