RESTORE Team Podcast Episode 2
Breaking Down Barriers to Evidence-Based Osteoarthritis Care with Laura ChurchillApr 10, 2023
WHAT YOU NEED TO KNOW
In today's podcast, we sat down with Dr. Laura Churchill to discuss her research related to breaking down barriers for osteoarthritis care. Articles discussed include:
- The development and validation of a multivariable model to predict whether patients referred for total knee replacement are suitable surgical candidates at the time of initial consultation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125923/2.
- A qualitative dominant mixed methods exploration of novel educational material for patients considering total knee arthroplasty: https://doi.org/10.1080/09638288.2020.1851782
- Primary care physicians’ perceptions of the utility of novel education materials for patients with knee osteoarthritis: https://doi.org/10.1080/09638288.2022.2107088
Listen to the podcast:
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Alexander Garbin 0:00
Hello and welcome to the restore podcast, a podcast brought to you by the restore team at the University of Colorado Anschutz Medical Campus, where we discuss research related to optimizing older adult health and function, and how it can impact clinical care and everyday older adult life. I'm your host, Alexander Garban. And today I'm joined by Dr. Laura Churchill. Laura Churchill is a physical therapist and researcher who completed most of her academic training in London, Ontario, Canada at Western University, including a combined master of physical therapy, and PhD in Health and Rehabilitation Sciences. Currently, she's a postdoctoral researcher in the restore lab at University of Colorado, Anschutz Medical Campus under Dr. Jennifer Stevens-Lapsley. Thank you for joining us.
Laura Churchill 0:42
Thanks for having me, Alex. It's fun to be here and to get to be on the podcast with you.
Alexander Garbin 0:47
So I thought it might be nice to start the episode with you describing your overall research area. Yeah, that sounds great.
Laura Churchill 0:53
Thanks, Alex. So my research really focuses on individuals with hip and knee osteoarthritis, and individuals considering a total knee replacement. And so my vision for my future program of research is really to develop and evaluate digital health tools that can improve access to education, exercise and physical activity for individuals with these conditions. Perfect. Yeah. And so if we think about, you know, just that's kind of the overview. You might be curious kind of how I got started on this work. So essentially, in my dissertation, I was presented with a clinical problem. So in Canada, our waitlists for total knee replacement, are very long. And what our orthopedic surgery team was discovering is that many patients who are referred to total knee replacement weren't actually what we would say, good candidates for surgery. And so in discussing with our orthopedic surgery team, you know, what are some of the reasons these patients weren't actually being booked for surgery, the commonly cited reasons were that patients had yet not yet tried other therapies that were known to be helpful. So some of these therapies include weight loss exercise, working with a physical therapist, and these are treatments that we know help a lot of people and, and many people with painful knee osteoarthritis. And so this was seen as an area that could have could be improved. And so that's kind of where I got started on some of this work.
Alexander Garbin 2:37
So rewinding a little bit. How big of a problem is arthritis in our older adult population?
Laura Churchill 2:42
Yeah, that's a great question. And point, essentially, arthritis is one of the most common musculoskeletal conditions. And so there's different statistics, I'm familiar with one that cites arthritis as being as common as one in 13, individuals will have some form of arthritis. And we know that the knee is the most commonly affected joint in terms of arthritis. So this is a very, very common chronic condition. And what I mean by that is that this is not a condition that we have a known cure for. So if you're diagnosed with osteoarthritis, we don't have a magic pill, and to cure it. And so it's chronic in nature, meaning individuals have arthritis for life.
Alexander Garbin 3:30
So your work is saying, we don't just need to do surgery for these people. They're all these other options, and you're trying to find a way to make that more approachable for patients.
Laura Churchill 3:43
Exactly. It's it's working with clinicians, and it's working with patients to, first of all, provide education that these are treatments that should be explored. A lot of the patients that I ended up talking to, as part of my dissertation, informed me that they didn't actually know that these are the things they could have been doing or should have been doing. Perhaps they thought that surgery was their next step. And they hadn't explored other treatments that upon receiving that information, they were very keen to explore because, you know, surgery is appropriate for many people with end stage severe arthritis, but not without really having explored other options first, to see if these options could potentially be a way to manage the condition.
Alexander Garbin 4:28
When talking with these patients, were there any reasons they wanted to not explore these really just go down that path of surgery that you encountered?
Laura Churchill 4:34
Yeah, it's a great question. Absolutely. So I think the patients that I chatted with and studied in a lot of my research studies that were more sure that they wanted the surgery had explored a lot of these non operative non surgical therapy. So these are patients that have been involved in with physical therapists for maybe 10 years or five years or they've been working with a physical therapy before they had previously tried a joint injection, so, for example, a corticosteroid joint injection, it would be a common one that they had tried. And they had been, you know, managing their arthritis for many years. And often these individuals had gotten to a point where, you know, the symptoms were so severe that they're impacting their physical function, impacting their sleep, impacting their ability to walk a short distance. And I think this is a really interesting and challenging aspect of this work is what when is the right decision to have surgery if you have knee arthritis, and my bias as a Canadian and in a public health care system is not before having tried non operative therapies that we know benefit many people?
Alexander Garbin 5:49
So putting the research hat on, how are you going about getting all this information with interviewing these patients?
Laura Churchill 5:55
Yeah, that's a great question. So I guess we'll take a few steps back in terms of my dissertation project. So if you think of, you know, the clinical question that was posed, it's, we have a lot of people we're seeing in clinic, that we end up telling them, you know, what, you're not a great candidate, you actually don't even have advanced arthritis on imaging, you haven't tried exercise, you might benefit from weight loss, like, why don't you try those things first. So the idea was, can we predict which patients go on to be booked for surgery and which patients are told they're not a good candidate at this time? And so we tried to identify predictors by having patients fill out all kinds of questionnaires, all kinds of surveys to see, are there any patient factors that we can identify, that could help like, could helpfully screen individuals out of the queue? And then could we kind of marry this predictive model with educational materials for patients and referring physicians,
Alexander Garbin 6:55
interesting. And were patients perceptive or not perceptive, reactive to being put into this predictive model? Or are they accepting of saying, surgery is not right for me based off of this type of model?
Laura Churchill 7:09
I will say with the predictive model work, it was largely, it was very straightforward in the sense that we just asked patients if they'd be willing to share with us a variety of measures in terms of how they're feeling their pain, their function, their willingness to undergo surgery. And then we recorded the outcome of the consults. So the this was the least patient facing side of my work, where the following work was more actually talking to patients and getting their perspectives and experiences. So this predictive work, I could summarize it very quickly by saying, We found factors that were predictive of individuals going on to be booked for a total knee replacement. Those predictors were somewhat informed by what Previous research has shown in this area as well. So they aligned with previous work by Dr. Gillian Hawker out of University of Toronto, and things like having tried a joint injection, older age. Having answered yes to a particular question that asks, If you were to remain in this symptom state, as you are now, would you consider this symptom state to be acceptable? So that's called the PASS measure? So if you answer no to this is not an acceptable state, then you're more likely to be booked. The other piece was if the patient was willing to undergo surgery, so just a simple question of willingness, they're more likely to be booked. So these aren't necessarily groundbreaking revelations in terms of predictors. But it is interesting from a perspective of if you're someone who's a referring provider, and you want to know if your patient would likely end up getting booked for surgery, probably talking them to them about the surgery would be an important first step and knowing if they're a good candidate,
Alexander Garbin 8:54
And are you taking these results and trying to make it so these questions are asked to better identify those that are most appropriate for surgery?
Laura Churchill 9:02
Yes. And so that kind of leads to the next line of my dissertation work, which was essentially, can we create educational modules for family physicians to use with their patients in making this decision to refer as well as helping patients understand what to expect from total knee replacement? So yeah, that was kind of the next step. Our idea in with my advisory committee and my supervisor was can we create educational modules that would support this predictive model and implement them in primary care?
Alexander Garbin 9:40
And how did that implementation go?
Laura Churchill 9:43
So the first step, Alex, you have to back it up. We have to back it up because we had to develop the educational modules. So that was a large component of my dissertation was working with a design team and we developing whiteboard videos. So if anyone's familiar, it's essentially a form of digital media where you tell a story and a hand is kind of writing out a cartoon, just like depicting the story. So we created five whiteboard education videos. Number one was what is osteoarthritis to help patients understand the disease a little bit more, and the associated illness as well. Then we did a video called What is appropriate imaging for knee osteoarthritis. And so this was essentially to demarket, the use of MRI, and to promote the use of, you know, a weight bearing X ray, because we know we can diagnose osteoarthritis with a weight bearing X ray, and that an MRI can often confuse the matter, and especially in Canada, this is an expensive form of imaging. This is a form of imaging that has a long waitlist associated with that. So sorry, that's kind of a bit tangential, but that's number two. Number three is what are the non operative therapies that patients should be trying so essentially outlining the value of exercise and physical activity and physical therapists as a very key player in this non operative treatments, but then also highlighting that, you know, joint injections might be appropriate and drug therapies are appropriate and, and who to possibly talk to about those therapies. So whether that's a sport medicine physician, a family physician, specialists like a rheumatologist, these are individuals that could offer that type of care. There's two more videos if you're up for it.
Alexander Garbin 11:41
Yeah, happy to hear.
Laura Churchill 11:42
Okay. So then the fourth video is more toward what you were getting at. And this video was about indications to proceed with surgery. So what are some of the factors that make someone a good candidate and more likely to be booked? And then the last video was what to expect from the surgery more toward those individuals that will proceed with surgery and want details on what that might look like?
Alexander Garbin 12:07
So are these videos provided to the patients to the physicians or to both parties?
Laura Churchill 12:13
It's a great question. That's something that was something I mulled over a lot during this process in terms of who are we really trying to reach with these videos, I think ultimately, the choice that I made with my team was to try to speak to patients, and have them hopefully be delivered in primary care to stimulate healthcare discussions. We know family physicians are extremely overburdened from a time perspective from a management perspective. So giving them something that they can hand their patient and say, you have osteoarthritis, we know that from you know, your X ray, and from your clinical signs and features, that you have a painful knee, etc. And there's a few more factors, obviously, but just to simplify things. So here's a video that can tell you more about what that means. And here's a video that can explain to you what are some helpful therapies. And we've already talked about all this, but now this is going to be something you can take home can reinforce those messages. And then let's schedule a follow up and we can talk about the videos in more detail at your next follow up. So just a way to really support primary care or referring providers in having those discussions.
Alexander Garbin 13:25
And what were the patient's perceptions of these videos? How well were they received?
Laura Churchill 13:31
Yeah, that's a really important question. So just to summarize, we created these videos, in conjunction with arthritis experts, family physicians, sport medicine physicians, orthopedic surgeons who specialize in in knee replacement. I'm probably missing someone, a physical therapist, of course. And so we really needed to understand is this messaging that we're providing in the whiteboard, video, something that helps patients that's the most important piece. And so we decided to do this in the form of a qualitative interview. So we essentially had patients that were coming to clinic for their first time considering a knee replacement, right before they met with a knee replacement surgeon. We asked them to watch the videos. So they watched five videos if they agreed to participate. And I'm missing a few details. But essentially, we had them complete some outcome measures before they watch the videos and after they watched the videos, and then they also participated in an interview after they watched the videos, and before they met with the surgeon for the first time. And so what we were able to glean from this essentially was whether, you know, we had any influence on what they understood about their condition and their decision to proceed with surgery, and also just general acceptability of the videos. Did this resonate? Did this make sense? Is this helpful at all for you in considering your next steps?
Alexander Garbin 14:59
And what were the results of that?
Yeah. So essentially, it was really helpful for us as researchers to get this feedback from patients, we found that many patients for unaware of some of the helpful therapies that they could be trying. So in some cases, I wouldn't say this was the absolute majority of cases. But there were cases where individuals expressed that if they would have seen these videos sooner, they would not have came for that consult with a surgeon. And so I think it definitely opened the door for some changing of minds. And on the flip side, it also for some patients really reinforced that they needed to be here, and they needed a knee replacement, likely because they had tried everything that we had suggested. And they were having the symptoms that we said were indicative, and they, you know, they did have that X ray that and etc, etc. So we're, it was really helpful to reinforce patient's decision making is essentially what we showed in that study with patients. And I'm happy to share more details in the manuscript, we can hopefully link that in the in the podcast description. Yeah, great.
Yeah, I should reference that the first discussion on the development of the model, and then this on the patient perceptions or really the facilitators and barriers. will be linked to the episode description below. As well as this next piece I want to ask you about, which is what were the physician perspectives or the surgeon perspectives, given they were being integrated into their clinics?
Laura Churchill 16:26
Yeah. So just to clarify, so we actually interviewed the referring providers, so it was primary care physicians that refer patients to orthopedic surgeons, so just to probably give an overview of the healthcare system that I was operating in for this dissertation. Essentially, in Canada, patients would go see their family physician, and then they would be referred to an orthopedic surgeon, and you would need that referral to access an orthopedic surgeon. So that's an important distinction you couldn't necessarily self refer to, to talk to orthopedic surgeon about a knee replacement, you'd have to get that referral from your family physician. And there's different models, actually, that are in play now in Canada with surgical screening clinics using physical therapists, but that was sort of not necessarily standard of care when I was doing this work. So back to your question, essentially, primary care physicians, we interviewed them, we got their feedback on the videos, I would say that the reception was largely positive. We heard from many physicians that this would potentially enhance their credibility when discussing these ideas with patients. And I heard and I can kind of remember vaguely, one of the quotes from the study really says something like, you know, I know they believe us, but I think this would really help, you know, send some of those messages home with patients and enhance that, you know, hey, the orthopedic surgeons think this is the right idea. The family physicians think this is the right idea. And now you have this thing that kind of summarizes that, hey, maybe, you know, you should try x y Zed before we have you have a discussion with an orthopedic surgeon about surgery.
Alexander Garbin 18:11
That's terrific. So with this work, and with the information, I'm sure you've learned through these qualitative interviews with patients and with those providers, do you have any next steps or future work that you've done with this information?
Laura Churchill 18:24
Yeah, so after my dissertation, and I was kind of, you know, you have some time to reflect on the work that you've done, and like where you could go next. And obviously, the pandemic happened, and we had a little bit more time on our hands. And I kind of got interested in a creative endeavor, with an orthopedic surgery resident out of Western University, whose name is Dr. Kristen Barton. And we essentially joined forces to create something for patients and we thought, you know, it's one thing to say, like, you should try exercise, and you should try weight loss. And, you know, maybe you should consider a joint injection. But we weren't really giving patients a means to do those things. And so, in terms of arthritis, osteoarthritis of the knee, there's lots of different programs available. But we wanted to make something that was free, that can be accessed anywhere by anyone. And we wanted it to be evidence based and high quality. So essentially, Kristen and I were fortunate enough to receive seed grants and small bits of funding from different organizations. And we, during the pandemic, we created what we refer to as joint management, which is an education and exercise platform for individuals with hip or knee osteoarthritis.
Alexander Garbin 19:45
And can this be accessed online currently?
Laura Churchill 19:48
So right now we're actually studying its use in a research study. And so it's currently not available to the public because we want to collect some initial data on it, however, and this has been our mission from the start is that we will never charge patients for the the use of this platform, it's going to be freely accessible once we have some initial data on it. And there might be periods where we, you know, refine, and there will be periods where we refine and improve the content. But the goal is to have this be something that patients can access and never have to worry about cost as a barrier.
Alexander Garbin 20:25
Laura Churchill 20:25
Alexander Garbin 20:26
If I was an older adult with osteoarthritis, and I were to access your site, what kind of things could I expect to find out there?
Laura Churchill 20:33
Yeah, so that's a great question. Essentially, what you'd find, if you logged on to the website, you start on a landing page, which would present you with a roadmap, explaining, you know, what are the core or initial treatments that you should consider looking into and which providers offer these core treatments. So it's really meant to be a pathway to help patients understand what are their treatment options, if you clicked along the pathway that would take you to different parts of our website. So there's education on osteoarthritis in general, there's education, on imaging, and what's appropriate. There is an a whole suite of exercise videos that are progressive in nature, there's a training plan that you could follow with sample workouts, there are sheets to log your adherence to the actual exercise program. And there's also a link to connect with physical therapists in a virtual capacity, if you're finding that, you know, you have all this information, but you're still not sure where to start, there's an option to connect with a physical therapist virtually, which I think could be refined in the future. But I think that's always an important option is to make sure that patients don't feel like alone in this journey. And that, you know, some patients are going to see a website like this and dig in and find value in it and other patients might need that more direct support and guidance.
Alexander Garbin 22:03
It all sounds very valuable. You mentioned right now you're still doing a research study. Is there a specific thing you're looking at in reference to the website?
Laura Churchill 22:12
Yeah, I think for us, this was just a way to get some preliminary data on acceptability. So we're going to, again, have patients that have been given access to this website, who have been seeking care, and who have mild to moderate osteoarthritis. And we're going to, you know, they're part of a trial that's really looking at exercise prescription, in conjunction with having access to a website that offers exercise. So we we hope that you know, with primary care physicians prescribing exercise, having these conversations, and then delivering a means to get started, our website joint management, that, you know, hopefully patients will have improved outcomes. And we're also just seeking to understand if patients, you know, even use the website or found it valuable, so lots of different aims within that study. But certainly, just to get a sense of, if patients enjoy using it, if they find value in it. And then going from there, I think there's lots of questions we can answer.
Yeah. Allvery useful information to know, I'd say. Is the idea then to keep it at a smaller level right now? Or do you anticipate spreading it out into the wider I guess Canadian system imagining Canada's more the goal for this?
Yeah, you know what I could, I could see this crossing borders, both nationally and internationally. So I think for us, the first step would probably be Canada and the US in terms of dissemination. And I want to actually shout out, one of my colleagues on the West Coast, who is a brilliant physiotherapist, and was an invaluable member and actually helping develop some of the educational content for the website. And so the reason I shout Matt out is he's over in Alberta, and is a clinician that I could see being a real champion of some of these resources. And so I've talked to Matt, in terms of how do we get this across Canada, and not just, you know, Ontario, where I did most of my training. And so the other piece is we're talking to different organizations and national health charities to figure out a plan to disseminate this work, because it's one thing to again, have education videos have an online tool, but if no one uses it, and it's not valuable. So we're really trying to rally support around it, and trying to kind of appreciate really the critical nature of translation. Something definitely that I've gained a lot of exposure to University of Colorado, working with Jen and so yeah, it's it's on our minds, and it's really in the forefront is how do we get this to patients that could benefit from using it?
Alexander Garbin 24:50
Awesome. Yeah. I'm excited to see what comes in the future for this project.
Laura Churchill 24:54
Thanks. Yeah, we're really excited about it and looking forward to just continue to learn more as we move through in this process?
Alexander Garbin 25:02
Well, thank you for summarizing a lot of your work over the past several years and using taking us through this journey of your predictive model the perceptions of providers and patients and now to your current website that people can hopefully access soon and that you're currently testing. One thing we like to do on this podcast is give a nice, brief summary for those that just want to end with a nice nugget for both the patient and the provider. So is that something you would be able to do?
Laura Churchill 25:29
Yeah, absolutely. I'll try to make this really digestible. And I think if I think about the journey that you kind of mentioned that I've been on, and that I'm still on, and I continue to learn new things and think about new ways of doing things every single day. And so essentially, if I were to talk to a patient with everything that I've learned from all of these studies, I would say, if you have been diagnosed with osteoarthritis, it's worth exploring exercise as an option to help manage your condition. It's worth talking to a physical therapist about management strategies, what an exercise program could look like. And you know, what other options there are for treatment? And so I think, obviously, I have a bias as a physical therapist, but I do think we play a key role in this pathway and in supporting patients. And, you know, I would I, the way I envision kind of everything coming together is that patients should have diverse options for care. For some patients, that's going to mean going and paying for an in person exercise program. And having really direct support for some patients that's again, going to be having that have the means and the the access to access a physical therapist in person and get direct support. And if that sounds like you, then that's a good option. And then for some patients who maybe have barriers because of time because of funds or money or because of remote or rural regions of the world. Maybe getting online and getting started it is a good option. And so I think, get started, get information from credible sources and seek help when you need it in terms of managing your osteoarthritis.
Alexander Garbin 27:17
Okay, terrific. Well, thank you again, Laura, for being on the podcast today. And thank you everyone for listening.
Laura Churchill 27:23
Thanks for having me, Alex.
Transcribed by https://otter.ai