CARE V Series: Integrating Patient Viewpoints Into Health Care Practice and Research

Data now demonstrate that patients and providers view outcomes of care differently.¹ Patients tend to view outcomes in a broad and socially relevant context,^2–4 whereas providers tend to view outcomes from a biomedical perspective. There is a growing recognition of patients as active members of the health care team and, in some countries, as integral members of clinical research study groups. This recognition has led to a shift in priorities in clinical practice and research.⁵

In April 2008, the CARE V Conference was held in Oslo, Norway, to foster international collaboration and provide a forum for key stakeholders, patients, and researchers in the field of rheumatology who are interested in advancing nonpharmacologic care. This 3-day conference built on the work of pioneers in arthritis research and care—on the collaborations that began in 2002 at the first CARE conference.⁶ In 2008, the fifth conference addressed key areas in nonpharmacologic arthritis care and included the identification of patient-oriented core outcomes, measurement challenges, models of care delivery, and effectiveness of interventions for arthritis. In addition, the conference included discussions that focused on ethical issues and strategies to integrate patient perspectives into care. In this issue, PTJ publishes the first in a series of papers that were presented at CARE V. In 2010, the series will explore ethical issues specific to the implementation of qualitative research and international perspectives on patient roles in health care, research, and professional education.

During the conference, researchers, patients, and clinicians examined care delivery models across the continuum of care—from pre-diagnosis and factors associated with early help-seeking behaviors to models of care delivery in primary and specialty practice. The presentations integrated the consumer's perspective, seeking to identify issues that may be associated with access to nonpharmacologic care and the use of this care.

“New Models for Primary Care Are Needed for Osteoarthritis”⁷ addresses the current gaps in care delivery for people with osteoarthritis and discusses how the treatment of these individuals can be enhanced through the development of management pathways. Using data from the United Kingdom, Dziedzic and colleagues postulate that the largest proportion of persons treated in primary care for musculoskeletal complaints are older adults with osteoarthritis. Even though the evidence exists to support the use of simple, easily accessible interventions to manage these patients, in practice patients are not receiving this care.⁸ The application of the medical model to primary care practice emphasizes the pathophysiology of the condition and leads to recommendations for surgery over nonpharmacologic approaches.

Integrated models such as the Chronic Care Model (CCM),⁹ a generic model for chronic diseases developed by individuals at the MacColl Institute for Healthcare Innovation and later refined by experts at the Robert Wood Johnson Foundation, delineate components of the health care system—such as community resources, self-management support, health care delivery system design, and clinical information system functionality—that promote excellence in chronic disease management. The CCM emphasizes the role of informed patients who are active participants in their care.¹⁰ Building on the concepts established in the CCM, Dziedzic et al⁷ note that the first approach to improve the primary care of patients with osteoarthritis is the integration of and continued support for self-management strategies. Encouraging use of self-management strategies is particularly important for patients with mild osteoarthritis, as these patients are generally overlooked. Although there is strong evidence that self-management improves health outcomes of people with arthritis,^11,12 the use of self-management strategies in primary care is limited. The authors explore the reasons for this lack of implementation and provide suggestions for changing clinical practice.

Moe and colleagues¹³ describe the evidence for nonpharmacologic interventions for hand osteoarthritis, a highly prevalent condition. Although numerous professional societies advocate the use of exercise and nonpharmacologic interventions to manage osteoarthritis, the recommendations lack specificity, particularly for hand osteoarthritis. These authors searched the literature and evaluated the outcomes of 4 systematic reviews of studies examining nonpharmacologic interventions for hand osteoarthritis using the Measurement Tool to Assess Systematic Reviews (AMSTAR).¹⁴ They conclude that there is some evidence for topical capsaicin and for splints to relieve pain and that exercise combined with patient education improves function compared with education alone.¹³ Based on their systematic review of the evidence, they emphasize the need for further research in hand osteoarthritis.

This paper raises some important questions. First, how valid are the results of umbrella reviews? To answer this question, we have to recognize the methodological strategies and issues inherent in this type of review—and this is a topic of considerable debate. Some scholars argue that there is a potential for selection bias, basing their argument on the premise that the process used to select randomized controlled trials for the primary reviews might lead to an oversight of seminal papers, which then are lost in the umbrella review. Others contend that the methodologic rigor used in evaluating the quality of the systematic reviews¹⁴ counters the selection bias argument. That said, the systematic review by Moe et al challenges us to examine the outcomes of hand splints, a commonly prescribed modality for hand osteoarthritis, in a more comprehensive and vigorous manner. In addition, this paper highlights the paucity of information on the frequency, mode, duration, and intensity of hand exercises. Future research should focus on the most effective dose of exercise for hand osteoarthritis, using a rigorous study to assess dose-response. This information may help to better inform patients and providers about what exercises are effective.

In January, Grotle and colleagues¹⁵ examine how team care is provided for patients with osteoarthritis following knee and hip arthroplasty and the impact of care delivery on health outcomes. Specifically, 183 Norwegian patients with osteoarthritis were followed prospectively for 6 months to determine the impact of the delivery of care on pain and function. The framework for this study is built on Donabedian's model of health care delivery, which assesses health care quality based on structures, processes, and outcomes.¹⁶ The intent is to provide a rich description of the process and key players in care delivery for these patients. At first glance, the reader might be compelled to argue that care in Norway is inherently different from care in the United States and, therefore, that US physical therapists might not see value in the work. It's true that processes and inputs in care delivery differ from country to country—but this fact does not negate the relative value of using this approach to examine outcomes of care delivery. As economic and other environmental influences such as workforce shortages continue to impact health care, we will need to look beyond our own practice venues to examine new approaches to care.

Other papers in the CARE V series will address new ethical frameworks for nonpharmacologic care, present data regarding education of health care professionals to enhance patient outcomes, and review the current state of evidence for interventions designed to manage arthritis. These issues, particularly the emphasis on integrating patients’ perspectives in arthritis care, will be explored further at the CARE VI Conference in Nancy, France, in April 2010. For further information, or to participate in the conference, contact Dr Francis Guillemin, the Local Organizer of CARE VI, at francis.guillemin{at}medecine.uhp-nancy.fr, or visit http://www.rheumacare.org.

• © 2009 American Physical Therapy Association