Transcript Physiotherapy management of osteoarthritis

The long wait for joint replacement surgery and
opportunities for improving the system
Dr Ilana Ackerman
NHMRC Public Health Research Fellow
Centre for Rheumatic Diseases
Department of Medicine, Royal Melbourne Hospital
The University of Melbourne
Background
• Joint replacements are effective interventions
• over 60,000 procedures performed annually (AOA 2007)
• number of procedures has doubled over past 11 years
• most are performed for OA
• Large public hospital waiting lists
• increasing demand for surgery
• likely to be a major problem in the years ahead
• ageing population
• increasing risk factors for OA
• limited public health care budgets
Impairments associated with osteoarthritis
Depression
Pain
Psychosocial
Anxiety
Muscle weakness
Altered muscle
activation
Stiffness
Joint laxity
Physical
impairments
Co-morbidities
Swelling
Joint malalignment
Balance impairment
Reduced physical function
Cardiovascular
deconditioning
Reduced quality of life
Health-Related Quality of Life while waiting for surgery
Group
n
Mean AQoL
score
SD
214
0.39
0.23
93
0.40
0.33
Community-dwelling OA
(Segal et al 2004)
158
0.52
0.22
General population
(Hawthorne & Osborne 2005)
2934
0.83
0.20
RMH orthopaedic waiting list
Recent stroke (Sturm et al 2002)
Ackerman IN, Graves SE, Wicks IP, Bennell KL, Osborne RH (2005), Arthritis Care & Research
Health-Related Quality of Life while waiting for surgery
Group
n
Mean AQoL
score
SD
214
0.39
0.23
93
0.40
0.33
Community-dwelling OA
(Segal et al 2004)
158
0.52
0.22
General population
(Hawthorne & Osborne 2005)
2934
0.83
0.20
RMH orthopaedic waiting list
Recent stroke (Sturm et al 2002)
Ackerman IN, Graves SE, Wicks IP, Bennell KL, Osborne RH (2005), Arthritis Care & Research
Health-Related Quality of Life while waiting for surgery
Group
n
Mean AQoL
score
SD
214
0.39
0.23
93
0.40
0.33
Community-dwelling OA
(Segal et al 2004)
158
0.52
0.22
General population
(Hawthorne & Osborne 2005)
2934
0.83
0.20
RMH orthopaedic waiting list
Recent stroke (Sturm et al 2002)
Ackerman IN, Graves SE, Wicks IP, Bennell KL, Osborne RH (2005), Arthritis Care & Research
Health-Related Quality of Life while waiting for surgery
Group
n
Mean AQoL
score
SD
214
0.39
0.23
93
0.40
0.33
Community-dwelling OA
(Segal et al 2004)
158
0.52
0.22
General population
(Hawthorne & Osborne 2005)
2934
0.83
0.20
RMH orthopaedic waiting list
Recent stroke (Sturm et al 2002)
Ackerman IN, Graves SE, Wicks IP, Bennell KL, Osborne RH (2005), Arthritis Care & Research
Magnitude of the problem
Ackerman et al (2005), Arthritis Care & Research
Psychological distress while waiting for surgery
90
Victorian population data (>65 years)
80
Frequency (%)
70
Victorian population data (all age groups)
60
OWL (baseline)
50
40
30
20
10
0
<16 (low)
16-21
22-29 (high)
30-50 (very high)
Kessler (K10) Psychological Distress scale score
Prevalence of high distress while waiting for surgery
Age
group
Waiting list
Population*
RR
95% CI
K10 ≥ 22†
K10 ≥ 22†
n
%
n
%
<55
13
42.0
586
11.5
3.6
2.4 to 5.6
55-64
14
33.3
76
7.4
4.5
2.8 to 7.3
65-74
24
29.0
54
6.7
4.4
2.8 to 6.7
≥75
19
32.7
30
6.0
5.4
3.3 to 9.0
* Department of Human Services (2002),Victorian Population Health Survey, N =7500
† High or very high psychological distress
Ackerman et al (2005)
Further deterioration while waiting
• 134 patients assessed at baseline and preadmission
• median wait for surgery was 9 months
• some patients waited up to 3 years
• small but clinically important deterioration in HRQoL
• minimal use of health professional or community
services
An international comparison
F=8.44, p<0.01
Ackerman IN, Dieppe PA, March LM, Roos EM, Nilsdotter AK, Brown
G, Sloan K, Osborne RH (in press), Arthritis Care & Research
Causes for concern
• poor pre-operative wellbeing
• long waiting times for surgery
• priority for surgery not always determined according to
clinical need
• minimal monitoring of patients on the OWL
• minimal use of allied health or community services
Time to improve the system
• The need for an evidence-based waiting list
prioritisation and management system
• To ensure equitable and timely access to treatment
for people with the greatest need
OWL Phase 1 (2004 - 2006)
• funding from the Victorian DHS
• development of a prioritisation tool (MAPT)
• consultation with patients and orthopaedic surgeons
• validation at 6 public hospitals
• tested on over 1000 patients
• translation into 12 languages
Assigning priority for surgery
OWL Phase 1 (2004 - 2006)
•
Design of a service delivery model
•
the OA Hip and Knee Service
•
establishment of musculoskeletal co-ordinators
•
early comprehensive assessment and monitoring
•
triage for orthopaedic assessment and management
•
education
• OA management including self-management
• available services
•
initiate appropriate conservative management
OWL Phase 2 (2006-2007)
• Successful pilot of OA Hip and Knee service
• 4 Victorian hospitals
• Melbourne Health
• St Vincent’s Health
• Barwon Health
• Peninsula Health
• involved system and workforce redesign
Important outcomes
• more appropriate use of limited orthopaedic services
• reduced waiting times for outpatient appointments
• conservative management was optimised
• up to 73% of patients referred for management
• more equitable access to care
• 13% fast-tracked due to urgent need for surgery
• 20% deferred and instead were monitored
• high patient satisfaction
Currently...
• OWL Phase 3 (2008-2009) is well underway
• state-wide implementation of the service
• 14 Victorian hospitals
• funding to set up musculoskeletal OWL Clinics
From evidence to care
Identification of the
problem
Changes in health
policy and health
care systems
Improved patient
care
More equitable access
to care
More patients getting
the right care sooner
Thank you