Patient education and self-management programs in arthritis

♦ Arthritis self-management programs (ASMPs) are integrated into many clinical practice guidelines and policies, and are the core business of Arthritis Foundations.

♦ Australian Arthritis Foundations are embarking on a National Quality Assurance Program which should raise awareness and improve confidence in such programs.

♦ ASMPs aim to empower people, improve quality of life while living with chronic disease, increase healthy activities and improve self-monitoring — each of which can assist with clinical management, but can be difficult to evaluate.

♦ Although there is modest high-quality evidence of traditional “clinical outcomes” from ASMPs, these programs are strongly endorsed by consumers, are being used as a vehicle for healthcare reform, and have the potential to substantially improve public health.

♦ Coordinated national delivery of patient education programs has the potential to improve healthcare and outcomes for people with arthritis.

Rural women's self-management of arthritis

Assesses the relevance of self-management for rural women suffering arthritic conditions, by identifying factors that enabled or constrained their ability to self-manage, and by discerning differences between women in terms of their capacities to utilise self-management. A typology was developed identifying four different groups of rural women: unconstrained, passive, determined, and marginalised; therefore highlighting the ways in which different types of women are enabled or constrained in their self-management.

Measuring the impact of arthritis on worker productivity : perspectives, methodologic issues and contextual factors

Leading up to the Outcome Measures in Rheumatology (OMERACT) 10 meeting, the goal of the Worker Productivity Special Interest Group (WP-SIG) was to make progress on 3 key issues that relate to the application and interpretation of worker productivity outcomes in arthritis: (1) to review existing conceptual frameworks to help consolidate our intended target and scope of measurement; (2) to examine the methodologic issues associated with our goal of combining multiple indicators of worker productivity loss (e.g., absenteeism <—> presenteeism) into a single comprehensive outcome; and (3) to examine the relevant contextual factors of work and potential implications for the interpretation of scores derived from existing outcome measures. Progress was made on all 3 issues at OMERACT 10. We identified 3 theoretical frameworks that offered unique but converging perspectives on worker productivity loss and/or work disability to provide guidance with classification, selection, and future recommendation of outcomes. Several measurement and analytic approaches to combine absenteeism and presenteeism outcomes were proposed, and the need for further validation of such approaches was also recognized. Finally, participants at the WP-SIG were engaged to brainstorm and provide preliminary endorsements to support key contextual factors of worker productivity through an anonymous “dot voting” exercise. A total of 24 specific factors were identified, with 16 receiving ≥ 1 vote among members, reflecting highly diverse views on specific factors that were considered most important. Moving forward, further progress on these issues remains a priority to help inform the best application of worker productivity outcomes in arthritis research.

Neighborhood disadvantage, individual-level socioeconomic position, and self-reported chronic arthritis : a cross-sectional multilevel study

Objective To examine the association between individual- and neighborhood-level disadvantage and self-reported arthritis.

Methods We used data from a population-based cross-sectional study conducted in 2007 among 10,757 men and women ages 40–65 years, selected from 200 neighborhoods in Brisbane, Queensland, Australia using a stratified 2-stage cluster design. Data were collected using a mail survey (68.5% response). Neighborhood disadvantage was measured using a census-based composite index, and individual disadvantage was measured using self-reported education, household income, and occupation. Arthritis was indicated by self-report. Data were analyzed using multilevel modeling.

Results The overall rate of self-reported arthritis was 23% (95% confidence interval [95% CI] 22–24). After adjustment for sociodemographic factors, arthritis prevalence was greatest for women (odds ratio [OR] 1.5, 95% CI 1.4–1.7) and in those ages 60–65 years (OR 4.4, 95% CI 3.7–5.2), those with a diploma/associate diploma (OR 1.3, 95% CI 1.1–1.6), those who were permanently unable to work (OR 4.0, 95% CI 3.1–5.3), and those with a household income <$25,999 (OR 2.1, 95% CI 1.7–2.6). Independent of individual-level factors, residents of the most disadvantaged neighborhoods were 42% (OR 1.4, 95% CI 1.2–1.7) more likely than those in the least disadvantaged neighborhoods to self-report arthritis. Cross-level interactions between neighborhood disadvantage and education, occupation, and household income were not significant.

Conclusion Arthritis prevalence is greater in more socially disadvantaged neighborhoods. These are the first multilevel data to examine the relationship between individual- and neighborhood-level disadvantage upon arthritis and have important implications for policy, health promotion, and other intervention strategies designed to reduce the rates of arthritis, indicating that intervention efforts may need to focus on both people and places.

The role of health literacy and social networks in arthritis patients' health information-seeking behavior : a qualitative study

Background. Patients engage in health information-seeking behaviour to maintain their wellbeing and to manage chronic diseases such as arthritis. Health literacy allows patients to understand available treatments and to critically appraise information they obtain from a wide range of sources.

Aims. To explore how arthritis patients' health literacy affects engagement in arthritis-focused health information-seeking behaviour and the selection of sources of health information available through their informal social network.

Methods. An exploratory, qualitative study consisting of one-on-one semi-structured interviews. Twenty participants with arthritis were recruited from community organizations. The interviews were designed to elicit participants' understanding about their arthritis and arthritis medication and to determine how the participants' health literacy informed selection of where they found information about their arthritis and pain medication.

Results. Participants with low health literacy were less likely to be engaged with health information-seeking behaviour. Participants with intermediate health literacy were more likely to source arthritis-focused health information from newspapers, television, and within their informal social network. Those with high health literacy sourced information from the internet and specialist health sources and were providers of information within their informal social network.

Conclusion. Health professionals need to be aware that levels of engagement in health information-seeking behaviour and sources of arthritis-focused health information may be related to their patients' health literacy.

Factors limiting participation in arthritis self-management programmes : an exploration of barriers and patient preferences within a randomized controlled trial

Objective. To improve understanding of barriers to participation in community-based arthritis self-management programmes and patient preferences for self-management education.

Methods. Individuals with hip or knee OA referred to orthopaedic surgeons or rheumatologists at six public and private hospitals in Victoria, Australia, were recruited for a randomized controlled trial (RCT) of the Stanford Arthritis Self-Management Programme (ASMP). As part of the study design, potential participants were asked during the screening and recruitment process about reasons for being unable to attend the course, reasons for not participating in the study and individual preferences for course scheduling.

Results. Of 1125 individuals assessed, 216 (19%) were unable to attend six ASMP sessions. This was commonly due to physical limitations, including illness, restricted mobility and pain (22%), difficulty getting to or from courses (22%), work commitments (22%), the time commitment required (17%) and family roles (12%). Among those who did not want to participate in the study (n = 258), the overwhelming reason was disinterest (74%). Specific preferences for course scheduling were frequent, confirming the practical challenges faced in organizing courses for the RCT.

Conclusion. Incorporating patients from public and private settings, this study has elicited new insights into barriers to ASMP participation. Many people with hip or knee OA have limited capacity and motivation to attend community-based group programmes. Future self-management programmes and research should include more accessible options for those who cannot attend group-based programmes.

Implementation of a quality care management system for patients with arthritis of the hip and knee

The Orthopaedic Unit of the Repatriation General Hospital (RGH) in Adelaide, South Australia has implemented a quality care management system for patients with arthritis of the hip and knee. The system not only optimises conservative management but ensures that joint replacement surgery is undertaken in an appropriate and timely manner. This new service model addresses identified barriers to service access and provides a comprehensive, coordinated strategy for patient management. Over 4 years the model has reduced waiting times for initial outpatient assessment from 8 to 3 months and surgery from 18 to 8 months, while decreasing length of stay from 6.3 to 5.3 days for hips and 5.8 to 5.3 days for knees. The service reforms have been accompanied by positive feedback from patients and referring general practitioners in relation to the improved coordination of care and enhanced efficiency in service delivery.

What is known about the topic? Several important initiatives both overseas and within Australia have contributed significantly to the development of this model of care. These include the UK National Health Service ‘18 weeks’ Project, the Western Canada Waiting List Project, the New Zealand priority criteria project, the Queensland Health Orthopaedic Physiotherapy Screening Clinic, and most importantly the Melbourne Health–University of Melbourne Orthopaedic Waiting List Project where a wide range of models were explored across Victorian hospitals from 2005 and the Multi-Attribute Prioritisation Tool (MAPT) was developed, validated and tested. This project became the Osteoarthritis Hip and Knee Service (OAHKS) and was operationalised in the Victorian healthcare system from 2012. These initiatives examined and addressed various aspects of management systems for patients with arthritis of the hip and knee in their particular setting.

What does this paper add? The development of this system is an extension of what is already known and is the first to encompass a comprehensive and coordinated strategy across all stages of the care management pathway for this patient group. Their management extends from the initial referral to development and implementation of a management plan, including surgery if assessed as necessary and organisation of long-term post operative follow up as required. By detailing the elements, key processes and measurable outcomes of the service redesign this paper provides a model for other institutions to implement a similar initiative.

What are the implications for practitioners? An important aspect of the design process was practitioner acceptance and engagement and the ability to improve their capacity to deliver services within an efficient and effective model. Intrinsic to the model’s development was assessment of practitioner satisfaction. Data obtained including practitioner surveys indicated an increased level of both satisfaction with the redesigned management service, and confidence in it to deliver its intended improvements.