Abstract
Objective
The Good Life with osteoArthritis: Denmark (GLA:D™) program for knee and hip osteoarthritis has been shown to be effective, but evaluations have yet to explore whether effectiveness differs by program context. The present study explores whether there are differences in effectiveness of the GLA:D™ program for treatment of hip and knee osteoarthritis across program location (i.e., rural, urban, metro) and program payor (i.e., public, private) within Alberta, Canada.
Design
The study population was adults with hip or knee osteoarthritis attending the 8-week GLA:D™ supervised exercise and education programme in Alberta between Sep 2017–Mar 2020. Outcomes of interest were joint-related pain and quality of life (HOOS/KOOS), health quality of life (EQ-5D-5L), and performance-based functional (30-s chair stand test; 40-m walk test) measures. Minimally clinically important changes were calculated for each outcome and ANOVA and chi-square tests were used to determine statistical significance by program location or payor.
Results
Of the 1321 eligible participants, 974 (73.7%) completed the baseline questionnaire, about 50% of participants participated in a metro area and 60% paid privately for the program. There were no statistically significant differences in improvements of joint-related pain, joint-related quality of life, health-related quality of life, or performance-based functional measures by program location or program payor, except for participants who received the program in a publicly covered primary care clinic who experienced significantly larger improvements in joint-related pain.
Conclusion
The implementation of the GLA:D™ program for the treatment of knee and hip osteoarthritis in Alberta is effective across a range of contexts.
Keywords: Osteoarthritis, Exercise, Effectiveness, Urban, Rural, Public healthcare, Private healthcare
1. Introduction
Osteoarthritis (OA) is a prevalent chronic condition globally characterized by pain, with increased risk of functional disability and poorer quality of life [1,2]. Data from the Global Burden of Disease Study has shown that the prevalence of OA has increased by approximately 113% in the last three decades [3]. Approximately 1 in 8 (or 3.9 million) Canadians over 20 years of age are living with OA with estimates to rise due to an aging society and increasing obesity [[4], [5], [6]].
Evidence-based guidelines recommend exercise and education as first line treatment [7] but these treatments are not often recommended by health providers [8,9]. There is an urgent need to better manage OA with conservative (i.e., non-surgical) treatments [10]. Programs such as the Good Life with osteoArthritis: Denmark (GLA:D™) have been developed to address this gap by offering first-line treatment for knee and hip OA [11]. The GLA:D™ program is an evidence-based education and neuromuscular exercise program for individuals living with hip and knee OA and consists of three components: 1) two structured education classes, 2) a 6-week supervised group exercise program, and 3) collection of patient outcome data at three time points (i.e., baseline, 3-months, and 12-months) [[11], [12], [13]].
The implementation of the GLA:D™ program has been shown to be feasible and effective [11,14,15] and is currently being implemented in several countries, including Canada [16,17]. Feasibility, safety, and effectiveness of GLA:D™ have been demonstrated in Danish adults with mild to severe hip and knee OA. The program has shown significant pain relief and reduced use of pain medications along with improvements in physical activity, function, quality of life, self-efficacy and return to work [11,18]. Program feasibility, including English language translation, in the Canadian context has also been reported in a small single publicly funded program in Ontario [14] and in Alberta [19]. Results from the country-wide implementation of the GLA:D™ program for knee in Australia found moderate improvements in pain and knee-related quality of life [15]. Longitudinal results from Denmark, Canada, and Australia have demonstrated that almost half of participants experienced clinically important improvements in pain [20].
Although program implementation evaluations conducted in Canada, Australia, and Denmark have shown GLA:D™ program to be feasible and effective, these evaluations have been primarily based on data obtained from large metropolitan areas [14,15] or from private payment models for the GLA:D™ program [11,15] which restricts applicability in other contexts. As GLA:D™ is increasingly being implemented across different settings in different countries, further investigation is needed to determine whether the program is consistently effective across diverse geographical settings and payment models.
2. Objective
Our study aims to assess whether there are differences in the effectiveness of the GLA:D™ program for hip and knee OA across program location (i.e., rural, urban, metro settings) and program payor (i.e., public, private) within Alberta, Canada. These findings will provide a better understanding of program outcomes in different contexts across Alberta after the initial implementation of the GLA:D™ program. As the international implementation of the GLA:D™ program increases, these findings can help inform the wide-spread adoption of the program to other contexts with similar health system characteristics.
3. Method
3.1. Study design
This study used registry-based data from patients who participated in the GLA:D™ program for hip or knee OA in Alberta. We used a cohort study design to evaluate program effectiveness and to determine if there were any differences in effectiveness based on program location and program payor. Reporting is in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guide (for completed checklist see Appendix A). This study received ethics approval from the Health Research Ethics Review Board of the University of Alberta (Pro00068308).
3.2. Setting
This study uses data from the national database of the GLA:D™ program for hip and knee OA in Alberta, Canada. Alberta is the fourth largest province in Canada with a population of approximately 4.5 million spread across five health regions. Over half of the Alberta population reside in the two metropolitan areas: Calgary and Edmonton [21]. Alberta uses a single payor health care system where rehabilitation and physiotherapy services can be paid for privately and are also covered, in a limited capacity, by the public healthcare system [22].
3.3. Participants
Individuals with knee or hip OA, who were referred to the GLA:D™ program through multiple avenues (e.g., patient self referral, surgeon referral, or family physician referral), were assessed for eligibility in the GLA:D™ program by a GLA:D™ trained provider. All GLA:D™ participants were asked for consent to have their data collected and entered in the GLA:D™ Canada registry. Those participants who did not consent could still participate in the program, but their data were not available. For this current analysis, criteria included: 1) adults (≥18 years of age), 2) living with symptomatic hip or knee OA, and 3) attended the GLA:D™ program between September 2017 to March 2020 in Alberta.
3.4. Data collection
The data collection period was from September 2017 (when data collection for the GLA:D™ program was initiated in Alberta) until March 2020 when in-person delivery of the GLA:D™ program was suspended due to the COVID-19 pandemic [19]. The GLA:D™ program participants completed a baseline self-reported questionnaire at the beginning of the program and follow-up questionnaires upon completion of the program at 3-months, and 12-months after baseline. The baseline questionnaire collected participant demographics (e.g., age, sex, marital status, education level, employment status, height and weight, and most affected knee or hip) and patient self-reported outcomes (e.g., HOOS/KOOS pain, joint-related quality of life, EQ-5D-5L quality of life). The follow-up questionnaires included only the patient self-reported outcomes. Data from these questionnaires were collected into a central national GLA:D™ program registry. Provider-reported performance tests for participants (e.g., 30-s sit stand and 40-m walk test) [23] were collected at the first GLA:D™ session (i.e., baseline) and at the last GLA:D™ session (i.e., approximately 2-month after baseline) into the GLA:D™ registry. Effectiveness of the program on joint-related pain, joint-related quality of life, and health-related quality of life were only calculated at 3-month compared with baseline. Effectiveness of the program for performance-based measures were calculated at program completion compared with baseline. Only participants with complete baseline data were included in the study (see Fig. 1).
Fig. 1.
Flowchart of study participants.
3.5. Program characteristics
Program characteristics included the location of the program and the program payor. First, program location was categorized as metro centres (population >500,000), metro-influenced (commuter communities surrounding the two major urban centres in the province), urban (>25,000, but <500,000) or rural (populations <25,000) based on the 6-digit postal code of the location of the GLA:D™ program [24]. Second, the type of program payor was classified as private pay (in which the individual participant or their extended healthcare insurance paid for the program), or publicly funded (in which costs were covered by the provincial health service) with the program being delivered in an outpatient physiotherapy clinic or a community-based primary care centre.
3.6. Primary outcome
Pain and joint-related quality of life were measured as components of the Hip disability and Osteoarthritis Outcomes Score (HOOS) and the Knee injury and Osteoarthritis Score (KOOS) [25,26]. The KOOS pain score was calculated based on nine items and 10 items for the HOOS. The joint-related quality of life score included four items which captured mental and social constructs such as awareness and lifestyle changes [26,27]. A normalized score is generated for each subscale ranging from 0 to 100 scale, where higher scores were indicative of less pain and better joint-related quality of life. A difference of 36 and 13 were considered minimally clinically important differences for the HOOS pain and hip-related quality of life summary scores, respectively [28]; where as a 16.7 and 15.6 difference were considered minimally clinically important differences for the KOOS pain and knee-related quality of life summary scores, respectively [29].
Health-related quality of life was assessed using scores from the EuroQol-5 Dimension (EQ-5D-5L) measure which evaluates mobility, self-care, usual activities, pain or discomfort, anxiety or depression [30]. A minimum difference of 0.1 was considered clinically important for EQ-5D-5L [31]. Providers measured and reported patients' scores for the 30-s chair stand test and a 40-m walk test [23]. A minimum difference of 2.0 repetitions and 0.2 m/s [32] were considered clinically important for the 30-s chair stand test and the 40-m walk test, respectively.
3.7. Statistical analysis
Descriptive analyses were performed for all variables to examine the study population. Chi-square tests and ANOVA were used to examine differences in baseline characteristics by location and payor. The absolute difference between baseline and the 3-month follow-up score was calculated. Minimally clinically important differences were used to categorize change scores into 3 categories – improved, no difference, or worsened. Chi-square tests were used to assess statistically significant differences in minimally clinically important improvements in outcomes by location and program payor.
The proportion of missing data at each time point varied considerably ranging from negligible (<1%) to substantial (>15%). Due to losses to follow-up, all outcome variables at 3-months had substantial missing data (see Appendix B). As a sensitivity analysis, multiple imputation using chained equations (MICE) was used to estimate missing data from HOOS/KOOS scores at 3-months based upon baseline functional assessment, pain, quality of life, affected joint, desire for surgery, BMI, and marital status (see Appendices C and D for results from MICE analyses). Due to the large percentage of missing data for the provider-measured functional status variables (over 55%), MICE was not used for these outcome measures.
4. Results
Among included 974 participants with baseline data, 76.6% were female, the majority (69.4%) had knee involvement. Almost half of participants attended the GLAD™ program in a metro area (47.3%) and most participants (61.5%) paid privately for the program. The average age was 65.1 (SD 8.2) years, with a mean BMI of 31.1 (SD 6.8) kg/m2 (Table 1). At baseline, participants had a mean HOOS/KOOS pain score of 53.5 (SD 15.5) and a mean HOOS/KOOS joint-related quality-of-life score of 37.3 (SD 18.4) (Table 1). Participants also had a mean EQ-5D-5L score of 0.7 (SD 0.2). Participants completed a mean number of 12.6 (SD 6.0) chair stands in 30 s and an average 34.0 (SD 18.1) seconds to walk 40-m.
Table 1.
Demographic characteristics of study participants at baseline (n = 974).
| Characteristic | Percent (n) |
|---|---|
| Affected Joint | |
| Hip | 30.6% (298) |
| Knee | 69.4% (676) |
| Sex | |
| Female | 76.6% (745) |
| Male | 23.4% (228) |
| Marital Status | |
| Married, common-law | 76.1% (740) |
| Single, separated, divorced, widowed | 24.0% (233) |
| Education | |
| High school diploma or less | 20.3% (184) |
| College or trade school | 33.7% (306) |
| University degree | 46.0% (417) |
| Employment Status | |
| Not currently working | 70.6% (659) |
| Current working | 29.4% (274) |
| Program Location | |
| Metro | 47.3% (461) |
| Metro-influenced | 20.7% (202) |
| Urban | 12.2% (119) |
| Rural | 19.7% (192) |
| Program Payor | |
| Private | 61.5% (599) |
| Publicly funded by Alberta Health Servicesa | 27.6% (269) |
| Publicly funded by a Primary Care Networkb | 11.6% (106) |
| Mean (SD) | |
| Age, years | 65.1 (8.2) |
| BMI kg/m2 | 31.1 (6.8) |
| Outcomes | Mean (SD) |
| HOOS/KOOS | |
| Pain | 53.5 (15.5) |
| Quality of life | 37.3 (18.4) |
| Health-related quality-of-life, EQ-5D-5L | 0.7 (0.2) |
| 30 s chair stand, count | 12.6 (6.0) |
| 40 m walk test, seconds | 34.0 (18.1) |
Publicly funded at outpatient physiotherapy.
Publicly funded at community-based primary care centres.
There were no statistically significant differences in participants’ baseline characteristics by the type of program locations (p > 0.05), except, participants receiving in the GLA:D™ program in rural locations were less likely to have completed university (p < 0.001) and were slightly older (p = 0.02), compared to those receiving the program in the other locations. Statistically significant differences in baseline functional status were observed in HOOS/KOOS joint-related quality of life (p = 0.0004) and 30-s chair stand (p = 0.0004) by program location (see Appendix E), although the difference in HOOS/KOOS joint-related quality of life did not constitute a clinically important difference. At baseline there was a clinically important difference in number of repetitions in the 30-s chair stand performance test where participants in urban locations performed statistically significantly fewer repetitions than those in metro locations.
Participant characteristics by program payor (i.e., private, publicly funded at outpatient physiotherapy, and publicly funded at community-based primary care centres) are displayed in Appendix F. Participants who paid for the GLA:D™ program were more likely to be currently working (p < 0.001), were more likely to have completed university (p < 0.001), were slightly younger (p < 0.001) and had a lower BMI (p < 0.001) than participants who accessed the GLA:D™ program through publicly funded sources. A statistically significant difference in baseline 30-s chair stand was observed by program payor, and this did constitute a clinically important performance difference. Clinically important differences in baseline functional status were observed on the 30-s chair stand, with participants who paid privately for the GLA:D™ program (p = 0.004) having a statistically and clinically higher baseline performance.
Overall, 974 participant who completed baseline, of which 554 (56.9%) included 3-month follow-up data (Fig. 1). A higher proportion of those people lost to follow-up were from locations other than metro centres, were not married, had a lower education level and higher BMI (see Appendix G). From baseline to 3-months 13.3% of participants had clinically important improvements in pain, 25.5% in joint-related quality of life, and 26.6% in health-related quality of life (Fig. 2). Clinically important improvements in functional tests were also observed from baseline to program completion, with 72.1% and 76.4% experiencing improvements on the 30-s chair stand and 40-m walk test, respectively (see also Appendix H for mean changes).
Fig. 2.
Proportion of GLA:D™ participants with clinically important changes from baseline to 3-months (self-reported measures) and from baseline to program completion (physical measures).
Table 2 presents clinically important improvements in study outcomes by program location. The proportion of participants with clinically important differences for any of the self-reported measures or performance-based test did not differ by program location (>0.05).
Table 2.
Proportion of GLA:D™ participants with clinically important improvement by program location, baseline to 3-months (self-reported measures) and from baseline to program completion (physical measures).
| Metro (n = 289) | Metro-influenced (n = 100) | Urban (n = 60) | Rural (n = 105) | P-value | |
|---|---|---|---|---|---|
| Outcomes | Percent (95% Confidence Interval) | ||||
| Pain, HOOS/KOOS | 11.6 (8.2–16.0) | 18.0 (10.8–28.3) | 13.7 (6.5–26.6) | 14.0 (8.2–22.8) | 0.71 |
| Joint-related quality of life, HOOS/KOOS | 25.3 (20.6–30.7) | 23.2 (15.8–32.7) | 24.6 (15.2–37.3) | 28.6 (20.6–38.1) | 0.49 |
| Health-related quality of life (EQ-5D-5L) | 27.9 (23.0–33.4) | 23.2 (15.8–32.7) | 31.2 (20.6–44.1) | 23.2 (13.3–28.9) | 0.87 |
| 30-s chair stand (count) | 70.4 (64.0–76.0) | 75.7 (64.0–84.5) | 79.6 (64.5–89.3) | 69.5 (58.5–78.7) | 0.38 |
| 40-m walk test (sec) | 72.2 (63.7–79.4) | 81.5 (68.4–89.9) | 75.0 (56.3–87.5) | 81.3 (69.5–89.2) | 0.47 |
As shown in Table 3 approximately 27.7% (16.5–42.6) of individuals receiving the GLA:D™ program in publicly funded at a community-based primary care centre reported clinically important improvement in joint-related pain compared to 11.5% (8.5–15.5) of individuals receiving the GLA:D™ program in privately funded clinics and 12.3% (7.5–19.5) publicly funded outpatient physiotherapy clinics. Similar to the program location, the proportion of those participants with clinically important differences for self-reported measures and performance-based tests did not differ by type of program payor.
Table 3.
Proportion of GLA:D™ participants with clinically important improvement by program payor, baseline to 3-months (self-reported measures) and from baseline to program completion (physical measures).
| Private (n = 353) | Publicly funded by Alberta Health Servicesa (n = 139) | Publicly funded by a Primary Care Networkb (n = 62) | P-value | |
|---|---|---|---|---|
| Outcomes | Percent (95% Confidence Interval) | |||
| Pain | 11.5 (8.5–15.5) | 12.3 (7.5–19.5) | 27.7 (16.5–42.6 | 0.03 |
| Joint-related quality of life | 24.8 (20.5–29.6) | 28.7 (21.6–36.7) | 22.6 (13.7–35.0) | 0.54 |
| Health-related quality of life | 27.6 (23.2–32.6) | 26.1 (19.3–34.3) | 21.3 (12.6–33.7) | 0.41 |
| 30-s chair stand (count) | 71.3 (65.4–76.5) | 73.0 (63.8–80.5) | 74.5 (59.6–85.2) | 0.32 |
| 40-m walk test (sec) | 75.3 (68.0–81.4) | 78.2 (68.1–85.7) | 77.8 (57.0–90.2) | 0.96 |
Publicly funded at outpatient physiotherapy.
Publicly funded at community-based primary care centres.
5. Discussion
The findings from this analysis did not show any systematic differences in the effectiveness of the GLA:D™ program by program location (i.e., urban and rural) and program payor (i.e., public and private settings). Program location within the provincial healthcare system was not significantly associated with participants’ outcomes of the GLA:D™ program upon completion of the program at 3-months follow-up. We also detected no evidence that the type of program payor was associated with clinically important improvement except for joint-related pain. Individuals receiving the GLA:D™ program in publicly funded community-based primary care centres experienced larger clinically relevant improvements in joint-related pain than those receiving the programs in private clinics. This finding may be an artefact of multiple testing or may be due to potential differences in participant populations in each of the clinics. The findings are unique in its examination of clinically important improvements over time in different program payor and location types. Participants attending publicly funded community-based primary care centres were slightly older, had a higher BMI, and had higher levels of employment than participants receiving the program in the other payment settings. Previous research has observed only small differences in outcomes based on individual and socioeconomic factors [33] and no differences related to co-morbidities [34]. These findings suggest that further research is needed to identify individual, interpersonal, or setting-based mediating factors of the GLA:D™ program.
Overall, the present study found that the provincial implementation of the GLA:D™ program had clinically important improvements ranging from approximately 15% of participants experiencing improvements in pain to 76% experiencing improvements in the 40-m walk tests, at 3-month follow-up. Joint-related quality of life and performance based measures (30-s sit stand test and 40 m walk test) were similar to other Canadian findings [14,20], yet joint-related pain relief was less than reported by others [14]. Future research work may explore why joint-related pain results in Alberta may be lagging those reported in Ontario.
To our knowledge this is the first study to assess differences in effectiveness outcomes by program location (i.e., metro, metro-influenced, urban, rural) and program payor (i.e., private, public) using data at a population level. Earlier evaluations of the GLA:D™ program have focused on a fairly homogenous program delivery in terms of geography and payment model for the program [11,14,15]. Our findings contribute to the mounting evidence of the effectiveness of the GLA:D™ program particularly within the Canadian context [14]. As more jurisdictions look to scale and spread, the GLA:D™ program is an effective, acceptable, safe, appropriate, and accessible program for OA [35]. Because cost [15,[36], [37], [38]] and location [36] are often barriers to access, offering the program through publicly funded avenues in several location settings across the province will increase accessibility of the GLA:D™ program. Improvements in quality of life and functional movement can be attained regardless of program location and the type of program payor within the context of the Alberta healthcare system.
5.1. Limitations
This study has limitations that should be considered when interpreting the findings. Foremost, program location only provided information on where the program was offered and not how far the participant travelled to receive the program. To better assess the accessibility of the program, comparing participants' address and program location could be useful. We were unable to do so because postal code data was not available from the GLA:D™ Canada database for research purposes. Results from the evaluation of patient experiences with the GLA:D™ program indicated that the location of the program was an enabler to participation given the convenience of nearby location and less travel (manuscript forthcoming). Yet, we do not know whether program location influenced GLA:D™ non-participants’ decision to not enroll in the GLA:D™ program given that transportation has been shown to be a concern for both older adults and those residing in rural regions [39]. Therefore, future research could examine the influence of the distance from individuals’ residence to nearest GLA:D™ program location on program participation. Second, substantial missing data (>65%) on several HOOS/KOOS sub-scales (i.e., active living and sport and recreation) in the GLA:D™ Canada registry precluded the inclusion of these domains. The provider-reported performance tests also had substantial missing, particularly at baseline, which may warrant further investigation of any barriers to data entry by the provider into the national registry. Third, there were some differences between participants who completed both baseline and 3 months and those lost to follow-up (see Appendix G). Respondents who completed the 3-month questionnaire were more likely to reside in a metro area, have a higher education and were more likely to be currently employed. These differences likely do not impact the major finding of the studies presented given the small differences seen in outcomes by program location. Education has been shown to have a only a small impact on outcome measures whereby more participants with less educational attainment have worse outcomes at baseline and have fewer improvements on health-related quality of life [33].
In conclusion, participants of the GLA:D™ program had clinically relevant improvements in joint-related quality of life, health-related quality of life and functional measures regardless of clinic location and type of payor within a Canadian provincial healthcare system. Overall, this study supports the effectiveness and feasibility of the GLA:D™ program for the treatment of knee and hip OA. These findings provide important insights for the evaluation of implementing the GLA:D™ program within diverse healthcare systems. These results can inform policy decisions and program planning for the provision of accessible and effective OA care in a universal healthcare setting that is accessed across various settings.
Author contributions
LAB, CAJ, AKR, and DAH contributed to the conception and design of the study. LAB, AM, CAJ, and GJP contributed to the analysis and interpretation of the data. The manuscript was drafted by GJP. AM and CAJ provided statistical expertise for this analysis. All authors reviewed the manuscript draft, provided critical revisions, and approved the final version of the article.
Role of the funding source
The authors received no specific funding for this work.
Declaration of competing interest
The authors declare no competing interests.
Acknowledgement
This study was supported in-kind by the Bone and Joint Health Strategic Clinical Network.
Handling Editor: Professor H Madry
Contributor Information
C. Allyson Jones, Email: cajones@ualberta.ca.
Geneviève Jessiman-Perreault, Email: genevieve.jessiman-perreault@ahs.ca.
Ania (Anna) Kania-Richmond, Email: anna.kania-richmond@ahs.ca.
Amy Metcalfe, Email: amy.metcalfe@ahs.ca.
David A. Hart, Email: hartd@ucalgary.ca.
Lauren A. Beaupre, Email: lauren.beaupre@ualberta.ca.
Appendix A. STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) Checklist for Cohort Studies
| Item No | Recommendation | Location in Manuscript | |
|---|---|---|---|
| Title and abstract | 1 | (a) Indicate the study's design with a commonly used term in the title or the abstract | Title Page (Page 1) |
| (b) Provide in the abstract an informative and balanced summary of what was done and what was found | Abstract (Page 2) | ||
| Introduction | |||
| Background/rationale | 2 | Explain the scientific background and rationale for the investigation being reported | Introduction (Paragraph 3&4) |
| Objectives | 3 | State specific objectives, including any prespecified hypotheses | Introduction (Paragraph 5) |
| Methods | |||
| Study design | 4 | Present key elements of study design early in the paper | Methods (Paragraph 1) |
| Setting | 5 | Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection | Methods (Paragraph 2) |
| Participants | 6 | (a) Give the eligibility criteria, and the sources and methods of selection of participants. Describe methods of follow-up | Methods (Paragraph 3 &4) |
| (b) For matched studies, give matching criteria and number of exposed and unexposed | N/A | ||
| Variables | 7 | Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if applicable | Methods (Paragraphs 5–7) |
| Data sources/measurement | 8∗ | For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group | Methods (Paragraph 4) |
| Bias | 9 | Describe any efforts to address potential sources of bias | Methods (Paragraph 8) |
| Study size | 10 | Explain how the study size was arrived at | Methods (Paragraph 4) |
| Quantitative variables | 11 | Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why | Methods (Paragraph 5) |
| Statistical methods | 12 | (a) Describe all statistical methods, including those used to control for confounding | Methods (Paragraph 7) |
| (b) Describe any methods used to examine subgroups and interactions | N/A | ||
| (c) Explain how missing data were addressed | Methods (Paragraph 9) | ||
| (d) If applicable, explain how loss to follow-up was addressed | Methods (Paragraph 9) | ||
| (e) Describe any sensitivity analyses | Methods (Paragraph 9) | ||
| Results | |||
| Participants | 13∗ | (a) Report numbers of individuals at each stage of study—eg numbers potentially eligible, examined for eligibility, confirmed eligible, included in the study, completing follow-up, and analysed | Results (Paragraph 1) |
| (b) Give reasons for non-participation at each stage | Methods (Fig. 1) | ||
| (c) Consider use of a flow diagram | Methods (Fig. 1) | ||
| Descriptive data | 14∗ | (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders | Results (Paragraph 1 and Table 1) |
| (b) Indicate number of participants with missing data for each variable of interest | Appendix B | ||
| (c) Summarise follow-up time (eg, average and total amount) | Methods (Paragraph 4) | ||
| Outcome data | 15∗ | Report numbers of outcome events or summary measures over time | Results (Fig. 2) |
| Main results | 16 | (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence interval). Make clear which confounders were adjusted for and why they were included | Result (Table 2, Table 3) |
| (b) Report category boundaries when continuous variables were categorized | N/A | ||
| (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period | N/A | ||
| Other analyses | 17 | Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses | N/A |
| Discussion | |||
| Key results | 18 | Summarise key results with reference to study objectives | Discussion (Paragraph 1) |
| Limitations | 19 | Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias | Discussion (Paragraph 4) |
| Interpretation | 20 | Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence | Discussion (Paragraph 5) |
| Generalisability | 21 | Discuss the generalisability (external validity) of the study results | Discussion (Paragraph 5) |
| Other information | |||
| Funding | 22 | Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based | The authors received no specific funding for this work. |
Appendix B. Proportion of missing data in outcome variables at baseline and 3-month follow-up
| Outcome | Time Period |
|
|---|---|---|
| Baseline | 3-months | |
| Pain, HOOS/KOOS | 7.7% | 49.6% |
| Quality of life, HOOS/KOOS | 0.4% | 43.1% |
| Health-related quality of life, EQ-5D-5L | 1.1% | 43.7% |
| 30 s chair stand, (count) | 42.6% | 56.4% |
| 40 m walk test, (sec) | 54.8% | 70.7% |
Appendix C. Proportion of GLA:D™ participants with clinically important improvement at 3-month follow-up by program location using multiple imputation to address missing data
| Metro (n = 442) |
Metro-influenced (n = 197) |
Urban (n = 114) |
Rural (n = 186) |
|
|---|---|---|---|---|
| Outcomes | Percent (95% Confidence Interval) | |||
| Pain | 11.1 (8.5–14.4) | 10.2 (6.6–15.2) | 7.9 (4.1–14.5) | 12.4 (8.3–17.9) |
| Joint-related quality of life | 21.3 (17.7–25.3) | 16.2 (11.7–22.1) | 18.4 (12.3–26.7) | 19.4 (14.3–25.7) |
∗p < 0.05, ∗∗p < 0.01, ∗∗∗p < 0.001.
Appendix D. Proportion of GLA:D™ participants with clinically important improvement at 3-month follow-up by program payor using multiple imputation to address missing data
| Private (n = 579) |
Publicly funded by Alberta Health Servicesa (n = 259) |
Publicly funded by a Primary Care Networkb (n = 101) |
|
|---|---|---|---|
| Outcomes | Percent (95% Confidence Interval) | ||
| Pain | 10.4 (8.1–13.1) | 9.7 (6.6–13.9) | 15.8 (9.9–24.4) |
| Joint-related quality of life | 19.7 (16.6–23.1) | 19.7 (15.3–25.0) | 17.8 (11.5–26.6) |
∗p < 0.05, ∗∗p < 0.01, ∗∗∗p < 0.001.
a Publicly funded at outpatient physiotherapy.
b Publicly funded at community-based primary care centres.
Appendix E. Demographic characteristics and baseline study outcomes by program location
| Metro (47.3%, n = 461) | Metro-influenced (20.7%, n = 202) | Urban (12.2%, n = 119) | Rural (19.7%, n = 192) | P-value | |
|---|---|---|---|---|---|
| Characteristics | Percent (95% Confidence Interval) | ||||
| Affected Joint | 0.07 | ||||
| Hip | 26.7 (22.8–30.9) |
34.7 (28.4–41.5) |
31.1 (23.4–40.0) |
35.4 (29.0–42.5) |
|
| Knee | 73.3 (69.1–77.2) |
65.3 (58.5–71.6) |
68.9 (60.0–76.6) |
64.6 (57.5–71.0) |
|
| Sex | 0.14 | ||||
| Female | 75.2 (71.1–79.0) |
74.8 (68.3–80.3) |
84.9 (77.2–90.3) |
76.6 (70.0–82.0) |
|
| Male | 24.8 (21.0–28.9) |
25.2 (19.7–31.7) |
15.1 (9.7–22.8) |
23.4 (18.0–30.0) |
|
| Marital Status | 0.39 | ||||
| Married, common-law | 75.1 (70.9–78.8) |
80.7 (74.6–85.6) |
74.6 (65.9–81.7) |
74.5 (67.8–80.2) |
|
| Single, separated, divorced, widowed | 24.9 (21.2–29.1) |
19.3 (14.4–25.4) |
25.4 (18.4–34.1) |
25.5 (19.8–32.2) |
|
| Education | <0.001 | ||||
| High school diploma or less | 16.0 (12.8–19.9) |
21.5 (16.2–27.9) |
22.4 (15.5–31.4) |
27.6 (21.6–34.5) |
|
| College or trade school | 29.7 (25.5–34.3) |
29.8 (23.8–36.7) |
43.9 (34.8–53.5) |
41.1 (34.2–48.3) |
|
| University degree | 54.2 (49.5–58.9) |
48.7 (41.6–55.8) |
33.6 (25.3–43.2) |
31.4 (25.1–38.4) |
|
| Employment Status | 0.14 | ||||
| Not currently working | 69.0 (64.5–73.2) |
73.5 (66.8–79.2) |
64.3 (55.0–72.6) |
75.4 (68.6–81.1) |
|
| Currently working | 31.0 (26.8–35.5) |
26.5 (20.8–33.2) |
35.7 (27.4–45.0) |
24.6 (18.9–31.4) |
|
| Program Payor | <0.001 | ||||
| Private | 91.1 (88.1–93.4) | 73.3 (66.7–78.9) | 1.0 (0.3–4.1) | 24.4 (17.5–32.9) | |
| Publicly funded by Alberta Health Servicesa | 0.0 | 0.0 | 95.3 (91.2–97.5) | 72.3 (63.5–79.6) | |
| Publicly funded by a Primary Care Networkb | 8.9 (6.6–11.9) | 26.7 (21.1–33.3) | 3.6 (1.7–7.5) | 3.4 (1.3–8.7) | |
| Characteristics | Mean (Standard Deviation) | ||||
| Age, years | 64.7 (7.6) |
64.7 (8.4) |
64.8 (8.2) |
66.8 (9.2) |
0.02 |
| BMI | 30.7 (6.7) |
31.3 (6.7) |
31.5 (6.7) |
31.9 (7.1) |
0.20 |
| Baseline Outcomes | Mean (Standard Deviation) | ||||
| HOOS/KOOS | |||||
| Pain | 53.2 (15.4) | 53.3 (15.5) | 52.2 (14.6) | 55.2 (15.9) | 0.35 |
| Quality of life | 35.6 (17.3) | 38.9 (19.4) | 34.1 (18.2) | 41.5 (18.9) | 0.0003 |
| Health-related quality-of-life, EQ5D-5L | 0.7 (0.2) |
0.7 (0.2) |
0.7 (0.2) |
0.7 (0.2) |
0.22 |
| 30 s chair stand (count) | 13.5 (6.2) |
12.3 (6.0) |
10.3 (4.3) |
12.1 (5.9) |
0.0004 |
| 40 m walk test (sec) | 33.7 (19.3) |
33.6 (11.7) |
29.5 (7.6) |
38.0 (24.6) |
0.05 |
aPublicly funded at outpatient physiotherapy.
bPublicly funded at community-based primary care centres.
Appendix F. Demographic characteristics and baseline study outcomes by program payor
| Private (61.5%, n = 599) |
Publicly funded by Alberta Health Servicesa (27.6%, n = 269) |
Publicly funded by a Primary Care Networkb (11.6%, n = 106) |
P-value |
|
|---|---|---|---|---|
| Characteristics | Percent (95% Confidence Interval) | |||
| Affected Joint | 0.12 | |||
| Hip | 28.4 (24.9–32.1) |
35.3 (29.8–41.2) |
31.1 (23.0–40.6) |
|
| Knee | 71.6 (67.9–75.1) |
64.7 (58.8–70.2) |
68.9 (59.4–77.0) |
|
| Sex | 0.51 | |||
| Female | 76.1 (72.5–79.3) |
78.8 (73.5–83.3) |
73.6 (64.3–81.1) |
|
| Male | 23.9 (20.7–27.5) |
21.2 (16.7–26.5) |
26.4 (18.9–35.7) |
|
| Marital Status | 0.48 | |||
| Married, common-law | 77.3 (73.8–80.5) |
74.6 (69.1–79.5) |
72.6 (63.3–80.3) |
|
| Single, separated, divorced, widowed | 22.7 (19.5–26.2) |
25.4 (20.5–30.9) |
27.4 (19.7–36.7) |
|
| Education | <0.001 | |||
| High school diploma or less | 15.7 (12.9–19.0) |
27.1 (21.9–32.9) |
28.7 (20.7–38.3) |
|
| College or trade school | 30.3 (26.6–34.2) |
42.6 (36.6–48.9) |
30.7 (22.4–40.4) |
|
| University degree | 54.1 (49.9–58.2) |
30.3 (24.9–36.3) |
40.6 (31.4–50.5) |
|
| Employment Status | <0.001 | |||
| Not currently working | 67.4 (63.4–71.1) |
71.0 (65.1–76.2) |
88.2 (80.4–93.2) |
|
| Currently working | 32.6 (28.9–36.6) |
29.0 (23.8–34.9) |
11.8 (6.8–19.6) |
|
| Characteristics | Mean (Standard Deviation) | |||
| Age, years | 64.3 (7.6) |
66.4 (8.8) |
66.6 (9.3) |
<0.001 |
| BMI | 30.5 (6.4) |
31.5 (6.8) |
33.7 (8.3) |
<0.001 |
| Baseline Outcomes | Mean (Standard Deviation) | |||
| HOOS/KOOS | ||||
| Pain | 53.4 (15.5) | 54.3 (15.8) | 51.8 (14.4) | 0.41 |
| Quality of life | 36.3 (17.8) | 38.7 (19.1) | 38.9 (19.5) | 0.13 |
| Health-related quality-of-life, EQ-5D-5L | 0.7 (0.2) |
0.7 (0.2) |
0.7 (0.2) |
0.11 |
| 30 s chair stand, (count) | 13.3 (6.2) |
11.3 (5.7) |
12.1 (5.2) |
0.004 |
| 40 m walk test (sec) | 33.9 (17.6) |
35.8 (21.4) |
30.9 (11.2) |
0.25 |
a Publicly funded at outpatient physiotherapy.
b Publicly funded at community-based primary care centres.
Appendix G. Demographic characteristics of respondents and loss to follow-up to 3-month questionnaire
| Respondents (n = 554) |
Loss to follow-up (n = 420) |
P-value |
|
|---|---|---|---|
| Characteristics | Percent (95% Confidence Interval) | ||
| Location | |||
| Metro | 52.2% (48.0–56.3) |
41.0% (36.3–45.7) |
<0.001 |
| Metro-influenced | 18.1% (15.1–21.5) |
24.3 (20.4–28.6) |
|
| Urban | 10.8% (8.5–13.7) |
14.1% (11.0–17.7) |
|
| Rural | 19.0% (15.9–22.4) |
20.7% (17.1–24.9) |
|
| Program Payor | |||
| Private | 63.7% (59.6–67.6) |
58.6% (53.8–63.2) |
0.13 |
| Publicly funded by Alberta Health Services | 25.1% (21.7–28.9) |
31.0% (26.7–35.6) |
|
| Publicly funded by Primary Care Network | 11.2% (8.8–14.1) |
10.5% (7.9–13.8) |
|
| Affected Joint | |||
| Hip | 30.9% 27.2–34.6) |
30.2% (26.0–34.8) |
0.83 |
| Knee | 69.1% (65.2–72.9) |
69.8% (65.2–74.0) |
|
| Sex | |||
| Female | 77.0% (73.3–80.4) |
76.0% (71.6–79.8) |
0.69 |
| Male | 23.0% (19.6–26.7) |
24.1% (20.2–28.4) |
|
| Marital Status | |||
| Married, common-law | 78.2% (74.5–81.4) |
73.3% (68.8–77.3) |
0.08 |
| Single, separated, divorced, widowed | 21.8% (18.6–25.5) |
26.7% (22.7–31.2) |
|
| Education | |||
| High school diploma or less | 17.5% (14.4–21.0) |
23.9% (19.9–28.4) |
0.03 |
| College or trade school | 33.5% (29.5–37.7) |
34.1% (29.6–38.9) |
|
| University degree | 49.0% (44.7–53.3) |
42.0% (37.2–46.9) |
|
| Employment Status | |||
| Not currently working | 74.2% (70.3–77.8) |
65.9% (61.1–70.4) |
0.006 |
| Currently working | 25.8% (22.2–29.7) |
34.1% (29.6–38.9) |
|
| Characteristics | Mean (Standard Deviation) | ||
| Age, years | 65.4 (8.0) |
64.7 (8.4) |
0.20 |
| BMI | 30.7 (6.4) |
31.7 (7.3) |
0.02 |
Appendix H. Mean changes in study outcomes from baseline to 3-months (self-reported measures) and from baseline to program completion (physical measures)
| Outcome | Mean (SD) |
|---|---|
| Pain, HOOS/KOOS | 5.0 (13.2) |
| Quality of life, HOOS/KOOS | 6.8 (15.1) |
| Health-related quality of life, EQ-5D-5L | 0.04 (0.1) |
| 30 s chair stand, (count) | 3.8 (5.6) |
| 40 m walk test, (sec) | −2.6 (9.3) |
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