Reducing Disparities in Musculoskeletal Care: Focusing on Bone and Joint Health
Originally Published in the Allegheny County Medical Society December 2020 Bulletin
Living an active life requires bone and joint health. Musculoskeletal conditions like osteoarthritis, a degenerative joint disease, inflammatory arthritis, and osteoporosis lessen a person’s quality of life, cause pain and disability, and significantly increase healthcare costs. The threat of limited mobility and disability from chronic pain and weakened bones is concerning for increasingly large portions of the aging US population.
Did You Know?
Estimates suggest that by 2040, the number of adults affected by arthritis will grow from the current 54 million Americans to over 78.4 million. In addition, 12 million people (80% of whom are women) suffer from osteoporosis, a condition that weakens bones, and can cause harmful fractures that may lead to surgery or disabilities with chronic pain.
Gender-based disparities in bone and joint health also present a significant challenge to meet patients’ needs. A “disparity” is defined as when there is a discrepancy, inconsistency, or imbalance of care and outcomes. For example, women are more likely to develop hip and knee arthritis than men, suffer worse severity of pain, and are more likely to delay seeking evaluation and treatment. Women are also four times more likely to suffer from osteoporosis than men.
Disparities also exist around treatment and interventions. Although 26% of women have arthritis (as opposed to 18% of men), women are three times less likely than men to undergo total joint replacement surgery (TJR), despite both having end stage degeneration. Even when women elect to have surgery, they are typically older and frailer, report worse arthritis pain and have worse pre-op and post-op function scores. Unfortunately, these bone and joint health disparities only worsen when factoring in social determinants of health like race, ethnicity, culture, sexual orientation, and others.
However, there are also opportunities to better understand and meet patients’ needs for non-operative interventions long before surgery is indicated. The progression of arthritis and degeneration can be slowed if diagnosed early and appropriately addressed. In addition, by learning to manage pain and symptoms at earlier stages, arthritis and osteoporosis sufferers can decelerate the disease progression while prolonging their mobility. Establishing this approach requires us to develop unique interdisciplinary care teams that focus on global bone and joint health.
Co-Designing Personalized Patient Care to Address Disparities
At the core of patient centered care is individualizing treatment to best meet their specific needs. By viewing the experience through the eyes of patients and families and engaging them in co-designing their own care around what matters most, we can develop more personalized programs. Jointly creating improved care programs with patients and families as co-designers can guide these efforts by putting the needs of the end user as the highest priority.
At the Bone and Joint Center in UPMC Magee-Womens Hospital, we sought to first better understand the issues facing our patients and then start to address disparities. Instead of asking patients and families “What’s the matter with you?”, we changed the conversation and asked, “What matters to you?”. In this way, the simple yet revolutionary What Matters to You (WMTY) concept makes healthcare conversations more meaningful and patient centered. Through the “What Matters to You?” surveys, distributed at several clinical services at UPMC Magee-Womens Hospital, we uncovered priority areas.
These collaborative efforts have resulted in several pilot projects, including the creation of the 90% female patient community, Arthritis Together (facebook.com/groups/arthritistogether), a woman-specific exercise program, gender specific patient educational materials, updated pain management education, and virtual bone and joint health presentations and multimedia content. We are also developing educational programs for patients, community members and providers to address disparities on the provider side. As an example, analysis of provider disparities revealed that only 6% of orthopaedic surgeons are women, with even fewer in the adult reconstruction subspecialty (<<1%).
Next Steps: An Interdisciplinary Approach to Bone and Joint Health
Patient and community feedback have pointed us to three areas of opportunity to improve care and population health: coordinated care, comprehensive pain management strategies using complementary, alternative and integrative medicine (CAIM), and enhanced education for patients, community members, and providers.
Through this emerging effort, along with related service lines at UPMC Magee-Womens Hospital, including the Midlife Health and Osteoporosis Care Center, Bariatric and Nutritional Services, and Pain Management, we hope to transform care by coordinating services based around what matters most to patients rather than along subspecialty lines. To that end, our mission and goals are as follows:
Identify and reduce gender and cultural disparities related to musculoskeletal care by developing unique teams and care programs in the areas of bone and joint health.
Co-design clinical programs with patients and providers that address patients’ needs.
Develop educational and training programs for patients, community, and providers to accelerate awareness of these disparities within the patient and provider communities.
Ultimately, we hope to develop and support system-wide changes that better address patients’ priorities, implement coordinated treatment plans, and identify opportunities for improvements. Expanded pain management offerings that include complementary and alternative approaches will provide options and access to combinations of treatment modalities that work best for particular patients. Customized education will ensure patients are informed and prepared to take charge of their wellness journey.
We believe our shared goal of reducing disparities in bone and joint health can unite us in developing immediate and long-term changes and improvements for patients. We are continuing to co-design and refine programs by listening to patients’ needs, leading to unique clinical collaborations that we expect to have high impact in patient experiences and care.