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Background Culminating evidence shows that current care does not optimally meet the needs of persons with parkinsonism, their carers and healthcare professionals. Recently, a new model of care was developed to address the limitations of usual care: Proactive and Integrated Management and Empowerment in Parkinson’s Disease (PRIME Parkinson). From 2021 onwards, PRIME Parkinson care will replace usual care in a well-defined region in The Netherlands. The utility of PRIME Parkinson care will be evaluated on a single primary endpoint (parkinsonism-related complications), which reflects the health of people with parkinsonism. Furthermore, several secondary endpoints will be measured for four dimensions: health, patient and carer experience, healthcare professional experience, and cost of healthcare. The reference will be usual care, which will be continued in other regions in The Netherlands. Methods This is a prospective observational study which will run from January 1, 2020 until December 31, 2023. Before the new model of care will replace the usual care in the PRIME Parkinson care region all baseline assessments will take place. Outcomes will be informed by two data sources. We will use healthcare claims-based data to evaluate the primary endpoint, and costs of healthcare, in all persons with parkinsonism receiving PRIME Parkinson care (estimated number: 2,000) and all persons with parkinsonism receiving usual care in the other parts of The Netherlands (estimated number: 48,000). We will also evaluate secondary endpoints by performing annual questionnaire-based assessments. These assessments will be administered to a subsample across both regions (estimated numbers: 1,200 persons with parkinsonism, 600 carers and 250 healthcare professionals). Discussion This prospective cohort study will evaluate the utility of a novel integrated model of care for persons with parkinsonism in The Netherlands. We anticipate that the results of this study will also provide insight for the delivery of care to persons with parkinsonism in other regions and may inform the design of a similar model for other chronic health conditions.

Parkinson’s disease is the second most common neurodegenerative condition after Alzheimer’s disease. The number of patients will rise dramatically due to ageing of the population and possibly also due to environmental issues. It is widely recognised that the current models of care for people with Parkinson’s disease or a form of atypical parkinsonism lack continuity, are reactive to problems rather than proactive, and do not adequately support individuals to self-manage. Integrated models of care have been developed for other chronic conditions, with a range of positive effects. A multidisciplinary team of professionals in the United Kingdom and the Netherlands, all with a long history of caring for patients with movement disorders, used knowledge of deficiencies with the current model of care, an understanding of integrated care in chronic disease and the process of logic modelling, to develop a novel approach to the care of patients with Parkinson’s disease. We propose a new model, termed PRIME Parkinson (Proactive and Integrated Management and Empowerment in Parkinson’s Disease), which is designed to manage problems proactively, deliver integrated, multidisciplinary care, and empower patients and their carers. It has five main components: (1) personalised care management, (2) education and empowerment of patients and carers, (3) empowerment of healthcare professionals, (4) a population health approach, and (5) support of the previous four components by patient- and professional-friendly technology. Having mapped the processes required for the success of this initiative, there is now a requirement to assess its effect on health-related and quality of life outcomes as well as determining its cost-effectiveness. In the next phase of the project, we will implement PRIME Parkinson in selected areas of the United Kingdom and the Netherlands.

Objective: We introduced a stepped-care strategy (SCS) for hip and knee osteoarthritis, focusing on delivery of high-quality stepped care. In this study, we aimed to identify factors associated with various steps of the SCS. Methods: We used data from a 2-year observational prospective cohort study, including 313 patients visiting their general practitioner (GP) with a new episode of hip/knee osteoarthritis. We used logistic multilevel analyses to identify factors at the level of the patient, the GP, and the general practice, related to treatment limited to primary care, referral to nonsurgical secondary care, or surgical procedures. Results: Patients whose treatment had been limited to primary care tended to function physically better (odds ratio [OR] 1.03). Furthermore, they less often received exercise therapy (OR 0.46), intraarticular injections (OR 0.08), and radiologic assessments (OR 0.06). Continuation of nonsurgical care after referral was more likely in employed patients (OR 2.90) and patients who had no exercise therapy (OR 0.19) or nonsteroidal antiinflammatory drugs (OR 0.35). Surgically treated patients more often received exercise therapy (OR 7.42). Referral and surgical treatment depended only to a limited extent on the GP or the general practice. Conclusion: After implementation of the SCS in primary care, the performance of exercise therapy, rather than disease severity or psychologic factors, seems to play a key role in the decision whether or not to refer for surgical or nonsurgical treatment in secondary care. To optimize patient-tailored treatment, future research should be adressed to determine the optimal moment of switching from primary to secondary care in patients with hip/knee osteoarthritis.

Objective To enhance guideline-based nonsurgical management of osteoarthritis (OA), a multidisciplinary stepped-care strategy has been implemented in clinical practice. This study aimed to describe health care use after implementation of this strategy and to identify factors related to such use at multiple levels. Methods For this 2-year observational prospective cohort, patients with symptomatic hip or knee OA were included by their general practitioner. Activities aligned with patients and health care providers were executed to implement the strategy. Health care use was described as the cumulative percentage of “users” for each modality recommended in the strategy. Determinants were identified at the level of the patient, general practitioner, and practice using backward stepwise logistic multilevel regression models. Results Three hundred thirteen patients were included by 70 general practitioners of 38 practices. Their mean ± SD age was 64 ± 10 years and 120 (38%) were men. The most frequently used modalities were education, acetaminophen, lifestyle advice, and exercise therapy, which were used by 242 (82%), 250 (83%), 214 (73%), and 187 (63%) patients, respectively. Fourteen percent of the overweight patients reported being treated by a dietician. Being female, having an active coping style, using the booklet “Care for Osteoarthritis,” and having limitations in functioning were recurrently identified as determinants of health care use. Conclusion After implementation of the stepped-care strategy, most recommended nonsurgical modalities seem to be well used. Health care could be further improved by providing dietary therapy in overweight patients and making more efforts to encourage patients with a passive coping style to use nonsurgical modalities.

Smink AJ, Van den Ende CH, Vliet Vlieland TP, Bijlsma JW, Swierstra BA, Kortland JH, Voorn TB, Teerenstra S, Schers HJ, Dekker J, Bierma-Zeinstra SM. Stepped care bij artrose. Huisarts Wet 2015;58(6):299-301. Vaststellen of een stepped-carebehandelstrategie in staat is zowel de gezondheid als het zorggebruik van patienten met knieof heupartrose te verbeteren. Prospectief observationeel cohortonderzoek met een follow-up van twee jaar, uitgevoerd tussen augustus 2010 en maart 2013 in 38 huisartsenpraktijken in de regio Nijmegen. De huisartsen ontvingen voorlichting over een stepped-carebenadering voor knie- en heupartrose, BART genaamd. Bij 280 patienten met knie- of heupartrose werden pijn, fysiek functioneren, zelfeffectiviteit en actieve pijncoping gemeten op baseline en na 6, 12, 18 en 24 maanden, en werd vastgesteld in hoeverre de aanbevolen behandelstrategie werd gevolgd. Ongeveer de helft van de 280 deelnemers kreeg zorg conform de aanbevolen behandelstrategie. Deze groep was gemiddeld jonger en had minder comorbiditeit, minder pijnlijke gewrichten en minder vaak een aanvullende verzekering. We vonden geen significante verschillen tussen beide groepen in pijn, fysiek functioneren, zelfeffectiviteit en actieve pijncoping. Verder onderzoek naar de toegevoegde waarde van stepped care zou zich moeten concentreren op de definitie van ‘optimale zorg’, de langetermijneffecten van te vroeg ingezette behandelingen en andere uitkomsten, zoals kosten en bijwerkingen.

Item does not contain fulltext OBJECTIVE: To improve the management of hip or knee osteoarthritis (OA), a stepped care strategy (SCS) has been developed that presents the optimal sequence for care in three steps. This study evaluates the extent to which clinical practice is consistent with the strategy after implementation and identifies determinants of SCS-consistent care. DESIGN: A 2-year observational prospective cohort study. SETTING: General practices in the region of Nijmegen in the Netherlands. PARTICIPANTS: Three hundred and thirteen patients with hip or knee OA and their general practitioner (GP). INTERVENTIONS: Multifaceted interventions were developed to implement the strategy. MAIN OUTCOME MEASURES: Consistency between clinical practice and the strategy was examined regarding three aspects of care: (i) timing of radiological assessment, (ii) sequence of non-surgical treatment options and (iii) making follow-up appointments. RESULTS: Out of the 212 patients who reported to have had an X-ray, 92 (44%) received it in line with the SCS. The sequence of treatment was inconsistent with the SCS in 58% of the patients, which was mainly caused by the underuse of lifestyle advice and dietary therapy. In 57% of the consultations, the patient reported to have been advised to make a follow-up appointment. No determinants that influenced all three aspects of care were identified. CONCLUSIONS: Consistency with the SCS was found in about half of the patients for each of the three aspects of care. Health care can be further optimized by encouraging GP s to use X-rays more appropriately and to make more use of lifestyle advice, dietary therapy and follow-up appointments.

Item does not contain fulltext BACKGROUND: A stepped care strategy (SCS) to improve adequate healthcare use in patients with osteoarthritis was developed and implemented in a primary care region in the Netherlands. AIM: To assess the association between care that is in line with the SCS recommendations and health outcomes. DESIGN AND SETTING: Data were used from a 2-year observational study of 313 patients who had consulted their GP because of osteoarthritis. METHOD: Care was considered 'SCS-consistent' if all advised modalities of the previous steps of the SCS were offered before more advanced modalities of subsequent steps. Pain and physical function were measured with the Western Ontario and McMaster Universities Osteoarthritis Index (range 0-100); active pain coping with the Pain Coping Inventory (range 10-40); and self-efficacy with the Dutch General Self-Efficacy Scale (range 12-48). Crude and adjusted associations between SCS-consistent care and outcomes were estimated with generalised estimating equations. RESULTS: No statistically significant differences were found in changes over a 2-year period in pain and physical function between patients who received SCS-inconsistent care (n = 163) and patients who received SCS-consistent care (n = 117). This was also the case after adjusting for possible confounders, that is, -4.3 (95% confidence interval [CI] = -10.3 to 1.7) and -1.9 (95% CI = -7.0 to 3.1), respectively. Furthermore, no differences were found in changes over time between groups in self-efficacy and pain coping. CONCLUSION: The results raised several important issues that need to be considered regarding the value of the SCS, such as the reasons that GPs provide SCS-inconsistent care, the long-term effects of the SCS, and the effects on costs and side effects.

Contains fulltext : 125747.pdf (Publisher’s version ) (Open Access) BACKGROUND: To enhance guideline-based non-surgical management of hip or knee osteoarthritis (OA), a multidisciplinary, stepped-care strategy has been implemented in primary care in a region of the Netherlands. To facilitate this implementation, the self-management booklet "Care for Osteoarthritis" was developed and introduced. The aim of the booklet was to educate patients about OA, to enhance the patient's active role in the treatment course, and to improve the communication with health care providers. To successfully introduce the booklet on a large scale we assessed barriers and facilitators for patients to using this booklet. METHODS: Seventeen primary care patients with hip or knee OA who received the self-management booklet participated in this qualitative study using semi-structured interviews. Purposive sampling was used to ensure diversity of the patients' view about the booklet. The interviews were transcribed verbatim and analysed using a thematic analysis approach. RESULTS: Three core themes with patient perceived barriers and facilitators to use the booklet emerged from the interviews: 1) the role of health care providers, 2) the patient's perceptions about OA and its manageability, and 3) the patient's perceptions about the usefulness of the booklet and patient's information needs. Regarding the first theme, a barrier was the lack of encouragement from health care providers to use the booklet in the treatment course of OA. Moreover, patients had doubts concerning the health care providers' endorsement of non-surgical treatment for OA. Barriers from the second theme were: thinking that OA is not treatable or that being pro-active during the treatment course is not important. In contrast, being convinced about the importance of an active participation in the treatment course was a facilitator. Third, patients' perceptions about the usefulness of the booklet and patients' information needs were both identified as barriers as well as facilitators for booklet use. CONCLUSIONS: This study contributes to the understanding of patient perceived barriers and facilitators to use a self-management booklet in the treatment course of OA. The results offer practical starting points to tailor the implementation activities of the booklet nationwide and to introduce comparable educational tools in OA primary care or in other chronic diseases.

To enhance guideline-based nonsurgical management of osteoarthritis (OA), a multidisciplinary stepped-care strategy has been implemented in clinical practice. This study aimed to describe health care use after implementation of this strategy and to identify factors related to such use at multiple levels.For this 2-year observational prospective cohort, patients with symptomatic hip or knee OA were included by their general practitioner. Activities aligned with patients and health care providers were executed to implement the strategy. Health care use was described as the cumulative percentage of "users" for each modality recommended in the strategy. Determinants were identified at the level of the patient, general practitioner, and practice using backward stepwise logistic multilevel regression models.Three hundred thirteen patients were included by 70 general practitioners of 38 practices. Their mean ± SD age was 64 ± 10 years and 120 (38%) were men. The most frequently used modalities were education, acetaminophen, lifestyle advice, and exercise therapy, which were used by 242 (82%), 250 (83%), 214 (73%), and 187 (63%) patients, respectively. Fourteen percent of the overweight patients reported being treated by a dietician. Being female, having an active coping style, using the booklet "Care for Osteoarthritis," and having limitations in functioning were recurrently identified as determinants of health care use.After implementation of the stepped-care strategy, most recommended nonsurgical modalities seem to be well used. Health care could be further improved by providing dietary therapy in overweight patients and making more efforts to encourage patients with a passive coping style to use nonsurgical modalities.

Contains fulltext : 117534.pdf (Publisher’s version ) (Open Access) BACKGROUND: To improve the management of hip or knee osteoarthritis (OA), a multidisciplinary guideline-based stepped-care strategy (SCS) with recommendations regarding the appropriate non-surgical treatment modalities and optimal sequence for care has been developed. Implementation of this SCS in the general practice may be hampered by the negative attitude of general practitioners (GPs) towards the strategy. In order to develop a tailored implementation plan, we assessed the GPs' views regarding specific recommendations in the SCS and their working procedures with regard to OA. METHODS: A survey was conducted among a random sample of Dutch GPs. Questions included the GP's demographical characteristics and the practice setting as well as how the management of OA was organized and whether the GPs supported the SCS recommendations. In particular, we assessed GP's views regarding the effectiveness of 14 recommended and non-recommended treatment modalities. Furthermore, we calculated their agreement with 7 statements based on the SCS recommendations regarding the sequence for care. With a linear regression model, we identified factors that seemed to influence the GPs' agreement with the SCS recommendations. RESULTS: Four hundred fifty-six GPs (37%) aged 30-65 years, of whom 278 males (61%), responded. Seven of the 11 recommended modalities (i.e. oral Non-Steroidal Anti-Inflammatory Drugs, physical therapy, glucocorticoid intra-articular injections, education, lifestyle advice, acetaminophen, and tramadol) were considered effective by the majority of the GPs (varying between 95-60%). The mean agreement score, based on a 5-point scale, with the recommendations regarding the sequence for care was 2.8 (SD = 0.5). Ten percent of the variance in GPs' agreement could be explained by the GPs' attitudes regarding the effectiveness of the recommended and non-recommended non-surgical treatment modalities and the type of practice. CONCLUSION: In general, GPs support the recommendations in the SCS. Therefore, we expect that their attitudes will not impede a successful implementation in general practice. Our results provide several starting points on which to focus implementation activities for specific SCS recommendations; those related to the prescription of pain medication and the use of X-rays. We could not identify factors that contribute substantially to GPs' attitudes regarding the SCS recommendations regarding the sequence for care.

Background Studies determining factors associated with the setting and content of care in patients with hip/knee osteoarthritis (OA) are mainly confined to patient demographics or disease-related factors associated with total joint replacement (TJR). To our knowledge, no studies integrated patient-related factors and factors related to the general practitioner (GP) or general practice to predict TJR, neither took attention to the content of previously utilized care. Moreover, it is unknown which factors are associated with the continuation of non-surgical care in patients once referred to secondary care. Objectives To identify both socio-demographic, health-related, disease-related and content-of-care-related factors at the level of the patient, as well as socio-demographic factors at the level of the GP and the general practice associated with 1) treatment restricted to primay care, 2) TJR, and 3) continuation of non-surgical treatment after a referral to secondary care in patients with hip/knee OA. Methods Data were used from a two-year observational prospective cohort study including 313 patients with hip/knee OA visiting their GP with a new episode of complaints 1 . Logistic multilevel analyses were conducted to identify relevant factors. Results The referral rate to secondary care amounted 53%. TJR was applied in 34% of this referred subpopulation, representing 18% of the total population. Non-referred patients less often reported knee OA, were faced with less severe complaints and were treated less extensively by non-surgical interventions than referred patients. Identified factors associated with treatment restricted to primary care were less limitations in physical functioning (p≤.01) and non-use of physiotherapy (p=.03), intra-articular injections (p≤.01), and radiological assessments (p≤.01). TJR was associated with the use of radiological assessment (p 99.9%), followed by the general practice ( Conclusions The present study shows that the setting and content of care in patients with hip/knee OA is mainly associated with the content of previously utilized care. In particular, it could be suggested that patients who did not receive physiotherapy are more likely to stay in primary care or, once referred, to continue non-surgical treatment compared to patients who received physiotherapy. Remarkably, pain severity and limitations in activities are not independently associated with TJR. Since only 34% of the patients referred to secondary care receive a TJR, GPs probably could optimize their referrals to secondary care by first ensuring optimal primary care has been delivered. References Smink AJ, van den Ende CH, Vliet Vlieland TP, et al. “Beating osteoARThritis”: development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis. Clin Rheumatol 2011 Dec;30(12):1623-9. Acknowledgements Financial support was provided by the Dutch Arthritis Association and the Royal Dutch Society for Physical Therapy Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.2208

Background Based on a stepped-care management strategy for hip or knee osteoarthritis (OA) 1 , the self-management booklet “Care for Osteoarthritis” was developed. The aim of this booklet is to enhance the patient’s active role in the treatment of OA and to improve communication with health care providers. Although patient booklets are a common strategy to enhance self-management, barriers and facilitators for patients to use such booklets are largely unknown. Objectives To identify patient perceived barriers and facilitators to use the self-management booklet “Care for Osteoarthritis”. Methods Seventeen patients with hip or knee OA who received the booklet participated in this qualitative study using semi-structured interviews. To ensure diversity of the patients’ view about the booklet, purposive sampling was used whereby we identified patients who used the booklet, who only read the booklet, and who did not use the booklet at all. All interviews were both video and audio taped. Data were analyzed using a thematic analysis approach. Results The study population included four “users”, eight “readers”, and five “non-users”. Three core themes with barriers and facilitators emerged from the data analysis: 1. The role of health care providers; 2. Patients’ perceptions about OA and its manageability; and 3. Patients’ perceptions about the usefulness of the booklet and information preferences. Regarding theme 1, patient perceived barriers were the lack of information given by health care providers about how to use the booklet, the limited encouragement to use the booklet in the management of OA, and the doubts concerning the health care providers’ endorsement of non-surgical treatment for OA. In contrast, encouragement from health care providers to use and discuss the booklet was also mentioned as being a facilitator. With respect to theme 2 thinking that OA is not treatable or being pro-active during the treatment course is not important were found to be barriers for usage, whereas being convinced about the importance of active participation in the management of OA was identified as a facilitator. Concerning theme 3, not willing to seek information, not wanting to know everything about OA, ignoring OA, or feeling to be already sufficiently informed by health care providers were found to be barriers for usage. On the other hand, the perception of having insufficient knowledge about OA or being interested in having more information served as facilitators to read or use the booklet. Conclusions Barriers and facilitators for patients with hip or knee OA to use a self-management booklet included the role of health care providers, patients’ perceptions about OA and its manageability and patients’ views on the provision of information. These findings suggest that an active positive attitude of the health care providers towards treatment modalities for OA and the usage of the booklet in the management of OA, with ensuing support in using the booklet tailored to the patients’ perceptions of OA and information provision may increase usage. References Smink A. et al. (2011). Clin Rheumatol;30:1623-9 Disclosure of Interest None Declared

Background To improve the management of hip or knee osteoarthritis (OA), a multidisciplinary guideline-based stepped-care strategy (SCS) with recommendations regarding the appropriate non-surgical treatment modalities and optimal sequence for treatment has been developed.(1) Implementation of this SCS in the general practice may be hampered by the negative attitude of general practitioners (GPs) towards the strategy. In order to develop a tailored implementation plan, we assessed the GPs’ views regarding specific SCS recommendations and their working procedures with regard to OA. Objectives The objectives of this study are 1) to describe GPs’ attitudes with respect to two key elements of the SCS, i.e. effectiveness of non-surgical treatment modalities and the optimal sequence for treatment and 2) to identify factors that could influence GPs’ agreement regarding SCS recommendations. Methods A survey was conducted among a random sample of Dutch GPs. Questions included the GP’s demographical characteristics and practice setting, as well ass how the management of OA was organized and whether the GPs supported SCS recommendations. In particular, we assessed GP’s views regarding the effectiveness of 14 recommended and non-recommended treatment modalities. Furthermore, we calculated their agreement with 7 statements based on SCS recommendations regarding the sequence for treatment. With a linear regression model, we identified factors that seemed to influence the GPs’ agreement with SCS recommendations. Results Four hundred fifty-six GPs (response rate 37%) aged 30-65 years, of whom 278 males (61%), responded. Seven of the 11 recommended modalities (i.e. oral NSAIDs, physical therapy, glucocorticoid intra-articular injections, education, lifestyle advice, acetaminophen, and tramadol) were considered effective by the majority of the GPs (varying between 60-95%). The mean agreement score, based on a 5-point scale, with recommendations regarding the sequence for treatment was 2.8 (SD=0.5). Ten percent of the variance in GPs’ agreement could be explained by GPs’ attitudes regarding the effectiveness of recommended and non-recommended non-surgical treatment modalities and the practice type. Conclusions In general, GPs support the SCS recommendations. Therefore, weexpect that their attitudes will not impede a successful implementation in general practice. Our results provide several starting points on which to focus implementation activities for specific SCS recommendations; those related to the prescription of pain medication and the use of X-rays. We could not identify factors that contribute substantially to GPs’ attitudes regarding SCS recommendations about the sequence for treatment. References Smink AJ, van den Ende CH, Vliet Vlieland TP, Swierstra BA, Kortland JH, Bijlsma JW, Voorn TB, Schers HJ, Bierma-Zeinstra SM, Dekker J. “Beating osteoARThritis”: development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis. Clinical Rheumatology,2011;30:1623-9 Disclosure of Interest None Declared

Background Recently, a stepped care strategy presenting the optimal order of conservative treatment options for osteoarthritis (OA) of the hip or knee has been developed. 1 It suggests in three steps that more advanced options should only be considered if the options tried initially lead to insufficient results. The first step consists options which could also be provided through self care (like education and paracetamol) whereas the second and third step comprise more advanced options (like physical therapy and NSAIDs). Objectives In the light of a covering study that aims to implement this stepped care strategy, we considered it important to gain more insight in the collaboration of general practitioners (GPs) with other professionals and their beliefs and policy regarding the efficacy and timing of the treatment options in OA. Methods A survey was sent to a random sample of GPs in the Netherlands (n=1224). GPs were asked about their collaboration with specific professionals (e.g. practice nurses, physical therapists, and medical specialists) in their OA management. Beliefs about the efficacy and timing of different treatment options were compared with recommendations of the stepped care strategy. GPs’ actual management was assessed with questions about their policy regarding referrals and prescriptions of drugs based on their last consultation with a patient with early symptoms of hip or knee OA. Results 456 GPs (37%), aged 30-65 years and 67% male, responded to the questionnaire. According to 17% of the GPs their practice nurse played a role in the treatment of OA. 77% reported to have no structural collaboration with other professionals. Almost half of the GPs reported to have incidental contact (once a month to once a week) with a physical therapist to discuss the treatment of one or more individual OA patients. Incidental contact with a dietician, rheumatologist and orthopaedic surgeon, was reported by 3%, 8%, and 14% of the GPs respectively. In general, GPs’ beliefs about the timing and efficacy of the different treatment options were in concordance with the stepped care strategy. Most GPs underlined the importance of education and lifestyle advice (87% and 86% respectively). Half of the GPs provided these options to a patient with early symptoms. More advanced options, like physical therapy, NSAIDs, and refferal to an orthopaedic surgeon, were also frequently provided (55%, 40%, and 23% respectively). Conclusions No barriers with respect to the collaboration of GPs, their beliefs and policy regarding OA management were identified that could interfere with the implementation of the stepped care strategy. However, some discrepancies were found between the actual OA management and recommendations of the stepped care strategy. References Smink AJ, van den Ende CH, Vliet Vlieland TP, Swierstra BA, Kortland JH, Bijlsma JW, Voorn TB, Schers HJ, Bierma-Zeinstra SM, Dekker J. “Beating osteoARThritis”: development of a stepped care strategy to optimize utilization and timing of non-surgical treatment modalities for patients with hip or knee osteoarthritis. Clinical Rheumatology, 2011;30:1623-9. Disclosure of Interest None Declared

Item does not contain fulltext Inadequacies in health care practices have been reported despite existing guidelines to manage hip or knee osteoarthritis. To facilitate guideline implementation and improve utilization of non-surgical treatment options a care strategy should be developed. This study describes the development of an evidence-based, multidisciplinary, patient-centered, stepped care strategy. A national, multidisciplinary, steering group developed the strategy in three phases: (1) consensus among steering group members (first draft); (2) written consultation of 23 representatives of patient organizations and professional associations involved in osteoarthritis care (second draft); (3) consensus of the final draft after discussion in two rounds during a conference with representatives from the different disciplines. The final stepped care strategy presents, in three tiers, the optimal order for non-surgical treatment modalities. It recommends that more advanced options should only be considered if options listed in previous steps failed to produce satisfactory results. Hence, the first step treatment options can be offered to all patients but may also be provided through self care (education, life style advice, and acetaminophen). The second step (exercise therapy, dietary therapy, and non-steroidal anti-inflammatory drugs) and third step treatment options (multidisciplinary care, intra-articular injections, and transcutaneous electrical nerve stimulation) can be considered for people with persisting complaints. Trough a consensus procedure, we succeeded to develop a multidisciplinary, patient-centered, stepped care strategy based on national guidelines. This strategy provides a framework for health care providers and patients with hip or knee osteoarthritis to discuss the optimal timing of the various treatment options.