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Chronic disease management: Improving care for people with osteoarthritis

https://doi.org/10.1016/j.berh.2014.01.011Get rights and content

Abstract

Chronic disease management (CDM) service models are being developed for many conditions; however, there is limited evidence to support their effectiveness in osteoarthritis (OA). A systematic review was undertaken to examine effectiveness, cost effectiveness and barriers to the use of osteoarthritis-chronic disease management (OA-CDM) service models. Thirteen eligible studies (eight randomised controlled trial (RCTs)) were identified. The majority focussed on delivery system design (n = 9) and/or providing self-management support (SMS) (n = 8). Overall, reported model effectiveness varied, and where positive impacts on process or health outcomes were observed, they were of small to moderate effect. There was no information about cost effectiveness. There is some evidence to support the use of collaborative care/multidisciplinary case management models in primary and community care and evidence-based pathways/standardisation of care in hospital settings. Multiple barriers were identified. Future research should focus on identifying the effective components of multi-faceted interventions and evaluating cost-effectiveness to support clinical and policy decision-making.

Introduction

Chronic diseases such as osteoarthritis (OA) now constitute the greatest health burden in developed countries and are an increasing burden in developing countries. The growing disease burden associated with OA, the most common chronic arthritic condition, has been extensively reported [1], [2]. The rise of chronic disease in the late-20th and early-21st centuries has created challenges for the health system at all levels, as it is clear that services designed for acute episodic illnesses do not adequately meet the needs of people with chronic conditions [3]. Internationally, jurisdictions are developing chronic disease policies to drive reforms at the macro- (government), meso- (organisation) and micro-levels (practitioner/patient interface) to improve care outcomes (Fig. 1). These levels are not mutually exclusive, and significant challenges exist to align efforts in order to implement policy into practice [4], *[5], [6], [7].

New thinking about the management of chronic diseases has resulted in several terms being used in the literature to refer to similar concepts. These terms include ‘chronic disease management’ (CDM), ‘chronic care management’, ‘chronic condition management’ and ‘integrated care’. These terms reflect different stakeholder epistemological perspectives, and there has been a trend over time to move away from terms that focus on disease (considered potentially disempowering) towards more neutral terminology that focusses on the process of care experience (e.g., ‘integrated’, ‘collaborative’ or ‘co-ordinated care’). Acknowledging these terminology issues, the term ‘CDM’ will be used in this paper as it is likely to be more familiar to health professionals.

There are also many different definitions of what constitutes CDM, although the common elements of CDM definitions [8] include the following:

  • a systematic approach to planning care;

  • utilisation of potentially multiple treatment modalities with a focus on patient self-management support (SMS);

  • use of coordinated care across health-care providers and sectors; and/or

  • use of multidisciplinary teams.

Increasingly, policymakers are formalising CDM aims and components to assist service planning. For instance, the Institute of Medicine (IOM), in developing a policy document to address identified gaps in provision of high-quality health-care, recommended that health-care reform and redesign should be based on six specific quality improvement aims, such that care is designed to be safe, effective, patient-centred, timely, efficient and equitable [3].

In the health system, it may be useful to conceptualise CDM models as a bridge between policy and practice, frameworks that provide information on planning, implementation, evaluation and ongoing improvement. Confusion arises in CDM as the term ‘CDM model’ can be used to describe high-level broad conceptual frameworks (for instance, the Chronic Care Model [9], [10], Expanded Chronic Care Model [11] and the World Health Organisation Innovative Care for Chronic Conditions Model [7]) or to describe organisation and practice-level service delivery models. In this paper, we focus on meso-/micro-level CDM service models, of which there are many thousands in operation worldwide. [12] Some models consider tiered or step-wise management across a broad disease severity spectrum, based on risk assessment, whilst others focus only on populations with more advanced disease that are high users of health-care resources. Although the target population may differ, CDM service models often share key operational design elements based on the broader CDM frameworks described above, including health-care organisation and planning, decision support, delivery system design, SMS, clinical information systems and community resource partnerships (Table 1).

Appraising research about CDM for all chronic conditions is challenging due to the lack of common terminology relating to the definition of CDM as well as the use of different components of broad CDM frameworks and different service model strategies. Evaluations commonly cite marked heterogeneity between studies and inconsistencies in reported impacts, although positive impacts on patient health outcomes including hospital utilisation, quality of life (QoL), functional health, patient satisfaction and process outcomes have now been documented for a number of chronic conditions [13], [14], [15], [16], [17], *[18].

One systematic review has reported on the impacts of osteoarthritis-chronic disease management (OA-CDM) service models as part of a broader review of chronic disease programmes [18]. Zwar and colleagues classified CDM studies focussed on primary care service delivery by their inclusion of CDM components (Table 1) and assessed effectiveness in relation to patient outcomes and adherence to guidelines by health professionals [18]. Of the 145 included studies, only eight (5.5%) were OA-focussed. There were 12 interventions investigated within the eight studies, five/eight included one intervention, two/eight included two interventions and one/eight included three interventions. Overall, 11/12 interventions were SMS. The review found that across all studies, the most effective intervention was SMS, specifically, patient education and motivational counselling. Further, the most effective combination of CDM components was SMS and delivery system design, although OA studies did not include interventions in the latter category. Similar to earlier research [17], the number of CDM elements included in the studies (overall conditions) was not associated with improved outcomes, although strong conclusions could not be made given the relatively small number of model components. It is now pertinent to examine studies that have been published since this systematic review, in particular to identify if researchers have extended their scope of interest to other CDM domains, whether reported models are cost effective and what barriers exist to their implementation and sustainability.

Section snippets

Aims of the review

In this paper, we aim to update and review the evidence about the use and effectiveness of CDM models of care for OA and develop recommendations for future research and practice. In addressing this aim, we focussed on the following questions:

  • 1.

    What evidence is there that OA-CDM service models are effective and cost effective?

  • 2.

    What are the barriers to developing and implementing effective OA-CDM service models?

Literature search

To identify evidence for CDM in OA and the impact on patient outcomes, a systematic

Search results

Our search identified 2410 papers of potential relevance that were published between January 2006 and July/August 2013. After screening, 13 studies were considered eligible for inclusion in this review. Of these, eight utilised an RCT or cluster RCT design and five/eight were undertaken in primary or community care settings. PEDro scores for the included RCTs ranged from five to eight, indicating moderate to high trial quality [20].

Evidence for CDM

The included papers reported research into a range of

Discussion

A positive finding of this review is that there is ongoing interest in developing and testing new OA-CDM service models, particularly outside of hospitals, with five of eight RCTs being undertaken in primary care or other community settings *[22], [24], *[30], *[34], *[36]. There is also an increasing interest in evaluating interventions that incorporate delivery system design, in contrast to earlier research that tended to focus on SMS alone. However, there remains limited evidence for the

Summary

This paper has reviewed the effectiveness of CDM models for OA and explored barriers to developing and implementing effective models of care. Studies conducted in primary care, hospital-based and community settings have focussed on delivery system design and provision of SMS, with few studies incorporating decision support tools, clinical information systems or linkages to community resources. While study heterogeneity precludes strong conclusions about effectiveness, there is some evidence to

Conflict of interest statement

The authors declare that there are no conflicts of interest in relation to this paper.

Acknowledgements

Dr Ackerman is supported by a National Health and Medical Research Council of Australia Public Health (Australian) Early Career Fellowship (#520004).

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