Preliminary effects of a regional approached multidisciplinary educational program on healthcare utilization in patients with hip or knee osteoarthritis: an observational study

Osteoarthritis (OA) is the most prevalent form of disability of posture and movement worldwide [1]. OA of the hip and knee is characterised by pain and stiffness which can impair daily functioning, and decrease physical activity [2]. This physical and accompanying mental burden influences the quality of life in patients with OA. Although there are no curative treatment options for OA, multiple effective non-surgical and surgical treatment options for reducing pain and improving movement ability and quality of life are available [2, 3].

International guidelines recommend a combination of pharmacological and non-pharmacologic modalities as primary approach for hip or knee OA [2‐4]. Non-pharmacological treatment modalities include psycho-educational interventions to improve self-management, physical activity and exercise therapy, and weight reduction. Recommended pharmacological treatment consists of the use of acetaminophen (paracetamol), the use of non-steroidal anti-inflammatory drugs (NSAIDs) or, when the patient is not responding satisfactorily to oral analgesic/anti-inflammatory agents, intra-articular injections [2]. Once non-surgical treatments become unsuccessful, joint replacement surgery is a cost-effective procedure that can be considered for patients with severe symptoms [3]. However, joint replacement surgery is advised to be postponed as long as possible, as the lifespan of prostheses are limited [2] and the results can vary [4].

In recent years the total number of hip and knee replacement surgeries increased with 50 and 196% respectively, especially in the age group of 75–85 years [5]. Possible explanations for this overall increase are ageing of the population and increase in obesity resulting in more people suffering from symptomatic OA. Despite recommendations, conservative treatment modalities in hip or knee OA are underused [6, 7] while timely usage of these treatment modalities is advocated [8] and may prevent untimely surgery.

The underuse of conservative treatment can be caused by healthcare providers related barriers for recommending conservative treatment modalities. Research shows that outcome expectations about conservative treatment options differ widely among healthcare providers and the confidence in competencies of other healthcare providers is low [9‐11]. As a result, patients with OA may not receive consistent information about effective, conservative treatment options. Receiving conflicting information is found to be associated with undesirable outcomes like non-adherence to treatment [12, 13]. Therefore, information on treatment options and strategies should be disseminated from a joint perspective of healthcare providers.

In addition, patient related factors might also influence the use of treatment modalities. Some patients are not aware of what they can do themselves and what conservative treatment options can be offered for their OA [14]. Providing relevant disease-related and self-management related information helps patients to become actively involved in their own care process [15]. Moreover, negative beliefs or unrealistic thoughts about different treatment modalities by patients might also influence the choice of treatment [16]. A recent systematic review showed that OA patients have a negative attitude towards the efficacy of conservative treatment and tend to prefer surgical treatment [17]. This emphasises the importance that patients are aware of benefits as well as possible disadvantages of both conservative and surgical treatment options, in order to have realistic expectations [4].

During a regional conference in the area of Nijmegen, the Netherlands, healthcare providers from different disciplines involved in the care for people with OA decided to develop a patient educational program with a multidisciplinary approach to tackle above outlined barriers for suboptimal care.

The aim of this program was to increase patients’ knowledge on OA, to stimulate self-management, to discuss benefits and disadvantages of treatment options, to promote the stepped care approach of treatments [8] and to provide consistent answers to frequently asked questions by patients. The objective of the present study was to determine preliminary effects of this OA educational program on healthcare utilization (HCU) and clinical outcomes.

Results of the present study show a decreased HCU, the proportion of patients having contact with a physio- or exercise therapist, or general practitioner decreased after following the educational program. We found an increase in knowledge on OA and patients’ perceptions towards their OA changed positively after the course. No significant changes were found in BMI, pain and functioning, physical activity, patient activation and self-efficacy.

Overall, our results are in line with the Cochrane review on self-management programs of Kroon el al. [25]; we also did not find any changes on self-efficacy, pain and functioning. This review however, did not evaluate the effect of self-management programs on illness perceptions, OA knowledge and HCU. We believe that the changes in these parameters are relevant to patients. This is in line with a recent randomized controlled trial, evaluating the effect of a patient decision aid for patients considering joint replacement, (including patient education on treatment options, benefits and risks) that reported positive results on knowledge and illness perceptions [26]. This is important to ensure realistic expectations of treatment outcomes in patients with hip or knee OA, and ultimately, to support self-management in the long-term.

The primary outcome in the evaluation of educational and self-management interventions is under debate [27‐29]. In the review by Newman et al. (2004) some included studies used outcomes that are not specifically targeted at the intervention. They concluded that this may decrease the overall effectiveness of educational self-management programs [27]. Similarly, Nolte et al. (2013) argue to critically choose outcome measures which are linked to those targeted for in the intervention, in order to prevent incorrect interpretation of effectiveness [28, 29]. However, in general, multiple outcome dimensions are targeted in self-management interventions. As a result across studies a wide variety of outcome measures is used to evaluate self-management interventions. Usually, pain and/or physical functioning are the primary outcome measures [25]. However, it is questionable whether changes can be expected in these outcomes, when self-management programs are aimed at providing individuals with skills how to cope with symptoms, manage their disease in daily living and navigate the healthcare system [29]. Knowledge on disease management is not the same as changing your behaviour into actually doing it yourself. Therefore, knowledge is often used as a process outcome, and seems more appropriate as secondary outcome. In contrast, HCU is more a measure for behaviour. Based on previous observations that self-management interventions can result in changes in healthcare utilization [29‐31] and the assumption that effective self-management ultimately impacts healthcare consumption our choice to explore HCU as primary outcome seems to be appropriate.

In our program we educated patients on what they can do for themselves, when to seek guidance for conservative treatment options and helped them to form realistic thoughts on the expected results of surgical treatment. Following this perspective, changes in HCU patterns could be expected. Our results showed a decrease in patients visiting primary care providers. However, only small non-significant changes in number of patients visiting secondary care specialists were found. Both observations may be explained by the short-term follow-up and small sample of our study. First, as we educated patients on what they can do for themselves (i.e. lifestyle advice on exercise, weight reduction and medication use), some patients may not have felt the need to visit a primary care healthcare provider on short-term, because they directly can put into practice what they have learned during the program [32]. Second, it is possible that patients were already referred to secondary care previous to the intervention, resulting in no short-term changes in secondary care use. Besides, research has shown that education in combination with exercise therapy may postpone surgery in hip OA patients in the long term [33, 34]. This emphasizes the desirability to study long-term results of our educational program in a larger sample.

Remarkably, the total number of contacts in primary care increased whereas the median number of contacts did not change. This finding may reflect the great variability in HCU between participants and specifically the difference in treatment between healthcare professionals. For example, patients will visit their GP once or twice for OA within 3 months, whereas they may visit a physiotherapist once or twice a week. This can sum up to a total of 12–24 visits over 3 months. In the present study several patients started physiotherapy treatment 1–2 weeks prior to the intervention (1–4 visits in the previous 3 months) and continued this treatment after the intervention (> 10 visits in the 3 months post-intervention) (data not shown). This may have contributed to the increased number of total visits in our sample. However, the low number of participants and short-term follow-up of the present study do not allow firm conclusions on this aspect of HCU.

We chose a multidisciplinary approach; in both the developmental process as well as in the execution of the program. This approach is based on previous research which argues to focus on the communication between healthcare providers involved in OA treatment to improve prescription of non-surgical treatment options [9]. In the process of achieving consensus on the content of the program and answering frequently asked questions on OA, we targeted differences in beliefs among healthcare providers regarding the efficacy of non-surgical treatments [9, 35] and clarified roles of different healthcare providers in the management of OA-patients [11]. Consequently, this resulted in clear and consistent information that could be disseminated during the course. This could explain the increased knowledge of patients after participating in the program. So far, little research has been done on the impact of consistency of information on self-management skills across settings and across disciplines for patients with osteoarthritis. In our opinion this is an important area for future research.

We chose to adapt the program to local context and patients preferences as it is known that adapting to local context positively influences knowledge translation [32, 36]. We involved local health care providers in the development and the execution of the program to support the role that health care providers have in patients’ treatment consideration [37] and offering patients options for local support. This may have contributed to the accessibility of the program and may have resulted that our educational program was highly valued by participants (satisfaction score 8 on a scale 1–10).

An important factor in the set-up of our program was the option for participants to bring their partner or a significant other person. Previous studies that focused on explaining reasons for underuse of conservative treatment, underline the importance of the social environment of patients to be involved their care process [9, 37]. Involving a spouse in an intervention may even enhance self-efficacy and improve coping abilities [38], and improve physical activity levels in in OA patients [39]. Our results showed no improvement in self-efficacy after the intervention and only a small, but non-significant increase in physical activity. However, only one-third of the patients who participated in the educational program indeed brought their partner. Future improvements of our intervention should focus on ways to better involve patients’ social environment [9].

This study has several limitations that should be taken into account when interpreting the results. First, the uncontrolled design of the study and the small sample size urges that conclusions drawn about the effect of the intervention should be taken with caution. In our study we examined short-term preliminary effects of a multidisciplinary educational program. However, a controlled trial with long-term follow-up is needed to further explore effects on HCU behaviour in patients with hip or knee OA. Second, we had a 25% loss to follow up, despite reminder letters. The overall high age of our participants might have contributed to the loss. Last, there may be a matter of selection bias. Although we tried to minimize this in our procedure when inviting patients for our study, we have no data available of patients who did not respond to our invitation to participate in our study.

Our results suggest that a multidisciplinary educational program, may result in changes in HCU and have positive effects on illness perceptions and knowledge in patients with hip or knee OA. These results indicate that patients may better understand and adjust their health seeking behaviour as a result of the program. Especially, the collaboration between health professionals from different disciplines, both in developing and executing the educational program, provides in adequate and consistent information on OA, treatment and self-management options. A randomized controlled trial with long-term follow-up with larger number of patients is needed to confirm these results.