ABSTRACT
Purpose: Osteoarthritis (OA) affects more than 300 million people worldwide with the knee and hip joints among the most clinically prevalent. Pain, stiffness, and physical disability are hallmark symptoms that impair quality of life. Good Life with osteoArthritis from Denmark (GLA:D®) is an evidence-based program providing education and exercise-therapy for people with knee and hip OA, now offered in 8 countries. A key barrier to GLA:D® is the need to attend 14 in-person sessions over 8-weeks, particularly for those in rural areas or with substantial occupational or family caring responsibilities. In the COVID-19 pandemic we expanded implementation support for GLA:D®in Australia to provide it via telehealth. The aim of this mixed methods project was to evaluate the implementation of GLA:D® via telehealth in Australia using the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) framework. Methods: Quantitative: People with knee or hip OA who reported completing GLA:D® via telehealth-only or a hybrid model of in-person and telehealth (minimum 3 telehealth sessions) at 3-month follow-up from March 2020-October 2021 were identified from the GLA:D®Australia registry. RE-AIM dimensions were examined descriptively. For the effectiveness domain mean differences [MD, (95% confidence intervals (CI)), effect size (ES)] from baseline to 3-month follow-up were calculated for pain (visual analogue scale, 0-100) and joint-related quality of life (knee injury and osteoarthritis outcome score or hip disability and osteoarthritis outcome score -quality of life sub-scales). Participants rated perceived recovery on a global rating of change (scale -3 to 3;1-3=recovered) and how satisfied they were with the GLA:D® program (scale 1-5;4,5=satisfied) at 3-month follow-up. Qualitative: One-on-one semi-structured interviews were conducted with 23 GLA:D® trained physiotherapists (n=12 telehealth adopters;n=11 non-adopters) from diverse (private/public practice, urban/rural) settings. Interviews were transcribed and analysed using a reflexive thematic approach guided by the RE-AIM QuEST framework. Results: Reach: 138 people (39 telehealth-only and 99 hybrid model;69% female) completed GLA:D.® Mean (SD) age and BMI were 64 (9) years 29.8 (5.5) kg/m2, respectively. Key themes on patient barriers and enablers for telehealth reach were technology literacy and access, personal preference and perceived value of telehealth, and availability of exercise equipment. Pandemic restrictions limiting access to in-person GLA:D® was an enabler. Effectiveness: For telehealth-only, average pain [MD=-10 (95%CI=-16, -4), ES=-0.54] and joint-related quality of life [MD=9 (95%CI=3, 14), ES=0.51] improved significantly. This was similar for hybrid model with average pain [MD=-11 (95%CI=-16, -6, ES=-0.43)] and joint-related quality of life [MD=12 (95%CI=8, 16, ES=0.65)] also improved. At 3-months, 81% of participants reported recovery and 88% were satisfied with GLA:D®. Most physiotherapists who adopted GLA:D® telehealth believed it was as effective as in-person for most patients and felt patients were better able to continue exercising at home upon completion. Adoption: 92 physiotherapists (74 health services) delivered GLA:D® via telehealth. Most physiotherapists who had adopted GLA:D® via telehealth stated it had become a normal part of their practice. Barriers to adoption included preferring, and greater confidence with providing, in-person GLA:D®. Implementation: Both education sessions were attended by 70% (n=96) of participants and 91% (n=125) attended more than 10 exercise-therapy sessions. GLA:D® telehealth implementation involved program modifications, including to assessment, exercise instruction, equipment modifications, and reduced fee structures. Maintenance: GLA:D® telehealth participants completed 3-month follow-ups throughout the entire study timeframe, with 16 (12%) in the final 2 months of evaluation, indicating ongoing participant engagement. Physio herapists stated GLA:D® telehealth was an opportunity for increased program access to immunocompromised, rural, and working patients. Barriers to sustainability identified included lack of personnel capacity, low patient demand, and a need for future telehealth training and support. Conclusions: Telehealth delivery of GLA:D® in Australia during the pandemic was most used as part of a hybrid model, combined with in-person delivery. Patient outcomes following GLA:D® via telehealth were comparable to published data related to in-person delivery, indicating it is an effective method to implement group-based care for OA. Yet, implementation was limited, impeded by low perceived value by patients and lack of confidence and training of physiotherapists. This evaluation will guide new strategies and training to support GLA:D via telehealth as a viable mode of program delivery in the future in Australia and internationally.
ABSTRACT
BACKGROUND: Musculoskeletal physiotherapy practice rapidly adopted telehealth during the COVID-19 pandemic, providing a unique opportunity to evaluate the experiences and attitudes of people who would not usually engage with these services. METHODS: A sequential mixed-methods study recruited people with musculoskeletal pain conditions accessing Australian private practice physiotherapist services. Part 1 involved an online survey of telehealth services accessed, treatments and resources provided, self-reported global change in condition, and attitudes toward telehealth. Part 2 involved semi-structured interviews with a subset of survey participants, exploring experiences and attitudes towards telehealth. Quantitative data was reported descriptively. Qualitative data was evaluated using inductive thematic analysis. RESULTS: 172 participants responded to the survey, and 19 were interviewed. 95% accessed video-based telehealth, and 85% reported condition improvement. 84% agreed it was an efficient use of their time, 75% agreed it was financially viable, and 73% agreed their condition was accurately diagnosed. 62% percent believed telehealth should be less expensive than in-person services. Qualitative analysis revealed four themes (17 subthemes), including (i) telehealth had value, but generally perceived as inferior to in-person care; (ii) challenges related to assessment, diagnosis, 'hands on' treatment, observation, communication, and technology; (iii) advantages to access safe, expert, and convenient care; and (iv) importance of supportive technology, including video and supplementary resources. CONCLUSION: Physiotherapist telehealth services provided to people with musculoskeletal pain during the pandemic was valued. However, telehealth was generally perceived as inferior to traditional in-person care, and may be best used as part of a hybrid model of care.