8Moving from evidence to practice: Models of care for the prevention and management of musculoskeletal conditions
Introduction
The perceived burden of disease attributed to chronic musculoskeletal conditions and the sequelae from musculoskeletal injury and trauma have been lower relative to other diseases more closely associated with mortality, such as cancer, kidney disease and ischaemic heart disease. However, the emerging evidence now unequivocally and consistently identifies the profound prevalence, socio-economic impact and burden of disease imposed by chronic musculoskeletal conditions and their associated pain burden and functional impairments. These outcomes are particularly relevant in conditions such as osteoarthritis (OA), rheumatoid arthritis (RA), osteoporosis (OP) and pain of musculoskeletal origin, especially low back pain *[1], [2], [3], [4], [5], *[6], [7].
In the most recent Global Burden of Disease Study, musculoskeletal conditions including RA, hip and knee OA, low back and neck pain, gout and other musculoskeletal disorders represented the second highest burden of disease globally, when expressed as years lived with disability – an index representing morbidity. At the condition level, low back pain was the leading global cause of years lived with disability across all 289 diseases and injuries examined [6]. Even when mortality was considered with morbidity (expressed as disability-adjusted life years), the burden of disease for musculoskeletal conditions was still substantial, representing the fifth highest condition group [5]. In developed nations, however, this ranking is substantially higher owing to a greater disease burden attributed to morbidity rather than mortality. Even more striking are the projections for the future burden of disease associated with musculoskeletal conditions. For example, a recent Australian socio-economic impact report based on Australian Health Survey data conservatively estimated that the prevalence of cases of musculoskeletal conditions will soar by 43% by 2032 [1]. Population modelling suggests that although the steepest trajectory will be in cases of OA (58%), the greatest absolute number of people will live with chronic back problems. More recent estimates of the projection of osteopenia and OP in Australia highlight a striking 31% increase in the number of Australians affected by these conditions by 2022 [7].
Despite the identified burden of musculoskeletal conditions, a substantial burden–service gap persists in most developed nations. Not only is the access to care variable according to geography, ethnicity and socio-economic status, thus creating care disparities [8], [9], [10], [11], but also the delivery of care from practitioners and health systems inadequately aligns with the best available evidence for what works [12], [13]. The burden–service gap is not easily solved as it is driven by a myriad of complex interdependencies at multiple levels: macro (health systems, organisations, health policy and socio-economic factors), meso (delivery systems, infrastructure and the volume and competencies and training of health practitioners) and micro (participation by consumers in co-care of their conditions). Access to, and delivery of, care is further complicated by the chronicity of musculoskeletal conditions. Health-care systems in developed nations are oriented towards acute care services and respond to mortality risk rather than long-term morbidity associated with musculoskeletal conditions and their co-morbidities, which stymies opportunities for service development. A fundamental change in the manner in which health-care systems and services are planned, implemented, delivered and evaluated is therefore needed to address disability associated with musculoskeletal ill health.
Models of Care (MoCs) can help to address the burden–service gap in musculoskeletal health [14]. A MoC is an evidence-informed strategy, framework or pathway that outlines the optimal manner in which care for specific types or groups of conditions should be made available and delivered to consumers. A MoC aims to include contemporary evidence with a framework to meet the current and projected community need, in the context of local operational requirements [182]. Importantly, a MoC is not a clinical practice guideline. While a high level of evidence, such as that contained in clinical practice guidelines, should underpin a MoC, the fundamental purpose of a MoC is to operationalise ‘what works’ into practice, rather than to appraise and to grade evidence and develop specific clinical practice recommendations [14]. MoCs may address service planning, implementation, delivery and evaluation at multiple levels, according to the contextual factors associated with the condition and with the intended implementation environment. While MoCs are increasingly accepted as a contemporary vehicle to drive evidence into practice; for example, in Australia *[14], *[182], a review of MoCs for musculoskeletal health conditions and injury and trauma has not been undertaken at an international level. Therefore, the aim of this chapter was to convene a multidisciplinary, international team to analyse this knowledge gap for specific musculoskeletal conditions including chronic pain of musculoskeletal origin, OA, RA, OP and musculoskeletal injury and trauma. We sought to provide an overview of current MoCs for these specific conditions across care settings and to offer recommendations for future policy and practice initiatives that reduce the burden–service gap for consumers with, or at risk of, musculoskeletal conditions.
Section snippets
Methods
A narrative review was undertaken of peer-reviewed published literature and relevant grey literature relating to MoCs for the suite of relevant musculoskeletal conditions and injuries. Search terms relevant to each of the specific conditions (chronic pain of musculoskeletal origin, OA, RA and OP) and musculoskeletal injury and trauma were developed and used in scholarly databases to identify published literature. Relevant grey literature was identified through Internet searches and knowledge of
Epidemiology and impact
Chronic musculoskeletal pain (CMP) is one of the most common reasons that people seek medical help, is costly, and yet still goes under-recognised and under-treated. The health and economic burdens associated with CMP are substantial for health consumers and for society *[1], [15]. The scale of chronic pain is enormous, affecting the lives of one in five people globally including children and adolescents, with CMP contributing a significant proportion of this burden [15], [16], [17]. People
Summary
The socio-economic and personal burden attributed to chronic musculoskeletal conditions and the sequelae of musculoskeletal injury and trauma are profound. Despite the burden of these conditions, the right care is not consistently delivered at the right time, in the right place or by the right team. Contemporary MoCs provide one solution to this burden–service gap [182]. Consistent features are observed across the various MoCs reviewed, including the importance of primary and secondary
Conflict of interest statement
The authors declare no conflicts of interest.
Acknowledgements
Winthrop Professor Fiona Wood and Dr Sudhakar Rao are acknowledged for providing comments in the Musculoskeletal Injury and Trauma sub-section.
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