Implementing a structured model for osteoarthritis care in primary healthcare: A stepped-wedge cluster-randomised trial

Author summary Why was this study done? Hip and knee osteoarthritis is a common chronic joint disease in the adult population causing significant pain and disability. Non-surgical treatment modalities including patient osteoarthritis education, exercise therapy, and weight management represent core treatments recommended in professional guidelines. However, they are currently underutilised in people with hip and knee osteoarthritis. It is not established to what extent a structured osteoarthritis care model can change this and improve the quality of care. What did the researchers do and find? A cluster-randomised trial was conducted to compare a structured osteoarthritis care model with usual care with respect to appropriate care delivery in people with hip and knee osteoarthritis. Forty general practitioners and 37 physiotherapists working in primary care attended workshops to get an update on recommendations for osteoarthritis care and were trained in the core elements of the structured care model: osteoarthritis education in groups, an individually tailored 8- to 12-week exercise programme, and a dietary intervention, if needed. Of the 393 patient participants, 284 were allocated to the intervention group and 109 to the usual care group. At 6 months, patient-reported quality of care and satisfaction with care were greater, more patients were referred to physiotherapy and fewer to orthopaedic surgeons, and more patients fulfilled physical activity criteria in the intervention group as compared to the usual care group. What do these findings mean? A structured osteoarthritis care model provided by trained primary care general practitioners and physiotherapists resulted in the provision of osteoarthritis care that was more in line with current care recommendations and in higher patient-reported quality of care and satisfaction as compared to usual care. A structured and well-planned approach, in line with evidence-based treatment recommendations for hip and knee osteoarthritis and executed in primary care, has the potential to improve patients’ health and reduce disability. In doing so, it may also reduce the risk of sick leave and may thereby reduce the direct and indirect costs of osteoarthritis for the individual and the society. Although a stepped-wedge cluster-randomised controlled trial design is appropriate to conduct an effectiveness study in a clinical practice setting, strategies to prevent selection bias and differences in recruitment rates in the control and intervention periods are needed

The population genomic legacy of the second plague pandemic

SummaryHuman populations have been shaped by catastrophes that may have left long-lasting signatures in their genomes. One notable example is the second plague pandemic that entered Europe in ca. 1,347 CE and repeatedly returned for over 300 years, with typical village and town mortality estimated at 10%–40%.1 It is assumed that this high mortality affected the gene pools of these populations. First, local population crashes reduced genetic diversity. Second, a change in frequency is expected for sequence variants that may have affected survival or susceptibility to the etiologic agent (Yersinia pestis).2 Third, mass mortality might alter the local gene pools through its impact on subsequent migration patterns. We explored these factors using the Norwegian city of Trondheim as a model, by sequencing 54 genomes spanning three time periods: (1) prior to the plague striking Trondheim in 1,349 CE, (2) the 17th–19th century, and (3) the present. We find that the pandemic period shaped the gene pool by reducing long distance immigration, in particular from the British Isles, and inducing a bottleneck that reduced genetic diversity. Although we also observe an excess of large FST values at multiple loci in the genome, these are shaped by reference biases introduced by mapping our relatively low genome coverage degraded DNA to the reference genome. This implies that attempts to detect selection using ancient DNA (aDNA) datasets that vary by read length and depth of sequencing coverage may be particularly challenging until methods have been developed to account for the impact of differential reference bias on test statistics.Results and discussion STAR★Method

The population genomic legacy of the second plague pandemic

Human populations have been shaped by catastrophes that may have left long-lasting signatures in their genomes. One notable example is the second plague pandemic that entered Europe in ca. 1,347 CE and repeatedly returned for over 300 years, with typical village and town mortality estimated at 10%–40%.1 It is assumed that this high mortality affected the gene pools of these populations. First, local population crashes reduced genetic diversity. Second, a change in frequency is expected for sequence variants that may have affected survival or susceptibility to the etiologic agent (Yersinia pestis).2 Third, mass mortality might alter the local gene pools through its impact on subsequent migration patterns. We explored these factors using the Norwegian city of Trondheim as a model, by sequencing 54 genomes spanning three time periods: (1) prior to the plague striking Trondheim in 1,349 CE, (2) the 17th–19th century, and (3) the present. We find that the pandemic period shaped the gene pool by reducing long distance immigration, in particular from the British Isles, and inducing a bottleneck that reduced genetic diversity. Although we also observe an excess of large FST values at multiple loci in the genome, these are shaped by reference biases introduced by mapping our relatively low genome coverage degraded DNA to the reference genome. This implies that attempts to detect selection using ancient DNA (aDNA) datasets that vary by read length and depth of sequencing coverage may be particularly challenging until methods have been developed to account for the impact of differential reference bias on test statistics.publishedVersio

A STRUCTURED MODEL FOR OA CARE IN PRIMARY HEALTHCARE IS A COST-EFFECTIVE ALTERNATIVE COMPARED TO USUAL CARE FOR PEOPLE WITH HIP AND KNEE OA

To improve quality of care for patients with hip and knee osteoarthritis (OA), a structured model for integrated OA care was developed based on international treatment recommendations. A previous analysis of a cluster RCT (cRCT) showed that compared to usual care, the intervention group reported higher quality of care and greater satisfaction with care. Also, more patients were treated according to international guidelines and fulfilled recommendations for physical activity at the 6-month follow-up

Implementing international osteoarthritis guidelines in an integrated care model – results from a cluster randomized controlled trial

Purpose: Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care has been developed. The main aim of the study was to assess the effectiveness and feasibility of a tailored strategy to implement the SAMBA model for integrated OA care in Norway.Methods: A cluster randomized controlled trial with stepped wedge cohort design was conducted in six municipalities (clusters). The SAMBA model was implemented in one municipality at the time by switching from “usual care” to the new SAMBA model. The implementation strategy was based on interactive workshops for general practitioners (GPs), physiotherapists (PTs) and orthopaedic surgeon in addition to educational material, educational outreach visits, feedback, and reminder material. The workshops included an update on current OA treatment recommendations and facilitated multidisciplinary (GP and PT) and multilevel collaboration (GP and orthopaedic surgeon). The GPs informed the patients about OA and treatment alternatives and referred the patients to PT. The PTs regularly arranged OA patient education programmes followed by twice weekly group exercise sessions for 8–12 weeks. Patient participants, people with hip and/or knee OA, completed questionnaires at baseline and at 3-, 6-, 9- and 12-months follow-ups. The primary outcome measure was patient-reported quality of care at the 6-months follow-up. It was measured with the OsteoArthritis Quality Indicator questionnaire that includes 16 quality indicators (QIs) related to OA patient education and information, regular provider assessments, referrals, and pharmacological treatment. Secondary outcomes included referrals to PT, MRI, and orthopaedic surgeon as well as patient satisfaction with care, overweight and fulfillment of physical activity recommendations (eg. >75 min hard/>150 min moderate activity per week). Register data on referrals are not yet available, so the results are based on analyses of patient-reported number of referrals. Data was analysed with longitudinal multilevel mixed-models adjusted for time and with Chi-square analyses.Results: 40 of 79 invited GPs and 37 of 87 invited PTs attended the workshops. Of 531 patients, 393 fulfilled the inclusion criteria and were included in the control (n = 109) or the intervention group (n = 284). In total 9 multidisciplinary workshops and 27 OA patient education programmes and exercise groups were initiated. At baseline achievement of QIs for OA care for the two groups were similar (39% vs 37%), but at the 6-month follow-up, the intervention group achieved a significantly (B: 19.9 95% CI 13.7, 26.0) higher achievement rate (60% vs 41%) indicating better quality of care compared to the control group. Compared to the control group, a larger proportion in the intervention group was referred to PT (OR 2.5 95% CI 1.1, 5.7) and a smaller proportion to orthopaedic surgeon (OR 0.3 95% CI 0.1, 0.9) at the 3- and 6-month follow-ups, respectively. The proportion of patients with MRI referrals and the proportion of patients with overweight were similar across the two groups at all time points. The intervention group reported significantly higher satisfaction with care (X2: 54.1, p< 0.001) and a larger proportion (X2: 14.1, p = 0.001) met the recommendations for physical activity level compared to the control group at the 6-month follow-up.Conclusions: The implementation strategy for the SAMBA model led to improved quality of care, higher patient satisfaction with care and higher physical activity levels among the patient participants. The implementation strategy with multidisciplinary workshops may be implemented in more municipalities and can be adjusted to fit other patient groups