Exploring the current and future osteoarthritis health service delivery needs in Aotearoa New Zealand
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Globally, osteoarthritis (OA) is a leading cause of chronic pain and disability.[[1,2]] In Aotearoa New Zealand, OA affects one in 10 people and prevalence is predicted to increase by 76% in the next 20 years due to obesity and population demographics and to drive healthcare costs up by 86%.[[3,4]] The rising burden of OA will place greater demand on clinical services.[[4–6]] OA can affect all aspects of a person’s sense of hauora (health), including hinengaro (mental and emotional), tinana (physical) and whānau (social).[[7–10]] International OA clinical management guidelines recommend people with OA should have access to care that provides appropriate person-centred education, exercise and weight loss (if applicable) before employing pharmacological or surgical management.[[12]] In contrast to these recommendations, OA management in Aotearoa New Zealand has been described as fragmented and regionally variable,[[5,13–15]] but little research has been undertaken on service delivery for people living with OA in Aotearoa New Zealand.
In December 2020, a transdisciplinary committee formed to improve collaboration between stakeholders interested in OA management in Aotearoa New Zealand. This group aimed to advocate for a National Model of Care for OA, similar to an initiative in Australia.[[16]] This committee delivered the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium in Auckland on 10 July 2021, with the aims of bringing together clinicians from all disciplines, health delivery organisations, consumers and researchers with a particular interest in managing OA in Aotearoa New Zealand, and developing a list of national priorities in OA research and innovative health delivery (https://events.otago.ac.nz/2021-osteoarthritis-basecamp/). The symposium was open to anyone in Aotearoa New Zealand with interest in OA healthcare. It brought together a national audience (n=82) of health professionals (dietitians, general medical practitioners, nurses, orthopaedic surgeons, physiotherapists, podiatrists, psychologists, rheumatologists, sports medicine physicians and clinical exercise physiologists), researchers (across fields from basic science to clinical trials) and health funders (services managers, policy workers).
Given the diverse sector representation, the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium provided an opportunity to share ideas and experiences, raise questions and expand thinking about how OA research and healthcare service delivery can be improved. The symposium’s morning sessions included presentations from national and international OA experts on best practice evidence about service delivery and research. The afternoon sessions included two interactive workshops which aimed to explore beliefs about national priorities in OA research and innovative OA health delivery in Aotearoa New Zealand from the perspective of actively engaged sector stakeholders. This manuscript presents the findings from the workshop about innovative OA health delivery in Aotearoa New Zealand.
Aim
To describe the views of interested people from the health sector about current and future OA health service delivery in the health system in Aotearoa New Zealand, including what works well, the barriers to service improvements, and priorities for OA health improvement initiatives.
Methods
Study design
We used a co-design approach,[[17]] informed by a realist philosophical lens, a qualitative descriptive methodology and thematic analysis to explore the current and future OA health service delivery need in Aotearoa New Zealand.[[18]] This participatory framework supports an interdisciplinary, collaborative design process to ensure that outcomes reflect real, rather than assumed, requirements and offer innovative strategies to resolve complex problems.[[19,20]]
Participants
Everyone who attended the 2-hour workshop at the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium in 2021 was invited to participate in the study. Attendance at the workshop was optional. People attending the workshop could choose for their data to be excluded from the analysis by drawing a small square on the back of their Post-it[[TM]] Notes. However, no one decided to do this.
Data collection
Ethics approval was obtained for the study from University of Otago Human Ethics Committee (D21/222). The participant information form was provided to all symposium registrants 1 week before the symposium. Written consent was obtained at the workshop.
Participants (attendees) worked in small groups (between four and eight people). An additional group of seven attended a pre-conference workshop at the University of Otago Medical School (Dunedin) on 24 June 2022. Participants were asked to brainstorm responses to questions about health service delivery for people with OA in Aotearoa New Zealand. Participants wrote their responses as bullet points on Post-it[[TM]] Notes. After 10–15 minutes, facilitators asked one group member to place all Post-it[[TM]] Notes on a wall-mounted poster for other attendees to see and consider. The facilitator then led discussion of the collective responses and then guided the groups to move to the next question. Table 1 lists the research questions participants discussed and responded to.
View Tables 1–4 and Figure 1.
For Questions 1 and 2, participants were asked to position their responses (Post-it[[TM]] Notes), after which they spent 10 minutes reading and reflecting on the group’s ideas. Then the facilitator led a group discussion on the themes represented, using co-design facilitation to generate participatory thematic analysis. Participants then went to the poster and organised the Post-it[[TM]] Notes into themes generated.
For Question 3, participants were asked to position their responses (Post-it[[TM]] Notes) on a journey map.[[21]] The journey map, conceived a priori by the researchers, represented the continuum of care in a person’s OA management. It included four subheadings or key touch points in the OA management journey (pre-OA, early identified OA, community and primary care, secondary care) under which the Post-it[[TM]] Notes could be placed (Figure 1) and the fifth subheading (lifespan or systemwide) placed at the bottom that spanned the whole journey map.
Data analysis
All written material generated during the workshop (Post-it[[TM]] Notes) was photographed in situ, collected, and used as the primary data source. All data were transferred into an Excel (Microsoft, 2022) spreadsheet, with each Post-it[[TM]] Note response in a cell. All responses were analysed using direct qualitative content analysis.[[22]] Analysis for Question 1 concluded with code grouping and naming; thematic analysis was conducted by the participants for Question 2, in the first instance, and code-grouping by the researchers was conducted independently post hoc. Since participants were asked to assign their responses to subheadings in the journey map for Question 3, we used these subheadings to frame the data analysis of this question. Thematic analysis of Question 3 was conducted by the researchers. Analysis of common responses across the journey map further informed the construction of the fifth subheading (lifespan or systemwide approach). The frequency of responses was not quantified because our goal was to capture the breadth of the data from workshop participants.
Two research team members (DOB and SN) collaboratively coded the responses (data) and then grouped codes that appeared conceptually connected. Next, these groups were named and presented to all research team members for feedback and refinement. To strengthen trustworthiness, results were continuously discussed between the research team with different competence and perspectives in triangulation between researchers.[[23]] A third team member (HA) reviewed the data, coding, code grouping and, for Question 3, conducted thematic analysis. Themes and sub-themes emerging from the coded data were returned to DOB and SN; these were discussed, and a working version was confirmed in a consensus meeting. Next, these themes and sub-themes were presented to all research team members for feedback before confirming a final version.
Results
Fifty-two people attended the 2-hour workshop. Participants came from various clinical (dietetics, general practice, nursing, orthopaedic surgery, physiotherapy, podiatry, psychology, rheumatology, sports medicine and clinical exercise physiology), health research and health funding backgrounds across Aotearoa New Zealand (Table 2). We have presented our results as they relate to the workshop questions and present data codes in “italics”. Names representing categories of grouped data are presented in bold. Themes and sub-themes are capitalised.
What works well in the management of OA in the public healthcare system?
Participants offered that OA management worked well when services work better together and focussed on building a healthcare service for all.
Work better together
OA management worked well when new pathways were developed with a “national perspective” that “recognised the need for change”, “reduced professional hierarchies” and developed and supported “triage clinics”. Furthermore, they reported that these changes had fostered a “willingness to share between groups, programmes and institutions” and greater “intersectoral collaboration”. Additionally, participants valued “engaging with local and international research” to support a move towards a more collaborative model of care.
Building a healthcare service for all
Participants believed that they had seen improvements in several areas of healthcare delivery, including cultural awareness, healthcare provider education, technological integration, and the implementation of a range of OA management programmes. Codes included “awareness of the need to build Māori health access”, more significant “Iwi and Māori consultation”, and “recognition of the value of equity” and the “patient voice”. They also reported improvements in “health workforce and undergraduate training” and believed the “quality of care for people was improving”. Participants also valued “increased investment in digital health models” and “technology advancement funding” as new initiatives improving OA management. Lastly, participants stated the benefit of the emergence of OA management programmes, including the Mobility Action Programme (MAP), Good Life with Arthritis: Denmark (GLA:D), Accident Compensation Corporation (ACC) injury prevention programmes, the Bay of Plenty Community Orthopaedic Triage Service (COTS) and the Canterbury Initiative.
What are the barriers to effective service delivery for people with OA?
Participants offered barriers or challenges, which they collaboratively analysed to the following themes (with example data codes): culture (institutional and clinician bias/racism; people’s motivation to take self-responsibility); resources (limitations of DHB [district health board] capacity; workforce to meet requirements; primary allied health services not funded; funding); accessibility (postcode healthcare; inequities; ethnicity and poverty); healthcare education (undergraduate training); focus of care (low prioritisation of OA; clinician-centred vs patient-centred); patient knowledge (common myths and misconceptions; poor patient awareness of treatment options); siloed (working in silos; lack of continuity in services); evidence-based practice (fewer evidence-based programmes in hospital and the community; data—access, outcomes).
Post hoc, we (DOB, SN) organised these into three code groups: 1) Knowledge and expectations, 2) Inequitable access to care, and 3) Patient- and whānau-(un)centred care.
1) Knowledge and expectations: Participants reported many challenges related to patient knowledge, health literacy and expectations. They referred to “a lack of understanding of OA in the general population” and limited knowledge of treatment options available (“population education”) and stated that more standardised resources and guidelines were needed. They also noted a “lack of patient-friendly resources” and “poor or inconsistent patient messaging”. Furthermore, participants identified the key barriers to the efficacy of existing clinical services as “patient adherence”, “unrealistic expectations” and “cultural differences”.
2) Inequitable access to care: The data highlighted participants’ concern about the inequitable access to OA management services in Aotearoa New Zealand in two categories: funding and access. Tensions with the funding of OA management in Aotearoa New Zealand included competition, real or perceived, to financing between “public, private and ACC”, between “primary and secondary care” (primary care being perceived as the more poorly funded) and compared to other long-term conditions such as cancer or diabetes (“low prioritisation at a DHB/MoH [Ministry of Health] level”). Participants also identified variability in access caused by “postcode healthcare”, “limited local resources (affordable pools or gyms)” and a “lack of access to weight management services and appropriate advice”.
3) Patient- and whānau-(un)centred care: Participants referred to the structure and culture of the health system and limited interprofessional collaboration, or working in silos, as system-level barriers to healthcare delivery. Specifically, critical barriers were “clinician-centred service design”, “institutional bias and racism”, a “one-size-fits-all approach”, and “a lack of authentic Māori engagement”. Moreover, some participants referred to “orthopaedics as the gate-keepers of referral to other programmes” and “a lack of buy-in from GPs and orthopaedics for non-surgical approaches”.
What are the key priorities for improvement initiatives for OA management in the Aotearoa New Zealand public healthcare system?
Table 3 shows key data codes for current Aotearoa New Zealand health delivery improvement initiatives participants were aware of or involved in, alongside potential future health delivery priorities for OA. Table 4 shows the themes, sub-themes, and key data code groups generated from the “key priorities for improvement” data.
Pre-OA
Participants’ responses highlight the value of injury prevention programmes and the many existing programmes that aim to increase physical activity, public education about OA and the benefits of exercise and physical activity (Table 3). Many responses regarding future healthcare delivery priorities, public health initiatives, health system changes and more robust methods of addressing obesity were considered by the researchers to be relevant beyond the “pre-OA” phase, so they were also carried through to the “lifespan or systemwide” axis of the journey map.
The codes and code groupings converged on two key themes (with sub-themes): a public health approach (sub-themes: policy, urban design, health literacy and prevention action); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Early OA
Data coded about the priorities for managing early OA were summed up with the notion that knowledge is power (Table 3). Participants listed resources and activities that would improve health literacy and knowledge about OA, both for patients and the public. They also wrote about the need for early screening to ensure appropriate access to patient pathways and that, in some instances, clinical services reprioritisation was needed (physiotherapy). Regarding future healthcare delivery priorities, participants wrote about needing to help patients self-manage their OA more effectively and enhance education via digital platforms, such as Health Navigator. Some suggested a more stratified, interprofessional approach to early management, matching patient need to available clinical services.
The codes and code groupings again converged on two key themes (with sub-themes): a public health approach (sub-theme: health literacy); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Community and primary care
The need for cohesive care across community and primary care OA management was prominent in the data, highlighting the need for greater accessibility, suggesting more use of technology and service hubs to reduce inequity of access for Māori and rural regions. More integrated and inclusive models of care, including Māori health models and Māori-led health services, were suggested. Again, the codes and code groupings converged on two key themes (with sub-themes): a public health approach (sub-themes: health literacy, programme action); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Secondary care
A range of data codes reflected access constraints and mapped ways to increase capacity—such as increasing workforce, surgical capacity, separating acute trauma capacity from elective surgery capacity, models bridging primary to secondary care or deploying allied health providers in secondary care, utilising private providers—and pathways to enable these. They reflected a need to redesign aspects of system flow to reduce delays for appropriate orthopaedic review, to avoid delays due to competing services (e.g., trauma surgery), and to identify non-surgical candidates and provide access to other services. The health delivery approach theme was most prominent; as well as the sub-themes of health system redesign, guidelines/pathways, and enabling providers, additional sub-themes of increasing capacity and new interventions were identified.
Lifespan or systemwide
The researchers considered several responses in the above four phases of the journey map relevant beyond the phase in which participants posted them, so they were also carried through to the “lifespan or systemwide” axis of the journey map. Data codes relating to this question clustered in four groups within this fifth element of the journey map. These were called: 1) a greater hauora/wellbeing focus, 2) increasing physical activity at all ages and stages, 3) an interprofessional approach to care, and 4) better connection of healthcare services across the four stages of the osteoarthritis journey map (Table 3). Interpretation of the participants' data suggested moving to a more holistic, person-centred approach to OA management, focussing on hauora/wellbeing. The public health approach theme suggested interventions that increase physical activity and reduce obesity. The health delivery approach theme suggested a redesign to better integrate health services (i.e., prevention, early identification and management, community and primary care, and secondary care) and enable a broader range of healthcare professions to contribute to managing OA.
Summative themes
Across all axes of the journey map, the codes and code groupings converged on two key themes (each with four sub-themes): a public health approach (sub-themes: policy, urban design, health literacy and programme action); and a health delivery approach (sub-themes: health system redesign, guidelines/pathways, enabling providers and increasing capacity) (Table 4).
Discussion
To our knowledge, this is the first study to explore priorities for health service delivery improvement initiatives for OA; while it has focussed on the Aotearoa New Zealand context, it offers international relevance. During the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium 2021, participants offered their informed views on OA care across the continuum, including current approaches that work well, barriers to care and current and future priorities. Participants cited the strengths of the existing services as a willingness to work together and develop services fit for all New Zealanders. Key barriers were poor knowledge and expectations, inequity of care and lack of patient- and whānau-centred care.
Participants offered recent positive changes to OA management in Aotearoa New Zealand, including steps to improve collaboration across primary and secondary services (e.g., triaging systems such as the Bay of Plenty COTS), an appreciation for the need to develop health delivery fit for all (especially for Māori) and the success of more person-centred interprofessional approaches to care (i.e., MAP). However, our findings suggest that these initiatives are not yet ubiquitous or comprehensive enough. Previous literature has called for management across the disease continuum,[[24]] to change the narrative and improve patient and public understanding of the disease,[[25,26]] and develop patient-centred health service delivery approaches that acknowledge the diversity of Aotearoa New Zealand and partner with Māori to meet service need.[[7,8]] These are critical areas to address in the Aotearoa New Zealand health system.
Analysis of the findings suggests there may be a need for a comprehensive, cohesive and equitable model of OA care. Given the symposium's aims and the participants’ decisions to attend, this finding is not surprising. A comprehensive and equitable OA service reflects recommendations for best-practice OA management.[[13,27–29]] While the data did not explicitly state a need to implement consistent national pathways or systems across Te Whatu Ora (the Aotearoa New Zealand public healthcare system), this imperative was implied in the statement of the workshop questions and the symposium’s broader kaupapa, and mirrors the intent of the current national health reform’s goals.[[30]] Secondly, there was a call for improving health literacy at all stages of the patient journey. Patient education is universally regarded as a cornerstone of OA management.[[12]]
Three recommended goals for the future health delivery for people with OA can be constructed from the analysis of our findings: first, the conceptualisation of OA management as a continuum so that injury prevention, obesity reduction and physical activity are actively considered along with primary and secondary care services. Second, establishing an evidence-informed model of care that guides the development and implementation of clinical services across the clinical course of (long-term) musculoskeletal conditions. The third is the development of clinical hubs or programmes for Māori hauora that specifically meet the needs of Māori.
This study's strengths are that it captured the perspectives of a broad range of people actively engaged in helping people with OA management in Aotearoa New Zealand, including research, and that we used methodologies suited to the nature of the research questions and the data, which provided an acceptable level of academic rigour.[[17]] The main limitations were that data were collected from people whose attendance at the symposium suggested that they are actively invested in OA management in Aotearoa New Zealanc; hence, their beliefs and attitudes may not reflect those of the wider population. Furthermore, there was no consumer input into the data or the data analysis (aside from health delivery stakeholders who secondarily identify as having OA), meaning a valuable perspective is missing and future studies are needed to explore this perspective. Lastly, data collection using Post-it[[TM]] Notes lacks the contextual richness of, for example, in-depth interview methodologies, meaning there is the risk of misinterpretation of short sentences. However, as most of the authors contributed to the running of the workshops (BH did not participate), this risk is reduced. Health resources are finite; hence, the next phase of our kaupapa (project) includes a prioritisation study aiming to capture stakeholder beliefs on which services for people with OA merit greatest investment. Furthermore, we will recruit people living with OA.
Conclusion
Our study identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Furthermore, our analysis recognised factors that could enhance OA care across the lifespan, including a greater focus on prevention, hauora/wellbeing rather than the disease, incorporation of a wider range of healthcare professionals, addressing capacity constraints, the potential value of a model of OA care or pathway that is evidence based and integrates healthcare from OA prevention to secondary care. Yet, more work is needed to prioritise what stakeholders consider to be high-value care, and any model of OA care or pathway would need to acknowledge and support the diversity of needs within Aotearoa New Zealand and place value on interprofessional collaboration and practice, and improvements in health literacy and self-management.
Summary
Abstract
Aim
Osteoarthritis (OA) affects the wellbeing of one in 10 people in Aotearoa New Zealand, yet current healthcare delivery for these people is fragmented, un-coordinated and inconsistent. How current and future needs should be addressed has not been systematically explored. This study aimed to describe the views of interested people from the health sector regarding current and future OA health service delivery in the public health system in Aotearoa New Zealand.
Method
Data were collected via a co-design approach within an interprofessional workshop at the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium and analysed using direct qualitative content analysis.
Results
The results highlighted several promising current healthcare delivery initiatives. Health literacy and obesity prevention policies featured in the thematic analysis suggesting a lifespan or systemwide approach is needed. Data highlighted a need for reformed systems that enhances hauora/wellbeing, promotes physical activity, facilitates interprofessional service delivery and collaborates across care settings.
Conclusion
Participants identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Public health policy initiatives are needed to reduce osteoarthritis risk factors. Developing future care pathways should support the diverse needs within Aotearoa New Zealand, coordinate and stratify care, value interprofessional collaboration and practice, and improve health literacy and self-management.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Exploring the current and future osteoarthritis health service delivery needs in Aotearoa New Zealand
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Globally, osteoarthritis (OA) is a leading cause of chronic pain and disability.[[1,2]] In Aotearoa New Zealand, OA affects one in 10 people and prevalence is predicted to increase by 76% in the next 20 years due to obesity and population demographics and to drive healthcare costs up by 86%.[[3,4]] The rising burden of OA will place greater demand on clinical services.[[4–6]] OA can affect all aspects of a person’s sense of hauora (health), including hinengaro (mental and emotional), tinana (physical) and whānau (social).[[7–10]] International OA clinical management guidelines recommend people with OA should have access to care that provides appropriate person-centred education, exercise and weight loss (if applicable) before employing pharmacological or surgical management.[[12]] In contrast to these recommendations, OA management in Aotearoa New Zealand has been described as fragmented and regionally variable,[[5,13–15]] but little research has been undertaken on service delivery for people living with OA in Aotearoa New Zealand.
In December 2020, a transdisciplinary committee formed to improve collaboration between stakeholders interested in OA management in Aotearoa New Zealand. This group aimed to advocate for a National Model of Care for OA, similar to an initiative in Australia.[[16]] This committee delivered the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium in Auckland on 10 July 2021, with the aims of bringing together clinicians from all disciplines, health delivery organisations, consumers and researchers with a particular interest in managing OA in Aotearoa New Zealand, and developing a list of national priorities in OA research and innovative health delivery (https://events.otago.ac.nz/2021-osteoarthritis-basecamp/). The symposium was open to anyone in Aotearoa New Zealand with interest in OA healthcare. It brought together a national audience (n=82) of health professionals (dietitians, general medical practitioners, nurses, orthopaedic surgeons, physiotherapists, podiatrists, psychologists, rheumatologists, sports medicine physicians and clinical exercise physiologists), researchers (across fields from basic science to clinical trials) and health funders (services managers, policy workers).
Given the diverse sector representation, the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium provided an opportunity to share ideas and experiences, raise questions and expand thinking about how OA research and healthcare service delivery can be improved. The symposium’s morning sessions included presentations from national and international OA experts on best practice evidence about service delivery and research. The afternoon sessions included two interactive workshops which aimed to explore beliefs about national priorities in OA research and innovative OA health delivery in Aotearoa New Zealand from the perspective of actively engaged sector stakeholders. This manuscript presents the findings from the workshop about innovative OA health delivery in Aotearoa New Zealand.
Aim
To describe the views of interested people from the health sector about current and future OA health service delivery in the health system in Aotearoa New Zealand, including what works well, the barriers to service improvements, and priorities for OA health improvement initiatives.
Methods
Study design
We used a co-design approach,[[17]] informed by a realist philosophical lens, a qualitative descriptive methodology and thematic analysis to explore the current and future OA health service delivery need in Aotearoa New Zealand.[[18]] This participatory framework supports an interdisciplinary, collaborative design process to ensure that outcomes reflect real, rather than assumed, requirements and offer innovative strategies to resolve complex problems.[[19,20]]
Participants
Everyone who attended the 2-hour workshop at the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium in 2021 was invited to participate in the study. Attendance at the workshop was optional. People attending the workshop could choose for their data to be excluded from the analysis by drawing a small square on the back of their Post-it[[TM]] Notes. However, no one decided to do this.
Data collection
Ethics approval was obtained for the study from University of Otago Human Ethics Committee (D21/222). The participant information form was provided to all symposium registrants 1 week before the symposium. Written consent was obtained at the workshop.
Participants (attendees) worked in small groups (between four and eight people). An additional group of seven attended a pre-conference workshop at the University of Otago Medical School (Dunedin) on 24 June 2022. Participants were asked to brainstorm responses to questions about health service delivery for people with OA in Aotearoa New Zealand. Participants wrote their responses as bullet points on Post-it[[TM]] Notes. After 10–15 minutes, facilitators asked one group member to place all Post-it[[TM]] Notes on a wall-mounted poster for other attendees to see and consider. The facilitator then led discussion of the collective responses and then guided the groups to move to the next question. Table 1 lists the research questions participants discussed and responded to.
View Tables 1–4 and Figure 1.
For Questions 1 and 2, participants were asked to position their responses (Post-it[[TM]] Notes), after which they spent 10 minutes reading and reflecting on the group’s ideas. Then the facilitator led a group discussion on the themes represented, using co-design facilitation to generate participatory thematic analysis. Participants then went to the poster and organised the Post-it[[TM]] Notes into themes generated.
For Question 3, participants were asked to position their responses (Post-it[[TM]] Notes) on a journey map.[[21]] The journey map, conceived a priori by the researchers, represented the continuum of care in a person’s OA management. It included four subheadings or key touch points in the OA management journey (pre-OA, early identified OA, community and primary care, secondary care) under which the Post-it[[TM]] Notes could be placed (Figure 1) and the fifth subheading (lifespan or systemwide) placed at the bottom that spanned the whole journey map.
Data analysis
All written material generated during the workshop (Post-it[[TM]] Notes) was photographed in situ, collected, and used as the primary data source. All data were transferred into an Excel (Microsoft, 2022) spreadsheet, with each Post-it[[TM]] Note response in a cell. All responses were analysed using direct qualitative content analysis.[[22]] Analysis for Question 1 concluded with code grouping and naming; thematic analysis was conducted by the participants for Question 2, in the first instance, and code-grouping by the researchers was conducted independently post hoc. Since participants were asked to assign their responses to subheadings in the journey map for Question 3, we used these subheadings to frame the data analysis of this question. Thematic analysis of Question 3 was conducted by the researchers. Analysis of common responses across the journey map further informed the construction of the fifth subheading (lifespan or systemwide approach). The frequency of responses was not quantified because our goal was to capture the breadth of the data from workshop participants.
Two research team members (DOB and SN) collaboratively coded the responses (data) and then grouped codes that appeared conceptually connected. Next, these groups were named and presented to all research team members for feedback and refinement. To strengthen trustworthiness, results were continuously discussed between the research team with different competence and perspectives in triangulation between researchers.[[23]] A third team member (HA) reviewed the data, coding, code grouping and, for Question 3, conducted thematic analysis. Themes and sub-themes emerging from the coded data were returned to DOB and SN; these were discussed, and a working version was confirmed in a consensus meeting. Next, these themes and sub-themes were presented to all research team members for feedback before confirming a final version.
Results
Fifty-two people attended the 2-hour workshop. Participants came from various clinical (dietetics, general practice, nursing, orthopaedic surgery, physiotherapy, podiatry, psychology, rheumatology, sports medicine and clinical exercise physiology), health research and health funding backgrounds across Aotearoa New Zealand (Table 2). We have presented our results as they relate to the workshop questions and present data codes in “italics”. Names representing categories of grouped data are presented in bold. Themes and sub-themes are capitalised.
What works well in the management of OA in the public healthcare system?
Participants offered that OA management worked well when services work better together and focussed on building a healthcare service for all.
Work better together
OA management worked well when new pathways were developed with a “national perspective” that “recognised the need for change”, “reduced professional hierarchies” and developed and supported “triage clinics”. Furthermore, they reported that these changes had fostered a “willingness to share between groups, programmes and institutions” and greater “intersectoral collaboration”. Additionally, participants valued “engaging with local and international research” to support a move towards a more collaborative model of care.
Building a healthcare service for all
Participants believed that they had seen improvements in several areas of healthcare delivery, including cultural awareness, healthcare provider education, technological integration, and the implementation of a range of OA management programmes. Codes included “awareness of the need to build Māori health access”, more significant “Iwi and Māori consultation”, and “recognition of the value of equity” and the “patient voice”. They also reported improvements in “health workforce and undergraduate training” and believed the “quality of care for people was improving”. Participants also valued “increased investment in digital health models” and “technology advancement funding” as new initiatives improving OA management. Lastly, participants stated the benefit of the emergence of OA management programmes, including the Mobility Action Programme (MAP), Good Life with Arthritis: Denmark (GLA:D), Accident Compensation Corporation (ACC) injury prevention programmes, the Bay of Plenty Community Orthopaedic Triage Service (COTS) and the Canterbury Initiative.
What are the barriers to effective service delivery for people with OA?
Participants offered barriers or challenges, which they collaboratively analysed to the following themes (with example data codes): culture (institutional and clinician bias/racism; people’s motivation to take self-responsibility); resources (limitations of DHB [district health board] capacity; workforce to meet requirements; primary allied health services not funded; funding); accessibility (postcode healthcare; inequities; ethnicity and poverty); healthcare education (undergraduate training); focus of care (low prioritisation of OA; clinician-centred vs patient-centred); patient knowledge (common myths and misconceptions; poor patient awareness of treatment options); siloed (working in silos; lack of continuity in services); evidence-based practice (fewer evidence-based programmes in hospital and the community; data—access, outcomes).
Post hoc, we (DOB, SN) organised these into three code groups: 1) Knowledge and expectations, 2) Inequitable access to care, and 3) Patient- and whānau-(un)centred care.
1) Knowledge and expectations: Participants reported many challenges related to patient knowledge, health literacy and expectations. They referred to “a lack of understanding of OA in the general population” and limited knowledge of treatment options available (“population education”) and stated that more standardised resources and guidelines were needed. They also noted a “lack of patient-friendly resources” and “poor or inconsistent patient messaging”. Furthermore, participants identified the key barriers to the efficacy of existing clinical services as “patient adherence”, “unrealistic expectations” and “cultural differences”.
2) Inequitable access to care: The data highlighted participants’ concern about the inequitable access to OA management services in Aotearoa New Zealand in two categories: funding and access. Tensions with the funding of OA management in Aotearoa New Zealand included competition, real or perceived, to financing between “public, private and ACC”, between “primary and secondary care” (primary care being perceived as the more poorly funded) and compared to other long-term conditions such as cancer or diabetes (“low prioritisation at a DHB/MoH [Ministry of Health] level”). Participants also identified variability in access caused by “postcode healthcare”, “limited local resources (affordable pools or gyms)” and a “lack of access to weight management services and appropriate advice”.
3) Patient- and whānau-(un)centred care: Participants referred to the structure and culture of the health system and limited interprofessional collaboration, or working in silos, as system-level barriers to healthcare delivery. Specifically, critical barriers were “clinician-centred service design”, “institutional bias and racism”, a “one-size-fits-all approach”, and “a lack of authentic Māori engagement”. Moreover, some participants referred to “orthopaedics as the gate-keepers of referral to other programmes” and “a lack of buy-in from GPs and orthopaedics for non-surgical approaches”.
What are the key priorities for improvement initiatives for OA management in the Aotearoa New Zealand public healthcare system?
Table 3 shows key data codes for current Aotearoa New Zealand health delivery improvement initiatives participants were aware of or involved in, alongside potential future health delivery priorities for OA. Table 4 shows the themes, sub-themes, and key data code groups generated from the “key priorities for improvement” data.
Pre-OA
Participants’ responses highlight the value of injury prevention programmes and the many existing programmes that aim to increase physical activity, public education about OA and the benefits of exercise and physical activity (Table 3). Many responses regarding future healthcare delivery priorities, public health initiatives, health system changes and more robust methods of addressing obesity were considered by the researchers to be relevant beyond the “pre-OA” phase, so they were also carried through to the “lifespan or systemwide” axis of the journey map.
The codes and code groupings converged on two key themes (with sub-themes): a public health approach (sub-themes: policy, urban design, health literacy and prevention action); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Early OA
Data coded about the priorities for managing early OA were summed up with the notion that knowledge is power (Table 3). Participants listed resources and activities that would improve health literacy and knowledge about OA, both for patients and the public. They also wrote about the need for early screening to ensure appropriate access to patient pathways and that, in some instances, clinical services reprioritisation was needed (physiotherapy). Regarding future healthcare delivery priorities, participants wrote about needing to help patients self-manage their OA more effectively and enhance education via digital platforms, such as Health Navigator. Some suggested a more stratified, interprofessional approach to early management, matching patient need to available clinical services.
The codes and code groupings again converged on two key themes (with sub-themes): a public health approach (sub-theme: health literacy); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Community and primary care
The need for cohesive care across community and primary care OA management was prominent in the data, highlighting the need for greater accessibility, suggesting more use of technology and service hubs to reduce inequity of access for Māori and rural regions. More integrated and inclusive models of care, including Māori health models and Māori-led health services, were suggested. Again, the codes and code groupings converged on two key themes (with sub-themes): a public health approach (sub-themes: health literacy, programme action); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Secondary care
A range of data codes reflected access constraints and mapped ways to increase capacity—such as increasing workforce, surgical capacity, separating acute trauma capacity from elective surgery capacity, models bridging primary to secondary care or deploying allied health providers in secondary care, utilising private providers—and pathways to enable these. They reflected a need to redesign aspects of system flow to reduce delays for appropriate orthopaedic review, to avoid delays due to competing services (e.g., trauma surgery), and to identify non-surgical candidates and provide access to other services. The health delivery approach theme was most prominent; as well as the sub-themes of health system redesign, guidelines/pathways, and enabling providers, additional sub-themes of increasing capacity and new interventions were identified.
Lifespan or systemwide
The researchers considered several responses in the above four phases of the journey map relevant beyond the phase in which participants posted them, so they were also carried through to the “lifespan or systemwide” axis of the journey map. Data codes relating to this question clustered in four groups within this fifth element of the journey map. These were called: 1) a greater hauora/wellbeing focus, 2) increasing physical activity at all ages and stages, 3) an interprofessional approach to care, and 4) better connection of healthcare services across the four stages of the osteoarthritis journey map (Table 3). Interpretation of the participants' data suggested moving to a more holistic, person-centred approach to OA management, focussing on hauora/wellbeing. The public health approach theme suggested interventions that increase physical activity and reduce obesity. The health delivery approach theme suggested a redesign to better integrate health services (i.e., prevention, early identification and management, community and primary care, and secondary care) and enable a broader range of healthcare professions to contribute to managing OA.
Summative themes
Across all axes of the journey map, the codes and code groupings converged on two key themes (each with four sub-themes): a public health approach (sub-themes: policy, urban design, health literacy and programme action); and a health delivery approach (sub-themes: health system redesign, guidelines/pathways, enabling providers and increasing capacity) (Table 4).
Discussion
To our knowledge, this is the first study to explore priorities for health service delivery improvement initiatives for OA; while it has focussed on the Aotearoa New Zealand context, it offers international relevance. During the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium 2021, participants offered their informed views on OA care across the continuum, including current approaches that work well, barriers to care and current and future priorities. Participants cited the strengths of the existing services as a willingness to work together and develop services fit for all New Zealanders. Key barriers were poor knowledge and expectations, inequity of care and lack of patient- and whānau-centred care.
Participants offered recent positive changes to OA management in Aotearoa New Zealand, including steps to improve collaboration across primary and secondary services (e.g., triaging systems such as the Bay of Plenty COTS), an appreciation for the need to develop health delivery fit for all (especially for Māori) and the success of more person-centred interprofessional approaches to care (i.e., MAP). However, our findings suggest that these initiatives are not yet ubiquitous or comprehensive enough. Previous literature has called for management across the disease continuum,[[24]] to change the narrative and improve patient and public understanding of the disease,[[25,26]] and develop patient-centred health service delivery approaches that acknowledge the diversity of Aotearoa New Zealand and partner with Māori to meet service need.[[7,8]] These are critical areas to address in the Aotearoa New Zealand health system.
Analysis of the findings suggests there may be a need for a comprehensive, cohesive and equitable model of OA care. Given the symposium's aims and the participants’ decisions to attend, this finding is not surprising. A comprehensive and equitable OA service reflects recommendations for best-practice OA management.[[13,27–29]] While the data did not explicitly state a need to implement consistent national pathways or systems across Te Whatu Ora (the Aotearoa New Zealand public healthcare system), this imperative was implied in the statement of the workshop questions and the symposium’s broader kaupapa, and mirrors the intent of the current national health reform’s goals.[[30]] Secondly, there was a call for improving health literacy at all stages of the patient journey. Patient education is universally regarded as a cornerstone of OA management.[[12]]
Three recommended goals for the future health delivery for people with OA can be constructed from the analysis of our findings: first, the conceptualisation of OA management as a continuum so that injury prevention, obesity reduction and physical activity are actively considered along with primary and secondary care services. Second, establishing an evidence-informed model of care that guides the development and implementation of clinical services across the clinical course of (long-term) musculoskeletal conditions. The third is the development of clinical hubs or programmes for Māori hauora that specifically meet the needs of Māori.
This study's strengths are that it captured the perspectives of a broad range of people actively engaged in helping people with OA management in Aotearoa New Zealand, including research, and that we used methodologies suited to the nature of the research questions and the data, which provided an acceptable level of academic rigour.[[17]] The main limitations were that data were collected from people whose attendance at the symposium suggested that they are actively invested in OA management in Aotearoa New Zealanc; hence, their beliefs and attitudes may not reflect those of the wider population. Furthermore, there was no consumer input into the data or the data analysis (aside from health delivery stakeholders who secondarily identify as having OA), meaning a valuable perspective is missing and future studies are needed to explore this perspective. Lastly, data collection using Post-it[[TM]] Notes lacks the contextual richness of, for example, in-depth interview methodologies, meaning there is the risk of misinterpretation of short sentences. However, as most of the authors contributed to the running of the workshops (BH did not participate), this risk is reduced. Health resources are finite; hence, the next phase of our kaupapa (project) includes a prioritisation study aiming to capture stakeholder beliefs on which services for people with OA merit greatest investment. Furthermore, we will recruit people living with OA.
Conclusion
Our study identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Furthermore, our analysis recognised factors that could enhance OA care across the lifespan, including a greater focus on prevention, hauora/wellbeing rather than the disease, incorporation of a wider range of healthcare professionals, addressing capacity constraints, the potential value of a model of OA care or pathway that is evidence based and integrates healthcare from OA prevention to secondary care. Yet, more work is needed to prioritise what stakeholders consider to be high-value care, and any model of OA care or pathway would need to acknowledge and support the diversity of needs within Aotearoa New Zealand and place value on interprofessional collaboration and practice, and improvements in health literacy and self-management.
Summary
Abstract
Aim
Osteoarthritis (OA) affects the wellbeing of one in 10 people in Aotearoa New Zealand, yet current healthcare delivery for these people is fragmented, un-coordinated and inconsistent. How current and future needs should be addressed has not been systematically explored. This study aimed to describe the views of interested people from the health sector regarding current and future OA health service delivery in the public health system in Aotearoa New Zealand.
Method
Data were collected via a co-design approach within an interprofessional workshop at the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium and analysed using direct qualitative content analysis.
Results
The results highlighted several promising current healthcare delivery initiatives. Health literacy and obesity prevention policies featured in the thematic analysis suggesting a lifespan or systemwide approach is needed. Data highlighted a need for reformed systems that enhances hauora/wellbeing, promotes physical activity, facilitates interprofessional service delivery and collaborates across care settings.
Conclusion
Participants identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Public health policy initiatives are needed to reduce osteoarthritis risk factors. Developing future care pathways should support the diverse needs within Aotearoa New Zealand, coordinate and stratify care, value interprofessional collaboration and practice, and improve health literacy and self-management.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Exploring the current and future osteoarthritis health service delivery needs in Aotearoa New Zealand
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Globally, osteoarthritis (OA) is a leading cause of chronic pain and disability.[[1,2]] In Aotearoa New Zealand, OA affects one in 10 people and prevalence is predicted to increase by 76% in the next 20 years due to obesity and population demographics and to drive healthcare costs up by 86%.[[3,4]] The rising burden of OA will place greater demand on clinical services.[[4–6]] OA can affect all aspects of a person’s sense of hauora (health), including hinengaro (mental and emotional), tinana (physical) and whānau (social).[[7–10]] International OA clinical management guidelines recommend people with OA should have access to care that provides appropriate person-centred education, exercise and weight loss (if applicable) before employing pharmacological or surgical management.[[12]] In contrast to these recommendations, OA management in Aotearoa New Zealand has been described as fragmented and regionally variable,[[5,13–15]] but little research has been undertaken on service delivery for people living with OA in Aotearoa New Zealand.
In December 2020, a transdisciplinary committee formed to improve collaboration between stakeholders interested in OA management in Aotearoa New Zealand. This group aimed to advocate for a National Model of Care for OA, similar to an initiative in Australia.[[16]] This committee delivered the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium in Auckland on 10 July 2021, with the aims of bringing together clinicians from all disciplines, health delivery organisations, consumers and researchers with a particular interest in managing OA in Aotearoa New Zealand, and developing a list of national priorities in OA research and innovative health delivery (https://events.otago.ac.nz/2021-osteoarthritis-basecamp/). The symposium was open to anyone in Aotearoa New Zealand with interest in OA healthcare. It brought together a national audience (n=82) of health professionals (dietitians, general medical practitioners, nurses, orthopaedic surgeons, physiotherapists, podiatrists, psychologists, rheumatologists, sports medicine physicians and clinical exercise physiologists), researchers (across fields from basic science to clinical trials) and health funders (services managers, policy workers).
Given the diverse sector representation, the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium provided an opportunity to share ideas and experiences, raise questions and expand thinking about how OA research and healthcare service delivery can be improved. The symposium’s morning sessions included presentations from national and international OA experts on best practice evidence about service delivery and research. The afternoon sessions included two interactive workshops which aimed to explore beliefs about national priorities in OA research and innovative OA health delivery in Aotearoa New Zealand from the perspective of actively engaged sector stakeholders. This manuscript presents the findings from the workshop about innovative OA health delivery in Aotearoa New Zealand.
Aim
To describe the views of interested people from the health sector about current and future OA health service delivery in the health system in Aotearoa New Zealand, including what works well, the barriers to service improvements, and priorities for OA health improvement initiatives.
Methods
Study design
We used a co-design approach,[[17]] informed by a realist philosophical lens, a qualitative descriptive methodology and thematic analysis to explore the current and future OA health service delivery need in Aotearoa New Zealand.[[18]] This participatory framework supports an interdisciplinary, collaborative design process to ensure that outcomes reflect real, rather than assumed, requirements and offer innovative strategies to resolve complex problems.[[19,20]]
Participants
Everyone who attended the 2-hour workshop at the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium in 2021 was invited to participate in the study. Attendance at the workshop was optional. People attending the workshop could choose for their data to be excluded from the analysis by drawing a small square on the back of their Post-it[[TM]] Notes. However, no one decided to do this.
Data collection
Ethics approval was obtained for the study from University of Otago Human Ethics Committee (D21/222). The participant information form was provided to all symposium registrants 1 week before the symposium. Written consent was obtained at the workshop.
Participants (attendees) worked in small groups (between four and eight people). An additional group of seven attended a pre-conference workshop at the University of Otago Medical School (Dunedin) on 24 June 2022. Participants were asked to brainstorm responses to questions about health service delivery for people with OA in Aotearoa New Zealand. Participants wrote their responses as bullet points on Post-it[[TM]] Notes. After 10–15 minutes, facilitators asked one group member to place all Post-it[[TM]] Notes on a wall-mounted poster for other attendees to see and consider. The facilitator then led discussion of the collective responses and then guided the groups to move to the next question. Table 1 lists the research questions participants discussed and responded to.
View Tables 1–4 and Figure 1.
For Questions 1 and 2, participants were asked to position their responses (Post-it[[TM]] Notes), after which they spent 10 minutes reading and reflecting on the group’s ideas. Then the facilitator led a group discussion on the themes represented, using co-design facilitation to generate participatory thematic analysis. Participants then went to the poster and organised the Post-it[[TM]] Notes into themes generated.
For Question 3, participants were asked to position their responses (Post-it[[TM]] Notes) on a journey map.[[21]] The journey map, conceived a priori by the researchers, represented the continuum of care in a person’s OA management. It included four subheadings or key touch points in the OA management journey (pre-OA, early identified OA, community and primary care, secondary care) under which the Post-it[[TM]] Notes could be placed (Figure 1) and the fifth subheading (lifespan or systemwide) placed at the bottom that spanned the whole journey map.
Data analysis
All written material generated during the workshop (Post-it[[TM]] Notes) was photographed in situ, collected, and used as the primary data source. All data were transferred into an Excel (Microsoft, 2022) spreadsheet, with each Post-it[[TM]] Note response in a cell. All responses were analysed using direct qualitative content analysis.[[22]] Analysis for Question 1 concluded with code grouping and naming; thematic analysis was conducted by the participants for Question 2, in the first instance, and code-grouping by the researchers was conducted independently post hoc. Since participants were asked to assign their responses to subheadings in the journey map for Question 3, we used these subheadings to frame the data analysis of this question. Thematic analysis of Question 3 was conducted by the researchers. Analysis of common responses across the journey map further informed the construction of the fifth subheading (lifespan or systemwide approach). The frequency of responses was not quantified because our goal was to capture the breadth of the data from workshop participants.
Two research team members (DOB and SN) collaboratively coded the responses (data) and then grouped codes that appeared conceptually connected. Next, these groups were named and presented to all research team members for feedback and refinement. To strengthen trustworthiness, results were continuously discussed between the research team with different competence and perspectives in triangulation between researchers.[[23]] A third team member (HA) reviewed the data, coding, code grouping and, for Question 3, conducted thematic analysis. Themes and sub-themes emerging from the coded data were returned to DOB and SN; these were discussed, and a working version was confirmed in a consensus meeting. Next, these themes and sub-themes were presented to all research team members for feedback before confirming a final version.
Results
Fifty-two people attended the 2-hour workshop. Participants came from various clinical (dietetics, general practice, nursing, orthopaedic surgery, physiotherapy, podiatry, psychology, rheumatology, sports medicine and clinical exercise physiology), health research and health funding backgrounds across Aotearoa New Zealand (Table 2). We have presented our results as they relate to the workshop questions and present data codes in “italics”. Names representing categories of grouped data are presented in bold. Themes and sub-themes are capitalised.
What works well in the management of OA in the public healthcare system?
Participants offered that OA management worked well when services work better together and focussed on building a healthcare service for all.
Work better together
OA management worked well when new pathways were developed with a “national perspective” that “recognised the need for change”, “reduced professional hierarchies” and developed and supported “triage clinics”. Furthermore, they reported that these changes had fostered a “willingness to share between groups, programmes and institutions” and greater “intersectoral collaboration”. Additionally, participants valued “engaging with local and international research” to support a move towards a more collaborative model of care.
Building a healthcare service for all
Participants believed that they had seen improvements in several areas of healthcare delivery, including cultural awareness, healthcare provider education, technological integration, and the implementation of a range of OA management programmes. Codes included “awareness of the need to build Māori health access”, more significant “Iwi and Māori consultation”, and “recognition of the value of equity” and the “patient voice”. They also reported improvements in “health workforce and undergraduate training” and believed the “quality of care for people was improving”. Participants also valued “increased investment in digital health models” and “technology advancement funding” as new initiatives improving OA management. Lastly, participants stated the benefit of the emergence of OA management programmes, including the Mobility Action Programme (MAP), Good Life with Arthritis: Denmark (GLA:D), Accident Compensation Corporation (ACC) injury prevention programmes, the Bay of Plenty Community Orthopaedic Triage Service (COTS) and the Canterbury Initiative.
What are the barriers to effective service delivery for people with OA?
Participants offered barriers or challenges, which they collaboratively analysed to the following themes (with example data codes): culture (institutional and clinician bias/racism; people’s motivation to take self-responsibility); resources (limitations of DHB [district health board] capacity; workforce to meet requirements; primary allied health services not funded; funding); accessibility (postcode healthcare; inequities; ethnicity and poverty); healthcare education (undergraduate training); focus of care (low prioritisation of OA; clinician-centred vs patient-centred); patient knowledge (common myths and misconceptions; poor patient awareness of treatment options); siloed (working in silos; lack of continuity in services); evidence-based practice (fewer evidence-based programmes in hospital and the community; data—access, outcomes).
Post hoc, we (DOB, SN) organised these into three code groups: 1) Knowledge and expectations, 2) Inequitable access to care, and 3) Patient- and whānau-(un)centred care.
1) Knowledge and expectations: Participants reported many challenges related to patient knowledge, health literacy and expectations. They referred to “a lack of understanding of OA in the general population” and limited knowledge of treatment options available (“population education”) and stated that more standardised resources and guidelines were needed. They also noted a “lack of patient-friendly resources” and “poor or inconsistent patient messaging”. Furthermore, participants identified the key barriers to the efficacy of existing clinical services as “patient adherence”, “unrealistic expectations” and “cultural differences”.
2) Inequitable access to care: The data highlighted participants’ concern about the inequitable access to OA management services in Aotearoa New Zealand in two categories: funding and access. Tensions with the funding of OA management in Aotearoa New Zealand included competition, real or perceived, to financing between “public, private and ACC”, between “primary and secondary care” (primary care being perceived as the more poorly funded) and compared to other long-term conditions such as cancer or diabetes (“low prioritisation at a DHB/MoH [Ministry of Health] level”). Participants also identified variability in access caused by “postcode healthcare”, “limited local resources (affordable pools or gyms)” and a “lack of access to weight management services and appropriate advice”.
3) Patient- and whānau-(un)centred care: Participants referred to the structure and culture of the health system and limited interprofessional collaboration, or working in silos, as system-level barriers to healthcare delivery. Specifically, critical barriers were “clinician-centred service design”, “institutional bias and racism”, a “one-size-fits-all approach”, and “a lack of authentic Māori engagement”. Moreover, some participants referred to “orthopaedics as the gate-keepers of referral to other programmes” and “a lack of buy-in from GPs and orthopaedics for non-surgical approaches”.
What are the key priorities for improvement initiatives for OA management in the Aotearoa New Zealand public healthcare system?
Table 3 shows key data codes for current Aotearoa New Zealand health delivery improvement initiatives participants were aware of or involved in, alongside potential future health delivery priorities for OA. Table 4 shows the themes, sub-themes, and key data code groups generated from the “key priorities for improvement” data.
Pre-OA
Participants’ responses highlight the value of injury prevention programmes and the many existing programmes that aim to increase physical activity, public education about OA and the benefits of exercise and physical activity (Table 3). Many responses regarding future healthcare delivery priorities, public health initiatives, health system changes and more robust methods of addressing obesity were considered by the researchers to be relevant beyond the “pre-OA” phase, so they were also carried through to the “lifespan or systemwide” axis of the journey map.
The codes and code groupings converged on two key themes (with sub-themes): a public health approach (sub-themes: policy, urban design, health literacy and prevention action); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Early OA
Data coded about the priorities for managing early OA were summed up with the notion that knowledge is power (Table 3). Participants listed resources and activities that would improve health literacy and knowledge about OA, both for patients and the public. They also wrote about the need for early screening to ensure appropriate access to patient pathways and that, in some instances, clinical services reprioritisation was needed (physiotherapy). Regarding future healthcare delivery priorities, participants wrote about needing to help patients self-manage their OA more effectively and enhance education via digital platforms, such as Health Navigator. Some suggested a more stratified, interprofessional approach to early management, matching patient need to available clinical services.
The codes and code groupings again converged on two key themes (with sub-themes): a public health approach (sub-theme: health literacy); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Community and primary care
The need for cohesive care across community and primary care OA management was prominent in the data, highlighting the need for greater accessibility, suggesting more use of technology and service hubs to reduce inequity of access for Māori and rural regions. More integrated and inclusive models of care, including Māori health models and Māori-led health services, were suggested. Again, the codes and code groupings converged on two key themes (with sub-themes): a public health approach (sub-themes: health literacy, programme action); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Secondary care
A range of data codes reflected access constraints and mapped ways to increase capacity—such as increasing workforce, surgical capacity, separating acute trauma capacity from elective surgery capacity, models bridging primary to secondary care or deploying allied health providers in secondary care, utilising private providers—and pathways to enable these. They reflected a need to redesign aspects of system flow to reduce delays for appropriate orthopaedic review, to avoid delays due to competing services (e.g., trauma surgery), and to identify non-surgical candidates and provide access to other services. The health delivery approach theme was most prominent; as well as the sub-themes of health system redesign, guidelines/pathways, and enabling providers, additional sub-themes of increasing capacity and new interventions were identified.
Lifespan or systemwide
The researchers considered several responses in the above four phases of the journey map relevant beyond the phase in which participants posted them, so they were also carried through to the “lifespan or systemwide” axis of the journey map. Data codes relating to this question clustered in four groups within this fifth element of the journey map. These were called: 1) a greater hauora/wellbeing focus, 2) increasing physical activity at all ages and stages, 3) an interprofessional approach to care, and 4) better connection of healthcare services across the four stages of the osteoarthritis journey map (Table 3). Interpretation of the participants' data suggested moving to a more holistic, person-centred approach to OA management, focussing on hauora/wellbeing. The public health approach theme suggested interventions that increase physical activity and reduce obesity. The health delivery approach theme suggested a redesign to better integrate health services (i.e., prevention, early identification and management, community and primary care, and secondary care) and enable a broader range of healthcare professions to contribute to managing OA.
Summative themes
Across all axes of the journey map, the codes and code groupings converged on two key themes (each with four sub-themes): a public health approach (sub-themes: policy, urban design, health literacy and programme action); and a health delivery approach (sub-themes: health system redesign, guidelines/pathways, enabling providers and increasing capacity) (Table 4).
Discussion
To our knowledge, this is the first study to explore priorities for health service delivery improvement initiatives for OA; while it has focussed on the Aotearoa New Zealand context, it offers international relevance. During the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium 2021, participants offered their informed views on OA care across the continuum, including current approaches that work well, barriers to care and current and future priorities. Participants cited the strengths of the existing services as a willingness to work together and develop services fit for all New Zealanders. Key barriers were poor knowledge and expectations, inequity of care and lack of patient- and whānau-centred care.
Participants offered recent positive changes to OA management in Aotearoa New Zealand, including steps to improve collaboration across primary and secondary services (e.g., triaging systems such as the Bay of Plenty COTS), an appreciation for the need to develop health delivery fit for all (especially for Māori) and the success of more person-centred interprofessional approaches to care (i.e., MAP). However, our findings suggest that these initiatives are not yet ubiquitous or comprehensive enough. Previous literature has called for management across the disease continuum,[[24]] to change the narrative and improve patient and public understanding of the disease,[[25,26]] and develop patient-centred health service delivery approaches that acknowledge the diversity of Aotearoa New Zealand and partner with Māori to meet service need.[[7,8]] These are critical areas to address in the Aotearoa New Zealand health system.
Analysis of the findings suggests there may be a need for a comprehensive, cohesive and equitable model of OA care. Given the symposium's aims and the participants’ decisions to attend, this finding is not surprising. A comprehensive and equitable OA service reflects recommendations for best-practice OA management.[[13,27–29]] While the data did not explicitly state a need to implement consistent national pathways or systems across Te Whatu Ora (the Aotearoa New Zealand public healthcare system), this imperative was implied in the statement of the workshop questions and the symposium’s broader kaupapa, and mirrors the intent of the current national health reform’s goals.[[30]] Secondly, there was a call for improving health literacy at all stages of the patient journey. Patient education is universally regarded as a cornerstone of OA management.[[12]]
Three recommended goals for the future health delivery for people with OA can be constructed from the analysis of our findings: first, the conceptualisation of OA management as a continuum so that injury prevention, obesity reduction and physical activity are actively considered along with primary and secondary care services. Second, establishing an evidence-informed model of care that guides the development and implementation of clinical services across the clinical course of (long-term) musculoskeletal conditions. The third is the development of clinical hubs or programmes for Māori hauora that specifically meet the needs of Māori.
This study's strengths are that it captured the perspectives of a broad range of people actively engaged in helping people with OA management in Aotearoa New Zealand, including research, and that we used methodologies suited to the nature of the research questions and the data, which provided an acceptable level of academic rigour.[[17]] The main limitations were that data were collected from people whose attendance at the symposium suggested that they are actively invested in OA management in Aotearoa New Zealanc; hence, their beliefs and attitudes may not reflect those of the wider population. Furthermore, there was no consumer input into the data or the data analysis (aside from health delivery stakeholders who secondarily identify as having OA), meaning a valuable perspective is missing and future studies are needed to explore this perspective. Lastly, data collection using Post-it[[TM]] Notes lacks the contextual richness of, for example, in-depth interview methodologies, meaning there is the risk of misinterpretation of short sentences. However, as most of the authors contributed to the running of the workshops (BH did not participate), this risk is reduced. Health resources are finite; hence, the next phase of our kaupapa (project) includes a prioritisation study aiming to capture stakeholder beliefs on which services for people with OA merit greatest investment. Furthermore, we will recruit people living with OA.
Conclusion
Our study identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Furthermore, our analysis recognised factors that could enhance OA care across the lifespan, including a greater focus on prevention, hauora/wellbeing rather than the disease, incorporation of a wider range of healthcare professionals, addressing capacity constraints, the potential value of a model of OA care or pathway that is evidence based and integrates healthcare from OA prevention to secondary care. Yet, more work is needed to prioritise what stakeholders consider to be high-value care, and any model of OA care or pathway would need to acknowledge and support the diversity of needs within Aotearoa New Zealand and place value on interprofessional collaboration and practice, and improvements in health literacy and self-management.
Summary
Abstract
Aim
Osteoarthritis (OA) affects the wellbeing of one in 10 people in Aotearoa New Zealand, yet current healthcare delivery for these people is fragmented, un-coordinated and inconsistent. How current and future needs should be addressed has not been systematically explored. This study aimed to describe the views of interested people from the health sector regarding current and future OA health service delivery in the public health system in Aotearoa New Zealand.
Method
Data were collected via a co-design approach within an interprofessional workshop at the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium and analysed using direct qualitative content analysis.
Results
The results highlighted several promising current healthcare delivery initiatives. Health literacy and obesity prevention policies featured in the thematic analysis suggesting a lifespan or systemwide approach is needed. Data highlighted a need for reformed systems that enhances hauora/wellbeing, promotes physical activity, facilitates interprofessional service delivery and collaborates across care settings.
Conclusion
Participants identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Public health policy initiatives are needed to reduce osteoarthritis risk factors. Developing future care pathways should support the diverse needs within Aotearoa New Zealand, coordinate and stratify care, value interprofessional collaboration and practice, and improve health literacy and self-management.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Contact diana@nzma.org.nz
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Exploring the current and future osteoarthritis health service delivery needs in Aotearoa New Zealand
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Globally, osteoarthritis (OA) is a leading cause of chronic pain and disability.[[1,2]] In Aotearoa New Zealand, OA affects one in 10 people and prevalence is predicted to increase by 76% in the next 20 years due to obesity and population demographics and to drive healthcare costs up by 86%.[[3,4]] The rising burden of OA will place greater demand on clinical services.[[4–6]] OA can affect all aspects of a person’s sense of hauora (health), including hinengaro (mental and emotional), tinana (physical) and whānau (social).[[7–10]] International OA clinical management guidelines recommend people with OA should have access to care that provides appropriate person-centred education, exercise and weight loss (if applicable) before employing pharmacological or surgical management.[[12]] In contrast to these recommendations, OA management in Aotearoa New Zealand has been described as fragmented and regionally variable,[[5,13–15]] but little research has been undertaken on service delivery for people living with OA in Aotearoa New Zealand.
In December 2020, a transdisciplinary committee formed to improve collaboration between stakeholders interested in OA management in Aotearoa New Zealand. This group aimed to advocate for a National Model of Care for OA, similar to an initiative in Australia.[[16]] This committee delivered the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium in Auckland on 10 July 2021, with the aims of bringing together clinicians from all disciplines, health delivery organisations, consumers and researchers with a particular interest in managing OA in Aotearoa New Zealand, and developing a list of national priorities in OA research and innovative health delivery (https://events.otago.ac.nz/2021-osteoarthritis-basecamp/). The symposium was open to anyone in Aotearoa New Zealand with interest in OA healthcare. It brought together a national audience (n=82) of health professionals (dietitians, general medical practitioners, nurses, orthopaedic surgeons, physiotherapists, podiatrists, psychologists, rheumatologists, sports medicine physicians and clinical exercise physiologists), researchers (across fields from basic science to clinical trials) and health funders (services managers, policy workers).
Given the diverse sector representation, the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium provided an opportunity to share ideas and experiences, raise questions and expand thinking about how OA research and healthcare service delivery can be improved. The symposium’s morning sessions included presentations from national and international OA experts on best practice evidence about service delivery and research. The afternoon sessions included two interactive workshops which aimed to explore beliefs about national priorities in OA research and innovative OA health delivery in Aotearoa New Zealand from the perspective of actively engaged sector stakeholders. This manuscript presents the findings from the workshop about innovative OA health delivery in Aotearoa New Zealand.
Aim
To describe the views of interested people from the health sector about current and future OA health service delivery in the health system in Aotearoa New Zealand, including what works well, the barriers to service improvements, and priorities for OA health improvement initiatives.
Methods
Study design
We used a co-design approach,[[17]] informed by a realist philosophical lens, a qualitative descriptive methodology and thematic analysis to explore the current and future OA health service delivery need in Aotearoa New Zealand.[[18]] This participatory framework supports an interdisciplinary, collaborative design process to ensure that outcomes reflect real, rather than assumed, requirements and offer innovative strategies to resolve complex problems.[[19,20]]
Participants
Everyone who attended the 2-hour workshop at the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium in 2021 was invited to participate in the study. Attendance at the workshop was optional. People attending the workshop could choose for their data to be excluded from the analysis by drawing a small square on the back of their Post-it[[TM]] Notes. However, no one decided to do this.
Data collection
Ethics approval was obtained for the study from University of Otago Human Ethics Committee (D21/222). The participant information form was provided to all symposium registrants 1 week before the symposium. Written consent was obtained at the workshop.
Participants (attendees) worked in small groups (between four and eight people). An additional group of seven attended a pre-conference workshop at the University of Otago Medical School (Dunedin) on 24 June 2022. Participants were asked to brainstorm responses to questions about health service delivery for people with OA in Aotearoa New Zealand. Participants wrote their responses as bullet points on Post-it[[TM]] Notes. After 10–15 minutes, facilitators asked one group member to place all Post-it[[TM]] Notes on a wall-mounted poster for other attendees to see and consider. The facilitator then led discussion of the collective responses and then guided the groups to move to the next question. Table 1 lists the research questions participants discussed and responded to.
View Tables 1–4 and Figure 1.
For Questions 1 and 2, participants were asked to position their responses (Post-it[[TM]] Notes), after which they spent 10 minutes reading and reflecting on the group’s ideas. Then the facilitator led a group discussion on the themes represented, using co-design facilitation to generate participatory thematic analysis. Participants then went to the poster and organised the Post-it[[TM]] Notes into themes generated.
For Question 3, participants were asked to position their responses (Post-it[[TM]] Notes) on a journey map.[[21]] The journey map, conceived a priori by the researchers, represented the continuum of care in a person’s OA management. It included four subheadings or key touch points in the OA management journey (pre-OA, early identified OA, community and primary care, secondary care) under which the Post-it[[TM]] Notes could be placed (Figure 1) and the fifth subheading (lifespan or systemwide) placed at the bottom that spanned the whole journey map.
Data analysis
All written material generated during the workshop (Post-it[[TM]] Notes) was photographed in situ, collected, and used as the primary data source. All data were transferred into an Excel (Microsoft, 2022) spreadsheet, with each Post-it[[TM]] Note response in a cell. All responses were analysed using direct qualitative content analysis.[[22]] Analysis for Question 1 concluded with code grouping and naming; thematic analysis was conducted by the participants for Question 2, in the first instance, and code-grouping by the researchers was conducted independently post hoc. Since participants were asked to assign their responses to subheadings in the journey map for Question 3, we used these subheadings to frame the data analysis of this question. Thematic analysis of Question 3 was conducted by the researchers. Analysis of common responses across the journey map further informed the construction of the fifth subheading (lifespan or systemwide approach). The frequency of responses was not quantified because our goal was to capture the breadth of the data from workshop participants.
Two research team members (DOB and SN) collaboratively coded the responses (data) and then grouped codes that appeared conceptually connected. Next, these groups were named and presented to all research team members for feedback and refinement. To strengthen trustworthiness, results were continuously discussed between the research team with different competence and perspectives in triangulation between researchers.[[23]] A third team member (HA) reviewed the data, coding, code grouping and, for Question 3, conducted thematic analysis. Themes and sub-themes emerging from the coded data were returned to DOB and SN; these were discussed, and a working version was confirmed in a consensus meeting. Next, these themes and sub-themes were presented to all research team members for feedback before confirming a final version.
Results
Fifty-two people attended the 2-hour workshop. Participants came from various clinical (dietetics, general practice, nursing, orthopaedic surgery, physiotherapy, podiatry, psychology, rheumatology, sports medicine and clinical exercise physiology), health research and health funding backgrounds across Aotearoa New Zealand (Table 2). We have presented our results as they relate to the workshop questions and present data codes in “italics”. Names representing categories of grouped data are presented in bold. Themes and sub-themes are capitalised.
What works well in the management of OA in the public healthcare system?
Participants offered that OA management worked well when services work better together and focussed on building a healthcare service for all.
Work better together
OA management worked well when new pathways were developed with a “national perspective” that “recognised the need for change”, “reduced professional hierarchies” and developed and supported “triage clinics”. Furthermore, they reported that these changes had fostered a “willingness to share between groups, programmes and institutions” and greater “intersectoral collaboration”. Additionally, participants valued “engaging with local and international research” to support a move towards a more collaborative model of care.
Building a healthcare service for all
Participants believed that they had seen improvements in several areas of healthcare delivery, including cultural awareness, healthcare provider education, technological integration, and the implementation of a range of OA management programmes. Codes included “awareness of the need to build Māori health access”, more significant “Iwi and Māori consultation”, and “recognition of the value of equity” and the “patient voice”. They also reported improvements in “health workforce and undergraduate training” and believed the “quality of care for people was improving”. Participants also valued “increased investment in digital health models” and “technology advancement funding” as new initiatives improving OA management. Lastly, participants stated the benefit of the emergence of OA management programmes, including the Mobility Action Programme (MAP), Good Life with Arthritis: Denmark (GLA:D), Accident Compensation Corporation (ACC) injury prevention programmes, the Bay of Plenty Community Orthopaedic Triage Service (COTS) and the Canterbury Initiative.
What are the barriers to effective service delivery for people with OA?
Participants offered barriers or challenges, which they collaboratively analysed to the following themes (with example data codes): culture (institutional and clinician bias/racism; people’s motivation to take self-responsibility); resources (limitations of DHB [district health board] capacity; workforce to meet requirements; primary allied health services not funded; funding); accessibility (postcode healthcare; inequities; ethnicity and poverty); healthcare education (undergraduate training); focus of care (low prioritisation of OA; clinician-centred vs patient-centred); patient knowledge (common myths and misconceptions; poor patient awareness of treatment options); siloed (working in silos; lack of continuity in services); evidence-based practice (fewer evidence-based programmes in hospital and the community; data—access, outcomes).
Post hoc, we (DOB, SN) organised these into three code groups: 1) Knowledge and expectations, 2) Inequitable access to care, and 3) Patient- and whānau-(un)centred care.
1) Knowledge and expectations: Participants reported many challenges related to patient knowledge, health literacy and expectations. They referred to “a lack of understanding of OA in the general population” and limited knowledge of treatment options available (“population education”) and stated that more standardised resources and guidelines were needed. They also noted a “lack of patient-friendly resources” and “poor or inconsistent patient messaging”. Furthermore, participants identified the key barriers to the efficacy of existing clinical services as “patient adherence”, “unrealistic expectations” and “cultural differences”.
2) Inequitable access to care: The data highlighted participants’ concern about the inequitable access to OA management services in Aotearoa New Zealand in two categories: funding and access. Tensions with the funding of OA management in Aotearoa New Zealand included competition, real or perceived, to financing between “public, private and ACC”, between “primary and secondary care” (primary care being perceived as the more poorly funded) and compared to other long-term conditions such as cancer or diabetes (“low prioritisation at a DHB/MoH [Ministry of Health] level”). Participants also identified variability in access caused by “postcode healthcare”, “limited local resources (affordable pools or gyms)” and a “lack of access to weight management services and appropriate advice”.
3) Patient- and whānau-(un)centred care: Participants referred to the structure and culture of the health system and limited interprofessional collaboration, or working in silos, as system-level barriers to healthcare delivery. Specifically, critical barriers were “clinician-centred service design”, “institutional bias and racism”, a “one-size-fits-all approach”, and “a lack of authentic Māori engagement”. Moreover, some participants referred to “orthopaedics as the gate-keepers of referral to other programmes” and “a lack of buy-in from GPs and orthopaedics for non-surgical approaches”.
What are the key priorities for improvement initiatives for OA management in the Aotearoa New Zealand public healthcare system?
Table 3 shows key data codes for current Aotearoa New Zealand health delivery improvement initiatives participants were aware of or involved in, alongside potential future health delivery priorities for OA. Table 4 shows the themes, sub-themes, and key data code groups generated from the “key priorities for improvement” data.
Pre-OA
Participants’ responses highlight the value of injury prevention programmes and the many existing programmes that aim to increase physical activity, public education about OA and the benefits of exercise and physical activity (Table 3). Many responses regarding future healthcare delivery priorities, public health initiatives, health system changes and more robust methods of addressing obesity were considered by the researchers to be relevant beyond the “pre-OA” phase, so they were also carried through to the “lifespan or systemwide” axis of the journey map.
The codes and code groupings converged on two key themes (with sub-themes): a public health approach (sub-themes: policy, urban design, health literacy and prevention action); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Early OA
Data coded about the priorities for managing early OA were summed up with the notion that knowledge is power (Table 3). Participants listed resources and activities that would improve health literacy and knowledge about OA, both for patients and the public. They also wrote about the need for early screening to ensure appropriate access to patient pathways and that, in some instances, clinical services reprioritisation was needed (physiotherapy). Regarding future healthcare delivery priorities, participants wrote about needing to help patients self-manage their OA more effectively and enhance education via digital platforms, such as Health Navigator. Some suggested a more stratified, interprofessional approach to early management, matching patient need to available clinical services.
The codes and code groupings again converged on two key themes (with sub-themes): a public health approach (sub-theme: health literacy); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Community and primary care
The need for cohesive care across community and primary care OA management was prominent in the data, highlighting the need for greater accessibility, suggesting more use of technology and service hubs to reduce inequity of access for Māori and rural regions. More integrated and inclusive models of care, including Māori health models and Māori-led health services, were suggested. Again, the codes and code groupings converged on two key themes (with sub-themes): a public health approach (sub-themes: health literacy, programme action); and health delivery approach (sub-themes: health system redesign, guidelines/pathways, and enabling providers).
Secondary care
A range of data codes reflected access constraints and mapped ways to increase capacity—such as increasing workforce, surgical capacity, separating acute trauma capacity from elective surgery capacity, models bridging primary to secondary care or deploying allied health providers in secondary care, utilising private providers—and pathways to enable these. They reflected a need to redesign aspects of system flow to reduce delays for appropriate orthopaedic review, to avoid delays due to competing services (e.g., trauma surgery), and to identify non-surgical candidates and provide access to other services. The health delivery approach theme was most prominent; as well as the sub-themes of health system redesign, guidelines/pathways, and enabling providers, additional sub-themes of increasing capacity and new interventions were identified.
Lifespan or systemwide
The researchers considered several responses in the above four phases of the journey map relevant beyond the phase in which participants posted them, so they were also carried through to the “lifespan or systemwide” axis of the journey map. Data codes relating to this question clustered in four groups within this fifth element of the journey map. These were called: 1) a greater hauora/wellbeing focus, 2) increasing physical activity at all ages and stages, 3) an interprofessional approach to care, and 4) better connection of healthcare services across the four stages of the osteoarthritis journey map (Table 3). Interpretation of the participants' data suggested moving to a more holistic, person-centred approach to OA management, focussing on hauora/wellbeing. The public health approach theme suggested interventions that increase physical activity and reduce obesity. The health delivery approach theme suggested a redesign to better integrate health services (i.e., prevention, early identification and management, community and primary care, and secondary care) and enable a broader range of healthcare professions to contribute to managing OA.
Summative themes
Across all axes of the journey map, the codes and code groupings converged on two key themes (each with four sub-themes): a public health approach (sub-themes: policy, urban design, health literacy and programme action); and a health delivery approach (sub-themes: health system redesign, guidelines/pathways, enabling providers and increasing capacity) (Table 4).
Discussion
To our knowledge, this is the first study to explore priorities for health service delivery improvement initiatives for OA; while it has focussed on the Aotearoa New Zealand context, it offers international relevance. During the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium 2021, participants offered their informed views on OA care across the continuum, including current approaches that work well, barriers to care and current and future priorities. Participants cited the strengths of the existing services as a willingness to work together and develop services fit for all New Zealanders. Key barriers were poor knowledge and expectations, inequity of care and lack of patient- and whānau-centred care.
Participants offered recent positive changes to OA management in Aotearoa New Zealand, including steps to improve collaboration across primary and secondary services (e.g., triaging systems such as the Bay of Plenty COTS), an appreciation for the need to develop health delivery fit for all (especially for Māori) and the success of more person-centred interprofessional approaches to care (i.e., MAP). However, our findings suggest that these initiatives are not yet ubiquitous or comprehensive enough. Previous literature has called for management across the disease continuum,[[24]] to change the narrative and improve patient and public understanding of the disease,[[25,26]] and develop patient-centred health service delivery approaches that acknowledge the diversity of Aotearoa New Zealand and partner with Māori to meet service need.[[7,8]] These are critical areas to address in the Aotearoa New Zealand health system.
Analysis of the findings suggests there may be a need for a comprehensive, cohesive and equitable model of OA care. Given the symposium's aims and the participants’ decisions to attend, this finding is not surprising. A comprehensive and equitable OA service reflects recommendations for best-practice OA management.[[13,27–29]] While the data did not explicitly state a need to implement consistent national pathways or systems across Te Whatu Ora (the Aotearoa New Zealand public healthcare system), this imperative was implied in the statement of the workshop questions and the symposium’s broader kaupapa, and mirrors the intent of the current national health reform’s goals.[[30]] Secondly, there was a call for improving health literacy at all stages of the patient journey. Patient education is universally regarded as a cornerstone of OA management.[[12]]
Three recommended goals for the future health delivery for people with OA can be constructed from the analysis of our findings: first, the conceptualisation of OA management as a continuum so that injury prevention, obesity reduction and physical activity are actively considered along with primary and secondary care services. Second, establishing an evidence-informed model of care that guides the development and implementation of clinical services across the clinical course of (long-term) musculoskeletal conditions. The third is the development of clinical hubs or programmes for Māori hauora that specifically meet the needs of Māori.
This study's strengths are that it captured the perspectives of a broad range of people actively engaged in helping people with OA management in Aotearoa New Zealand, including research, and that we used methodologies suited to the nature of the research questions and the data, which provided an acceptable level of academic rigour.[[17]] The main limitations were that data were collected from people whose attendance at the symposium suggested that they are actively invested in OA management in Aotearoa New Zealanc; hence, their beliefs and attitudes may not reflect those of the wider population. Furthermore, there was no consumer input into the data or the data analysis (aside from health delivery stakeholders who secondarily identify as having OA), meaning a valuable perspective is missing and future studies are needed to explore this perspective. Lastly, data collection using Post-it[[TM]] Notes lacks the contextual richness of, for example, in-depth interview methodologies, meaning there is the risk of misinterpretation of short sentences. However, as most of the authors contributed to the running of the workshops (BH did not participate), this risk is reduced. Health resources are finite; hence, the next phase of our kaupapa (project) includes a prioritisation study aiming to capture stakeholder beliefs on which services for people with OA merit greatest investment. Furthermore, we will recruit people living with OA.
Conclusion
Our study identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Furthermore, our analysis recognised factors that could enhance OA care across the lifespan, including a greater focus on prevention, hauora/wellbeing rather than the disease, incorporation of a wider range of healthcare professionals, addressing capacity constraints, the potential value of a model of OA care or pathway that is evidence based and integrates healthcare from OA prevention to secondary care. Yet, more work is needed to prioritise what stakeholders consider to be high-value care, and any model of OA care or pathway would need to acknowledge and support the diversity of needs within Aotearoa New Zealand and place value on interprofessional collaboration and practice, and improvements in health literacy and self-management.
Summary
Abstract
Aim
Osteoarthritis (OA) affects the wellbeing of one in 10 people in Aotearoa New Zealand, yet current healthcare delivery for these people is fragmented, un-coordinated and inconsistent. How current and future needs should be addressed has not been systematically explored. This study aimed to describe the views of interested people from the health sector regarding current and future OA health service delivery in the public health system in Aotearoa New Zealand.
Method
Data were collected via a co-design approach within an interprofessional workshop at the Taupuni Hao Huatau Kaikōiwi: Osteoarthritis Aotearoa New Zealand Basecamp symposium and analysed using direct qualitative content analysis.
Results
The results highlighted several promising current healthcare delivery initiatives. Health literacy and obesity prevention policies featured in the thematic analysis suggesting a lifespan or systemwide approach is needed. Data highlighted a need for reformed systems that enhances hauora/wellbeing, promotes physical activity, facilitates interprofessional service delivery and collaborates across care settings.
Conclusion
Participants identified several promising healthcare delivery initiatives for people with OA in Aotearoa New Zealand. Public health policy initiatives are needed to reduce osteoarthritis risk factors. Developing future care pathways should support the diverse needs within Aotearoa New Zealand, coordinate and stratify care, value interprofessional collaboration and practice, and improve health literacy and self-management.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Exploring the current and future osteoarthritis health service delivery needs in Aotearoa New Zealand
Globally, osteoarthritis (OA) is a leading cause of chronic pain and disability. In Aotearoa New Zealand, OA affects one in 10 people and prevalence is predicted to increase by 76% in the next 20 years due to obesity and population demographics and to drive healthcare costs up by 86%.
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