ABSTRACT
Introduction: The Good Life with osteoArthritis from Denmark (GLA:D) program provides group-based education (2 sessions) and exercise-therapy (12 sessions) for people with knee and hip osteoarthritis at >500 sites in Australia and is associated with clinically meaningful improvements in pain and quality of life (QoL). During the COVID-19 pandemic, physiotherapists in Australia were supported to provide GLA:D via telehealth. The aim of this mixed-methods project was to evaluate the implementation of GLA:D via telehealth. Method(s):Evaluation Framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST). Quantitative: People with knee or hip osteoarthritis participating in GLA:D via telehealth-only or a hybrid delivery of in-person and telehealth (>=3 telehealth sessions) from March 2020-October 2021. Mean differences (MD) and effect sizes (ES) from baseline to 3-month follow-up were calculated for average pain (0-100) and joint-related QoL (KOOS-QOL, HOOS-QOL sub-scales). Participants rated perceived recovery (global rating of change scale -3 to 3;1-3=recovered) and program satisfaction (scale 1-5;4,5=satisfied).Qualitative: 23 GLA:D trained physiotherapists (n=12 telehealth adopters;n=11 non-adopters) from diverse (private/public practice, urban/rural) settings completed one-on-one semi-structured interviews. Interviews were transcribed and analysed using a reflexive thematic approach. Results :Reach: 138 people (39 telehealth-only and 99 hybrid delivery;69% female) participated in GLA:D via telehealth.. Mean (SD) age and BMI were 64 (9) years and 29.8 (5.5) kg/m2, respectively. Identified barriers and enablers for reach included technology literacy and access, personal preference and perceived value of telehealth, and availability of exercise equipment. Pandemic restrictions to in-person GLA:D was an enabler. Effectiveness: Average pain decreased for telehealth-only (MD, 95%CI=-10, -16 to -4;ES=-0.54) and hybrid delivery (MD=-11, -16 to -6;ES=-0.43) GLA:D. Joint-related QoL improved for telehealth-only (MD=9, 3 to 14;ES=0.51) and hybrid delivery (MD=12, 8 to 16;ES=0.65) GLA:D. At 3-months, 81% of participants were recovered and 88% were satisfied. Most physiotherapists believed telehealth was as effective as in-person and felt patients were better able to continue exercising at home. Adoption: 92 physiotherapists (74 health services) delivered GLA:D via telehealth, most stating it had become a normal part of their practice. Adoption barriers included preferring, and greater confidence with providing, in-person GLA:D. Implementation: 70% (n=96) of participants attended both education sessions and 91% (n=125) attended >10 exercise-therapy sessions. Telehealth-delivered GLA:D involved modifications to assessment, exercise instruction, equipment, and reduced fee structures. Maintenance: Lack of personnel capacity, low patient demand, and a need for telehealth training and support were sustainability barriers. Discussion(s): Telehealth-delivered GLA:D in Australia during the pandemic predominantly involved hybrid delivery. Patient outcomes following telehealth-delivered GLA:D were comparable to published in-person registry data. However, implementation was limited, impeded by low perceived value by patients and lack of confidence and training of physiotherapists. Impact and application to the field * Telehealth-delivered group-based education and exercise provides a viable and effective option to provide people with osteoarthritis appropriate first-line care in Australia. * Findings highlight the need for, and can help guide, community education about the value of telehealth, alongside training to support physiotherapists delivering GLA:D via telehealth. My co-authors and I have no conflict of interest related to the submission of this Copyright © 2022
ABSTRACT
Introduction: Guidelines recommend education and exercise-therapy as first-line treatments for knee osteoarthritis. The Good Life with osteoArthritis from Denmark (GLA:D) program provides physiotherapist-led group-based education and exercise-therapy at >500 sites in Australia. It is associated with clinically meaningful improvements in pain and quality of life (QoL). However, inability to attend in-person sessions due to geography, transportation requirements, or other commitments limits access. Telehealth (videoconferencing) may improve the equity of access to GLA:D. One-on-one telehealth services for knee musculoskeletal pain conditions including osteoarthritis are reported to be non-inferior to in-person care, but there is a lack of research evaluating group-based telehealth services. This randomised clinical trial (RCT) aimed to determine if GLAD delivered via telehealth was non-inferior to in-person delivery for knee-related burden at 3- (primary timepoint) and 12-months. Method(s): This pre-registered (ACTRN12619000235101) two-arm (telehealth, in-person), non-inferiority RCT commenced in April 2019. Knee osteoarthritis clinical diagnosis was based on NICE guidelines. Difference between groups for change in knee-related burden (primary outcome) was evaluated by averaging four Knee injury and Osteoarthritis Outcome Score subscales (KOOS4: pain, symptoms, function in daily living, QoL), measured at 3- and 12-months follow-up. The KOOS-QoL subscale was evaluated to relate findings to GLA:D Australia registry data. Planned sample size (n=88) was powered at 90% to detect a minimal important difference between groups of 10 (SD=16) points for KOOS4. Result(s): Forty-four participants enrolled at baseline (22 per group), with no difference between telehealth and in-person groups for sex distribution (female/male: 14/8 v 12:10), age (years: 62+/-8 v 64+/-10), or body mass index (kg/m2: 29.8+/-5.3 v 31.1+/-5.2). Recruitment ceased in March 2020 due to COVID-19 restrictions on in-person healthcare. Forty-three (98%) and 40 (91%) participants provided 3- and 12-month follow-up data respectively. Primary Outcome: There were no between group differences for changes in KOOS4, with outcomes favouring telehealth at 3-months (mean difference, 95%CI = 6, -2 to 15), and neither group at 12-months (0, -9 to 9). The lower limit of the 95%CI was within the non-inferiority margin (i.e. -10 points) at both time points. Secondary outcome: Changes in KOOS-QoL at 3- and 12-months for telehealth (18 and 14 points) and in-person (10 and 15) were comparable to published GLA:D registry data (13 and 16). Discussion(s): This RCT was underpowered due to COVID-19 pandemic restrictions causing early cessation, but findings do indicate telehealth-delivered GLA:D is unlikely to be inferior to in-person delivery for knee-related burden at 3- and 12-months. This finding builds on recently published qualitative findings indicating patient acceptability of telehealth-delivered GLA:D and positive telehealth outcomes from the GLA:D registry during the pandemic (submitted to SMA 2022: Ezzat et al). Further supporting implementation, findings are also consistent with published non-inferiority trials of one-on-one telehealth services for knee osteoarthritis and other musculoskeletal pain conditions, and KOOS-QoL outcomes in both groups were consistent with published GLA:D registry data. Implications and application to the field * Telehealth-delivered group-based education and exercise-therapy for knee osteoarthritis appears unlikely to be inferior to in-person delivery. * Physiotherapists should be supported to implement telehealth-delivered GLA:D in Australia. Conflict of interest: A/Profs Barton and Kemp lead the 'not-for-profit' implementation initiative, GLA:D Australia, which trains Australian physiotherapists to implement guideline-recommended education and exercise-therapy. Copyright © 2022
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.