Implementing international osteoarthritis treatment guidelines in primary health care: study protocol for the SAMBA stepped wedge cluster randomized controlled trial

Osteoarthritis (OA) is a joint disease characterized by pain, disability, and impaired quality of life. The OA prevalence increases with age and is growing due to the aging of the population and the epidemic of obesity [1]. OA is one of the leading causes of pain and disability for the adult population worldwide [2] and is one of the major contributors to years lived with disability [3]. The costs of treatment and work-related losses are a considerable economic burden [4]. Knee and hip joint replacements for treatment of advanced OA represent a common inpatient surgery. Due to the growing obesity epidemic coupled with aging of the population, the demand for these procedures is expected to accelerate and quadruple by 2030 [5].

Internationally, evidence-based recommendations and standards of care have been developed to improve OA management [2, 6‐8]. There is currently no known cure for OA, but non-pharmacological modalities like education, exercise, and weight reduction represent core interventions [2]. The recent national recommendation for imaging in musculoskeletal diseases in general practice recommends conventional radiographs and not magnetic resonance imaging (MRI) in decisions on indication for joint arthroplasty [9]. However, Norwegian and international research indicate that an overall increased access to MRI will result in an increased number of MRI referrals [10], probably also in people with OA.

Structured approaches and stepped care strategies for OA management in order to endorse quality of OA care have been developed in other countries. While Porcheret et al. developed a stepped care strategy for older adults in primary care with knee pain or knee OA [11], the Dutch stepped care strategy (Beating osteoARThritis (BART)) provided a framework for health care providers and people with hip or knee OA to discuss the optimal timing of the various treatment options [12‐14]. In the UK MOSAICS study, practice nurses have been trained to provide OA consultations and follow-ups and coordinate referrals to the multidisciplinary care [15]. In Australia, initiatives to reduce the surgery waiting list have been implemented, for example the Osteoarthritis Chronic Care Program (OACCP) in New South Wales. In this programme, a new model of care is being tested, in which a musculoskeletal coordinator assesses individuals and links them with relevant health care providers to support timely and effective care [16]. During 2008, a Swedish project called ‘Better management of patients with OsteoArthritis’ (BOA) was initiated to improve OA care and reduce sick leave among people with OA [17]. The aim of BOA is to offer evidence-based OA information and exercise according to treatment recommendations [2, 6‐8] and that surgical interventions should only be considered if non-surgical treatment has been tried and failed. In 2013, a similar project was started in Denmark ‘Good Life with Arthritis in Denmark’ (GLA:D) [18]. Although the health care systems and the models of OA care are somewhat different across countries, the recommendations in the various national and international guidelines are very similar. Thus, aspects of these approaches are likely to be applicable also for other countries.

In the new health sector reform, the Norwegian Directorate of Health has placed the main responsibility for OA treatment in primary health care [19]. However, recent Norwegian research has indicated that people with OA are not receiving the recommended and optimal treatment [20, 21]. This was particularly evident for receipt of OA information, guidance on lifestyle changes, self-management, and weight management. Previous research in general practice has revealed that general practitioners (GPs) are reluctant to discuss weight issues with their patients [22]. A British study on OA monitoring among GPs revealed that the GPs favoured monitoring physical function, pain, and analgesia use over body mass index (BMI), self-management plans, and exercise advice [23]. The authors suggested that the provision of suboptimal care did not result from lack of knowledge and that interventions to improve OA care must address barriers to GPs engaging in optimal care provision [23]. A study among Norwegian physiotherapists (PTs) in private practice showed that exercise treatment was frequently provided but also revealed that the PTs also provided several other treatment modalities with moderate to low quality of evidence or with no evidence from systematic reviews [24].

While good communication is an important element of health care quality, the GP consultation has a limited duration. This implies a challenge for the GPs with respect to patient communication and restricts the amount of information and guidance that can be included within a short consultation. Current OA guidelines recommend physical activity and a healthy lifestyle [2, 6‐8]. However, behavioural changes are hard to achieve, and long-term follow-up may be needed. To support for behavioural changes and self-management is a challenge within a GP consultation. A recent systematic review showed that organized follow-up on change of health behaviour can lead to increased level of physical activity [25]. Apart from private physiotherapy, there have up until recently been few other kinds of services that people with OA can be referred to. Frisklivssentral (FLS) (Healthy Living Centre) is a relatively new Norwegian primary health care service that aims to guide and support health-related behavioural changes for individuals with increased risk of, or those who already have, a disease or illness [26]. PTs represent the majority of employees at FLS, but people with other professions may also work at FLS [27]. Close to half of the Norwegian municipalities had established FLSs by 2014. Earmarked subsidies are granted and other incentives for further development are present [28].

Based on international recommendations for OA care and previous research, the SAMBA model for integrated care for people with hip and/or knee OA in Norwegian primary health care has been developed (Additional file 1) and will be implemented in this study. The purpose of the model is to improve quality of OA care in primary health care services by implementing evidence-based international recommendations for OA care among GPs and PTs. An implementation of the model should ensure the provision of optimal, high-quality treatment, and that GPs and PTs deliver the same consistent message to people with OA. However, according to previous research, implementing new care models is challenging, and a systematic review highlighted that there are ‘no magic bullets’ for improving quality of health care [29], but identifying barriers and enablers of implementing guidelines can guide the selection of more effective implementation strategies that are tailored to address those determinants [30].

The barriers and facilitators may be different at different levels of health care [31]. Grol & Wensing have suggested to categorize barriers to and incentives for change among health care professionals into awareness, knowledge, attitude, motivation to change, and behavioural routines [31]. For patients, knowledge, skills, attitude, and compliance are examples of barriers to and incentives for change. Further, barriers and facilitators at the social, organizational, economic, and political context may be present as well [31]. According to Sanders et al., one key obstacle for a successful implementation in primary care may be to achieve ‘coherence’ of the desired practice change with the GPs [32]. GPs may not be able to overcome the inertia of previous practice, may not have the motivation to change, or may not recognize the new approach as distinct from usual practice [33, 34]. Among determinants of guideline use among PTs in primary were care lack of time, poor availability, and limited access to evidence the most important barriers, whereas awareness of and positive attitudes towards guidelines and evidence-based practice, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guidelines were associated with frequent use of guidelines [35]. In a recent publication, it is stated that one of the major barriers to implement effective management in OA care is suboptimal patient adherence with aspects of the management programme [36].

Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines or educational materials [37]. Previous research has showed that successful guideline implementation strategies should be multifaceted and actively engage clinicians throughout the process [38]. To identify barriers and facilitators for our OA care model, we performed three focus groups with eight GPs, six PTs, and three patient representatives, respectively (Additional file 2). Based on these discussions, we developed an implementation strategy tailored to the barriers and facilitators identified by the focus group participants (Table 1). The protocol has been reported using the SPIRIT recommendations and the CONSORT guidelines for non-pharmacological interventions [39, 40].