Improved Management of Patients with Hip and Knee Osteoarthritis in Primary Health Care, 2017

Current political documents recommend that patients with osteoarthritis should mainly be managed in primary health care. However, recent Norwegian research indicated that the quality of primary health care services is sub-optimal for this patient group. In this project a model for integrated care among persons with hip and knee osteoarthritis and a training package for the health care professionals was developed. The intention was to improve professional practice and patient outcomes, and reduce non-desired events (e.g. unnecessary referrals to secondary care, unnecessary use of costly imaging modalities, use of treatment modalities supported by low quality of evidence). The model meets the current need for a multidisciplinary approach to manage patients with chronic diseases and strengthen the health care services through collaboration while keeping the patient in focus.

现行政策文件建议，骨关节炎（osteoarthritis）患者的诊疗应以初级卫生保健为主导。然而挪威近期的研究显示，针对该患者群体的初级卫生保健服务质量未达最优水平。本项目针对髋膝骨关节炎患者开发了整合照护（integrated care）模式，并为医疗卫生专业人员研发了配套培训包，旨在优化专业诊疗实践、改善患者结局，同时减少不良事件发生——具体包括不必要的二级医疗机构转诊、不必要的高成本影像学检查使用，以及采用证据等级较低的治疗手段。该模式契合当前慢性病患者管理需采用多学科协作模式的需求，通过跨团队协作强化医疗卫生服务能力，且始终以患者为中心。