To untangle the barriers and facilitators to implementation of a multidisciplinary screening clinic and patient uptake of non-surgical interventions.To untangle the barriers and facilitators to implementation of a multidisciplinary screening clinic and patient uptake of non-surgical interventions.
Design: Qualitative phenomenological inductive approach.
Interviews conducted in March 2023 were recorded, transcribed and de-identified. Interview themes were returned to participants for checking. The thematic analysis was augmented by a framework based on the aims of the project: to understand what was working well, what needed improvement, what a model of care would look like, and barriers and enablers to implementation of that model.
Participants: purposive sampling included patients (n=6), general practitioners (GPs) (n=7), surgeons and registrars (n=6), public community and acute service physiotherapists, and private physiotherapists (n=5), and CHS executive (n=5).
Working well
Patients, GPs and surgeons had high degree of confidence and satisfaction in, and recognition of APP expertise. Surgeons appreciated identification of patients who had exhausted non-surgical interventions and were ready for surgery. This face-to-face comprehensive assessment provided patients with confidence that they had been properly examined, had their voices heard and been assisted to navigate health systems to provide them with the best outcome.
Needs improving now
The lack of monitoring of patients, lack of reporting on patient caseload and waiting times, and extensive waits to see a surgeon and have surgery, were leading to poor patient journeys, and high-risk situations for patients and surgical teams. The ‘silent wait list’ and the patient journey was described by surgeons as ‘utterly hopeless’.
Model of care
Key principles identified by participants included the importance of non-surgical management as first line of care and managing patients at the right time and place, equitable access to care, and efficient transition between services.
Barriers and enablers
A critical barrier to patients receiving non-surgical care was community attitude that KOA equates to needing a knee replacement. A further barrier was the extended wait list, which included those not needing surgery. The lack of qualified advanced practice allied health practitioners means that models of care that rely on them cannot be rolled out. Funding models (Medicare fee for (medical) service) also acts as a barrier to change.
There was widespread support of an APP led osteoarthritis clinic. Barriers to patients receiving best practice care were both community and structural but can be overcome with planning and political will.
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We recommend adequate resourcing of APPs in the orthopaedic service to see all referred patients; establishment a community multidisciplinary osteoarthritis clinic led by APP and supported by other allied health, enabled to review and refer to orthopaedic surgeons; provision of infrastructure to report on service loads and wait times; and a community wide KOA public health education program.
patient journey
