Can a disease-specific education program augment self-management skills and improve Health-Related Quality of Life in people with hip or knee osteoarthritis?

Background: Patient education and self-management programs are offered in many countries to people with chronic conditions such as osteoarthritis (OA). The most well-known is the disease-specific Stanford Arthritis Self-Management Program (ASMP). While Australian and international clinical guidelines promote the concept of self-management for OA, there is currently little evidence to support the use of the ASMP. Several meta-analyses have reported that arthritis self-management programs had minimal or no effect on reducing pain and disability. However, previous studies have had methodological shortcomings including the use of outcome measures which do not accurately reflect program goals. Additionally, limited cost-effectiveness analyses have been undertaken and the cost-utility of the program has not been explored.

Methods/design: This study is a randomised controlled trial to determine the efficacy (in terms of Health-Related Quality of Life and self-management skills) and cost-utility of a 6-week group-based Stanford ASMP for people with hip or knee OA.

Six hundred participants referred to an orthopaedic surgeon or rheumatologist for hip or knee OA will be recruited from outpatient clinics at 2 public hospitals and community-based private practices within 2 private hospital settings in Victoria, Australia. Participants must be 18 years or over, fluent in English and able to attend ASMP sessions. Exclusion criteria include cognitive dysfunction, previous participation in self-management programs and placement on a waiting list for joint replacement surgery or scheduled joint replacement.

Eligible, consenting participants will be randomised to an intervention group (who receive the ASMP and an arthritis self-management book) or a control group (who receive the book only). Follow-up will be at 6 weeks, 3 months and 12 months using standardised self-report measures. The primary outcome is Health-Related Quality of Life at 12 months, measured using the Assessment of Quality of Life instrument. Secondary outcome measures include the Health Education Impact Questionnaire, Western Ontario and McMaster Universities Osteoarthritis Index (pain subscale and total scores), Kessler Psychological Distress Scale and the Hip and Knee Multi-Attribute Priority Tool. Cost-utility analyses will be undertaken using administrative records and self-report data. A subgroup of 100 participants will undergo qualitative interviews to explore the broader potential impacts of the ASMP.

Discussion: Using an innovative design combining both quantitative and qualitative components, this project will provide high quality data to facilitate evidence-based recommendations regarding the ASMP.

Consumer participation in designing community based consumer-directed disability care : lessons from a participatory action research-inspired project

User participation has been embraced worldwide as a means to provide better consumer outcomes in health and community care. However, methodologies to achieve effective consumer engagement at the programme design level have remained under-explored. The purpose of this study was to evaluate the impact of a Participatory Action Research (PAR)-inspired methodology used to develop a consumer-directed community care/individualised funding service model for people with disabilities. A retrospective analysis of case notes and internal reports for the first 6 years of an ongoing project were examined. The findings suggest that PAR methodologies need to take into account community development, group support, and capacity building as well as succession planning and risk management issues in order to facilitate the often lengthy policy and project development process. Drawing on these findings, this article discusses five lessons and their methodological implications for PAR in a health or social policy/programme design context.

Guideline for the non-surgical management of hip and knee osteoarthritis

Introduction: Chronic disease is a major public health burden on Australian society. An increasing proportion of the population has risk factors for, or at least one, chronic disease, leading to increasing public health costs. Health service policy and delivery must not only address acute conditions, it must also effectively respond to the wide range of health and public service requirements of people with chronic illness.^1,2 Strong primary health care policy is an important foundation for a successful national health delivery system and long term management of public health, and is linked to practical outcomes including lower mortality, decreased hospitalisation and improved health outcomes.¹ National strategic health policy has recently given increased recognition to the importance of chronic disease management, with the Australian Federal Government endorsement of a number of initiatives for the prevention (or delay in onset), early detection and evidence based management of chronic disease, including osteoarthritis.^1,3
Chronic musculoskeletal conditions, including arthritis, account for over 4% of the national disease burden in terms of disability adjusted life years. Over 6 million Australians (almost one-third of the population) are estimated to have a chronic musculoskeletal disease; chronic musculoskeletal disease represents the main cause of long term pain and physical disability. In Australia, osteoarthritis is self reported by more than 1.4 million people (7.3% of the population4) and is the tenth most commonly managed problem in general practice.5 This number is set to rise as the elderly population grows. Osteoarthritis exerts a significant burden on the individual and the community through reduction in quality of life, diminished employment capacity and an increase in health care costs. For further details, refer to the Evidence to support the National Action Plan for Osteoarthritis, Rheumatoid Arthritis and Osteoporosis: Opportunities to improve health-related quality of life and reduce the burden of disease and disability (2004).⁶
As such, federal government health policy has identified arthritis as a National Health Priority Area and adopted a number of initiatives aimed at decreasing the burden of chronic disease and disability; raising awareness of preventive disease factors; providing access to evidence based knowledge; and improving the overall management of arthritis within the community.4 In 2002, all Australian health ministers designated arthritis and musculoskeletal conditions as Australia’s seventh National Health Priority Area. In response, a National Action Plan was developed in 2004 by the National Arthritis and Musculoskeletal Conditions Advisory Group (NAMSCAG).6 The aim of this document was to provide a blueprint for national initiatives to improve the health related quality of life of people living with osteoarthritis, rheumatoid arthritis and osteoporosis; reduce the cost and prevalence of these conditions; and reduce the impact on individuals, their carers and their communities within Australia. The National Action Plan was developed to complement both the National Chronic Disease Strategy – which is broader – and the National Service Improvement Framework for Osteoarthritis, Rheumatoid Arthritis and Osteoporosis, in addition to other national and state/ territory structures.

Employer satisfaction with employees with a disability

Previous research that addressed determents of employer satisfaction with employees with a disability (EWDs) mainly targeted employers’ perceptions of workplace performance. This thesis used quantitative and qualitative approaches to examine perspectives of employers and disability employment service providers (DESPs) on the complex nature of employer satisfaction with EWDs within an ecological paradigm. Three studies were undertaken. The first analysed questionnaire ratings for 656 employers of workplace performance of EWDs. Analyses found: (1) employers rated EWDs lower than non-disabled employees (NDEs) on employer satisfaction and work performance; (2) determinants of employer satisfaction differed between EWDs and NDEs; (3) employers were more satisfied with EWDs than NDEs in relation to work performance; (4) lower comparative ratings on employer satisfaction for EWDs influenced future employment intentions toward people with a disability; (5) employers’ perceptions of job-match affected ratings on employer satisfaction and performance; (6) effects of job-match on employer satisfaction were direct and indirect, through work performance; and (7) variables representing job-match were relatively more important to employers’ decisions to hire and retain a person with a disability than variables representing Social Concerns and employer/management items. A theoretical model that depicted the influence of processes (job-match) and outcomes (work performance) on employer satisfaction with EWDs was supported. The second study analysed questionnaire ratings from 36 non-employers of EWDs. Findings indicated very similar responses between employers and non-employers of EWDs on experiences related to employer satisfaction with NDEs. Views about the relative importance of variable related to hiring and retaining a person with a disability suggested that generalising findings from the first study to all employers was reasonable. The third study analysed data from interviews with 50 employers and 40 DESPs; and questionnaire responses for 56 DESPs and 36 non-employers of EWDs. This study validated the importance of job-match to successful employment outcomes; suggesting DESPs were undervaluing their services to the employers. The study also showed that Bronfenbrenner’s Ecological Systems Theory provided a relevant framework with which to interpret complex information from different stakeholders, important to understanding employer satisfaction. In summary, employer satisfaction was shown to be a relative concept that varied with referent, and a developmental phenomenon that was influences by many factors operating and interacting at a number of ecological levels. Policies and practices to promote employer satisfaction with EWDs need co-ordinated approaches that recognise the influence of contexts internal and external to the workplace and the dynamic nature and interrelationships of characteristics within these contexts.

Are workers with a disability less productive or less understood? An empirical investigation from an entrepreneurial business planning perspective

This study investigated selected work-performance data of a large call centre using the entrepreneurial business planning paradigm as a theoretical framework and tested the hypothesis that levels of productivity would be different for each group between workers with a disability and workers without a disability. On five measures of productivity, no significant differences were discernible but on a sixth measure, length of employment, it was found that disability workers remained in employment significantly longer. These results strongly refute the ‘intuitive wisdom’ that workers with a disability are less productive. The results support a growing body of corporate experience and descriptive research indicating that workers with a disability perform as well as or better than their non-disability colleagues. Yet workers with a disability remain disproportionately under-employed. The key to translating the growing evidence of this research into higher levels of employment of workers with disabilities will depend upon employers adopting an entrepreneurial approach to the planning of human resource management.

A new vision of management : full potential management model

This paper establishes the Full Potential Management (FPM) Model based upon the social model of disabilities coupled with principles of diversity management and disability-oriented human resource management. Despite the fact that the concept of management was once envisioned as having 'value to society ' by improving the quality of life through efficient practices (Rimler, 1976), management literature has narrowly defined management as a means to gain increased productivity and achieve organizational goals, thus overlooking the social formation and implementation design for a better life (Diener & Seligman, 2004; Small, 2004; Whitley 1989). Based upon the diversity literature, we propose that social-oriented diversity management principles and practices are the key to transforming management concepts from achieving organizational potential to achieving social aims that maximize the potential and quality of life of each person.

The management of individuals with bipolar disorder : a review of the evidence and its integration into clinical practice

Bipolar disorder is a common, debilitating, chronic illness that emerges early in life and has serious consequences such as long-term unemployment and suicide. It confers considerable functional disability to the individual, their family and society as a whole and yet it is often undetected, misdiagnosed and treated poorly. In the past decade, many new treatment strategies have been trialled in the management of bipolar disorder with variable success. The emerging evidence, for pharmacological agents in particular, is promising but when considered alone does not directly translate to real-world clinical populations of bipolar disorder. Data from drug trials are largely based on findings that identify difterences between groups determined in a time-limited manner, whereas clinical management concerns the treatment of individuals over the life-long course of the illness. Considering the findings in the context of the individual and their particular needs perhaps besl bridges the gap between the evidence from research studies and their application in clinical practice. Specifically, only lithium and valproate have moderate or strong evidence for use across all three phases of bipolar disorder, Anticonvulsants, such as lamotrigine. have strong evidence in maintenance; whereas antipsychotics largely have strong evidence in acute mania, with the exception of quetiapine, which has strong evidence in bipolar depression. Maintenance data for antipsychotics is emerging but at present remains weak. Combinations have strong evidence in acute phases of illness but maintenance data is urgently needed. Conventional antidepressants only have weak evidence in bipolar depression and do not have a role in maintenance therapy. Therefore, this paper summarizes the efficacy data for treating bipolar disorder and also applies clinical considerations to these data when

Cost effectiveness of a general practice chronic disease management plan for coronary heart disease in Australia

Background. The cost effectiveness of a general practice-based program for managing coronary heart disease (CHD) patients in Australia remains uncertain. We have explored this through an economic model.

Methods. A secondary prevention program based on initial clinical assessment and 3 monthly review, optimising of pharmacotherapies and lifestyle modification, supported by a disease registry and financial incentives for quality of care and outcomes achieved was assessed in terms of incremental cost effectiveness ratio (ICER), in Australian dollars per disability adjusted life year (DALY) prevented.

Results. Based on 2006 estimates, 263 487 DALYs were attributable to CHD in Australia. The proposed program would add $115 650 000 to the annual national heath expenditure. Using an estimated 15% reduction in death and disability and a 40% estimated program uptake, the program’s ICER is $8081 per DALY prevented. With more conservative estimates of effectiveness and uptake, estimates of up to $38 316 per DALY are observed in sensitivity analysis.

Conclusions. Although innovation in CHD management promises improved future patient outcomes, many therapies and strategies proven to reduce morbidity and mortality are available today. A general practice-based program for the optimal application of current therapies is likely to be cost-effective and provide substantial and sustainable benefits to the Australian community.

What is known about this topic? Chronic disease management programs are known to provide gains with respect to reductions in death and disability among patients with coronary heart disease. The cost effectiveness of such programs in the Australian context is not known.

What does this paper add? This paper suggests that implementing a coronary heart disease program in Australia is highly cost-effective across a broad range of assumptions of uptake and effectiveness.

What are the implications for practitioners? These data provide the economic rationale for the implementation of a chronic disease management program with a disease registry and regular review in Australia.

Diabetes and risk of physical disability in adults: a systematic review and meta-analysis

Background
According to previous reports, the risk of disability as a result of diabetes varies from none to double. Disability is an important measure of health and an estimate of the risk of disability as a result of diabetes is crucial in view of the global diabetes epidemic. We did a systematic review and meta-analysis to estimate this risk.

Methods
We searched Ovid, Medline, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature up to Aug 8, 2012. We included studies of adults that compared the risk of disability—as measured by activities of daily living (ADL), instrumental activities of daily living (IADL), or mobility—in people with and without any type of diabetes. We excluded studies of subpopulations with specific illnesses or of people in nursing homes. From the studies, we recorded population characteristics, how diabetes was diagnosed (by doctor or self-reported), domain and definition of disability, and risk estimates for disability. We calculated pooled estimates by disability type and type of risk estimate (odds ratio [OR] or risk ratio [RR]).

Results
Our systematic review returned 3224 results, from which 26 studies were included in our meta-analyses. Diabetes increased the risk of mobility disability (15 studies; OR 1·71, 95% CI 1·53—1·91; RR 1·51, 95% CI 1·38—1·64), of IADL disability (ten studies; OR 1·65, 95% CI 1·55—1·74), and of ADL disability (16 studies; OR 1·82, 95% CI 1·63—2·04; RR 1·82, 95% CI 1·40—2·36).

Interpretation
Diabetes is associated with a strong increase in the risk of physical disability. Efforts to promote healthy ageing should account for this risk through prevention and management of diabetes.

Funding
Monash University, Baker IDI Bright Sparks Foundation, Australian Postgraduate Award, VicHealth, National Health and Medical Research Council, Australian Research Council, Victorian Government.

Diabetes in people with an intellectual disability : a systematic review of prevalence, incidence and impact.

To establish the prevalence and incidence of Type 1 and Type 2 diabetes in people with an intellectual and developmental disability and determine their impact on health and well-being and to appraise the evidence available to inform good practice in diabetes management for people with intellectual and developmental disabilities.

Individual and organisational factors associated with the use of seclusion in disability services

Background: Seclusion is a restrictive intervention that results in some form of containment and social isolation of a person from others. Little is known about the relationships between individual and organisation factors and the use of seclusion in disability services. Method: The reported use of seclusion in disability services in Victoria, Australia, was examined over a 3-year period, with a focus on the characteristics of those who were secluded (n = 146) and the characteristics of organisations that reported seclusion compared to others who were reported to be restrained but not secluded (n = 2,482). Results: Results from a logistic regression showed that the individual factors of age, the presence of autism and/or a psychiatric disorder put people at risk of being secluded. In terms of organisational factors, receiving accommodation services in institutions or in the community and the location of the organisation were risk factors. Conclusions: The findings are consistent with previous research but add to this literature by showing that certain organisational characteristics are also risk factors for seclusion. Understanding these factors is important in order to help disability support staff find other more ethical and appropriate alternatives to seclusion.

An effective program design to support older workers with intellectual disability to participate individually in community groups

The foreshadowed increase of older people with intellectual disability has become a reality in many developed countries. As these adults age, improved quality of life can be achieved through applications of conjoint policy aims of inclusion and participation. A transition-to-retirement (TTR) program developed for employees of a large multisite disability employment service in Sydney, Australia, used these aims to effect successful partial retirement. The authors describe the program logic of the TTR, detailing its conceptual components as the first step to enabling it to be tested and replicated in other settings. The TTR program has three components: promoting the concept of retirement, laying the groundwork for inclusion of would-be retirees with intellectual disability in the community, and constructing the reality. The third component comprised five stages: planning, locating a group, mapping new routine, recruiting and training mentors, and monitoring and ongoing support. The project's participants were 24 older employees, who replaced 1 day a week of work with membership of a community group and were supported by mentors who facilitated involvement of the participants in their group. Data collected provided information on the implementation of the program, the time and costs expended, and challenges encountered. Key to the model was a coordinator, skilled in generic case management and specific disability interventions (such as active support), who collaborated with others to manage the program. The authors note that by detailing the program logic underpinning the TTR program, they have exposed the hidden work of supporting meaningful inclusion of people with intellectual disability in community groups and added to the limited stock of evidence-informed programs in this area. © 2014 International Association for the Scientific Study of Intellectual and Developmental Disabilities and Wiley Periodicals, Inc.