Improving diagnosis and treatment of knee osteoarthritis in persons with type 2 diabetes: development of a complex intervention.

BACKGROUND: Symptomatic knee osteoarthritis (OA) commonly co-occurs in people with type 2 diabetes (T2DM) and increases the risk for diabetes complications, yet uptake of evidence-based treatment is low. We combined theory, stakeholder involvement and existing evidence to develop a multifaceted intervention to improve OA care in persons with T2DM. This was done in partnership with Arthritis Society Canada to leverage the existing infrastructure and provincial funding for community arthritis care. METHODS: Each step was informed by a User Advisory Panel of stakeholder representatives, including persons with lived experience. First, we identified the target groups and behaviours through consulting stakeholders and current literature. Second, we interviewed persons living with T2DM and knee OA (n = 18), health professionals (HPs) who treat people with T2DM (n = 18) and arthritis therapists (ATs, n = 18) to identify the determinants of seeking and engaging in OA care (patients), assessing and treating OA (HPs) and considering T2DM in OA treatment (ATs), using the Theoretical Domains Framework (TDF). We mapped the content to behavioural change techniques (BCTs) to identify the potential intervention components. Third, we conducted stakeholder meetings to ascertain the acceptability and feasibility of intervention components, including content and modes of delivery. Fourth, we selected intervention components informed by prior steps and constructed a programme theory to inform the implementation of the intervention and its evaluation. RESULTS: We identified the barriers and enablers to target behaviours across a number of TDF domains. All stakeholders identified insufficient access to resources to support OA care in people with T2DM. Core intervention components, incorporating a range of BCTs at the patient, HP and AT level, sought to identify persons with knee OA within T2DM care and refer to Arthritis Society Canada for delivery of evidence-based longitudinal OA management. Diverse stakeholder input throughout development allowed the co-creation of an intervention that appears feasible and acceptable to target users. CONCLUSIONS: We integrated theory, evidence and stakeholder involvement to develop a multifaceted intervention to increase the identification of knee OA in persons with T2DM within diabetes care and improve the uptake and engagement in evidence-based OA management. Our partnership with Arthritis Society Canada supports future spread, scalability and sustainability. We will formally assess the intervention feasibility in a randomized pilot trial.

Barriers and enablers to health care providers assessment and treatment of knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the Theoretical Domains Framework.

Objectives: Symptomatic knee osteoarthritis (OA) commonly co-exists in persons with Type 2 diabetes (T2DM) and may impede diabetes self-management. Yet, OA is often underdiagnosed and undertreated due to competing health care demands. We sought to determine healthcare providers' (HCPs') perceptions of the barriers and enablers to assessing and treating knee OA in persons with T2DM. Design: We conducted 18 semi-structured telephone interviews with HCPs who manage persons with T2DM (family physicians, endocrinologists, diabetes educators). Interviews were analyzed deductively using Theoretical Domains Framework (TDF), a framework developed to comprehensively identify behavioural determinants. Within relevant domains, data were thematically analyzed to generate belief statements, and these were compared across the different HCP disciplines. Results: Six TDF domains influenced HCPs behaviour to assess and treat knee OA in persons with T2DM. For all HCPs, important barriers included not seeing assessment/treatment of joint pain as a priority for their patients (intention), and insufficient access to required resources such as physiotherapy to treat OA (environmental context and resources). Endocrinologists and diabetes educators perceived having insufficient knowledge and skills to identify and manage OA (knowledge, skills), did not consider it within their professional role to do so (professional role and identity), and perceived other physicians would not want to receive a referral for OA care (social influences). Conclusions: We identified barriers and enablers encountered by diabetes HCPs to assessing and treating knee OA in persons with T2DM involving multiple domains of the TDF. These will help inform development of a complex intervention to improve health outcomes.

Understanding the behavioural determinants of seeking and engaging in care for knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the theoretical domains framework.

Objectives: Symptomatic knee osteoarthritis (OA) frequently co-occurs in individuals with type 2 diabetes mellitus (T2DM). In the context of T2DM, OA is often underdiagnosed and undertreated. To elucidate strategies to improve OA care in persons with T2DM, we assessed their perceptions of the barriers and enablers to seeking and engaging in OA care. Design: We conducted semi-structured interviews with 18 individuals with T2DM and symptomatic knee OA in Ontario, Canada. Transcripts were deductively coded using the Theoretical Domains Framework (TDF), an implementation science framework that incorporates theoretical domains of behaviour determinants, which can be linked to behaviour change techniques. Within each of the relevant domains, data were thematically analyzed to generate belief statements. Results: Seven of the TDF domains prominently influenced the behaviour to seek and engage in OA care. Participants described insufficient receipt of OA knowledge to fully engage in care (knowledge), feeling incapable of participating in physical activity due to joint pain (beliefs about capabilities), uncertainty about effectiveness of therapies (optimism) and lack of guidance from health care providers and insufficient access to community programs/supports (environmental context and resources). Key enablers were strong social support (social influences), sources of accountability (behavioural regulation) and experiencing benefit from treatment (reinforcement). Participants did not see concomitant T2DM as limiting the desire to seek OA care. Conclusions: Among individuals with symptomatic knee OA and T2DM, we identified behavioural determinants of seeking and engaging in OA care. These will be mapped to behavioural change techniques to inform development of a complex intervention.

'It's a Dance Between Managing Both': a qualitative study exploring perspectives of persons with knee osteoarthritis and type 2 diabetes mellitus on the impact of osteoarthritis on diabetes management and daily life.

OBJECTIVES: Type 2 diabetes (T2DM) and knee osteoarthritis (OA) commonly co-occur and epidemiologic studies suggest concomitant symptomatic knee OA increases the risk of T2DM complications. We sought to explore the experiences and perspectives of individuals' living with both symptomatic knee OA and T2DM, with a focus on the impact of OA on T2DM management and daily life. DESIGN: We conducted qualitative semistructured telephone interviews with persons living with T2DM and knee OA. We inductively coded and analysed interview transcripts, informed by interpretative description. SETTING: We recruited participants from a community arthritis self-management programme and an academic hospital's family medicine clinic in Ontario, Canada. PARTICIPANTS: We included 18 participants who had a physician diagnosis of both T2DM and knee OA, with variation age, gender, and duration of T2DM and knee OA. RESULTS: Participants with T2DM described how concomitant painful and disabling knee OA made it difficult to engage in physical activity, negatively impacting blood glucose control. Joint pain itself, associated sleep disturbance and emotional distress were also seen to affect blood glucose control. Beyond diabetes management, the impact of OA-related pain and functional limitations on nearly all aspects of daily life led participants to view their OA as important. Despite this, many participants described that their health professionals paid little attention to their OA, which left them to self-manage. Balancing both conditions also required navigating a medical system that provided piecemeal care. CONCLUSIONS: Individuals with T2DM view symptomatic knee OA as an important barrier to both T2DM management and overall well-being, yet are frequently met with insufficient support from health professionals. Greater recognition and management of knee OA in persons with T2DM could help improve patient-centred care and potentially disease outcomes.

Formulating Knee Osteoarthritis Management Plans Taking Type 2 Diabetes Into Account: Qualitative Study of Arthritis Therapists Using Theoretical Domains Framework.

OBJECTIVE: Delivering person-centered care in individuals with knee osteoarthritis (OA) necessitates consideration of other chronic conditions that frequently co-occur. We sought to understand the extent to which arthritis therapists consider type 2 diabetes mellitus (T2DM) when treating persons with knee OA and concomitant T2DM, and barriers to doing so. METHODS: We conducted 18 semistructured telephone interviews with arthritis therapists working within a provincially funded arthritis care program (Arthritis Society Canada) in Ontario, Canada. We first analyzed interviews deductively using the Theoretical Domains Framework (TDF) to comprehensively identify barriers and enablers to health behaviors. Then, within TDF domains, we inductively developed themes. RESULTS: We identified 5 TDF domains as prominently influencing the behavior of arthritis therapists considering concomitant T2DM when developing a knee OA management plan. These were as follows: therapists' perceived lack of specific knowledge around comorbidities including diabetes; the lack of breadth in skills in behavioral change techniques to help patients set and reach their goals, particularly when it came to physical activity; variable intention to factor a patient's comorbidity profile to influence their treatment recommendations; the perception of their professional role and identity as joint focused; and the environmental context with lack of formalized follow-up structure of the current Arthritis Society Canada program that limited sufficient patient monitoring and follow-up. CONCLUSION: Within the context of a Canadian arthritis program, we identified several barriers to arthritis therapists considering T2DM in their management plan for persons with knee OA and T2DM. These results can help inform strategies to improve person-centered OA care and overall health outcomes.

Minimal clinically important difference for improvement in six-minute walk test in persons with knee osteoarthritis after total knee arthroplasty.

BACKGROUND: The interpretability of the six-minute walk test (6MWT) in individuals with knee osteoarthritis (OA) is unclear. We aimed to determine the minimal clinically important difference (MCID) for improvement in 6MWT in persons with knee OA at 12 months after total knee arthroplasty (TKA), and if it differed by baseline walking ability. METHODS: Participants with knee OA were assessed 1 month pre- and 12 months post-TKA, including completion of 6MWT. At 12 months, participant-perceived change in walking ability was assessed on an 8-point Likert scale ranging from "extremely worse" to "extremely better". Using logistic regression, ROC curves examined the ability of change in 6MWT distance to discriminate those who perceived walking was improved. MCID was selected overall and then by quartile of baseline 6MWT distance using the Youden method. RESULTS: Two hundred seventy-eight participants were included: mean age 67 years (SD 8.5), 65.5% female, mean pre-TKA 6MWT distance 323.1 (SD 104.7) m, and mean 12-mo 6MWT distance 396.0 (SD 111.9) m. The overall MCID was 74.3 m (AUC 0.65). Acceptable model discrimination (AUC > 0.70) was achieved for individuals in the lowest quartiles of baseline 6MWT distance: Quartile 1: MCID 88.63 m (AUC 0.73); Quartile 2: MCID 84.47 m (AUC 0.72). CONCLUSIONS: In persons with knee OA 12 months post-TKA, 6MWT MCID is dependent on baseline walking ability. Poor model discrimination for those in the highest (best) quartiles of baseline walking ability raise questions about 6MWT use across the full spectrum of walking ability. Further research is needed to better understand use of 6MWT as a performance-based measure of physical function for persons with knee OA.

Engaging primary care physicians in care coordination for patients with complex medical conditions.

OBJECTIVE: To explore the dynamics of primary care physicians' (PCPs') engagement with the Seamless Care Optimizing the Patient Experience (SCOPE) project. DESIGN: Qualitative study using semistructured interviews. SETTING: Solo and small group primary care practices in urban Toronto, Ont. PARTICIPANTS: A total of 22 of the 29 SCOPE PCPs (75.8%) were interviewed 14 to 19 months after the initiation of SCOPE. METHODS: Qualitative semistructured interviews were conducted to examine influencing factors associated with PCPs' engagement in SCOPE. Transcripts were analyzed using a grounded theory-informed approach and key themes were identified. MAIN FINDINGS: The SCOPE project provided practical mechanisms through which PCPs could access information and connect with resources. Contextual and historical factors including strained relationships between hospital specialists and community PCPs and PCPs' feelings of responsibility, isolation, disconnection, and burnout influenced readiness to engage. Provision of clinically useful supports in a trusting, collaborative manner encouraged PCPs' engagement in newer, more collaborative ways of working. CONCLUSION: The SCOPE project provided an opportunity for PCPs to build meaningful relationships, reconnect to the broader health care system, and redefine their roles. For many PCPs, reestablishing connections reaffirmed their role in the system and enabled a more collaborative care model. Strategies for connecting community-based PCPs to the broader system need to consider contextual factors and the effects of new linkages and coordination on the identities and relationships of PCPs.

A multifaceted primary care practice-based intervention to reduce ED visits and hospitalization for complex medical patients: A mixed methods study.

BACKGROUND: The management of complex, multi-morbid patients is challenging for solo primary care providers (PCPs) with limited access to resources. The primary objective of the intervention was to reduce the overall rate of Emergency Department (ED) visits among patients in participating practices. METHODS AND FINDINGS: An interrupted time series design and qualitative interviews were used to evaluate a multifaceted intervention, SCOPE (Seamless Care Optimizing the Patient Experience), offered to solo PCPs whose patients were frequent users of the ED. The intervention featured a navigation hub (nurse, homecare coordinator) to link PCPs with hospital and community resources, a general internist on-call to provide phone advice or urgent assessments, and access to patient results on-line. Continuous quality improvement (QI) strategies were employed to optimize each component of the intervention. The primary outcome was the relative pre-post intervention change in ED visit rate for patients of participating practices compared with that for a propensity-matched control group of physicians over the contemporaneous period. Themes were identified from semi-structured interviews on PCP's experiences and influential factors in their engagement. Twenty-nine physicians agreed to participate and were provided access to the intervention over an 18-month time period. There were a total of 1,525 intervention contacts over the 18-months (average: 50.6±60.8 per PCP). Both intervention and control groups experienced a trend towards lower rates of ED use by their patients over the study time period. The pre-post difference in trend for the intervention group compared to the controls was not significant at 1.4% per year (RR = 1.014; p = 0.59). Several themes were identified from qualitative interviews including: PCPs felt better supported in the care of their patients; they experienced a greater sense of community, and; they were better able to provide shared primary-specialty care. CONCLUSIONS: This multifaceted intervention to support solo PCPs in the management of their complex patients did not result in a reduced rate of ED visits compared to controls, likely related to variable uptake among PCPs. It did however result in more comprehensive and coordinated care for their patients. Future directions will focus on increasing uptake by improving ease of use, increasing the range of services offered and expanding to a larger number of PCPs.

The impact of hip and knee osteoarthritis on the subsequent risk of incident diabetes: a population-based cohort study.

AIMS/HYPOTHESIS: This study examined the relationship between hip/knee osteoarthritis and incident diabetes. We hypothesised that hip/knee osteoarthritis would be independently related to an increased risk of incident diabetes and that this relationship would be due, at least in part, to walking difficulty. We also hypothesised a stronger relationship with incident diabetes for knee than hip osteoarthritis because of the higher prevalence in the former of obesity/the metabolic syndrome. METHODS: A population cohort aged ≥55 years recruited from 1996 to 1998 was followed through provincial health administrative data to 2014. Participants with baseline diabetes were excluded. Hip/knee osteoarthritis was defined as swelling, pain or stiffness in any joint lasting 6 weeks in the past 3 months and indication on a joint homunculus that a hip/knee was 'troublesome'. Walking limitation was defined as self-reported difficulty standing or walking in the last 3 months (yes/no). Using Cox regressions, we examined the relationship of baseline hip/knee osteoarthritis with incident diabetes as defined from health administrative data, controlling for age, sex, BMI, income, prior hypertension, cardiovascular disease and primary care exposure. We tested whether the observed effect was mediated through walking limitation. RESULTS: In total, 16,362 participants were included: median age 68 years and 61% female. Of these, 1637 (10%) individuals met the criteria for hip osteoarthritis, 2431 (15%) for knee osteoarthritis and 3908 (24%) for walking limitation. Over a median follow-up of 13.5 years (interquartile range 7.3-17.8), 3539 individuals (22%) developed diabetes. Controlling for confounders, a significant relationship was observed between number of hip/knee joints with osteoarthritis and incident diabetes: HR for two vs no osteoarthritic hips 1.25 (95% CI 1.08, 1.44); HR for two vs no osteoarthritic knees 1.16 (95% CI 1.04, 1.29). From 37% to 46% of this relationship was explained by baseline walking limitation. CONCLUSIONS/INTERPRETATION: In a large population cohort aged ≥55 years who were free of diabetes at baseline, and controlling for confounders, the presence and burden of hip/knee osteoarthritis was a significant independent predictor of incident diabetes. This association was partially explained by walking limitation. Increased attention to osteoarthritis and osteoarthritis-related functional limitations has the potential to reduce diabetes risk.

Improving System Integration: The Art and Science of Engaging Small Community Practices in Health System Innovation.

UNLABELLED: This paper focuses on successful engagement strategies in recruiting and retaining primary care physicians (PCPs) in a quality improvement project, as perceived by family physicians in small practices. Sustained physician engagement is critical for quality improvement (QI) aiming to enhance health system integration. Although there is ample literature on engaging physicians in hospital or team-based practice, few reports describe factors influencing engagement of community-based providers practicing with limited administrative support. The PCPs we describe participated in SCOPE: Seamless Care Optimizing the Patient Experience, a QI project designed to support their care of complex patients and reduce both emergency department (ED) visits and inpatient admissions. SCOPE outcome measures will inform subsequent papers. All the 30 participating PCPs completed surveys assessing perceptions regarding the importance of specific engagement strategies. Project team acknowledgement that primary care is challenging and new access to patient resources were the most important factors in generating initial interest in SCOPE. The opportunity to improve patient care via integration with other providers was most important in their commitment to participate, and a positive experience with project personnel was most important in their continued engagement. Our experience suggests that such providers respond well to personalized, repeated, and targeted engagement strategies.

All-cause mortality and serious cardiovascular events in people with hip and knee osteoarthritis: a population based cohort study.

BACKGROUND: Because individuals with osteoarthritis (OA) avoid physical activities that exacerbate symptoms, potentially increasing risk for cardiovascular disease (CVD) and death, we assessed the relationship between OA disability and these outcomes. METHODS: In a population cohort aged 55+ years with at least moderately severe symptomatic hip and/or knee OA, OA disability (Western Ontario McMaster Universities (WOMAC) OA scores; Health Assessment Questionnaire (HAQ) walking score; use of walking aids) and other covariates were assessed by questionnaire. Survey data were linked to health administrative data to determine the relationship between baseline OA symptom severity to all-cause mortality and occurrence of a composite CVD outcome (acute myocardial infarction, coronary revascularization, heart failure, stroke or transient ischemic attack) over a median follow-up of 13.2 and 9.2 years, respectively. RESULTS: Of 2156 participants, 1,236 (57.3%) died and 822 (38.1%) experienced a CVD outcome during follow-up. Higher (worse) baseline WOMAC function scores and walking disability were independently associated with a higher all-cause mortality (adjusted hazard ratio, aHR, per 10-point increase in WOMAC function score 1.04, 95% confidence interval, CI 1.01-1.07, p = 0.004; aHR per unit increase in HAQ walking score 1.30, 95% CI 1.22-1.39, p<0.001; and aHR for those using versus not using a walking aid 1.51, 95% CI 1.34-1.70, p<0.001). In survival analysis, censoring on death, risk of our composite CVD outcome was also significantly and independently associated with greater baseline walking disability ((aHR for use of a walking aid = 1.27, 95% CI 1.10-1.47, p = 0.001; aHR per unit increase in HAQ walking score = 1.17, 95% CI 1.08-1.27, p<0.001). CONCLUSIONS: Among individuals with hip and/or knee OA, severity of OA disability was associated with a significant increase in all-cause mortality and serious CVD events after controlling for multiple confounders. Research is needed to elucidate modifiable mechanisms.