J. Eyles1, S. Redman2, G. Dawson2, S. Newell2, J. Bowden1, M. Williams3, K. Foster4, X. Wang1, L. Melo2, M. Dório5, D. Hunter1,6
1The University of Sydney, Faculty of Medicine & Health, Kolling Institute of Medical Research, Sydney, Australia, 2The Sax Institute, Sydney, Australia, 3Royal North Shore Hospital, Physiotherapy, Sydney, Australia, 4University of Queensland, Office of Medical Education, Brisbane, Australia, 5Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Division of Rheumatology, São Paulo, Brazil, 6Royal North Shore Hospital, Rheumatology, Sydney, Australia

Background: The Osteoarthritis Chronic Care Program (OACCP) aims to reduce pain, improve function and quality of life of people with hip and knee osteoarthritis through the provision of evidence-based care by a multidisciplinary team, led and coordinated by a physiotherapist. The OACCP was developed and piloted by the Agency for Clinical Innovation from 2009 and has been scaled out to all public hospitals across New South Wales (NSW), Australia. There is substantial variation regarding implementation within and between existing sites.

Purpose: Our primary aim was to identify and understand the perceived barriers and enablers to OACCP implementation. Our secondary aim was to identify professional education and training priorities.

Methods: NSW OACCP coordinators (physiotherapists) from 16 established sites were invited to participate in this cross-sectional mixed methods study. Semi-structured interviews were recorded, transcribed and analysed thematically by two researchers. Using a theory-driven approach based on a systematic review we identified system, staff, and intervention barriers and enablers to implementation of hospital-based interventions (Geerlings, 2018). One week later, participants completed the modified Hennessy-Hicks Training Needs Analysis Questionnaire with questions about key functions of their role, perceptions of their professional performance, education and training needs.

Results: Recruitment of coordinators continued until thematic saturation was reached. Sixteen coordinators from 14 hospitals participated (9 females, mean OACCP experience 40 months, aged 42 years). Perceived enablers of OACCP implementation included:
  1. system-level: remotely-delivered OACCP capability; clinical champions and stakeholder support; data management and reporting/evaluation capability,
  2. staff-level: interdisciplinary sharing of clinical roles; discrete skill sets of multidisciplinary teams; ability to establish a strong therapeutic alliance,
  3. intervention-level: behaviour change techniques training for multidisciplinary team; group exercise/education/nutrition sessions; patient educational resources. 
Commonly perceived barriers to implementation of the OACCP included-
  1. system-level: referral pathways from joint replacement waitlists were sub-optimal; physical space and accessibility; lack of data management systems; understaffing; variations in funding/resources between sites,
  2. staff-level: work beyond physiotherapy scope; lack of clinical expertise and multidisciplinary support (e.g. weight-loss and medications),
  3. intervention-level: participant attitudes, beliefs, motivation, adherence, and difficult conversations regarding OA treatments (e.g. weight loss, counseling); lengthy, fixed periods between follow-ups; high administrative burden.
Survey results found coordinators believed OACCP implementation performance improvement could be delivered by training alone (versus system-level changes). The following perceived training needs were identified:
  1. professional performance self-appraisal;
  2. critical appraisal of research; 
  3. areas for future quality improvement/research; 
  4. participant psychosocial needs assessment;
  5. translating research evidence into practice;
  6. time management skills.
Coordinators identified important topics for professional education/training including pain medications, injectables and dietary supplements; health coaching for participant motivation/adherence; pain coping skills; collecting & reporting clinical data; review of latest evidence for OA management; comorbidity management. Preferences for professional education included: asynchronous online modules, videos/presentations, live online interactive workshops.

Conclusion(s): Physiotherapists identified intervention, system and staff-level barriers and enablers to implementation of OACCP and outlined topics for future education/training.

Implications: It is interesting that despite identifying a number of system level barriers in the interviews, coordinators felt education and training were most important to improving OACCP. This work informs the development of strategies to address barriers to implementation, gaps in knowledge and skills.

Funding, acknowledgements: This work was funded by a Rapid Applied Research Translation grant, Australian Government, Department of Health.

Keywords: implementation, osteoarthritis, education

Topic: Research methodology, knowledge translation & implementation science

Did this work require ethics approval? Yes
Institution: Northern Sydney Local Health District
Committee: Human Research Ethics Committee
Ethics number: RESP/18/128; HREC/16/HAWKE/430

All authors, affiliations and abstracts have been published as submitted.

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