National osteoarthritis strategy brief report: Advanced care.

This article is part three in a three-part series on the National Osteoarthritis Strategy. Background Osteoarthritis (OA) is one of the most common chronic joint diseases and a leading cause of pain and disability in Australia. A National Osteoarthritis Strategy (the Strategy) was developed to outline a national plan to achieve optimal health outcomes for people at risk of, or with, OA. Objective This article focuses on the theme of advanced care of patients with OA within the Strategy. Strategy was developed group, working groups, an implementation committee, the public. This Strategy identified three priorities in advanced care for osteoarthritis. In brief, these include surgical decision making, for evidence-informed non-surgical alternatives and surgical services. A set of goals within these priority areas and strategies was also proposed by the working group in consultation with stakeholders nationwide. Peak arthritis bodies and major healthcare professional associations the


Background
Osteoarthritis (OA) is one of the most common chronic joint diseases and a leading cause of pain and disability in Australia. A National Osteoarthritis Strategy (the Strategy) was developed to outline a national plan to achieve optimal health outcomes for people at risk of, or with, OA.

Objective
This article focuses on the theme of advanced care of patients with OA within the Strategy.

Discussion
The Strategy was developed in consultation with a leadership group, thematic working groups, an implementation advisory committee, multisectoral stakeholders and the public. This Strategy identified three priorities in advanced care for osteoarthritis. In brief, these include surgical decision making, referral for evidence-informed non-surgical alternatives and surgical services. A set of goals within these priority areas and strategies was also proposed by the working group in consultation with stakeholders nationwide. Peak arthritis bodies and major healthcare professional associations currently endorse the Strategy. OSTEOARTHRITIS (OA) is the most common chronic joint condition globally and in Australia: one in five Australians over the age of 45 years have OA. 1 Nevertheless, the care that patients receive in Australia is fragmented and, in some cases, inappropriate. The National OA Strategy (the Strategy) informs how to better coordinate existing limited health services and deliver more effective and appropriate care. The aim of the Strategy is to outline Australia's national response to OA, covering three thematic areas: 'prevention', 'living well with OA' and 'advanced care'. The methods of developing the Strategy are detailed in part one of the Strategy series. 2 The second part of this series focuses on priorities for action for people living with OA. 3 This article, part three, focuses on 'advanced care'.

Limitations of existing decision aids and selection of patients
Total joint replacement (TJR) surgery should be indicated on the basis of evidence-based criteria and only undertaken when appropriate non-operative strategies have failed. Currently, up to one-quarter of TJR surgeries are performed on inappropriate candidates, 4 and there are very few predictive tools to help the referring practitioners, especially general practitioners (GPs), determine which patients are likely to be good or poor responders to surgery. According to previous patient selection criteria for the appropriateness of TJR, 20-45% of the patients were considered 'uncertain'; 5 therefore, these tools are difficult to use in daily practice. Most orthopaedic surgeons recognise the need for a decision aid embedded with effective communication tools to facilitate shared decision making with patients and other care providers across disciplines. 6 However, there are concerns about the use of mandatory cut-off points for patient-reported outcomes and the medico-legal implications of using such decision aids. 7 In addition, an audit to evaluate clinical effectiveness and collect user feedback of the decision aid may be necessary for surgeons to gain confidence in its legitimacy.

Perceived insufficient non-operative alternatives
There is a perceived lack of non-operative alternatives for the management of severe OA by Australian surgeons. 7 Despite studies showing pre-operative physiotherapy 8 -consisting of structured patient education, exercise and weight loss programs 9 -significantly reduced joint symptoms in people with knee/ hip OA awaiting TJR, the uptake of pre-operative interventions remains low in Australia. A survey showed only 20% of people on orthopaedic waitlists have tried exercise or weight loss within the preceding five years before being placed on the waiting list (MD & PC, unpublished data). There is a substantial need for clinicians to provide or refer to optimal conservative care National osteoarthritis strategy brief report Advanced care as per evidence-based guidelines 10,11 pre-operatively, even after a patient has been scheduled for surgery (refer to part two of the Strategy series on 'living well with OA' for examples of existing non-surgical OA management services). 3

Issues with the waiting list for joint replacement
A key priority for the Commonwealth Government is to provide timely access to TJR surgery for OA. However, several challenges exist, such as difficulty in obtaining appropriate surgical referrals, long waiting periods and limited availability of specialists in remote areas. The current three-tiered (urgent, semi-urgent and non-urgent) TJR surgery priority system is relatively unstructured and insensitive to the individual's need. 12 Several tools have been developed for the determination of clinical urgency of TJR for people with OA, but the validity and reliability warrant further investigation. For example, the Western Canada Waiting List Project tested a TJR priority criteria tool showing the high and low categories of urgency were well discriminated; however, an overlap was found between adjacent urgency categories. 13 An Australian Multi-attribute Arthritis Prioritisation Tool (MAPT) was used in Victoria, but evidence shows that the MAPT score was not well associated with radiographic severity of OA and waitlist priority category. 14 Additionally, patients waiting for surgery should be routinely reviewed by GPs and surgeons as appropriate to detect and prevent potential rapid physical or psychological deteriorations. 15

Priorities and strategic responses
The evidence provided in the previous section served as the evidence basis for the determination of priority areas of the Strategy. Three priorities have been identified by the advanced care working group. Actionable strategies to address the priorities and achieve the proposed impact (goals) are proposed on the basis of the Consolidated Framework for Implementation Research (CFIR; Figure 1). 16 The OA Strategy leadership group are currently developing business plans for each of the key strategies and initiating advocacy work with major organisations (eg Department of Health, Arthritis Australia, Sport Australia) to facilitate the implementation of the key actions.
The full document including detailed implementation plans for each  17  1. Evaluate and audit existing non-surgical osteoarthritis programs to replicate and promote evidence-based models of care involving primary care and allied health 2. Ensure non-surgical management is available for people who are not suitable joint replacement candidates and promoted by institutional healthcare providers 3. Consult with and seek support from primary care to develop strategies and pathways for community-based service delivery for people with osteoarthritis III. Implement standardised clinical pathway for osteoarthritis surgical management Actions: 1. Perform multidisciplinary pre-surgery assessments to identify possible surgical risk factors and inform discharge planning 2. Monitor patients' statuses while on a surgical wait list using an appropriate simple tool to identify patients who are deteriorating rapidly and should be fast-tracked for surgery 3. Emphasise discharge to the home environment where access to appropriate postoperative care services is available Goals Improve surgical decision making Improve surgical services