General practitioners' perspectives on a proposed new model of service delivery for primary care management of knee osteoarthritis: a qualitative study

Barriers and Facilitators to the Implementation of Digital Health Services for People With Musculoskeletal Conditions in the Primary Health Care Setting: Systematic Review

BACKGROUND

In recent years, the effectiveness and cost-effectiveness of digital health services for people with musculoskeletal conditions have increasingly been studied and show potential. Despite the potential of digital health services, their use in primary care is lagging. A thorough implementation is needed, including the development of implementation strategies that potentially improve the use of digital health services in primary care. The first step in designing implementation strategies that fit the local context is to gain insight into determinants that influence implementation for patients and health care professionals. Until now, no systematic overview has existed of barriers and facilitators influencing the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting.

OBJECTIVE

This systematic literature review aims to identify barriers and facilitators to the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting.

METHODS

PubMed, Embase, and CINAHL were searched for eligible qualitative and mixed methods studies up to March 2024. Methodological quality of the qualitative component of the included studies was assessed with the Mixed Methods Appraisal Tool. A framework synthesis of barriers and facilitators to implementation was conducted using the Consolidated Framework for Implementation Research (CFIR). All identified CFIR constructs were given a reliability rating (high, medium, or low) to assess the consistency of reporting across each construct.

RESULTS

Overall, 35 studies were included in the qualitative synthesis. Methodological quality was high in 34 studies and medium in 1 study. Barriers (-) of and facilitators (+) to implementation were identified in all 5 CFIR domains: "digital health characteristics" (ie, commercial neutral [+], privacy and safety [-], specificity [+], and good usability [+]), "outer setting" (ie, acceptance by stakeholders [+], lack of health care guidelines [-], and external financial incentives [-]), "inner setting" (ie, change of treatment routines [+ and -], information incongruence (-), and support from colleagues [+]), "characteristics of the healthcare professionals" (ie, health care professionals' acceptance [+ and -] and job satisfaction [+ and -]), and the "implementation process" (involvement [+] and justification and delegation [-]). All identified constructs and subconstructs of the CFIR had a high reliability rating. Some identified determinants that influence implementation may be facilitators in certain cases, whereas in others, they may be barriers.

CONCLUSIONS

Barriers and facilitators were identified across all 5 CFIR domains, suggesting that the implementation process can be complex and requires implementation strategies across all CFIR domains. Stakeholders, including digital health intervention developers, health care professionals, health care organizations, health policy makers, health care funders, and researchers, can consider the identified barriers and facilitators to design tailored implementation strategies after prioritization has been carried out in their local context.

Selection of criteria for a telemedicine framework for designing, implementing, monitoring and evaluating telemedicine interventions: Validation using a modified Delphi process

Objectives

The call to scale up telemedicine services globally as part of the digital health transformation lacks an agreed-upon set of constructs to guide the implementation process. A lack of guidance hinders the development, consolidation, sustainability and optimisation of telemedicine services. The study aims to reach consensus among telemedicine experts on a set of implementation constructs to be developed into an evidence-based support tool.

Methods

A modified Delphi study was conducted to evaluate a set of evidence-informed telemedicine implementation constructs comprising cores, domains and items. The study evaluated the constructs consisting of five cores: Assessment of the Current Situation, Development of a Telemedicine Strategy, Development of Organisational Changes, Development of a Telemedicine Service, and Monitoring, Evaluation and Optimisation of Telemedicine Implementation; seven domains: Individual Readiness, Organisational Readiness, Clinical, Economic, Technological and Infrastructure, Regulation, and Monitoring, Evaluation and Optimisation; divided into 53 items. Global telemedicine specialists (n = 247) were invited to participate and evaluate 58 questions. Consensus was set at ≥70%.

Results

Forty-five experts completed the survey. Consensus was reached on 78% of the constructs evaluated. Regarding the core constructs, Monitoring, Evaluation and Optimisation of Telemedicine Implementation was determined to be the most important one, and Development of a Telemedicine Strategy the least. As for the domains, the Clinical one had the highest level of consensus, and the Economic one had the lowest.

Conclusions

This research advances the field of telemedicine, providing expert consensus on a set of implementation constructs. The findings also highlight considerable divergence in expert opinion on the constructs of reimbursement and incentive mechanisms, resistance to change, and telemedicine champions. The lack of agreement on these constructs warrants attention and may partly explain the barriers that telemedicine services continue to face in the implementation process.

A self-directed digital exercise program for hip osteoarthritis ("My Hip Exercise"): protocol for a randomised controlled trial

BACKGROUND

Hip osteoarthritis (OA) is a leading global cause of chronic pain and disability. Given there is no cure for OA, patient self management is vital with education and exercise being core recommended treatments. However, there is under-utilisation of these treatments due to a range of clinician and patient factors. Innovative service models that increase patient accessibility to such treatments and provide support to engage are needed. This study primarily aims to determine the effects of a self-directed digital exercise intervention comprising online education and exercise supported by a mobile app to facilitate adherence on the primary outcomes of changes in hip pain during walking and patient-reported physical function at 24-weeks when compared to online education control for people with hip OA.

METHODS

We will conduct a two-arm, superiority parallel-design, randomised controlled trial involving 182 community volunteers aged 45 years and over, with painful hip OA. After completing the baseline assessment, participants will be randomly assigned to either: i) digital exercise intervention; or ii) digital education (control). Participants randomised to the intervention group will have access to a website that provides information about hip OA and its management, advice about increasing their physical activity levels, a 24-week lower limb strength exercise program to be undertaken at home three times per week, and a mobile app to reinforce home exercise program adherence. Participants in the control group will have access to a website containing only information about hip OA and its management. All participants will be reassessed at 24 weeks after randomisation. Primary outcomes are severity of hip pain while walking using an 11-point numeric rating scale and physical function using the Western Ontario and McMaster Universities Osteoarthritis Index subscale. Secondary outcomes are the Hip dysfunction and Osteoarthritis Outcome Score subscales of pain, hip-related quality of life, and function, sports and recreational activities; global change in hip condition; health-related quality of life; measures of physical activity levels; fear of movement; self efficacy for pain and for exercise; and use of oral pain medications.

DISCUSSION

Innovative and scalable approaches to OA education, physical activity, and exercise are required in order to improve exercise participation/engagement and mitigate physical inactivity in the hip OA population. This will help minimise the burden of this major public health issue on individuals and society.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ACTRN12622001533785).

What does high value care for musculoskeletal conditions mean and how do you apply it in practice? A consensus statement from a research network of physiotherapists in New South Wales, Australia

OBJECTIVES

To develop a physiotherapist-led consensus statement on the definition and provision of high-value care for people with musculoskeletal conditions.

DESIGN

We performed a three-stage study using Research And Development/University of California Los Angeles Appropriateness Method methodology. We reviewed evidence about current definitions through a rapid literature review and then performed a survey and interviews with network members to gather consensus. Consensus was finalised in a face-to-face meeting.

SETTING

Australian primary care.

PARTICIPANTS

Registered physiotherapists who are members of a practice-based research network (n=31).

RESULTS

The rapid review revealed two definitions, four domains of high value care and seven themes of high-quality care. Online survey responses (n=26) and interviews (n=9) generated two additional high-quality care themes, a definition of low-value care, and 21 statements on the application of high value care. Consensus was reached for three working definitions (high value, high-quality and low value care), a final model of four high value care domains (high-quality care, patient values, cost-effectiveness, reducing waste), nine high-quality care themes and 15 statements on application.

CONCLUSION

High value care for musculoskeletal conditions delivers most value for the patient, and the clinical benefits outweigh the costs to the individual or system providing the care. High-quality care is evidence based, effective and safe care that is patient-centred, consistent, accountable, timely, equitable and allows easy interaction with healthcare providers and healthcare systems.

A systematic review of telemedicine systems use barriers: primary health care providers' perspective

Purpose

The purpose of this review paper was identifying barriers to the use of telemedicine systems in primary health-care individual level among professionals.

Design/methodology/approach

This study used Scopus and PubMed databases for scientific records identification. A systematic review of the literature structured by PRISMA guidelines was conducted on 37 included papers published between 2009 and 2019. A qualitative approach was used to synthesize insights into using telemedicine by primary care professionals.

Findings

Three barriers were identified and classified: system quality, data quality and service quality barriers. System complexity in terms of usability, system unreliability, security and privacy concerns, lack of integration and inflexibility of systems-in-use are related to system quality. Data quality barriers are data inaccuracy, data timeliness issues, data conciseness concerns and lack of data uniqueness. Finally, service reliability concerns, lack of technical support and lack of user training have been categorized as service quality barriers.

Originality/value

This review identified and mapped emerging themes of barriers to the use of telemedicine systems. This paper also through a new conceptualization of telemedicine use from perspectives of the primary care professionals contributes to informatics literature and system usage practices.

What affects the implementation of lifestyle interventions in patients with osteoarthritis? A multidisciplinary focus group study among healthcare professionals

PURPOSE

To identify factors affecting the implementation of lifestyle interventions (LIs) in patients with hip and/or knee osteoarthritis (OA) from the perspective of primary and secondary healthcare professionals (HCPs) in the Dutch healthcare system.

METHODS

Multidisciplinary focus groups were composed. Data analysis was performed following thematic analysis. The Tailored Implementation for Chronic Diseases checklist was used to guide data analysis.

RESULTS

Four focus groups meetings were conducted with 38 participating HCPs (general practitioners (or in-training), orthopedic surgeons (or in-training), physiotherapists, dieticians, a general practice assistant, lifestyle counselors, and nurse practitioners). Influencing factors were grouped into nine themes: (1) intervention factors; (2) individual HCP factors; (3) patient factors; (4) professional interactions; (5) incentives and resources; (6) capacity for organizational change; (7) social, political and legal factors; (8) patient and HCP interactions; and (9) disease factors.

CONCLUSIONS

A wide variety of factors affecting the implementation of LIs was identified in this study, where the importance of effective interdisciplinary collaboration was emphasized by the multidisciplinary group of participants. This thorough analysis of influencing factors is an important first step toward improved implementation of LIs within OA care. Further research is required to identify the most significant targets for change in daily practice.Implications for RehabilitationThe implementation of lifestyle interventions (LIs) by healthcare professionals (HCPs) in patients with hip and/or knee osteoarthritis (OA) is affected by both individual and environmental factors.The influencing factors identified in this study can support the development of interventions aimed at improving the implementation of LIs in OA care.A multilevel approach is required when developing interventions to improve the implementation of LIs in OA care.Continued efforts of both primary and secondary HCPs and policymakers are needed in order to promote the use of LIs within OA care.

Factors That Patients Consider in Their Choice of Non-Surgical Management for Hip and Knee Osteoarthritis: Formative Qualitative Research for a Discrete Choice Experiment

BACKGROUND

Approximately half of patients with hip and knee osteoarthritis have tried non-surgical management before surgical consultation. Understanding the many factors affecting the uptake of recommended strategies is important to inform future development of such management strategies.

OBJECTIVES

The aim of this study was to explore and identify factors that patients with osteoarthritis consider when choosing non-surgical management for hip and knee osteoarthritis, as formative research for a study of patient preferences for non-surgical management programs for osteoarthritis.

METHODS

A qualitative research design was used. Participants were recruited using a combination of stratified and convenience sampling. Interviews were conducted, using a semi-structured interview guide, with English-speaking patients who had self-reported hip and/or knee osteoarthritis and at least one joint that had not undergone replacement surgery. Data were thematically analyzed.

RESULTS

Thirteen patients participated in these interviews. Sixteen factors that participants considered when choosing non-surgical osteoarthritis management were identified. Eleven were extrinsic, relating to features of programs and services, and are categorized as types of interventions, general program and service details, and program-specific details. Five were intrinsic to the individual and influenced how decisions for osteoarthritis management were approached and the options available to choose from. Three novel factors included participants' desire for further management, their views about joint replacement surgery, and whether they felt personal choice was available in osteoarthritis management strategies.

CONCLUSION

Key factors were identified that patients considered when making decisions about non-surgical management for their osteoarthritis that will be used to inform a discrete choice experiment (DCE) that aims to measure preferences for these factors.

Digital Health Opportunities to Improve Primary Health Care in the Context of COVID-19: Scoping Review

BACKGROUND

The COVID-19 pandemic brought social, economic, and health impacts, requiring fast adaptation of health systems. Although information and communication technologies were essential for achieving this objective, the extent to which health systems incorporated this technology is unknown.

OBJECTIVE

The aim of this study was to map the use of digital health strategies in primary health care worldwide and their impact on quality of care during the COVID-19 pandemic.

METHODS

We performed a scoping review based on the Joanna Briggs Institute manual and guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) Extension for Scoping Reviews. A systematic and comprehensive three-step search was performed in June and July 2021 in multidisciplinary health science databases and the gray literature. Data extraction and eligibility were performed by two authors independently and interpreted using thematic analysis.

RESULTS

A total of 44 studies were included and six thematic groups were identified: characterization and geographic distribution of studies; nomenclatures of digital strategies adopted; types of information and communication technologies; characteristics of digital strategies in primary health care; impacts on quality of care; and benefits, limitations, and challenges of digital strategies in primary health care. The impacts on organization of quality of care were investigated by the majority of studies, demonstrating the strengthening of (1) continuity of care; (2) economic, social, geographical, time, and cultural accessibility; (3) coordination of care; (4) access; (5) integrality of care; (6) optimization of appointment time; (7) and efficiency. Negative impacts were also observed in the same dimensions, such as reduced access to services and increased inequity and unequal use of services offered, digital exclusion of part of the population, lack of planning for defining the role of professionals, disarticulation of actions with real needs of the population, fragile articulation between remote and face-to-face modalities, and unpreparedness of professionals to meet demands using digital technologies.

CONCLUSIONS

The results showed the positive and negative impacts of remote strategies on quality of care in primary care and the inability to take advantage of the potential of technologies. This may demonstrate differences in the organization of fast and urgent implementation of digital strategies in primary health care worldwide. Primary health care must strengthen its response capacity, expand the use of information and communication technologies, and manage challenges using scientific evidence since digital health is important and must be integrated into public service.

Barriers and facilitators perceived by healthcare professionals for implementing lifestyle interventions in patients with osteoarthritis: a scoping review

OBJECTIVE

To provide an overview of barriers and facilitators that healthcare professionals (HCPs) perceive regarding the implementation of lifestyle interventions (LIs) in patients with hip and/or knee osteoarthritis (OA).

DESIGN

Scoping review.

DATA SOURCES

The databases PubMed, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from inception up to January 2021.

ELIGIBILITY CRITERIA

Primary research articles with a quantitative, qualitative or mixed-methods design were eligible for inclusion if they reported: (1) perceptions of primary and/or secondary HCPs (population); (2) on implementing LIs with physical activity and/or weight management as key components (concept) and (3) on conservative management of hip and/or knee OA (context). Articles not published in English, German or Dutch were excluded.

DATA EXTRACTION AND SYNTHESIS

Barriers and facilitators were extracted by two researchers independently. Subsequently, the extracted factors were linked to a framework based on the Tailored Implementation for Chronic Diseases checklist.

RESULTS

Thirty-six articles were included. In total, 809 factors were extracted and subdivided into nine domains. The extracted barriers were mostly related to non-optimal interdisciplinary collaboration, patients' negative attitude towards LIs, patients' low health literacy and HCPs' lack of knowledge and skills around LIs or promoting behavioural change. The extracted facilitators were mostly related to good interdisciplinary collaboration, a positive perception of HCPs' own role in implementing LIs, the content or structure of LIs and HCPs' positive attitude towards LIs.

CONCLUSIONS

Multiple individual and environmental factors influence the implementation of LIs by HCPs in patients with hip and/or knee OA. The resulting overview of barriers and facilitators can guide future research on the implementation of LIs within OA care. To investigate whether factor frequency is related to the relevance of each domain, further research should assess the relative importance of the identified factors involving all relevant disciplines of primary and secondary HCPs.

PROSPERO REGISTRATION NUMBER

CRD42019129348.

Exploring views of orthopaedic surgeons, rheumatologists and general practitioners about osteoarthritis management

BACKGROUND

Delivery of recommended treatments for hip and knee osteoarthritis (OA) is known to be discordant with guideline recommendations. However, professional views related to OA management across medical and surgical disciplines are not well understood. The aim of this study was to explore the views of medical professionals about management of hip and knee OA.

METHODS

Qualitative study. Semistructured individual interviews were conducted with orthopaedic surgeons, rheumatologists and general practitioners routinely involved in the management of OA. Interviews were audiotaped, transcribed, member-checked, coded and thematically analysed.

RESULTS

Fifteen medical professionals were interviewed. Three main themes were: (i) recognition of the importance of nonsurgical management of hip and knee OA, focussed on self-management, exercise-therapy, weight management and analgesia; (ii) joint replacement being considered the 'last resort' for end stage disease not responding to nonsurgical management; and (iii) determination of management 'success' through patient perceptions was more common than the use of validated instruments. Views on management broadly converged across disciplines, except for the role of joint replacement, considered an adjunct in the overall management of OA by rheumatologists and as a definitive cure by orthopaedic surgeons.

CONCLUSIONS

Aligning with current guidelines, medical professionals recognised the importance of nonsurgical management focussed on exercise-therapy for hip and knee OA, and concurred that joint replacement surgery should be a last resort. A focus on patient education was less prominent, which along with implementation of validated outcome measures in routine medical practice, may require greater health system support.

How Do People Communicate About Knee Osteoarthritis? A Discourse Analysis

OBJECTIVE

To explore the ways in which people talk about knee osteoarthritis and how this may influence engagement in physical activity and activity-based interventions as recommended by clinical practice guidelines.

DESIGN

A qualitative synthesis using discourse analysis methods.

METHODS

Systematic review methods were used to identify qualitative studies exploring the perceptions of people with knee osteoarthritis, their carers, and/or clinicians. Methodological quality was evaluated through the use of the Critical Appraisal Skills Programme. Raw quotes extracted from each study were analyzed with inductive discourse analysis.

RESULTS

A search of five electronic databases from inception until August 2019 yielded 778 articles. Sixty-two articles from 56 studies were included, reporting data (1,673 direct quotes) from people with knee osteoarthritis, carers, and clinicians in 16 countries. Two overarching discourses were identified-impairment and participation. The overarching impairment discourse prevailed in all participant groups and study settings. In this discourse, knee osteoarthritis was likened to a machine that inevitably wore down over time and required a doctor to repair. The overarching participatory discourse almost always coexisted alongside an impairment discourse. According to this discourse, a "busy body" was perceived as "healthy," and people could remain active despite knee osteoarthritis.

CONCLUSION

The prevailing impairment discourse may potentially discourage people from using knees that have passed their "use-by date" and increase reliance on doctors to repair joint damage. Consistent with recommendations in clinical practice guidelines, a participatory discourse may provide an alternative way of communicating that may encourage people with knee osteoarthritis to continue to engage in physical activity by focusing on what they can do, rather than what they cannot do.

Patient experiences with physiotherapy for knee osteoarthritis in Australia-a qualitative study

OBJECTIVE

Physiotherapists commonly provide non-surgical care for people with knee osteoarthritis (OA). It is unknown if patients are receiving high-quality physiotherapy care for their knee OA. This study aimed to explore the experiences of people who had recently received physiotherapy care for their knee OA in Australia and how these experiences aligned with the national Clinical Care Standard for knee OA.

DESIGN

Qualitative study using semistructured individual telephone interviews and thematic analysis, where themes/subthemes were inductively derived. Questions were informed by seven quality statements of the OA of the Knee Clinical Care Standard. Interview data were also deductively analysed according to the Standard.

SETTING

Participants were recruited from around Australia via Facebook and our research volunteer database.

PARTICIPANTS

Interviews were conducted with 24 people with recent experience receiving physiotherapy care for their knee OA. They were required to be aged 45 years or above, had activity-related knee pain and any knee-related morning stiffness lasted no longer than 30 min. Participants were excluded if they had self-reported inflammatory arthritis and/or had undergone knee replacement surgery for the affected knee.

RESULTS

Six themes emerged: (1) presented with a pre-existing OA diagnosis (prior OA care from other health professionals; perception of adequate OA knowledge); (2) wide variation in access and provision of physiotherapy care (referral pathways; funding models; individual vs group sessions); (3) seeking physiotherapy care for pain and functional limitations (knee symptoms; functional problems); (4) physiotherapy management focused on function and exercise (assessment of function; various types of exercises prescribed; surgery, medications and injections are for doctors; adjunctive treatments); (5) professional and personalised care (trust and/or confidence; personalised care) and (6) physiotherapy to postpone or prepare for surgery.

CONCLUSION

Patients' experiences with receiving physiotherapy care for their knee OA were partly aligned with the standard, particularly regarding comprehensive assessment, self-management, and exercise.

PARTNER: a service delivery model to implement optimal primary care management of people with knee osteoarthritis: description of development

OBJECTIVE

Implementation strategies, such as new models of service delivery, are needed to address evidence practice gaps. This paper describes the process of developing and operationalising a new model of service delivery to implement recommended care for people with knee osteoarthritis (OA) in a primary care setting.

METHODS

Three development stages occurred concurrently and iteratively. Each stage considered the healthcare context and was informed by stakeholder input. Stage 1 involved the design of a new model of service delivery (PARTNER). Stage 2 developed a behavioural change intervention targeting general practitioners (GPs) using the behavioural change wheel framework. In stage 3, the 'Care Support Team' component of the service delivery model was operationalised.

RESULTS

The focus of PARTNER is to provide patients with education, exercise and/or weight loss advice, and facilitate effective self-management through behavioural change support. Stage 1 model design: based on clinical practice guidelines, known evidence practice gaps in current care, chronic disease management frameworks, input from stakeholders and the opportunities and constraints afforded by the Australian primary care context, we developed the PARTNER service-delivery model. The key components are: (1) an effective GP consultation and (2) follow-up and ongoing care provided remotely (telephone/email/online resources) by a 'Care Support Team'. Stage 2 GP behavioural change intervention: a multimodal behavioural change intervention was developed comprising a self-audit/feedback activity, online professional development and desktop software to provide decision support, patient information resources and a referral mechanism to the 'Care Support Team'. Stage 3 operationalising the 'care support team'-staff recruited and trained in evidence-based knee OA management and behavioural change methodology.

CONCLUSION

The PARTNER model is the result of a comprehensive implementation strategy development process using evidence, behavioural change theory and intervention development guidelines. Technologies for scalable delivery were harnessed and new primary evidence was generated as part of the process.Trial registration number ACTRN12617001595303 (UTN U1111-1197-4809).

Factors Impacting Clinicians' Adoption of a Clinical Photo Documentation App and its Implications for Clinical Workflows and Quality of Care: Qualitative Case Study

BACKGROUND

Mobile health (mHealth) tools have shown promise in clinical photo and wound documentation for their potential to improve workflows, expand access to care, and improve the quality of patient care. However, some barriers to adoption persist.

OBJECTIVE

This study aims to understand the social, organizational, and technical factors affecting clinicians' adoption of a clinical photo documentation mHealth app and its implications for clinical workflows and quality of care.

METHODS

A qualitative case study of a clinical photo and wound documentation app called imitoCam was conducted. The data were collected through 20 in-depth interviews with mHealth providers, clinicians, and medical informatics experts from 8 clinics and hospitals in Switzerland and Germany.

RESULTS

According to the study participants, the use of mHealth in clinical photo and wound documentation provides numerous benefits such as time-saving and efficacy, better patient safety and quality of care, enhanced data security and validation, and better accessibility. The clinical workflow may also improve when the app is a good fit, resulting in better collaboration and transparency, streamlined daily work, clinician empowerment, and improved quality of care. The findings included important factors that may contribute to or hinder adoption. Factors may be related to the material nature of the tool, such as the perceived usefulness, ease of use, interoperability, cost, or security of the app, or social aspects such as personal experience, attitudes, awareness, or culture. Organizational and policy barriers include the available clinical practice infrastructure, workload and resources, the complexity of decision making, training, and ambiguity or lack of regulations. User engagement in the development and implementation process is a vital contributor to the successful adoption of mHealth apps.

CONCLUSIONS

The promising potential of mHealth in clinical photo and wound documentation is clear and may enhance clinical workflow and quality of care; however, the factors affecting adoption go beyond the technical features of the tool itself to embrace significant social and organizational elements. Technology providers, clinicians, and decision makers should work together to carefully address any barriers to improve adoption and harness the potential of these tools.

Understanding Clinicians' Adoption of Mobile Health Tools: A Qualitative Review of the Most Used Frameworks

BACKGROUND

Although there is a push toward encouraging mobile health (mHealth) adoption to harness its potential, there are many challenges that sometimes go beyond the technology to involve other elements such as social, cultural, and organizational factors.

OBJECTIVE

This review aimed to explore which frameworks are used the most, to understand clinicians' adoption of mHealth as well as to identify potential shortcomings in these frameworks. Highlighting these gaps and the main factors that were not specifically covered in the most frequently used frameworks will assist future researchers to include all relevant key factors.

METHODS

This review was an in-depth subanalysis of a larger systematic review that included research papers published between 2008 and 2018 and focused on the social, organizational, and technical factors impacting clinicians' adoption of mHealth. The initial systematic review included 171 studies, of which 50 studies used a theoretical framework. These 50 studies are the subject of this qualitative review, reflecting further on the frameworks used and how these can help future researchers design studies that investigate the topic of mHealth adoption more robustly.

RESULTS

The most commonly used frameworks were different forms of extensions of the Technology Acceptance Model (TAM; 17/50, 34%), the diffusion of innovation theory (DOI; 8/50, 16%), and different forms of extensions of the unified theory of acceptance and use of technology (6/50, 12%). Some studies used a combination of the TAM and DOI frameworks (3/50, 6%), whereas others used the consolidated framework for implementation research (3/50, 6%) and sociotechnical systems (STS) theory (2/50, 4%). The factors cited by more than 20% of the studies were usefulness, output quality, ease of use, technical support, data privacy, self-efficacy, attitude, organizational inner setting, training, leadership engagement, workload, and workflow fit. Most factors could be linked to one framework or another, but there was no single framework that could adequately cover all relevant and specific factors without some expansion.

CONCLUSIONS

Health care technologies are generally more complex than tools that address individual user needs as they usually support patients with comorbidities who are typically treated by multidisciplinary teams who might even work in different health care organizations. This special nature of how the health care sector operates and its highly regulated nature, the usual budget deficits, and the interdependence between health care organizations necessitate some crucial expansions to existing theoretical frameworks usually used when studying adoption. We propose a shift toward theoretical frameworks that take into account implementation challenges that factor in the complexity of the sociotechnical structure of health care organizations and the interplay between the technical, social, and organizational aspects. Our consolidated framework offers recommendations on which factors to include when investigating clinicians' adoption of mHealth, taking into account all three aspects.

Social, Organizational, and Technological Factors Impacting Clinicians' Adoption of Mobile Health Tools: Systematic Literature Review

Background

There is a growing body of evidence highlighting the potential of mobile health (mHealth) in reducing health care costs, enhancing access, and improving the quality of patient care. However, user acceptance and adoption are key prerequisites to harness this potential; hence, a deeper understanding of the factors impacting this adoption is crucial for its success.

Objective

The aim of this review was to systematically explore relevant published literature to synthesize the current understanding of the factors impacting clinicians’ adoption of mHealth tools, not only from a technological perspective but also from social and organizational perspectives.

Methods

A structured search was carried out of MEDLINE, PubMed, the Cochrane Library, and the SAGE database for studies published between January 2008 and July 2018 in the English language, yielding 4993 results, of which 171 met the inclusion criteria. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and the Cochrane handbook were followed to ensure a systematic process.

Results

The technological factors impacting clinicians’ adoption of mHealth tools were categorized into eight key themes: usefulness, ease of use, design, compatibility, technical issues, content, personalization, and convenience, which were in turn divided into 14 subthemes altogether. Social and organizational factors were much more prevalent and were categorized into eight key themes: workflow related, patient related, policy and regulations, culture or attitude or social influence, monetary factors, evidence base, awareness, and user engagement. These were divided into 41 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them.

Conclusions

The study results can help inform mHealth providers and policymakers regarding the key factors impacting mHealth adoption, guiding them into making educated decisions to foster this adoption and harness the potential benefits.

Social, Organizational, and Technological Factors Impacting Clinicians' Adoption of Mobile Health Tools: Systematic Literature Review

BACKGROUND

There is a growing body of evidence highlighting the potential of mobile health (mHealth) in reducing health care costs, enhancing access, and improving the quality of patient care. However, user acceptance and adoption are key prerequisites to harness this potential; hence, a deeper understanding of the factors impacting this adoption is crucial for its success.

OBJECTIVE

The aim of this review was to systematically explore relevant published literature to synthesize the current understanding of the factors impacting clinicians' adoption of mHealth tools, not only from a technological perspective but also from social and organizational perspectives.

METHODS

A structured search was carried out of MEDLINE, PubMed, the Cochrane Library, and the SAGE database for studies published between January 2008 and July 2018 in the English language, yielding 4993 results, of which 171 met the inclusion criteria. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and the Cochrane handbook were followed to ensure a systematic process.

RESULTS

The technological factors impacting clinicians' adoption of mHealth tools were categorized into eight key themes: usefulness, ease of use, design, compatibility, technical issues, content, personalization, and convenience, which were in turn divided into 14 subthemes altogether. Social and organizational factors were much more prevalent and were categorized into eight key themes: workflow related, patient related, policy and regulations, culture or attitude or social influence, monetary factors, evidence base, awareness, and user engagement. These were divided into 41 subthemes, highlighting the importance of considering these factors when addressing potential barriers to mHealth adoption and how to overcome them.

CONCLUSIONS

The study results can help inform mHealth providers and policymakers regarding the key factors impacting mHealth adoption, guiding them into making educated decisions to foster this adoption and harness the potential benefits.

Protocol for the process and feasibility evaluations of a new model of primary care service delivery for managing pain and function in patients with knee osteoarthritis (PARTNER) using a mixed methods approach

INTRODUCTION

This protocol outlines the rationale, design and methods for the process and feasibility evaluations of the primary care management on knee pain and function in patients with knee osteoarthritis (PARTNER) study. PARTNER is a randomised controlled trial to evaluate a new model of service delivery (the PARTNER model) against 'usual care'. PARTNER is designed to encourage greater uptake of key evidence-based non-surgical treatments for knee osteoarthritis (OA) in primary care. The intervention supports general practitioners (GPs) to gain an understanding of the best management options available through online professional development. Their patients receive telephone advice and support for OA management by a centralised, multidisciplinary 'Care Support Team'. We will conduct concurrent process and feasibility evaluations to understand the implementation of this new complex health intervention, identify issues for consideration when interpreting the effectiveness outcomes and develop recommendations for future implementation, cost effectiveness and scalability.

METHODS AND ANALYSIS

The UK Medical Research Council Framework for undertaking a process evaluation of complex interventions and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) frameworks inform the design of these evaluations. We use a mixed-methods approach including analysis of survey data, administrative records, consultation records and semistructured interviews with GPs and their enrolled patients. The analysis will examine fidelity and dose of the intervention, observations of trial setup and implementation and the quality of the care provided. We will also examine details of 'usual care'. The semistructured interviews will be analysed using thematic and content analysis to draw out themes around implementation and acceptability of the model.

ETHICS AND DISSEMINATION

The primary and substudy protocols have been approved by the Human Research Ethics Committee of The University of Sydney (2016/959 and 2019/503). Our findings will be disseminated to national and international partners and stakeholders, who will also assist with wider dissemination of our results across all levels of healthcare. Specific findings will be disseminated via peer-reviewed journals and conferences, and via training for healthcare professionals delivering OA management programmes. This evaluation is crucial to explaining the PARTNER study results, and will be used to determine the feasibility of rolling-out the intervention in an Australian healthcare context.

TRIAL REGISTRATION NUMBER

ACTRN12617001595303; Pre-results.

Lifetime risk of knee and hip replacement following a GP diagnosis of osteoarthritis: a real-world cohort study

OBJECTIVE

The aim of this study was to estimate lifetime risk of knee and hip replacement following a GP diagnosis of osteoarthritis and assess how this risk varies with patient characteristics.

METHODS

Routinely collected data from Catalonia, Spain, covering 2006 to 2015, were used. Study participants had a newly recorded GP diagnosis of knee or hip osteoarthritis. Parametric survival models were specified for risk of knee/hip replacement and death following diagnosis. Survival models were combined using a Markov model and lifetime risk estimated for the average patient profile. The effects of age at diagnosis, sex, comorbidities, socioeconomic status, body mass index (BMI), and smoking on risk were assessed.

RESULTS

48,311 individuals diagnosed with knee osteoarthritis were included, of whom 2,561 underwent knee replacement. 15,105 individuals diagnosed with hip osteoarthritis were included, of whom 1,247 underwent hip replacement. The average participant's lifetime risk for knee replacement was 30% (95% CI: 25-36%) and for hip replacement was 14% (10-19%). Notable patient characteristics influencing lifetime risk were age at diagnosis for knee and hip replacement, sex for hip replacement, and BMI for knee replacement. BMI increasing from 25 to 35 was associated with lifetime risk of knee replacement increasing from 24% (20-28%) to 32% (26-37%) for otherwise average patients.

CONCLUSION

Knee and hip replacement are not inevitable after an osteoarthritis diagnosis, with average lifetime risks of less than a third and a sixth, respectively. Patient characteristics, most notably BMI, influence lifetime risks.