Croakey is closed for summer holidays and will resume publishing in the week of 13 January 2025. In the meantime, we are re-publishing some of our top articles from 2024.
This article was first published on Thursday, August 15, 2024
Introduction by Croakey: A revised national clinical standard for knee osteoarthritis, published today, aims to reduce unnecessary imaging and surgery, promote non-surgical treatments, and improve patient understanding of the condition.
Earlier this week, a CroakeyLIVE webinar provided context for the new guidance from the Australian Commission on Safety and Quality in Health Care, including calls for more flexible Medicare funding, primary care reform, and funding and implementation of the National Preventive Health Strategy.
The new standard also puts a focus on cultural safety and the need for better care for Aboriginal and Torres Strait Islander people.
Watch the 60-minute webinar, sponsored by the Australian Physiotherapy Association, here. It is the latest in a #CroakeyLIVE series marking the 40th anniversary of Medicare.
Marie McInerney writes:
An updated national clinical standard for knee osteoarthritis, released today, aims to shift patient perceptions that surgery is ‘an inevitable magic bullet’, amid projections that the number of knee replacements in Australia each year will triple by 2030.
The revised Australian Commission on Safety and Quality in Health Care (ACSQHC) standard for knee osteoarthritis comes as an innovative ACT project is delivering excellent early results in redirecting non-urgent patients away from unnecessary consultations with surgeons, which has freed up surgeons (and waitlists), in line with best practice and the clinical care standard.
A timely #CroakeyLIVE webinar on better care for knee osteoarthritis held this week heard that the Canberra Health Services (CHS) advanced practice physiotherapy screening project has slashed waiting times for an appointment with a knee surgeon from 800 days to 90 over 18 months, and halved the number of people ultimately referred for surgery.
Designating knee osteoarthritis as a chronic disease to be managed at the community and primary care level would be a mechanism for scaling up the project across Australia, the webinar heard.
“Overall, we’ve basically identified what a really efficient pathway of care looks like in the public health system,” said Danealle Gilfillan, an Advanced Practice physiotherapist.
The new care pathway had been welcomed by surgeons, allied health practitioners, and health executives, as well as by patients, Gilfillan said.
Meanwhile, Gold Coast orthopaedic surgeon Adjunct Professor Christopher Vertullo, one of the experts involved in reviewing the new standard, said that in his own practice, “about a third of referred patients don’t need to see me, and about 60 percent of all my patients have had an inappropriate investigation or scan, without any initial management for osteoarthritis”.
In a statement released by the Commission, Vertullo, who is Deputy Clinical Director of the Australian Orthopaedic Association National Joint Replacement Registry, said Australia has seen a gradual fall in rates of knee arthroscopy (keyhole surgery to examine the joint and remove damaged tissue).
However, there continued to be “rising rates of investigations such as X-rays, MRIs, ultrasounds and CT scans, reduced rates of proper clinical assessment, and lower rates of appropriate management before a patient is referred for surgery”.
“I am having regular conversations about the need to maximise non-surgical management,” he said.
Vertullo’s comments echoed the experience and advice of Melbourne knee surgeon Dr Nigel Hartnett in a preview of Croakey’s webinar, who said “there are always options for treating knee arthritis that do not involve knee replacement”.
The webinar was sponsored by the Australian Physiotherapy Association and moderated by Dr Elizabeth Deveny, CEO of the Consumers Health Forum of Australia.
Summing up the webinar, Deveny said it had highlighted the need to shift healthcare funding and mechanisms in a system that “too often rewards low value care and underfunds high value care”.
Treat the person, not the scan
According to the Commission, more than 1.2. million Australians were estimated in 2022 to have knee osteoarthritis, with 53,500 knee replacements performed. It says that figure is expected to increase by a massive 276 percent by 2030.
Yet the evidence shows that “most people can successfully reduce their pain and improve mobility without major surgery and the associated costs, recovery period and potential complications”, it said in launching the 2024 Osteoarthritis of the Knee Clinical Care Standard.
Dr Phoebe Holdenson Kimura, a Sydney GP and a medical advisor for the ACSQHC, told the webinar that evidence of high rates of low value osteoarthritis care such as knee arthroscopy had led to the original 2017 standard, which had seen “very good uptake”, particularly in multidisciplinary clinics based in hospital outpatient settings.
Holdenson Kimura is seeing increasing numbers of patients in her own practice who want to avoid surgery if they can, understanding that it might not be the best, only, or first option.
However, she says an ongoing challenge is that clinicians often still use language that “catastrophises osteoarthritis”. Phrases like ‘bone-on-bone’ and ‘wear and tear’ can make patients think that exercise is risky, non-surgical treatment options are futile as they cannot replace lost cartilage, and that a knee replacement is inevitable.
“That’s simply not true”, she said, warning that it puts patients “in a very passive position”.
Non-operative approaches such as physical activity, exercise and weight management make a big difference to quality of life for most people with knee osteoarthritis. Knowing that “joints are designed to be loaded and nourished by movement is a really, really powerful message”, she said.
Holdenson Kimura said the 2024 standard has been revised to align with new evidence, contemporary international guidelines and advances in person centered care, to improve non-surgical management, and further reduce low value care such as unnecessary imaging.
“We definitely don’t want to be treating the scan rather than the person,” she said. What’s needed instead is “a very thorough approach to the assessment, not only the history and the examination, but also thinking about how much it’s impacting that person’s function and what they’ve already tried”.
Consistency matters
According to the Commission, key updates in the standard will:
- clarify the scope of the standard to exclude knee pain other than suspected knee osteoarthritis
- expand and strengthen statements on appropriate use of imaging and weight management, nutrition, physical activity, and exercise, and
- provide additional information on psychosocial wellbeing considerations, cultural safety and equity considerations, and communicating with patients to support self-management.
Acknowledging that knee osteoarthritis can involve many causes, multi-morbidity and treatments, the Commission seeks to promote best practice care throughout a patient’s journey, by GPs, physiotherapists, exercise physiologists and dietitians, as well as rheumatologists, orthopaedic surgeons and other specialists.
“Consistency is key: consistency of care, consistency of message, and consistency of funding,” Croakey Co-Chair Professor Bronwyn Fredericks told the webinar.
Cultural safety
Fredericks, who is Deputy Vice-Chancellor (Indigenous Engagement) at the University of Queensland and a Goori-Murri woman, highlighted the focus in the new standard on culturally safe care for Aboriginal and Torres Strait Islander people with osteoarthritis, though warned that failure to invest in growing the Aboriginal and Torres Strait Islander health workforce would continue to impact progress.
In the new standard, the Commission acknowledges that Aboriginal and Torres Strait Islander people generally experience poorer health outcomes than other Australians, “with systemic racism a root cause”.
It says Aboriginal and Torres Strait Islander peoples are 1.5 times more likely than non-Indigenous people to have osteoarthritis, more likely to experience it at a younger age, and 50 percent less likely to access primary care management of knee osteoarthritis.
“The considerations for improving cultural safety and equity in this clinical care standard focus primarily on overcoming cultural power imbalances and improving outcomes for Aboriginal and Torres Strait Islander people through better access to health care,” it says.
The standard says ineffective communication between healthcare providers and patients is an important reason why Aboriginal and Torres Strait Islander people with osteoarthritis disengage from care, and highlights the need for health professionals and services to:
- take a person-centred collaborative approach to ensure interventions are tailored to the individual’s needs and preferences for care
- support people to self-report their Aboriginal or Torres Strait Islander status
- engage interpreters/translators when appropriate
- engage Aboriginal and Torres Strait Islander Health Workers and Practitioners as part of a patient’s multidisciplinary team.
- encourage the involvement of a person’s carers, family members or friends
- provide flexible service delivery to optimise attendance and build trust with Aboriginal and Torres Strait Islander people and communities.
Slashing waiting lists
The webinar heard that knee osteoarthritis treatment for public patients in the ACT is being transformed through the ‘GLA:D in the community’ program and the two-year HCF funded research project in collaboration with University of Canberra that runs alongside it at Canberra Health Services (CHS).
Research project manager, Danealle Gilfillan, an Advanced Practice physiotherapist, said the CHS had seen waiting lists for surgeons “blown out’ in recent years, exacerbated by COVID-19. Non-urgent patients were waiting up to 800 days for a consultation with a surgeon, with a third finally told they should have received physiotherapy in the first place and to go back and try that first.
A boosted screening program has physiotherapists working at the top of their scope of practice, seeing patients referred by GPs before they see a surgeon, providing a “really patient-centred assessment” on what the best care pathway for them looks like, and redirecting them where appropriate to non-surgical treatment, particularly the acclaimed GLA:D program out of Denmark.
The project scaled up screening rates from 15 percent of patients with knee osteoarthritis to 80 percent and evaluated what happened, she said, noting that Queensland has a similar screening program
This year all referred patients now wait an average 47 days to get a screening appointment; about half are then redirected to the GLA:D program and the other half go on to see a surgeon in less than 90 days.
About 65 percent of this group are “surgery ready” when they first meet with the surgeon, she said. This meant the surgeon has all necessary information and the patient is ready and willing for surgery, having exhausted all non surgical options available to them.
Patients had told researchers they were not wedded to being seen immediately by a surgeon versus another health professional.
“They just wanted someone who knew what they were doing to look at them and give them advice,” she said.
The research is also showing that English language proficiency, high body weight or poor health were not barriers to participation in the GLA:D program, that “even patients who are frail and have low mobility can be catered to, because these programs can be scaled up and down”.
Asked about the potential to roll out such a program more widely across Australia, Gilfillan said the major factor is funding flexibility.
“Having funding available for physio screening and an alternative care pathway, in this case the GLA:D program, has been the key to the success for us in reducing the waiting times and addressing our waiting list for surgery issues,” she said.
“The GPs tell us that they struggle to provide access to non-surgical management for their patients, and sometimes are just referring them to a surgeon for advice on what to do, because there’s blockages in the system elsewhere,” she said.
“So I think that what we all really want to see is knee arthritis considered a chronic disease and managed at the community and primary care level as chronic disease first,” she said, noting that is what the standard promotes.
Problematic systems
APA President Scott Willis agreed that too many patients are referred for surgical intervention “because that’s where the funding mechanism is”.
Equivalent or even better funding and mechanisms for non-operative procedures would increase access to care and to non-surgical treatment, including in rural, regional and remote areas, said Willis, a Palawa man who is based in Burnie.
“Health outcomes would actually improve and the heath spend would actually decrease,” he said, adding that Medicare funding structures are “no longer fit for purpose”.
“We’re not saying that you shouldn’t actually have a total hip or a total knee replacement,” said Willis.
“What we’re saying is that there are some alternate pathways that may actually be a better care for you at that time in your process, so you might have to have access to a different type of clinician, and that might be through non-surgical interventions, such as physiotherapy, such as dietetics, such as maybe an exercise physiologist, or any other type of allied health practitioner.”
Willis said the Commission’s revised standard is a “great step forward” to ensure that all health professions are “talking the same language” on knee osteoarthritis.
That will allow them to “put the pressure on government to look at how do we actually fund it and how do we get the government structure right to ensure that the consumer, the patient, has got access to the right care by the right person at the right time,” he said.
It’s further evidence of the critical need for a fully funded national preventative health strategy “that we have spoken about for many years but still haven’t had a government that’s bold enough to effectively fund it”, he said, pointing not only to the high costs of surgery but also of medications involved in current knee osteoarthritis treatments.
Willis said nations like Denmark are “actually closing hospitals” because they have got primary health and preventative strategies right, an argument that still floundered in Australia where the focus on investment remains on politically-popular hospitals versus public health and prevention spending.
“Could you imagine the headlines in the media here if the government actually shut down a hospital?” Willis asked.
Noting that Medicare is “very much fee for service”, Willis urged governments to look at different models of care and funding – including, for example, block funding for a program like GLA:D.
“So it might be that, instead of spending $25,000 to $30,000 on the total joint replacement, Medicare will pay $2-3,000 for the non-surgical intervention as block funding”, he said.
Reflecting on consumer perspectives, Deveny said critical issues included affordability of services like physiotherapy, particularly in the current cost of living crisis and the need to address the reluctance by some patients to see allied healthcare professionals versus doctors and surgeons.
She also had concerns around the clinical governance of people on waiting lists who become “out of sight, out of mind” for primary care providers and hospitals.
Asked by Deveny what successful implementation of the new standard would look like, Holdenson Kimura said the main national measure would be a continuing fall in arthroscopy rates.
“At an individual patient or consumer level, what we’re really wanting to see is for everybody living with osteoarthritis to be provided the same care pathway,” she said.
That included the right messaging from the start about their knee, equitable access to non-surgical management at the time of diagnosis, and if they need to go on to surgery, “that it is explained well and carried out in a really consistent way as well”.
See this list of information, support, and resources for clinicians, healthcare services, and consumers, compiled by the Commission.
Participant views
Ninety people registered for the webinar, with 49 attending. Below are some of their comments.
• Croakey Health Media Co-Chairs Professor Bronwyn Fredericks and James Blackwell will host a #CroakeyLIVE from 5pm AEST on Monday, 16 September in the lead up to the one-year anniversary of the Voice Referendum. More details to come.
Watch on replay
