- Title
- Telephone-based management for patients with osteoarthritis and other musculoskeletal conditions
- Creator
- O'Brien, Kate Maree
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2019
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Musculoskeletal conditions, including osteoarthritis of the knee or hip and spinal pain, are leading causes of global disability. Despite this, evidence suggests that the vast majority of patients with osteoarthritis and spinal pain do not receive care that is consistent with evidence-based clinical practice guidelines, including encouragement to engage in physical activity and support to lose weight. Two key barriers to the provision of guideline-recommended care are concerned with the accessibility of such care, and scalability of existing clinical models of care. Telephone-based models of care are a promising option to support patients with musculoskeletal conditions. While a number of trials investigating the use of telephone-based interventions for osteoarthritis and spinal pain have been published there remains uncertainty about the effectiveness and cost-effectiveness of telephone interventions for patients in this population group. In Chapter Two, a systematic review was conducted to assess the effectiveness of telephone-based interventions to support patients with osteoarthritis and spinal pain on pain intensity and disability. Seven electronic databases were searched for randomised controlled trials (RCTs) and non-randomised controlled trials that aimed to test the effectiveness of telephone-based interventions for patients with osteoarthritis and spinal pain. Twenty-three studies with a total of 4,994 participants were included. All included studies examined interventions focused on supporting self-management and providing education in addition to a range of intervention targets, for example, physical activity. The review found moderate-quality evidence that telephone-based interventions reduce pain intensity (n = 5 trials, n = 1,357 participants, standardised mean difference (SMD) -0.27, 95%CI:-0.53 -0.01, Tau2 = 0.06, I2 = 74%) and disability (n = 7 trials, n = 1,537 participants, SMD -0.21, 95%CI: -0.40 to -0.02, Tau2 = 0.03, I2 = 56%) compared to usual care. There was moderate-quality evidence that telephone plus face-to-face interventions are no more effective than face-to-face interventions alone. The results highlight the potential for telephone-based services to support osteoarthritis and spinal pain patients to access better quality care. All clinical practice guidelines for osteoarthritis recommend weight loss as a core treatment for patients with knee osteoarthritis. Despite these recommendations, few overweight patients with knee osteoarthritis receive care to support weight loss. There is evidence to support telephone-based approaches in achieving modest weight loss among overweight participants in the general population. Similarly, telephone-based interventions have been found to be effective in addressing behavioural determinants of weight, diet and physical activity in the general population. However, there are no previous studies primarily focused on the provision of weight loss care via telephone for patients with knee osteoarthritis. Chapters Three and Four presents an a priori protocol and statistical analysis plan for a high-quality pragmatic RCT testing the effectiveness of referring patients with knee osteoarthritis, who are overweight or obese, to an existing non-condition specific telephone-based weight loss intervention. Eligible patients (n=120) were randomly allocated to receive the weight loss intervention or usual care. Chapter Five presents the results of the trial and showed that there were no differences between groups for knee pain intensity over 6 months (area under the curve, mean difference 5.4, 95%CI: -13.7 to 24.5, p=0.58; equivalent to a 0.2 point difference on the pain intensity numerical rating scale 95%CI: -0.53 to 0.94) or weight change (the hypothesised mechanism to reduce pain intensity) at 6 months (self-reported weight; mean difference -0.4, 95%CI: -2.6 to 1.8, p=0.74). These results suggest that among patients with knee osteoarthritis who are overweight, telephone-based weight loss support, provided using an existing weight loss intervention might not adequately support patients with knee osteoarthritis to reduce knee pain intensity or weight. Given the scarce resources in healthcare, policy-makers are increasingly requiring evidence of economic value for healthcare interventions to make informed decisions about how to allocate resources. Therefore, undertaking economic evaluations of knee osteoarthritis management approaches is important. Chapter Six presents an economic evaluation of the RCT presented in Chapters Three, Four and Five. Quality-adjusted life years (QALYs) was the utility measure of effect and pain intensity, disability, weight, and BMI were the clinical measures of effect. Costs included intervention costs, healthcare utilisation costs (healthcare services and medication use) and absenteeism costs due to knee pain, collected using a patient self-reported inventory. The primary cost-effectiveness analysis was performed from the societal perspective, which accounted for a range of cost categories (intervention costs, healthcare utilisation costs and absenteeism costs due to knee pain). Mean cost differences between groups (intervention minus control) were $493 (95%CI: -3513 to 5363) for healthcare costs, $-32 (95%CI: -73 to 13) for medication costs, and $125 (95%CI: -151 to 486) for absenteeism costs. The total mean difference in societal costs was $1197 (95%CI: - 2887 to 6106). For QALYs and all clinical measures of effect, the probability of the intervention being cost-effective compared with usual care was less than 0.36 at all willingness-to-pay values. These findings suggest from a societal perspective referral to an existing non-condition specific telephone-based weight loss service was not a cost-effective relative to usual care for quality-adjusted life years (QALYs). Whilst the studies included in this thesis have advanced the evidence-base regarding the effectiveness of telephone-based interventions for the delivery of recommended care for patients with osteoarthritis and spinal pain, there remain a number of aspects that require further investigation. Specifically, although the systematic review found that telephone-based interventions should be considered for the management of osteoarthritis and spinal pain, the referral of patients with knee osteoarthritis patients who were overweight or obese to an existing telephone weight loss service was neither effective nor cost-effective despite offering a scalable, accessible option for the delivery of weight loss care. Given the high prevalence of osteoarthritis, and that excess weight is a key driver for the onset and progression of this condition; a dedicated line of research to understand how to best deliver weight loss support at scale is warranted. This research should focus on how to best integrate and optimise scalable, effective weight loss interventions into clinical practice; such that clinicians can embed this care into routine practice and improve outcomes for patients with osteoarthritis.
- Subject
- systemaic review; meta-analysis; lifestyle; telephone; randomised controlled trial; statistical analysis plan; weight loss; obesity; cost-effectiveness; thesis by publication; osteoarthritis; spinal pain; intervention; pain; disability; low back pain; knee
- Identifier
- http://hdl.handle.net/1959.13/1405176
- Identifier
- uon:35452
- Rights
- Copyright 2019 Kate Maree O'Brien
- Language
- eng
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Thesis | 10 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 109 KB | Adobe Acrobat PDF | View Details Download |