ObjectivesThe present study investigated (1) trends in the prevalence and incidence of knee osteoarthritis over a 20-year period (1996–2015); (2) trends in multimorbidity and (3) trends in drug ...prescriptions.DesignRegistry-based study.SettingPrimary healthcare, Flanders, Belgium.ParticipantsData were collected from Intego, a general practice-based morbidity registration network. In the study period between 1996 and 2015, data from 440 140 unique patients were available.Outcome measuresTrends in prevalence and incidence rate of knee osteoarthritis were computed using joinpoint regression analysis. The mean disease count was calculated to assess trends in multimorbidity. In addition, the number of drug prescriptions was identified by the Anatomical Therapeutic Chemical Classification code and trends were equally recorded with joinpoint regression.ResultsThe total age-standardised prevalence of knee osteoarthritis increased from 2.0% in 1996 to 3.6% in 2015. An upward trend was observed with an average annual percentage change (AAPC) of 2.5 (95% CI 2.2 to 2.9). In 2015, the prevalence rates in the 10 year age groups from the 45–54 years age group onwards were 3.1%, 5.6%, 9.0% and 13.9%, to reach 15.0% in people aged 85 years and older. The incidence remained stable with 3.75‰ in 2015 (AAPC=−0.5, 95% CI −1.4 to 0.5). The mean disease count significantly increased from 1.63 to 2.34 (p<0.001) for incident cases with knee osteoarthritis. Finally, we observed a significantly positive trend in the overall prescription of acetaminophen (AAPC=6.7, 95% CI 5.6 to 7.7), weak opioids (AAPC=4.0, 95% CI 0.9 to 7.3) and glucosamine (AAPC=8.6, 95% CI 2.4 to 15.1). Oral non-steroidal anti-inflammatory drugs were most prescribed, with a prevalence rate of 29.8% in 2015, but remained stable during the study period (AAPC=0.0, 95% CI −1.1 to 1.1).ConclusionsIncreased prevalence, multimorbidity, and number of drug prescriptions confirm an increased burden of knee osteoarthritis. In future, these trends can be used to prioritise initiatives for improvement in care.
Computerised clinical decision support (CDS) can potentially better inform decisions, and it can help with the management of information overload. It is perceived to be a key component of a learning ...health care system. Despite its increasing implementation worldwide, it remains uncertain why the effect of CDS varies and which factors make CDS more effective.
To examine which factors make CDS strategies more effective on a number of outcomes, including adherence to recommended practice, patient outcome measures, economic measures, provider or patient satisfaction, and medical decision quality.
We identified randomised controlled trials, non-randomised trials, and controlled before-and-after studies that directly compared CDS implementation with a given factor to CDS without that factor by searching CENTRAL, MEDLINE, EMBASE, and CINAHL and checking reference lists of relevant studies. We considered CDS with any objective for any condition in any healthcare setting. We included CDS interventions that were either displayed on screen or provided on paper and that were directed at healthcare professionals or targeted at both professionals and patients. The reviewers screened the potentially relevant studies in duplicate. They extracted data and assessed risk of bias in independent pairs or individually followed by a double check by another reviewer. We summarised results using medians and interquartile ranges and rated our certainty in the evidence using the GRADE system.
We identified 66 head-to-head trials that we synthesised across 14 comparisons of CDS intervention factors. Providing CDS automatically versus on demand led to large improvements in adherence. Displaying CDS on-screen versus on paper led to moderate improvements and making CDS more versus less patient-specific improved adherence modestly. When CDS interventions were combined with professional-oriented strategies, combined with patient-oriented strategies, or combined with staff-oriented strategies, then adherence improved slightly. Providing CDS to patients slightly increased adherence versus CDS aimed at the healthcare provider only. Making CDS advice more explicit and requiring users to respond to the advice made little or no difference. The CDS intervention factors made little or no difference to patient outcomes. The results for economic outcomes and satisfaction outcomes were sparse.
Multiple factors may affect the success of CDS interventions. CDS may be more effective when the advice is provided automatically and displayed on-screen and when the suggestions are more patient-specific. CDS interventions combined with other strategies probably also improves adherence. Providing CDS directly to patients may also positively affect adherence. The certainty of the evidence was low to moderate for all factors.
PROSPERO, CRD42016033738.
Knee osteoarthritis is a common problem, but often underdiagnosed and undertreated in primary care as compared to evidence-based guidelines. Educational outreach visits are an effective strategy to ...improve guideline adherence, but its contribution to knee osteoarthritis management is largely unknown. The aim of this study was to evaluate the overall effectiveness of educational outreach visits on process quality indicators for knee osteoarthritis management, more specifically on the referral for physical therapy.
An educational intervention study, non-randomized and controlled, was designed for general practitioners (GPs) in Belgium. During four months, 426 GPs were visited by academic detailers and allocated to the intervention group. The control group was selected from GPs not visited by academic detailers during the study period. Six months post-intervention, both groups received a questionnaire with two case-vignettes to measure the effectiveness of the educational outreach. Outcomes were assessed with a Belgian set of quality indicators for knee osteoarthritis management and focused on the number of prescriptions for appropriate physical therapy (i.e. muscle strengthening, aerobic, functional or range of motion exercises) and the adherence to eight additional quality indicators related to knee osteoarthritis management. For the analysis, multivariable logistic regression models were used and Generalized Estimating Equations to handle the correlation between the multiple results per GP.
The intervention group showed a tendency to prescribe more frequently at least one appropriate physical therapy for a case (43.8%), compared to the control group (31.3%, p = 0.057). Muscle strengthening exercises were the most frequently prescribed therapy with 37.0% in the intervention versus 26.9% in the control group. The adherence to the other quality indicators showed no significant difference between the intervention and control group and varied between 8.9 and 100% in the intervention group.
This intervention did not alter significantly the adherence to quality indicators and in particular the probability of prescribing physical therapy. To change general practitioners' prescription behavior, more extensive or combined interventional approaches seem warranted.
Abstract
Purpose
The aim of this systematic review was (i) to assess whether electronic audit and feedback (A&F) is effective in primary care and (ii) to evaluate important features concerning ...content and delivery of the feedback in primary care, including the use of benchmarks, the frequency of feedback, the cognitive load of feedback and the evidence-based aspects of the feedback.
Data sources
The MEDLINE, Embase, CINAHL and CENTRAL databases were searched for articles published since 2010 by replicating the search strategy used in the last Cochrane review on A&F.
Study selection
Two independent reviewers assessed the records for their eligibility, performed the data extraction and evaluated the risk of bias. Our search resulted in 8744 records, including the 140 randomized controlled trials (RCTs) from the last Cochrane Review. The full texts of 431 articles were assessed to determine their eligibility. Finally, 29 articles were included.
Data extraction
Two independent reviewers extracted standard data, data on the effectiveness and outcomes of the interventions, data on the kind of electronic feedback (static versus interactive) and data on the aforementioned feedback features.
Results of data synthesis
Twenty-two studies (76%) showed that electronic A&F was effective. All interventions targeting medication safety, preventive medicine, cholesterol management and depression showed an effect. Approximately 70% of the included studies used benchmarks and high-quality evidence in the content of the feedback. In almost half of the studies, the cognitive load of feedback was not reported. Due to high heterogeneity in the results, no meta-analysis was performed.
Conclusion
This systematic review included 29 articles examining electronic A&F interventions in primary care, and 76% of the interventions were effective. Our findings suggest electronic A&F is effective in primary care for different conditions such as medication safety and preventive medicine. Some of the benefits of electronic A&F include its scalability and the potential to be cost effective. The use of benchmarks as comparators and feedback based on high-quality evidence are widely used and important features of electronic feedback in primary care. However, other important features such as the cognitive load of feedback and the frequency of feedback provision are poorly described in the design of many electronic A&F intervention, indicating that a better description or implementation of these features is needed. Developing a framework or methodology for automated A&F interventions in primary care could be useful for future research.
Rationale, aims and objectives
Guidelines for patients with knee osteoarthritis (OA) are suboptimally implemented in clinical care. To improve guideline adherence, patients' perceived barriers and ...facilitators in current care were investigated.
Methods
Eleven patients with knee OA were extensively interviewed using a semistructured script based on quality indicators. Directed content analysis, within the framework of Grol and Wensing, was performed to describe barriers and facilitators in 6 domains: guideline, health care professional, patient, social environment, organization, and financial context. Data were analyzed using NVIVO 10 software.
Results
In total, 38 barriers, at all 6 domains, were identified. The most frequently mentioned barriers were in the domains of the patient and the health care professional, namely, patients' disagreement with guidelines recommendations, negative experience with drugs, patients' limited comprehension of the disease process, and poor communication by the health care professional. The patients' disagreement with recommendations is further explained by the following barriers: “insistence on medical imaging,” “fear that physiotherapy aggravates pain,” and “perception that knee OA is not a priority health issue”. Patients also reported 20 facilitators, all of which are listed as opposing barriers.
Conclusions
Patients indicate that both personal factors and factors related to health care professionals play an important role in nonadherence. An interview script, based on quality indicators, was a significant aid to structurally formulate barriers and facilitators in the perceived knee OA care. Future guideline implementation strategies should take the identified barriers and facilitators into account.
Computerised decision support (CDS) based on trustworthy clinical guidelines is a key component of a learning healthcare system. Research shows that the effectiveness of CDS is mixed. Multifaceted ...context, system, recommendation and implementation factors may potentially affect the success of CDS interventions. This paper describes the development of a checklist that is intended to support professionals to implement CDS successfully.
We developed the checklist through an iterative process that involved a systematic review of evidence and frameworks, a synthesis of the success factors identified in the review, feedback from an international expert panel that evaluated the checklist in relation to a list of desirable framework attributes, consultations with patients and healthcare consumers and pilot testing of the checklist.
We screened 5347 papers and selected 71 papers with relevant information on success factors for guideline-based CDS. From the selected papers, we developed a 16-factor checklist that is divided in four domains, i.e. the CDS context, content, system and implementation domains. The panel of experts evaluated the checklist positively as an instrument that could support people implementing guideline-based CDS across a wide range of settings globally. Patients and healthcare consumers identified guideline-based CDS as an important quality improvement intervention and perceived the GUIDES checklist as a suitable and useful strategy.
The GUIDES checklist can support professionals in considering the factors that affect the success of CDS interventions. It may facilitate a deeper and more accurate understanding of the factors shaping CDS effectiveness. Relying on a structured approach may prevent that important factors are missed.
Objective
To describe the quality of osteoarthritis care in general practice from a patient’s perspective and to identify novel associations between process quality indicators and patient‐reported ...outcome and experience measures.
Methods
For this study, 235 individuals with knee osteoarthritis completed a survey based on both process and outcome indicators. Process indicators were extracted from international guidelines and included the domains: diagnosis, self‐management, treatment, and follow‐up. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and RAND 36‐item Short Form health survey (SF‐36) were used to assess patient‐reported outcomes. Patient‐reported experience with care was evaluated with the European Task Force on Patient Evaluations of General Practice Care (EUROPEP) instrument. A series of multilevel regression analyses were then performed to analyze determinants at the patient level (i.e., age, sex, body mass index, and education) and associations between process and outcome indicators.
Results
Overall, low adherence to the process indicators was observed (38%), particularly on informing patients about the importance of weight loss (24% 95% confidence interval (95% CI) 19–31) or referring them for physical therapy (41% 95% CI 33–49). Patients described their quality of life as moderate, with an overall score of 63% and 35% on the SF‐36 and WOMAC surveys, respectively. Regarding the determinants, patients with a higher education level were better informed (odds ratio OR 3.4; P = 0.0003). Associations between process and outcome indicators were scarce, with the exception of patient satisfaction with care and use of nonsteroidal antiinflammatory drugs (NSAIDs) (OR 2.9; P = 0.0014).
Conclusion
Patients with knee osteoarthritis receive suboptimal conservative management. They report a moderate quality of life. This study confirms the evidence suggesting that NSAIDs are the backbone of osteoarthritis pain management but also adds evidence from a patient’s perspective.
Clinical practice patterns greatly diverge from evidence-based recommendations to manage knee osteoarthritis conservatively before resorting to surgery.
This study aimed to tailor a guideline-based ...computerized decision support (CDS) intervention that facilitates the conservative management of knee osteoarthritis.
Experts with backgrounds in clinical medicine, research, implementation, or health informatics suggested the most important recommendations for implementation, how to develop an implementation strategy, and how to form the CDS algorithms. In 6 focus group sessions, 8 general practitioners and 22 patients from Norway, Belgium, and Finland discussed the suggested CDS intervention and identified factors that would be most critical for the success of the intervention. The focus group moderators used the GUideline Implementation with DEcision Support checklist, which we developed to support consideration of CDS success factors.
The experts prioritized 9 out of 22 recommendations for implementation. We formed the concept for 6 CDS algorithms to support implementation of these recommendations. The focus group suggested 59 unique factors that could affect the success of the presented CDS intervention. Five factors (out of the 59) were prioritized by focus group participants in every country, including the perceived potential to address the information needs of both patients and general practitioners; the credibility of CDS information; the timing of CDS for patients; and the need for personal dialogue about CDS between the general practitioner and the patient.
The focus group participants supported the CDS intervention as a tool to improve the quality of care for patients with knee osteoarthritis through shared, evidence-based decision making. We aim to develop and implement the CDS based on these study results. Future research should address optimal ways to (1) provide patient-directed CDS, (2) enable more patient-specific CDS within the context of patient complexity, and (3) maintain user engagement with CDS over time.
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