Information for GPs: Comprehensive Osteoarthritis Pathway

What is COAP and were is it located?

The Comprehensive Osteoarthritis Pathway provides a program to better manage patients presenting with hip or knee osteoarthritis.

COAP clinics are operated by the Tasmanian Health Service – Southern Region (THS-S), located within the Orthopaedic Department, Wellington Clinics, Level 12, Argyle Street, Hobart.

How will the COAP Pathway benefit my patients?

The COAP pathway will help patients better manage their osteoarthritis (OA) by developing and coordinating a management plan that best suits their needs. The service provides information and guidance on the best way to manage OA, and can assist in detecting deterioration in a range of key health markers through regular monitoring (e.g. quality of life scores, walking endurance, pain tolerance etc).

A similar system has been used in other Australian hospitals, including the OAHKS program in Victoria, and has demonstrated improvements in the coordination and management of patients with hip of knee OA through early assessment and development of management plans, prioritisation of patients according to clinical need, and referral for a range of conservative treatment strategies. These include physiotherapy, hydrotherapy, occupational therapy, rheumatology and self-management group programs.

How does conservative management, including physiotherapy, help with OA?

Clinical guidelines such as the RACGP Guideline for the non-surgical management of hip and knee OA (2009) and Referral for Joint Replacement Guide (2007), provide strong evidence for conservative management strategies including exercise, simple analgesia and weight loss. These documents recommend referral for surgical management only once all conservative options have been explored.

Physiotherapy has a pivotal role in non-pharmacological management of this patient group. Data from a recent audit carried out by the Physiotherapy Orthopaedic Surgical Initiative (POSI); found the majority of referred patients had not had adequate conservative management prior to being waitlisted for hip or knee arthroplasty.

How will the COAP Pathway improve outpatient and surgical waiting lists?

The COAP pathway will provide a timely and comprehensive assessment of all patients referred with OA of the hip or knee. It will help to reduce the large orthopaedic outpatient waiting list at the RHH by effectively dealing with a group of patients that do not require surgical input at this time.

Those patients not requiring or ready for surgery will be discharged with an appropriate conservative management plan.  COAP patients will be actively managed and regularly monitored. They will be referred for surgical assessment when and if it is required. Through an active management process, patients with the greatest need will get timely access to surgery resulting in more appropriate use of orthopaedic specialist services.

Why can I not directly refer to a surgeon, and why should I take advice from a Physiotherapist?

The COAP pathway was developed in response to the overwhelming need for changes within the Orthopaedic service at THS-S. Referral to the COAP will provide more effective and efficient  triaging and management of patients, and an active management process based on a clinical prioritisation of their presenting condition with regular opportunities for communication with referring health practitioners.

All physiotherapists working at the COAP clinic have advanced musculoskeletal assessment and management skills, postgraduate qualifications and clinical experience. They work closely with other members of the Orthopaedic department and have ready access to other health care professionals within THS-S, including ortho-geriatricians, rheumatologists, pharmacists and occupational therapists. Physiotherapists are well placed to provide holistic healthcare within a biopsychosocial model of care to this patient group.

What feedback will I get and how do I give feedback if required?

Regular and open communication with GP's has been identified as a requirement for ensuring continuity of care for patients with OA. It is a key aim of the COAP clinic to provide regular communication with GP's throughout the pathway. This will include a clearly defined management plan following their initial assessment, and regular updates on those patients who require ongoing monitoring. Feedback from the referring GP is always welcome through email, phone and/or mail and recommendations will be duly considered and incorporated into the patients care plan if appropriate. In time, there may be opportunities for interested GP's to visit the Clinic, observe and learn about the process and, potentially, contribute to the delivery of some clinical services.

Where do I find the Hip and Knee Questionnaire, and will my patient be disadvantaged if this is not completed on referral?

The Hip and Knee questionnaire is available for download from the Victorian Department of Health and Human Services website in 12 languages. The questionnaire is used in conjunction with clinical assessment to prioritise patients according to clinical need. Including the questionnaire with your patient's referral will greatly assist the efficiency and effectiveness of the triaging and early assessment processes.

How do I explain to my patient they will be seen through COAP when they believe they require an operation?

The development of COAP is a new model of care providing prompt assessment and management for patients with OA of the hip and/or knee. Although this pathway has a focus on conservative management, it does not exclude surgical management when appropriate. An advantage of the COAP is that it will help manage patient expectations regarding conservative versus surgical management. Many patients currently referred for orthopaedic review have not engaged with adequate conservative management and clinically do not require immediate surgical care. Through assessment and monitoring of patients we will be better able to identify the most effective management plan for their stage of disease and prioritise their care according to need, including referring for a surgical opinion. There is also strong evidence that appropriate conservative management can delay, and in some cases avoid, the need for joint arthroplasty, and help to better prepare patients who do need surgery, supported by reduced length of stay data.