Assessment of Educational Needs in Patients with Knee Osteoarthritis in a Latin American Cohort.
https://doi.org/10.46856/grp.10.et100
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García Coello AD, Rillo O, Quintero M, Brigante A, Sciortino R, Espinosa Morales R, et al.. Assessment of the educational needs in patients with knee osteoarthritis in a latin american cohort [Internet]. Global Rheumatology. Vol 2 / Jul - Dic [2021]. Available from: https://doi.org/10.46856/grp.10.et100
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Assessment of Educational Needs in Patients with Knee Osteoarthritis in a Latin American Cohort.
Introduction: The Educational Needs Assessment Tool–Spanish version (SpENAT) is a questionnaire that evaluates the educational needs (ENs) of patients. This study identified the sources of information patients use and assessed the ENs of patients with knee OA using the SpENAT.
Material and Methods: A cross-sectional, prospective, multicenter study was conducted in patients with knee OA in 9 Latin American countries. Demographic data, educational level, VAS, RAPID3, and sources of information were recorded. The SpENAT consists of 39 questions grouped into 7 domains (pain, movement, feelings, OA, medical treatments, self-help, and support system).
Results: A total of 1341 patients with knee OA were included (78.9% women). Median age: 63.99 years. Work disability: 1.8%. Mean SpENAT scores: 116 (IQR 101–134); pain domain 17.42 (IQR 14–20), mobility 15.44 (IQR 12–18), feelings 12.95 (IQR 10–16), OA 21.52 (IQR 18–25), medical treatments 20.52 (IQR 16–24), self-help 17.41 (IQR 14–20), and support system 12 (IQR 8–14). Sources of information reported by patients included rheumatologists 74.9%, orthopedic surgeons 16.8%, internet 14.3%, primary care physicians 10%, other health professionals 9.9%, print media 3.6%, radio 1.9%, television 0.9%, and family and friends 10.7%.
Conclusion: Most patients showed high SpENAT scores and great interest in learning more about OA. Higher SpENAT values were associated with consulting a rheumatologist for information. We consider it important to recognize both the ENs and the sources of information used by patients with OA in order to develop better therapeutic decisions.
Osteoarthritis, Arthrosis or Osteoarthrosis (OA) represents one of the most common joint pathology and the main cause of musculoskeletal pain, disability in the aging population around the world1–2. It is a degenerative disease, with varying degrees of swelling. It has been defined as a heterogeneous group of conditions that lead to symptoms and joint signs that are associated with cartilage integrity defects and changes in the subchondral bone. New definitions describe the whole joint in OA "that compromises any joint tissues and structure; the cartilage degenerates and demonstrates fibrillation lesions, with fissures and ulcerations that cause the total loss of the thickness of the articular surface”3.
Patient's knowledge about the OA is one of the most important limitations in the treatment and in their recovery process. In addition, it is essential to implement or improve personal care, daily activities and decision-making. The educational process has been evaluated in patients with inflammatory arthritis, especially in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and few European patients with hand OA4–6. It is an important part as it may lead to an active participation of patients in the therapeutic decision process and provide new strategies that may be more suitable for them.
Our health system does not offer routine structures and time that to facilitate the education of patients, a task that is conducted informally and depends largely on the goodwill of the health professional. For this reason, doctors need a tool that assesses the ENs of patients. The ENAT (Educational Needs Assessment Tool) is a self-administered questionnaire that was originally developed in the United Kingdom and has been translated into several languages. The Spanish version of this questionnaire is the SpENAT7,8. It comprises 39 questions grouped into 7 domains: pain management (6 questions), movement (5 questions), feelings (4 questions), arthritis process (7 questions), treatments (7 questions), self-help measures (6 questions) and support systems (4 questions). Each of them has 5 categories of rating according to the Likert scale from 0 to 4 and these include: Not at all important (0) A little important (1) Fairly important (2) Very important (3) Extremely important (4). The result is a total score of educational needs that varies from 0 to 156.
It is important to have a better understanding of the educational needs of our patients with OA to provide a personalized treatment plan. This study evaluated the educational needs of patients with knee OA using the SpENAT and the relationship between the educational needs and gender, age, the clinical characteristics of the disease and functional capacity. Additionally, as a specific objective, this study also aimed at establishing which are the main sources of information the patients use and to which SpENAT values it corresponds.
International, multicenter, prospective, and cross-sectional study involving 9 countries, which included patients aged ≥ 50 years diagnosed with KOA (primary and secondary) according to the Altman R. classification criteria from 1986⁹,¹⁰. Patients with other rheumatic diseases (RA, PsA, and crystal-induced arthritis) as well as those unable to read and/or write or understand the questionnaire were excluded.
Demographic data, education level, clinical data, and the sources of information consulted were recorded. The total SpENAT score was calculated by summing the scores of each domain (range 0–156), with higher scores indicating greater educational needs (ENs).
A comparison of ENs was also performed according to gender, education level, disease duration, use of SYSADOA (symptomatic slow-acting drugs for osteoarthritis), and functional capacity, using the ANOVA test and Bonferroni method. A variable analysis was conducted according to type and distribution, as well as VAS and RAPID3.
All patients who completed the SpENAT questionnaire were also asked to answer the following question: Where or from whom do you obtain information about your disease? The options were: a) Rheumatologist, b) Primary care physician, c) Orthopedic specialist, d) Other healthcare professionals (physical therapist, nurse, nursing staff, among others), e) Family or friends, f) Internet, radio and/or television.
We included 1341 patients from 9 countries (Argentina, Bolivia, Colombia, Cuba, Mexico, Paraguay, Dominican Republic, Uruguay and Venezuela). The mean age of the patients with KOA was 63.99 years (SD + 11.85 - C.I 95%: 63.35-64.62) and 78.9% of the participants were women. Ethnic distribution8 of our cohort was mostly 44.8% mestizo followed by white 38.1%, LA / Africans 7% and Amerindian 3%. With 79.7% urban residence and rural 20.3%. The mean time of education was 9.72 years (+/- 4.43 IC95% 9.49-9.63). Occupation: homemaker 42.1%; trade 10%, administrative 2.2%, teachers 3%, professionals 4%, unemployed 6,4%, retired 14%, students 0.2%; work disability 1.8%. The BMI of participants was normal 22%, overweight 45.9%, obese 31% and morbid obesity 2%. Primary OA was found in 78.1%, with a mean evolution time in months of 43.59 months (+/- 39.39 IC95% 41.4-45.7). Comorbidities at 82.70% (hypertension 45%, DM 16%, Osteoporosis 6%, hypothyroidism 4%, dyslipidemias 4%, gastrointestinal 1.2%, other 6%). In our cohort, the mean VAS pain was 42.64 mm (+/-33.7 IC95% 40.8-44.4), patient VAS was 43.02mm (32.36 IC95% 41.2-44-7), and physician VAS was 36.61mm (30.4 IC95% 34.9-38.9), respectively (Table 1).
The median RAPID311,12 in our cohort was17 (IQR 12-22) meaning that they are defined as moderate severity (MS) and high severity (HS). Patients with KOA were treated with NSAIDs 58.61%, paracetamol 50.56%, opioids 3.5%, PPI 29.8% and SYSADOAs (Symptomatic Slow Action Drugs for Osteoarthritis) 68.43%, of which 15.1% Glucosamine, SG + CS 43%. Intra-articular treatment: 26.17% (3,1% with Hyaluronic Acid) and their SpENAT median was 121 (IQR 106-136). It is shown in Figure 1, patients have more demands for the resource for the domains of OA and treatments health professionals. The ENs of patients with KOA according to SpENAT domains are shown in Table 2.
SpENAT median scores for KOA was116 (IQR 101-134). The mean for the different SpENAT domains obtained from our cohort of patients with OA were as follows: pain was 17.42 (+/- 4.75 IC95 17.1-17.6), mobility 15.44 (+/- 4.61 IC95 15.1-15.6), feelings 12.95 (+/- 4.73 IC9512.6-13.2), medical treatments was 20.64 (+/- 6 IC95 20.3-20.9), personal treatments 17.41 (+/- 5.9 IC95 17-17.7), and support system 11.7 (+/- 26.9 IC95 11.5-11.8).
More educational needs were observed in the domains of movement, feelings and OA (Table 2). Patients with a higher educational level (> 10 years) reported an average of 118.4, higher than the educational level under 10 years that reported 115.5.
The correlations between the demographic variables and the SpENAT domains were summarized in the Table 3.
The ENs according to age and pain management were statistically significant (p<0.05), domain of mobility and feeling was related to the educational level at disease progression in months. Correlation between RAPID3 and SpENAT Rho 0.30 p = 0.001, even though RAPID3 could be affected by patient’s educational status, when we compared, there was a low correlation. The support domain is associated with all demographic variables with a Rho 0.635 and p-value <0.05. All SpeNAT domains showed a positive correlation with each other, the most important being movement, feeling, OA, medical treatment and other therapies such as exercise. The ENs related to the length of the disease were the same. That is, patients have a similar interest in learning at the beginning of the disease as well as those having more than 5 years with OA.
The primary sources of information for our cohort were obtained from Rheumatologist 74.9%, Traumatologist 16.8%, internet 14.3%, clinical 10%, other health professionals 9.9%, written press 3.6%, radio 1.9 %, television 0.9%, family and friends 10.7% (Figure 2). Internet consultation was found primarily in the younger age group (18-40 years old), p = 0.035.
This study evaluated the sources of information used by patients with knee osteoarthritis (KOA) to learn more about their disease. Approximately 0.2 to 1% of the general population is affected by OA¹,². OA impacts patients' quality of life in various ways; when a patient is diagnosed with OA, they may have different reactions, develop anxiety and depression, experience a negative impact, and feel fear. Therefore, it is essential that patients with OA receive appropriate information about their condition.
Clinical practice guidelines have been established for patients with OA, and education is a key component of treatment⁶. However, a large amount of information comes from different sources, and there may be a risk of misinformation and/or information overload if patients do not know where to turn or are unfamiliar with the basic aspects of their disease¹³. Part of the non-pharmacological treatment of OA is related to providing patients with adequate information that is understandable, written in clear and user-friendly language¹⁴.
Few studies have evaluated the educational needs of patients with OA, and there is limited literature on the use of the SpENAT to assess the sources from which patients obtain their information. Moreover, several studies have shown that standard education has limited long-term results in the treatment of inflammatory diseases, suggesting a need for more patient-centered education that addresses the specific educational needs of the affected individual¹⁵–¹⁷. Our study shows that patients with KOA are interested in learning more about their treatment options. The main source of information for patients was the rheumatologist, which is consistent with results obtained in another study in Latin America⁴. However, as previously described, there may be an inherent bias since the questionnaire was administered only by rheumatologists. We also found that, after rheumatologists, the most commonly used source of information by patients with KOA in our cohort was the internet.
Since technology is increasingly accessible, a noticeable increase in internet use has been observed¹⁴. The quality of the information available online has been previously discussed¹⁴–¹⁶, and although it seems to have improved in recent years, there are still many inconsistencies in the information available to users, and much of it is not specifically directed at KOA patients—particularly on certified websites such as those of foundations or national rheumatology societies, which should be responsible for providing this type of information.
Recent studies have evaluated the effects of an assessment focused on the patient's educational needs and how gender and educational level may influence those needs¹⁶–¹⁹. According to our results, significant differences were found among women and their educational level. Ndosi et al²⁰ found that these differences are related to patient knowledge, which can affect aspects of their health such as pain, stiffness, and sleep. Our results are consistent with these findings. Our results highlight the need for an integrated approach; as previously noted, rheumatologists should focus on personalized treatment and pay closer attention to the educational needs of their patients, as this may contribute to their independence and reinforce treatment adherence²⁰–²³.
A limitation of this study could be that prior knowledge was not assessed before administering the SpENAT to our patients; therefore, such prior knowledge may have influenced individual educational needs. A strength of the study is the participation of several centers across 9 Latin American countries, thereby including regions with significant social, economic, and cultural differences.
Most patients showed high scores on the SpENAT and a strong interest in learning about KOA and its treatment. Patients with KOA demonstrated a high level of interest in understanding their disease. A low correlation was found between the SpENAT and RAPID3. A higher SpENAT score was associated with seeking information from a rheumatologist. Finally, we consider it important to understand our patients’ educational needs and sources of information, as they constitute a valid set of tools that allow us to reinforce key aspects of therapeutic management, help prevent misinformation and lack of knowledge, and thus strengthen treatment adherence.
Sin financiación para este trabajo.
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