Publicação
Prevalence, burden and healthcare needs of people living with osteoarthritis in Portugal: contribution to the development of a Model of Care
| Resumo: | ABSTRACT - Background: Hip and/or knee Osteoarthritis (HKOA) are a leading and rising cause of disability worldwide. Evidence-based guidelines recommend core non-pharmacological and pharmacological interventions to improve pain, disability and quality of life. However, literature has shown that the outcomes of current care are far from optimal. Current interventions are heterogeneous, centred on symptomatic control with pharmacological interventions and surgical procedures, with a lack of processes to tailor treatment selection according to patient characteristics and preferences. To overcome this reality several countries and regions have implemented Models of Care (MoCs) for OA. These are frameworks that outline what care should be offered and how care should be delivered that aim to decrease the evidence-practice gap and optimize patient-level outcomes, quality of care and sustainability of health systems. To successfully implement an HKOA MoC in a country it is necessary to identify and understand the unmet needs of people living with this disease, the healthcare delivery and the pattern of healthcare utilization of these populations. Furthermore, it is needed to map effective solutions based on literature and identify which of them can be successfully applied in a specific setting. The work presented in this thesis used Portugal as a case-based setting for the future development of an HKOA MoC, with the following specific objectives: 1) to estimate the prevalence of HKOA and factors associated with its clinical and radiographic severity in Portugal. 2) to estimate the prevalence and factors associated with unmanageable pain levels among people with HKOA in Portugal. 3) to determine the trajectories of physical function and HRQoL and the factors associated with different trajectories in a 10-year longitudinal follow-up. 4) to analyse the healthcare services utilization of people with knee OA in Portugal, focusing on behavioral determinants for healthcare utilization. 5) to map and synthesize the literature of MoCs developed and implemented for people with knee OA. Methods: This thesis has two different phases. In the first phase, we analysed data from the nationwide population-based cohort – EpiDoC study (2011-2021) that included a representative sample of the Portuguese population randomly selected. In the first wave of EpiDoC study, after a structured interview where sociodemographic, lifestyle and health-related data were collected, participants were invited to an appointment with a rheumatologist, that validated the diagnosis of rheumatic diseases. These participants were then invited to participate in the subsequent waves (EpiDoC 2, 3 and 4) where structured interviews were again implemented. In the studies of the first phase of this thesis, we included participants that were diagnosed with HKOA by a rheumatologist in EpiDoC 1. In the second phase – potential solutions – we systematically analysed the published evidence published in peer-review and grey data sources, to perform a scoping review that mapped and synthesized the literature of MoCs developed and implemented for people with HKOA in primary care. Results: Across the 4 studies of the EpiDoC cohort we concluded that 14.1% (95%CI 12.6-15.7) of the Portuguese population have HKOA, and two-thirds self-report unmanageable pain levels. Age, female sex, multimorbidity, overweight/obesity, no regular exercise and education level were identified as factors associated with clinical severity. More than half of the population maintains moderate/low stable trajectories of physical function and HRQoL for 10 years. High users of healthcare services represent approximately 35% of people with HKOA. But, approximately 80% of participants with HKOA do not exercise regularly or are overweight/obese, which suggests a low uptake of evidence-based core interventions. The utilization of healthcare services seems not to be based just on clinical needs, revealing inequities in access to healthcare. The scoping review included 13 MoCs, that were implemented worldwide, delivering the core interventions in stepped care pathways at the primary care level. Despite the promising results at the patient-, organization- and implementation level, the heterogeneity in the report and the implementation strategies may difficult the transferability to other contexts and demand further high-quality research. Notwithstanding, it was possible to identify care pathways, evidence-based interventions and implementation strategies that could fit into the Portuguese healthcare system Conclusions: This thesis contributes to understanding the prevalence, characteristics and health-related status of people with HKOA in Portugal, as well as the suggested evidence-practice gap and inequities in the access to care regarding healthcare utilization. These results raise hypotheses about the uptake of core interventions and the access to healthcare by people with HKOA that should concern health authorities and call for future research in this area. Also, our results suggest the need to implement national strategies to optimize outcomes of care, and decrease and prevent future healthcare demands and rising costs related to HKOA, like MoCs. The implementation of a MoC in Portugal may be challenged by external, local and individual health context features that should be considered in the implementation process. |
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| Autores principais: | Costa, Daniela Sofia Albino |
| Assunto: | Osteoarthritis Epidemiology Models of care Epidemiologia Osteoartrose Modelos de cuidados |
| Ano: | 2022 |
| País: | Portugal |
| Tipo de documento: | tese de doutoramento |
| Tipo de acesso: | acesso aberto |
| Instituição associada: | Universidade Nova de Lisboa |
| Idioma: | inglês |
| Origem: | Repositório Institucional da UNL |
| Resumo: | ABSTRACT - Background: Hip and/or knee Osteoarthritis (HKOA) are a leading and rising cause of disability worldwide. Evidence-based guidelines recommend core non-pharmacological and pharmacological interventions to improve pain, disability and quality of life. However, literature has shown that the outcomes of current care are far from optimal. Current interventions are heterogeneous, centred on symptomatic control with pharmacological interventions and surgical procedures, with a lack of processes to tailor treatment selection according to patient characteristics and preferences. To overcome this reality several countries and regions have implemented Models of Care (MoCs) for OA. These are frameworks that outline what care should be offered and how care should be delivered that aim to decrease the evidence-practice gap and optimize patient-level outcomes, quality of care and sustainability of health systems. To successfully implement an HKOA MoC in a country it is necessary to identify and understand the unmet needs of people living with this disease, the healthcare delivery and the pattern of healthcare utilization of these populations. Furthermore, it is needed to map effective solutions based on literature and identify which of them can be successfully applied in a specific setting. The work presented in this thesis used Portugal as a case-based setting for the future development of an HKOA MoC, with the following specific objectives: 1) to estimate the prevalence of HKOA and factors associated with its clinical and radiographic severity in Portugal. 2) to estimate the prevalence and factors associated with unmanageable pain levels among people with HKOA in Portugal. 3) to determine the trajectories of physical function and HRQoL and the factors associated with different trajectories in a 10-year longitudinal follow-up. 4) to analyse the healthcare services utilization of people with knee OA in Portugal, focusing on behavioral determinants for healthcare utilization. 5) to map and synthesize the literature of MoCs developed and implemented for people with knee OA. Methods: This thesis has two different phases. In the first phase, we analysed data from the nationwide population-based cohort – EpiDoC study (2011-2021) that included a representative sample of the Portuguese population randomly selected. In the first wave of EpiDoC study, after a structured interview where sociodemographic, lifestyle and health-related data were collected, participants were invited to an appointment with a rheumatologist, that validated the diagnosis of rheumatic diseases. These participants were then invited to participate in the subsequent waves (EpiDoC 2, 3 and 4) where structured interviews were again implemented. In the studies of the first phase of this thesis, we included participants that were diagnosed with HKOA by a rheumatologist in EpiDoC 1. In the second phase – potential solutions – we systematically analysed the published evidence published in peer-review and grey data sources, to perform a scoping review that mapped and synthesized the literature of MoCs developed and implemented for people with HKOA in primary care. Results: Across the 4 studies of the EpiDoC cohort we concluded that 14.1% (95%CI 12.6-15.7) of the Portuguese population have HKOA, and two-thirds self-report unmanageable pain levels. Age, female sex, multimorbidity, overweight/obesity, no regular exercise and education level were identified as factors associated with clinical severity. More than half of the population maintains moderate/low stable trajectories of physical function and HRQoL for 10 years. High users of healthcare services represent approximately 35% of people with HKOA. But, approximately 80% of participants with HKOA do not exercise regularly or are overweight/obese, which suggests a low uptake of evidence-based core interventions. The utilization of healthcare services seems not to be based just on clinical needs, revealing inequities in access to healthcare. The scoping review included 13 MoCs, that were implemented worldwide, delivering the core interventions in stepped care pathways at the primary care level. Despite the promising results at the patient-, organization- and implementation level, the heterogeneity in the report and the implementation strategies may difficult the transferability to other contexts and demand further high-quality research. Notwithstanding, it was possible to identify care pathways, evidence-based interventions and implementation strategies that could fit into the Portuguese healthcare system Conclusions: This thesis contributes to understanding the prevalence, characteristics and health-related status of people with HKOA in Portugal, as well as the suggested evidence-practice gap and inequities in the access to care regarding healthcare utilization. These results raise hypotheses about the uptake of core interventions and the access to healthcare by people with HKOA that should concern health authorities and call for future research in this area. Also, our results suggest the need to implement national strategies to optimize outcomes of care, and decrease and prevent future healthcare demands and rising costs related to HKOA, like MoCs. The implementation of a MoC in Portugal may be challenged by external, local and individual health context features that should be considered in the implementation process. |
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