Chronicle in Dagens Medisin by Ingvild Kjeken, senior researcher at Diakonhjemmet Hospital and professor of occupational therapy at OsloMet and Kari-Jussie Lønning, hospital director, Diakonhjemmet Hospital.
At rheumatology departments, we take the government's call for task sharing seriously. We have shifted responsibility for patients with osteoarthritis from doctors to other healthcare personnel. However, strict regulations prevent us from getting the full effect of these measures.
Task sharing frees up resources in the health service
Task sharing is one of the government's strategies to ensure that citizens receive good and effective healthcare services in the future. A cost-effective task sharing is to shift tasks from healthcare professionals with a long education to those with a shorter education. Another form is digital task sharing using mobile apps. Here, responsibility is shifted directly to the patient, who, using customized apps, learns about their own illness, carries out training using videos and reminders, or monitors their own health status by regularly measuring selected disease parameters. The latter makes it possible for patients to contact the healthcare system when the need arises, instead of attending routine check-ups that are not always as useful.
Effective treatment course for hand osteoarthritis
Task sharing is well suited to treating diseases for which there is no cure and where lifestyle changes are the core treatment. Hand osteoarthritis is one such disease and affects nearly half of all women and a quarter of men during their lifetime. The disease often causes pain, stiffness, problems with daily activities and reduced work capacity. Patients should mainly be treated in the municipal health service, but the services there are inadequate. Therefore, patients are increasingly referred to a rheumatologist or surgeon in the specialist health service. However, they do not have much to offer and often refer the patient to an occupational therapist, who has good expertise in hand osteoarthritis.
To avoid this "detour", we at Diakonhjemmet Hospital and Martina Hansens Hospital have conducted a study of a course where patients with hand osteoarthritis come directly to an occupational therapist, who initiates the recommended treatment. If there is doubt about the diagnosis, a rheumatologist is consulted, and if necessary, the patient is referred for assessment by a surgeon. With support from the Research Council of Norway, we have evaluated whether this course is as effective and safe as a traditional rheumatologist-led course (link to Lancet article https://authors.elsevier.com/a/1lF859UBHvvgBI ). The results show that the treatment response is similar in the two groups. The same is true for the number of negative events, which are few and of low severity. The occupational therapist-led course also has lower costs, mainly due to fewer consultations with a rheumatologist and lower salary costs for occupational therapists. Patient satisfaction with the service is high and similar in the two courses. The occupational therapist-led course has therefore now been implemented at both hospitals.
It is still important to avoid an increase in the number of referrals to specialist health services. With support from the Dam Foundation, we have therefore collaborated in parallel with the Norwegian Rheumatology Association and people with hand osteoarthritis to develop the coping app Happy Hands. The app guided patients with hand osteoarthritis in carrying out exercise and changing work habits. During testing of the app, we interviewed users. They said that the app gave them knowledge about their own disease and what they could do to cope with it, and courage and help to make necessary changes. Data directly from the app showed that 75% of users did regular hand exercises, and that pain, hand strength and activity performance had noticeably improved after three months.
Our conclusion is that this app is an effective first-line treatment for hand osteoarthritis. Patients can easily download it on the advice of a doctor, healthcare professional or acquaintances who themselves have hand osteoarthritis. This ensures they have access to recommended treatment with minimal use of resources in the health service. However, new and strict requirements for CE marking of patient apps as medical devices make the path to such a solution unnecessarily long and expensive.
Sustainable developments are stopped by strict regulations
If the full effect of task sharing is to be realized, responsibility for new tasks must be accompanied by the opportunity to carry them out. In our study, we found that occupational therapists' lack of the right to request X-rays slowed down the ability to assess the need for and refer to a surgeon. Requiring a signature from a rheumatologist on an application for reimbursement of orthopedic aids, in this case a thumb splint adapted by an occupational therapist, also created unnecessary additional work and waiting time. If the full benefits of task sharing are to be realized, laws and regulations must therefore be made more flexible to allow for effective redistribution of tasks.
The same applies to the process of CE marking of patient apps in the lowest risk classes. In our coping app, we have collected information that is already fully available, and deliver this at a time of the user's choosing. That such an app has to go through the same strict risk assessment as a hip prosthesis or an artificial heart valve is incomprehensible to us.
In Germany, they have taken this into account and created a "fast-track" with rapid risk assessment of apps in low risk classes. We also need this in Norway. Patients must have quick access to new digital tools that can improve their health.
The Minister of Health already knows all this. Now we look forward to action in this area!
Here you can read the article in Dagens Medisin.
