AIHI Seminar Series 2016 – Professor David Hunter

AIHI Seminar Series 2016 – Professor David Hunter


I’m Rick Day.
I’m the honorary professor here working in the institute
from time to time. But it’s a great pleasure
today to be focusing on musculoskeletal health
which is a priority internationally and nationally. I have David Hunter who is
our speaker and guest today. David’s a very distinguished
osteoarthritis researcher. He’s the Florence and Cope
Professor of Rheumatology at the University of Sydney
based at North Shore Hospital, and he has a tremendously
good track record. He has degrees in medicine
but also public health and epidemiology from
multiple universities – UNSW, University of Sydney,
University of Newcastle. I might have left
one out there, David, I’m not sure. His post-doctoral
work was world-class. Such that he’s rated as
the most significant osteoarthritis
researcher on the globe from various agencies but
his great area of interest and contribution has been in epidemiology and also
programming interventions, translation of what we know
into effective outcomes. He’s very active here and I’m looking very
much to hearing David. So welcome, David. Thank you. Thanks very much, Rick, and it’s a pleasure to be here. I understand that Jeffrey’s
traveling overseas. Despite his very generous
invitation to come, I came anyway. Thank you all for coming. I always like to start
with a question, and obviously this is a
relatively small group. So hopefully we can make this
a little bit interactive. How many of you have a
first-degree family relative who has osteoarthritis? Keep your hands up. How many of you have torn your
ACL with a meniscal tear? Not many, okay. For all of you who’ve
put your hand up, hopefully you’ll be more
interested in what I have to say because I think there is a large
number of people out there in the general community
who have this, and a large number of people
who are going to get this despite the fact of
all of what you do. All right, there are
a lot of things that you can do to
prevent this disease, and I’m going to talk a little
about that and then also talk a little about how
we manage that disease. I’m going to start by telling
you a little bit about why I think osteoarthritis is important
and I appreciate coming out here because I use slides
that come from this group on a regular basis or at least
two slides in particular which you will see today. I want to talk about the burden
of the disease to start off with, and then I want to
talk about the ways that we’re going about
approaching it. I’m here to learn as well, so anything that you have to
suggest about what I’m doing that doesn’t make a lot of
sense and/or alternatives to what we’re doing that you
think might be sensible, please don’t hesitate
to let me know. Most of my support comes
from Arthritis Australia and some of it from the NHMRC, and I also have
consulted for a number of different companies, and I developed a brace for a
knee with an American company. Firstly, osteoarthritis. The modern definition of
osteoarthritis is this is a disease of the whole
joint and as a disease, it presents for the person
who complains of pain and limited function. Historically, it’s been defined
in lots of different ways. It was very cartilage-centric
in the first instance, and a lot of epidemiologic
studies have focused on the radiographic definition, but I think the clinical
definition is the one that’s really important because that’s
what promotes a person to come along and seek care
because they’ve got pain and limited function as a consequence
of their joint disease. Typically, the most common
joints that are affected are the hands, the
knees, and the hip. The most frequent presentation
is a person presenting with two to three joints
that are symptomatic. The life course is a long one. I think it’s important to
appreciate and understand that, but the average life course
of symptoms for a person that has osteoarthritis
is about 26 years. In that context, it doesn’t
make a lot of sense to focus on treatments have a mean
duration of effect of about two weeks which is
oftentimes what happens with injectable therapies. It’s incredibly important
for us to appreciate that this is very common. It affects about one in eight
adults in western communities. It provides a huge burden to the
individuals that are affected. The average person that
has osteoarthritis, the last time that they were
pain-free was three years ago, so that they live with this
chronic burden of pain for long period of time. It also places a huge impact
on our healthcare system. For the healthcare costs in 2012
– I think this is from 2013 but it’s 2012 data –
the healthcare costs were 3.8 billion dollars to the
Australian healthcare system. Most of that relates to joint
replacement – total knee and hip replacement which the
overwhelming indication for a person having their joint
replaced is because they’ve got osteoarthritis in their joints. That accounts for about
half of the cost related to healthcare for osteoarthritis
and a substantial portion also relates to
rehabilitation costs, the costs related to people
following their joint replacement, going and getting rehabilitation
which more often than not is in-patient but it probably
doesn’t necessarily need to be. That’s increasing exponentially
by virtue largely of the aging of our community, but also increasing numbers of
people who have this disease because either they’re
overweight or obese or they’ve injured their joint. The healthcare
costs are massive, but the indirect costs
are even larger. This is about 60% of the cost
to the Australian community for osteoarthritis relates
to indirect cost. The large chunk of that
relates to productivity in a particular reduced
employment rate. This is the most common reason
a person retires prematurely from the workplace is because
of their osteoarthritis. Now everybody thinks
that this is a disease just of older adults, but I think it’s really
important for you to understand that two-thirds of the
people that are affected are of working age, between
the ages of 45 and 65. This just isn’t a disease
of older people, and whilst my practice probably
doesn’t reflect most other rheumatologist’s practice
and it doesn’t reflect the practice of most people
who see a lot of people with osteoarthritis, the
mean age of the patients that I see in my
clinical practice is 32. That’s largely because I
tend to see a lot of people who’ve sustained injuries
to their joints, and by virtue of something they
did when they are in their late teens or early 20s,
they have osteoarthritis. So that tells you a little
bit about the burden and impact of this disease.
A lot of people are affected. They’re affected in
a substantial way from a personal perspective,
and from a societal perspective, it has a huge impact. I now want to go on and talk a
little bit about what we’re doing to try and
address that impact, to try to address the
evidence-practice gap that we know exists that you guys have
helped to highlight, and some efforts that
we’re going to continue to make in that arena. Firstly, before I
do that though, just a little bit about the
type of research that we do and I’ve been accompanied here by
two of my colleagues who do most of the work and I stand
up and tell everybody about the work that gets done. We do a little bit on disease
and pain mechanisms, quite a lot of on bio market
development particularly around imaging applications
to better understanding the relationship between
structure and function, and the application of that
imaging in clinical trials. We do a lot of clinical trials
both in disease modification, but also developing targeted
treatments for hand, hip, and knee osteoarthritis. What I’m going to
focus on today though, is very much around
health services and the work that we’re doing in an
advocacy and policy space. All right. In terms of what I’m going
to talk about today, I’m going to talk briefly
about prevention guidelines and appropriate care, looking at some consumer-targeted
interventions, looking at the evolution
of a clinical trial that we did to health
services implementation, a new model of care that we’re
in the process of developing, and then hopefully a
discussion about what next. I leave that question open
because I really want your input rather than for me to tell you
what I think is a good idea. I want your input about what
you think we should actually be doing. So this is a very simple schema,
I’m trying to remember his name, Ron Huckstep, the professor
of orthopedic surgeon. Some of you may know
at Prince of Wales, but he always used to exist
in the rule of threes. I always try and simplify
things down to three because my brain doesn’t
extend beyond that. At the moment, for
osteoarthritis, I would characterise the
way we manage this disease as palliative.
For a person who requires palliative care
for other diseases, I don’t want it to sound
like it’s a pejorative term, but for osteoarthritis I
want it to sound like it’s a pejorative term. Essentially, you present to
your health professional. More often than not, you’re
given the anti-inflammatory. When that fails, you’re provided
a referral to a surgeon. That’s the usual course
of events for a person that has osteoarthritis, and there’s a lot of other
things that we can do outside of that palliative approach. What we’re trying to do a lot
is impact on progression of the disease by virtue of
trying to reduce load, make a difference to the
progression of the underlying structure changes and symptoms
that a person complains of. I’ll show you a
slide in a second, but the overwhelming majority of
people that have osteoarthritis, the disease is preventable.
Unfortunately as a society, we don’t do a lot
about it, but we can. When you think about the
population attributable risk for osteoarthritis, the
two biggest risk factors – obesity being overweight and
injury are both preventable. Obesity and overweight counts
for about 45% of why a person develops osteoarthritis
of the knee; an injury, about 15% in women and
about 25% in men. Men tend to do a lot of
things to themselves that put them at risk, but both of these are
imminently preventable. When you look at that slide, close to 75% of the disease
theoretically could be prevented through public
health interventions, but unfortunately at
this point in time, we don’t do a lot as an
Australian community about either of
those risk factors. One risk factor that has
been shown to be imminently preventable and modifiable in
Scandinavian countries and some other centers
around the world is that of injury prevention. Essentially through
neuromuscular training, to teach a person how to land
on their knee properly as opposed to landing
on their knee with it in a flexed
valgus position. In that position, if
you land on your knee, you place your knee
at risk of rupturing your anterior
cruciate ligament. By virtue of training – and
there’s lots of different programs that are around the
world including that by FIFA, one that’s mandated by the IOC, the PET program – different
countries have been able to reduce their ACL injury
rates by 60% by instituting some of these programs. When they stopped doing it,
their injury rate goes back up. When they reinstitute it, their
injury rate goes back down. So by virtue of this, we
could potentially reduce the number of people who are
developing osteoarthritis theoretically by 15 to
20% just by instituting something like this nationally. With the Australian
Orthopedic Association, the Australian
Sports Commission, we’re in the process of trying
to see if we can adopt this nationally through their
training program for trainers and sports coaches. But it’s a bit of an uphill
battle because the policy makers aren’t necessarily on
board with us actually doing that at this point in time. All right, once a person
has osteoarthritis, how should that be managed?
These are the most recent Osteoarthritis Research
Society guidelines, which we brought out in
2014, but essentially, the overwhelming
majority of people, where appropriate,
they should exercise, lose weight, and learn about
managing their disease. That should be the
core treatments – that yellow box at the top. About 80% of people in
Australia who get onto the orthopedic waiting list never
get exposed to any of that. So you can see a surgeon. You can get put on the
operating waiting list for a knee or hip replacement, but you don’t necessarily need
to have any of that done in advance of you actually
being referred and/or put on that
waiting list. So that’s what should happen, but as you know through the
CareTrack study and other things, not everybody’s necessarily
receiving appropriate care. Now, there’s lots of different
options depending upon a person’s responsiveness to those
interventions depending upon whether they’ve got knee
osteoarthritis alone without or with comorbidities. I think it’s really important
we understand that the average person who has
osteoarthritis of the knee or hip has two to
three comorbidities, the most common of which are
hypertension, diabetes, and depression. The importance of
telling you about that is that more often than not, when we treat a person
that has osteoarthritis, we either don’t recognise that
they have that condition or potentially make it worse
with some of the management options that we choose
for our patients. This is one of the two
slides which are borrowed extensively from
people who work here which is from the
Caretrack study. Looking at the proportion of
people who receive appropriate care and for a lot of other
common non-communicable diseases to proportionate people
who receive appropriate care, looks very favorable. For osteoarthritis, it’s
down here at about 40%. This isn’t a criticism
of the study, but I think it’s very
generous to suggest that 40% of people are receiving
appropriate care based upon at least the patients that we
see coming along for our trials in the epidemiologic
studies that we see. So 40% at best are receiving
appropriate care, but as I say, I think
that’s quite generous. All right, I think another I
think of your studies is looking at the proportion of people, where we’re actually
failing these people. This is the quality of
osteoarthritis care, and they looked at quality
indicator a pass rates for a number of different domains for
osteoarthritis management, including pain and
functional assessment, non-drug treatment, drug
treatment, and surgical referral. The proportionate people who
were receiving or at least deemed to be touching that
quality indicator for surgical referral is approaching 80%, which for the right patient
at the right time, a joint replacement
is a great procedure. Not everybody necessarily
needs to see the surgeon, and I think what you’ve
demonstrated quite clearly in this study is that for
non-drug treatment and even for that
matter drug treatment, the overwhelming majority of
people are not necessarily approaching that quality
indicator threshold. There’s lots of improvements
that can be made both in terms of our assessment of patients
and more conservative options for treatment than surgery. Leaping on from that,
are our patients happy? I guess within the last month,
there’s a publication that came out of the AHA group
looking at patient satisfaction with the treatments that they
were receiving in Australia. This is an older slide that
tells the story a little bit differently to that, but essentially the overwhelming
majority of patients are not necessarily ready for
total knee replacement. A large proportion of them are
not satisfied with the care that they are receiving, so
there’s lots of improvements that patients want to see as well. We recognise looking at quality
indicator studies that we’re failing in
a lot of areas, and our patients want
to see us doing better. What can we do to make
that situation improve? Like any good academic, we did
a little bit of navel-gazing and essentially
thought to ourselves, What can we do better
about the management of osteoarthritis in the
general community, and how can we help consumers
out there with the management of their own disease?
I didn’t do this in isolation. Obviously, a lot of academics
did the navel-gazing in a very introspective way, but I’m very fortunate that I
work with a very collegial productive group who are
very insightful so we did navel-gazing together. We’re also, to a large extent,
inspired by consumer interaction. We spent a lot of time with
patient-public involvement, trying to get consumers
more involved in the work that we’re doing. This is Barbara. Barbara’s a 65-year-old
grandmother of six. She retired from stacking shelves
in the supermarket about six years ago because she
couldn’t tolerate pain in her knee anymore. Prior to that, she was
an avid tennis player. She loved bushwalking. She went along to her GP and was
prescribed an anti-inflammatory, but unfortunately, that made her
hypertension control much worse, so she had to come off her
anti-inflammatories she then went along and had an
injection into her knee which provided her about two to
three weeks of relief, but she still had
pain in her knee as a consequence of
her osteoarthritis. She’s got a body
mass index of 29. She’s relatively sedentary, doesn’t do any exercise
at this point in time. The next intervention that
was provided to her was a referral to a surgeon who
suggested that she should have an arthroscopy of her knee, which we know from many different
studies doesn’t actually provide any benefit over and
above sham physiotherapy and a whole host of other
interventions. That story is quite
consistent with what happens to a lot of our patients, and it’s not to lay
blame in any direction. I think it’s largely by virtue
of the fact that there’s a lot of misinformation that goes
out to the general community, and there’s a great requirement
on us to educate both consumers and health
professionals about how to better manage
this disease. One of the first things that
we did in collaboration with Arthritis Australia with the
support of Bupa was to develop this resource
called MyJointPain. This is a consumer-oriented
resource to try to provide better information about
management options that can be individually tailored on
the website for patients that have osteoarthritis, to link them using a Google
mapping technique to health professionals in the community
that will help to facilitate that sort of interaction, to allow them to monitor
and track their disease and also to connect with
the community of people that have osteoarthritis. This was launched coming
on two years ago now. I think in general, it’s
been well-received by the community of people
that have used it. Like any website, it’s
always difficult to know how much traction
you truly get. With the support of an ARC
discovery grant and great work that’s been done by one of
my research coordinators, Hema Umapathy, we looked at
evaluating to see whether we’re actually making
any difference to quality indicator outcomes. This is a Norwegian tool
called the OAQI which lists a whole lot of different
quality indicators for the management
of osteoarthritis. We did essentially a
before and after study comparing MyJointPain users, to people who’ved come along
to the website versus their baseline management and also
compared it to a group of controls who hadn’t been
exposed to the website. What you can see is that
for some of the domains in the quality indicator tool, we see a small improvement. That is statistically
significant, but I think if you truly
look at the magnitude of these improvements, they are small in terms of
proportion of people who are actually reaching that
different quality indicator. Again, if you look at
differences between people who’ve used MyJointPain
and controls, there are small differences
in self-management rates and weight reduction. But again, I think if you
look at the magnitude, the proportion of people
who are actually changing, the magnitude is quite small. So I think if we’re truly
being critical here, we can make a difference, but we need greater traction, greater – hopefully –
stickiness of the site and interaction with the participants
to get greater input. In addition to that, we looked at health education and
the impact it has on patients. Now, blue is the
MyJointPain users, and for all of these domains,
a positive is a good thing. For emotional distress
it’s actually flipped, so we’re not actually making
people more emotionally distressed by being
exposed to MyJointPain, it’s actually working. But again, small incremental
improvements in a lot of these domains about health
education and its impact, but none of them reach
statistical significance. It’s difficult to know from a
magnitude perspective whether we’re truly making a difference to
health education and its impact, and people that have
osteoarthritis. So again, just a greater plea, and we’ve taken this
information on board, and we’re in the process of
revising it and coming out with a new website to hopefully
be more interactive. Now as I mentioned
to you before, one of our greatest risk factors
is overweight and obesity. If we look at the number one
risk factor for why people develop the disease, it’s this. And this is the same for many
other non-communicable diseases, which are very prevalent to that
community including diabetes. As a society at present, we
seem almost powerless to do anything about this
particular risk factor. There’s a lot of
things that we can do, but by virtue of the fact
that – including us – we’re sticking our head in the
sand from a public policy perspective about
primary prevention, we figured we’d try
and tackle this from a secondary
prevention standpoint. This is a study we completed
relatively recently where we recruited 450 overweights
and obese people with knee osteoarthritis, and over the course
of 18 months, got them to lose 10% of
their body weight through a very low-calorie
diet and exercise. A lot of people say when
they’ve got osteoarthritis, I can’t exercise, and I don’t
want to change my diet. In that context, it
becomes very difficult from the behavioral
perspective, but this is the beautiful world
of randomised control trial and by virtue of the fact
that they’re all in this randomised control trial, they lost 10% of their
body weight on average. Over the course of
that 18 months, their pain and function
improved by 50%. This is the WOMAC scale which
is a scale that we use for monitoring pain
in this instance, but function
improved similarly. You can see a 50% improvement
in a person’s pain over the course of 18 months with
a 10% weight reduction. The diet and exercise alone
groups obviously had some improvement but did not reach
the same level of improvement as diet and exercise. A large proportion of people
actually got into what we’d call a remission-type
state, about 40% of people. Their WOMAC score was
less than 1 out of 20, which for them was a
dramatic improvement on what it was at baseline. We know that weight loss
improves pain and function. The great challenge
we have, though, is does it work in the
general community. More recently, in collaboration
with an Australian group called Healthy Weight for Life, they have a programme that they
run for people with diabetes, heart disease, and more recently
a programme that they’ve been running for people with
knee and hip osteoarthritis. We evaluated their weight
loss intervention in an Australian population to see
whether we can actually achieve this in an
Australian community sample. This is their baseline
characteristics. Like most other
osteoarthritis samples, they’re older age,
predominantly female. You can see that their body
mass index here is in what you’d classify as
the obese category. Their pain and function on
the KOOS pain and function subscale suggested moderate
degrees of symptoms. Over the course of a
four-month intervention, this was the average weight
loss for different groups. About 30% lost 10%
of their weight. About 23% lost 7.6 to 10%, and about 24% lost that amount
Cat will probably correct me, but the minimum clinically
important difference for this scale is in the order
of about ten units. Is that okay? It’s okay. So you can say the vast
majority of patients, by virtue of weight loss
in the Australian community, if they lost weight with
their symptomatic joints, obtained a minimum clinically
important difference, and you can see that there is
somewhat of a dose response relationship here.
So the more weight you lose, the more your symptoms
are likely to improve. And I think that’s
incredibly important, because I think a lot of
people look at trial data, and they say, Well, yeah, sure, but you can’t do that
in the real world. But this is the real world. These are people who have
been referred essentially for a diet and
exercise program, which is provided remotely, so they don’t necessarily
need to go anywhere to make this happen for them. And we can actually demonstrate
changes that are reasonably similar to what we get in a
randomized control trial. So it can work. Unfortunately the vast
majority of patients who have osteoarthritis in
the Australian community don’t necessarily have this
option provided to them, and/or are unaware of it. Another intervention that we
were very fortunate enough to get involved in the development
of is what’s called the Osteoarthritis Chronic
Care Program. So back in – I want
to say – 2011, the New South Wales state
government was incredibly embarrassed about the amount
of time people were spending on the wait list for a
knee or hip replacement, and they said, Is there anything
we can do for these people while they’re on the wait list
for a knee or a hip replacement? And so we developed the Osteoarthritis Chronic
Care Program, which is essentially a multidisciplinary
coordinated care program where a person comes in
to the public hospital, they see a physiotherapist
who’s the coordinator of that program, and then the physiotherapist
determines who else they need to see based upon whether
they’ve got obesity, so they’ll – in that context
– typically see a dietician. If they’re depressed,
stressed, or anxious, then they’ll see someone
for psychological support. If they need a brace, they’ll
see an orthotist, and so on. So in that context, this multidisciplinary
coordinated care program has been running since 2011, and it started in
six pilot centers, and we started focused on people
who were on the wait list for a knee or a
hip replacement, an offered this to people who were
waiting on that wait list, and about 90% of them chose to
participate in the program. One in five people who were
on the wait list decided that they no longer wanted
to have the surgery. So they voluntarily chose to
come off the wait list by virtue of being involved
in that program. As I said, it’s called the Osteoarthritis Chronic
Care Program. It’s now running at 16
centers in New South Wales, and a lot of the local health
districts have taken this up by virtue of the fact
that they see large– I’m not allowed to say savings
– they see cost shifts by virtue of the implementation
of this program. So for every dollar that gets
invested in this program, there’s $5 that are
shifted – but I think it’s easier to understand
the word saved, but shifted – in the
healthcare system, because people don’t necessarily
want to have the joint replacement that they’re
on the waiting list for. It appears to be
working quite well, and we’ve published a
number of papers on this, including Cat’s done some analyses
on this data set as well. Now, one of the great limitations
we’ve seen in guidelines is the fact that
guidelines are a long, laundry list of recommendations
that are not necessarily as scribable, or prescribable, to the individual
that presents to the health professionals that are
trying to provide their care. So more recently, Sarah
Meneses and a group of people internationally have come up with
algorithms that are case-based, so try to individually tailor
this according to typical common scenarios that a person
presents with in the context of either hand, hip or
knee osteoarthritis. And these case scenarios are
built around the scenarios where a person would
typically receive some care, more oftentimes than
not inappropriate. Oftentimes they’re
being mismanaged. So in that context, there’s
lots of different therapeutic options that are available, and potentially
prescribable to patients that have osteoarthritis, but again, unfortunately,
more often than not, these options are not
necessarily provided. So this was an effort on our
part to try to make guidelines interpretable and
understandable. Another exercise that I feel
completely impotent talking about is that of social media
and patient public involvement. And this is, at
least in our group, largely being driven
by Luciano Miller. In the first instance we
set this up primarily as a recruitment tool. But now it’s also more about
consumer information and providing opportunities for
consumers out there in the community to get
involved in webinars and other patient
public involvement. So he set up a Facebook site, and it’s got thousands
of followers. I don’t exactly know how many. It’s been very helpful
for us for recruiting for the clinical
trials that we do, but it’s also I think been
very helpful in providing information to the consumers
that are out there about how best to manage
their diseases. We’re running monthly webinars
for people in the community about how better to manage
their disease and regularly involve consumers in the
research work that we do. Now, the most recent
initiative – and like Rick, we are fortunate enough to get
a partnership grant recently from the NHMRC – is what’s
called the Partner Project. And Jocelyn Bodin is the victim
who we’ve brought in to run this. And Jocelyn’s
sitting over there. But essentially, most of the
people unfortunately that we’ve treated to date have been
in a tertiary care setting. The overwhelming majority of
people that have osteoarthritis are not in a tertiary care setting
and they don’t need to be, and should ideally
be being treated in a primary care setting. So the program we’re in the
process of trying to sort out is a complex coordinated
multidisciplinary intervention involving GP education, some modifications to the
electronic medical record to facilitate care coordination, referral to a care support team
to essentially provide all of that multidisciplinary
care that we’ve spoken about already including exercise, weight loss, self-management
advice, medication advice, psychological
support and so on. And then obviously regular
interaction with the GP. And this is a cluster randomized
control trial that we’re doing in Victoria and New South
Wales which we’re in the process of building
at the moment, or at least Jocelyn’s in
the process of building, and I get to talk about it. But, as I say, the intent being
that we’re very much trying to shift the delivery
and focus to where it should be being focused, specifically in primary care
and very much targeted towards consumers that
have this disease. So that’s pretty much where
I wanted to leave it, but obviously there’s a lot
of different strategies that we’ve taken to try to
facilitate improving disease management out there
in the community. And I don’t think
we’ve got it right, and I think there’s a
lot of work for us to do to improve
that situation. And, as I’ve said, I think
we’ve got an increasing focus at the moment, both on
consumers and primary care. But as I said, there’s a
lot of work to be done and I’d appreciate any feedback
from the very insightful people that are here because you
probably have some great suggestions as to how we
should do that better. But thank you for the opportunity
to speak to you today. I’m very happy to
take questions. The neuromuscular training
initiatives that have focused on joint injury prevention have
been rolled out now in a number of Scandinavian
countries. And, at least in Norway, the best data would suggest
they prevent about 60% of new injuries from occurring
when it’s rolled out, and it can be rolled
out nationally, and that’s what’s
happened in Norway. And as I said, it’s been done
in a number of the other Scandinavian countries as well. And at least modeling suggests
it makes a huge difference to, obviously, short term injury
consequences for athletes and their sporting
participation. But medium to longer term, the requirements for ACL
reconstruction, joint replacement, and work disability
is a consequence. And so from an
economic perspective, it makes an amazing
amount of sense. But unfortunately, sense doesn’t
necessarily drive public policy. Unfortunately, no. I mean, I think if you look
at the Caretrack study, the vast majority of patients
aren’t receiving appropriate care, and I can’t really comment
on how that was defined. If you look at the BEACH study,
which was a large GP sample, about 14% of patients with
osteoarthritis go to a physio. Much more proportion of people
go along and see a dietician or have some weight
loss intervention, and the number of people who
get to see an orthopedic surgeon is a factor of at
least two to three times what would have Allied
Healthcare intervention. That was published in
2012, I think it was. So there’s vast improvements
that can be made in the Australian healthcare
setting with regards to the appropriateness of delivery
of patients of their care. The person who should be
pivotally involved in managing this disease as the first
point of reference is a physiotherapist. The reason I say that is
because more often than not exercise just gets ignored, and in addition to
that, obviously, if a person’s
overweight and obese, they should have a weight
loss intervention. Rheumatologists are, again, impotent to the
delivery of exercise and weight loss interventions. We’re very good at helping to
facilitate care coordination, but the vast majority
of rheumatologists, I don’t think, want to
see osteoarthritis. And if they do, they’re probably
better off being seen by a physiotherapist or a dietician
or some other weight loss intervention the
first instance. I definitely think the
problem is the referral. The referral needs to be the
appropriate direction in the first instance because if
you refer to a surgeon who does knee arthroplasty, he’s going to do that because
he thinks that’s what’s going to provide a benefit
to the patient. So we need to provide better
education to GPs and to provide them an accessible
mechanism whereby people can actually get access to care
that involves exercise and weight loss. And traditionally, that’s been
challenging because we know from a Medicare perspective
that a patient can only get five visits to an Allied
Healthcare professional. So that’s another advocacy thing
that we’re in the process of trying to work on is to see
if we can change that as well, but also that care
support team. Assuming Partner, the latest
project we’re working on works, and that care support team, which would be remotely
delivered weight loss, exercise, support around
psychological support, medication support – if we can
demonstrate that that works, I think that’ll be a relatively
inexpensive way compared to the alternate
referral processes. My private practice is at
the North Sydney Orthopedic and Sports Medicine Center. So I work and one rheumatologist
amongst a whole bunch of different orthopedic surgeons. It really takes education
of them as well. I think good orthopedic surgeons
recognize that the vast majority of people that they
see in the first instance don’t need surgery, and more often than not they
spend a lot of time counseling them out of surgery. Then if the patient,
that’s all that they want, they’ll go off and have the
surgery done somewhere else. So I don’t think
surgeons are going to be short of business anytime soon. There’s plenty of people out
there who have these problems, who just want to get a
surgical intervention done, but given the average patient
with osteoarthritis has two to three joints that
are symptomatic when they first present, replacing one joint
is not the way we’re going to fix
this disease. For a number of the
programs that we run now, we actually make it such
that we tell the patient that they’re being referred, but the referral goes
direct to the program, and then the program contacts
them and brings them in. Because I think if you
leave what we – and again, it’s just anecdotal – but I
think if you leave it in the hands of the patient, what we were finding is
more than 50% don’t call. Changing behavior is hard. So if you’re trying to encourage
an overweight a sedentary person to exercise
and lose weight, we know it’s incredibly
complicated. But ultimately, that’s
what we need to do. We need to make our program such
that people want to be in them. And that’s an option that
they see as opposed to just a quick surgical fix that is
otherwise being offered to them. Getting information out
there to consumers is incredibly important. I don’t think we’ve
necessarily found the answer. I think MyJointPain, so I think we’ve
had I don’t know, in excess of 200,000 people
that have visited the site. In terms of the number of
people who regularly use it to monitor their disease and
manage their disease, it’s much, much
smaller than that. So we need to get greater
traction in the community, and we need to get the people
to stick to that program because it’s
lifelong management. And I don’t’ think
we’ve got the answer. So MPS, as you’re
probably aware, we’re in the process of developing
some osteoarthritis resources. And so I think from an Australian
community perspective, I think there will be resources
that are available and accessible. But what– and obviously, they’ll be not just for
consumers but for healthcare professionals as well. But what drives a person to go
and access those resources, I think, is the huge
challenge we have here. Why should they access
those resources, and how can we make that such
that it’s systematically part of the healthcare system or
part of community education? I don’t think anybody’s
done that very well. To be honest, obesity’s a
little bit like cigarettes. So the great inroads
that we’ve made in smoking have been around, not
necessarily a personal choice, it’s been very much centered
around policy decisions to reduce the ability to
smoke in public places, taxes on cigarettes. I think everybody gets frightened
about the nanny state concept. But if we look at personal
behavioral control in the context of obesity, they’re not
cost-effective interventions. If you look at Jenny Craig
or stomach stapling or all of those things, they’re not necessarily
cost-effective interventions. But if you look at banning
junk food advertising, getting physical activity
programs running at schools, putting taxes on unhealthy foods,
the save the healthcare system, they save the economy
a lot of money, but we don’t have the politicians
who are brave enough to make that happen. Alex Frieden, who runs
the CDC at the moment, but was running a similar
program in New York, tried to ban the jumbo
soft drink beverages, which I have no understanding
why anybody would buy a bucket let alone
drink out of it, but he was initially
successful in doing so. But unfortunately, the power
of the fructose lobby over there is such that they
got that reversed. It’s just unbelievable. I think David has been
a great presentation, very interesting and involving
us all one way or another as consumers or researchers, doctors and other
healthcare professionals. It’s been terrific, and the
questions have been great. So thanks to the audience,
I thank you very much. As a small token, Jeffrey personally
selected this he told me. So I’d like to thank you on
behalf of the– Thank you very much for coming.

Leave a Reply

Your email address will not be published. Required fields are marked *