Multi-level reform is required to support high-value osteoarthritis care delivery: outcomes of a multinational survey of clinicians and students

Abstract

Purpose: Evidence-practice gaps in osteoarthritis (OA) care are commonly observed, particularly in primary care settings, resulting in many people receiving low-value care. Building workforce capacity to deliver high-value OA care requires a contemporary understanding of barriers to care delivery at multiple levels: at micro (clinical practice and training), meso (service/organisational), and macro (health system) levels. We aimed to explore factors related to OA care delivery across these levels from the perspectives of clinicians and final-year students. Methods: A cross-sectional study sampling clinicians (physiotherapists, primary care nurses, general practitioners (GPs), GP registrars; total possible denominator: n=119,735) and final-year physiotherapy and medical students (denominator: n=2,215) was undertaken across Australia, New Zealand and Canada in 2017. Respondents answered a survey consisting of customised and standard items requiring nominal and free-text responses, from which quantitative and qualitative data, respectively, were derived. At the micro-level we evaluated intrinsic factors (self-perceived confidence in OA knowledge and clinical skills, attitudes towards musculoskeletal pain (measured with Pain Attitudes Beliefs Scale (PABS)), attitudes towards high- and low-value OA care approaches, and the extent to which personal knowledge/skills were barriers to care) and extrinsic factors (use of guidelines in practice and patient-related factors). At the meso-level we explored workplace/clinical placement factors, and at the macro-level, health system factors, as potential barriers to high-value OA care delivery. Quantitative data were analysed using frequency statistics and Bonferroni-corrected general linear models. Content analysis was used to analyse and synthesise qualitative data. Results: 1,886 clinicians (1380 physiotherapists, 158 nurses, 267 GPs, 81 GP registrars) and 1,161 students (465 medical, 696 physiotherapy) responded. At the micro-level, self-rated confidence in OA knowledge and skills was significantly greater in physiotherapists compared to GPs, GP registrars and nurses; in GPs compared to nurses and GP registrars; and in GP registrars compared to nurses. Students’ confidence scores were not different. Biomedical treatment attitudes measured with the PABS were significantly greater in nurses compared to physiotherapists, GPs, and GP registrars; in GPs compared to physiotherapists; in GP registrars compared to physiotherapists and GPs; and in medical students compared to physiotherapy students (Table 1). Some clinicians and students agreed that people with OA ultimately require total joint replacement (7-19% and 19-22%, respectively); that arthroscopy is an appropriate intervention for knee OA (18-36% and 35-44%) and that MRI is informative for diagnosis and clinical management of hip/knee OA (8-61% and 21-52%). Most agreed (90-98% and 92-97%) that exercise is indicated irrespective of the stage of OA. Knowledge and skills gaps were identified as applicable barriers to care delivery by 37-88% of clinicians and 68-85% of students. Meta-synthesis of qualitative data highlighted skills gaps in: specific components of OA care; assessment, measurement and monitoring; tailoring care; managing case complexity; and translating knowledge to practice, especially among students. Extrinsically, patient-related factors and use of guidelines in practice were identified as applicable barriers to care by 49-85% and 14-59% of clinicians, respectively, and 61-71% and 23-53%, respectively, of students. At the meso (workplace)-level, 29-62% of clinicians and 22-51% of students cited barriers to care and qualitative data identified general infrastructure limitations (particularly community facilities) and inconsistent care as the most significant meso-level factors. At the macro (health system)-level, 48-70% of clinicians and 34-37% of students cited barriers to care. Qualitative data identified financing models and time pressures as relevant factors at the macro level. Overall, health system (macro) and patient-related factors (micro) were the most applicable barriers to OA care delivery for clinicians, whereas for students, personal knowledge and skills (micro) and patient-related factors (micro) were the most applicable (Figure 1). Conclusions: Clinicians and students perceived varied barriers to the delivery of high-value care for OA. Improvement strategies therefore need to be directed at all three levels, with a particular focus on closing knowledge and skills gaps at the micro-level and reforming financing models at the macro level.Table 1Summary measures of confidence and attitudes outcomes, reported as mean (SD).OutcomePhysiotherapistsPrimary care nursesGeneral practitionersGeneral practitioner registrarsMedical studentsPhysiotherapy studentsConfidence in OA knowledge [possible score range: 11-55]38.9 (7.0)asignificantly different to all clinical disciplines (p<0.05)29.6 (7.8)asignificantly different to all clinical disciplines (p<0.05)36.8 (6.2)asignificantly different to all clinical disciplines (p<0.05)33.9 (6.1)asignificantly different to all clinical disciplines (p<0.05)34.6 (6.1)35.1 (6.0)Confidence in OA skills [possible score range: 16-80]59.6 (10.2)asignificantly different to all clinical disciplines (p<0.05)45.0 (11.4)asignificantly different to all clinical disciplines (p<0.05)57.2 (8.9)asignificantly different to all clinical disciplines (p<0.05)53.6 (8.7)asignificantly different to all clinical disciplines (p<0.05)54.2 (9.1)53.2 (8.9)PABS-biomed [possible score range: 10-60]28.0 (6.8)asignificantly different to all clinical disciplines (p<0.05)34.9 (5.5)asignificantly different to all clinical disciplines (p<0.05)29.4 (6.0)asignificantly different to all clinical disciplines (p<0.05)32.2 (5.3)asignificantly different to all clinical disciplines (p<0.05)33.4 (5.5)bsignificant difference between student group31.4 (5.8)bsignificant difference between student groupa significantly different to all clinical disciplines (p<0.05)b significant difference between student group Open table in a new tab