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Facilitators to implement standards of care for rheumatoid arthritis and osteoarthritis: the EUMUSC.NET project
  1. Rikke H Moe1,
  2. Ingemar F Petersson2,
  3. Loreto Carmona3,
  4. Rolf Greiff4,
  5. Francis Guillemin5,
  6. Gabriela Udrea6,
  7. Estibaliz Loza3,
  8. Michaela A Stoffer7,
  9. Maarten de Wit8,
  10. Dieter Wiek9,
  11. Theodora Vliet Vlieland10,
  12. Anthony D Woolf11,
  13. Till Uhlig1,
  14. the EUMUSC.NET working group
  1. 1Department of Rheumatology, National Advisory Unit on Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
  2. 2Orthopedics and Rheumatology, Clinical Sciences Lund, Lund University, Lund, Sweden
  3. 3Instituto de Salud Musculosqueletica, Spain
  4. 4Swedish Rheumatism Association, Sweden
  5. 5Lorraine Paris Descartes University, Paris, France
  6. 6Dr Ion Cantacuzino Clinical Hospital, Bucharest, Romania
  7. 7Medizinsche Universität Wien, Vienna, Austria
  8. 8Reumapatiëntenbond, The Netherlands
  9. 9Deutsche Reuma-Liga, Bonn, Germany
  10. 10Leiden University Medical Center, The Netherlands
  11. 11Royal Cornwall Hospital, Truro Cornwall, UK
  1. Correspondence to Rikke Helene Moe, Department of Rheumatology, Diakonhjemmet Hospital, P.O. Box 23, Vinderen, Oslo 0319, Norway; rikmoe{at}


Background Rheumatoid arthritis (RA) and osteoarthritis (OA) are important musculoskeletal diseases that the EUMUSC.NET project developed Standards of Care (SOC) for.

Objective The purpose was to explore factors to enable successful implementation of the SOC for RA and OA.

Methods A combined set of methods was used; a literature search, a European survey among patients, clinicians and policymakers; and focus groups.

Results Potential facilitators were identified during a literature search. The online survey captured 282 responses from clinicians, patients and policymakers from 35 European countries, and focus groups from 5 countries contributed with knowledge about possible additional facilitators and strategies. Both the survey and the focus groups endorsed all 11 facilitators. The most important facilitators for implementing the SOC were motivation, agreement, knowledge and personal attitude. The focus groups underlined the lack of access to recommended care in some countries, that multidisciplinary teams should be strengthened and that some healthcare reimbursement systems need change to implement recommended clinical practice.

Conclusion Eleven facilitators key for the implementation of the SOC for RA and OA were endorsed by patients and clinicians from 35 European countries. This knowledge may contribute to improved care for patients with RA and OA in Europe.

  • Osteoarthritis
  • Rheumatoid Arthritis
  • Health services research
  • Patient perspective

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Rheumatic and musculoskeletal diseases (RMD) are the most common cause of physical disability and a frequent reason for long-term treatment in the European Union (EU).1 The burden of RMD is increasing parallel to the proportion of elderly in the society. Treating people with RMD efficiently requires evidence-based knowledge about assessment and management.2 ,3

Evidence-based management implies using the best currently available research-based evidence in the decisions about patient care4 and is dependent on adherence.5 ,6 Non-optimal adherence among patients and clinicians is frequent7 ,8 and can increase the use of treatments unsupported by scientific evidence.9 ,10 EUMUSC.NET is a European project supported by the EU and European League Against Rheumatism (EULAR) with the aim to improve the care of RMDs in Europe ( Recently, the EUMUSC.NET developed an updated set of Standards of Care (SOC)11 and Health Care Quality Indicators (HCQI)12 ,13 for rheumatoid arthritis (RA) and osteoarthritis (OA) (see online supplementary table S1). Implementing SOC for RA and OA may contribute to improved healthcare.11 Equity of care in Europe can only be achieved by enhancing facilitators and overcoming modifiable barriers. The work package 7 (WP7) of EUMUSC specifically examined facilitators for implementing SOC for RA and OA in healthcare systems across Europe.

The objective of this study was to explore factors that could enable successful implementation of the SOC for RA and OA.


Step 1: detecting facilitators

A comprehensive literature search to identify factors (facilitators and barriers) for the implementation of SOC, guidelines and recommendations for OA and/or RA was performed in Medline, Cochrane and EMBASE search engines up until August 2012. The search captured 479 scientific publications that were independently screened by two assessors, and then 200 publications were read in detail. From these, the reviewers extracted published facilitators and barriers and generated a list. The EUMUSC.NET working group decided to focus on facilitators because they were rarely described in the literature. The working group selected the potential facilitators after presentation of different choices per email and by consensus during the first working group meeting (

Step 2: Survey

To collect information on facilitators in the European countries, the group developed a web-based survey focusing on known facilitators for implementing nine SOC. These SOC were chosen for inclusion in the survey based on perceived relevance to a newly diagnosed patient with RA or OA, following the principles of a 'patient journey’, including diagnoses, assessment and management. After testing a pilot questionnaire among the EUMUSC.NET collaborators, the survey link was distributed to patients, clinicians and policymakers from 35 European countries who were asked to rate the importance of each facilitator from their own perspective in March–August 2012. With the purpose of achieving a high participation rate, an open, direct, personal approach for recruiting contacts within healthcare, patient organisations, rheumatology care and policymakers was chosen, for which mailing lists from EULAR, national professional and patient organisations were used. All data were collected anonymously from volunteers with respect to the Helsinki declaration.

Step 3: Focus groups

Focus groups with 8–12 participants were conducted in France, Germany, Norway, Romania and Sweden, including local patients, clinicians and policymakers with the aim of exploring results from the survey further. The theme was ‘What is important to enable successful implementation of standards of care for OA and/or RA’. The content was analysed and synthesised by local qualitative researchers.


Step 1

A facilitator list was derived from the literature review. After a consensus process (email rounds and group discussion), the EUMUSC.NET group selected 11 potential facilitators (table 1) to be tested. The facilitator list was very similar to the framework established by Cabana et al.14

Table 1

List of facilitators tested in the EUMUSC.NET survey

Step 2: Survey results

Of 1610 invited individuals, 282 participants from 35 different European countries completed all items of the survey (table 2) after two reminders (response rate 18%). The survey invitation could also be forwarded to other individuals than the ones invited. A low response rate from Eastern European countries prevented meaningful comparisons between regions, and only few policymakers participated in the survey.

Table 2

Survey respondents

Roughly one-third of the responders were health professionals (n=199); rheumatologists (n=67), physical therapists (n=48), medical doctors (n=26), occupational therapists (n=22), nurses (n=14), other health professionals such as surgeons, social workers and psychologists also responded. Countries with most participants were Norway (n=67), the Netherlands (n=23), Italy (n=20), Austria (n=19), Sweden (n=19), the UK (n=16) and Denmark (n=12). There were few and non-significant differences between countries on how participants responded to the survey.

All 11 facilitators were endorsed by participants across Europe (figure 1). For RA, the facilitators most frequently scored of ‘much’ or ‘very much’ importance were agreement, knowledge and motivation. For OA, the facilitators of most importance were motivation, agreement and personal attitude (see online supplementary table S2). In general, cultural factors were rated least important and received the scoring alternative ‘I don't know’ more frequently than the other facilitators. The longer experience the participants had with working or living with the diseases, the slightly more important all facilitators were scored for both RA and OA (data not shown).

Figure 1

Importance of the different facilitators for implementing the Standards of Care.

Step 3: Focus groups

In the focus groups with patients and clinicians (see online supplementary table S3), the facilitators were endorsed. In addition, the focus groups emphasised the need of educating clinicians and patients about the SOC. Access to translated SOC was suggested to help implement them. The facilitator organisation was emphasised as important to exchange information and improve communication between different levels of healthcare. The focus groups underlined the need to strengthen the availability of multidisciplinary teams, and that reimbursing patient education may be important to meet the SOC. Access to care can be a challenge in rural areas, and some health economic systems may need change to avoid inequity of care, such as insurance-based reimbursement. The focus group from Romania demonstrated the complicated gap between accepting and agreeing with the standards, and challenges with limited access to recommended care, such as care by multidisciplinary teams.


Focus groups emphasised that clinicians need to take OA symptoms more seriously; more competent clinicians are needed to meet the challenges of OA and implement the standards. The focus group from Sweden suggested: “The patient should have a well educated contact person in the health-care system that is available on the phone”. Educating clinicians was considered an important facilitator, as well as increasing patients’ awareness about the disease. The importance of assessments and physical activity was generally emphasised. Information and advice should be given independent of the background (or economic incentives for specific treatments) of the specialist. High-quality treatment plans may be difficult to achieve due to a lack of knowledge about therapeutic options.

Rheumatoid arthritis

Time, education and strengthened multidisciplinary teams are needed to assess, treat and monitor the individual patient. Successful implementation is dependent on early referral systems; better understanding in primary care and faster referral to specialist care were deemed crucial for implementation. In addition, health professionals with specialised skills are needed to implement some of the standards. Access to multidisciplinary specialists is a challenge. Patients call for availability of educational materials.


In this study, we explored the importance of facilitators that could contribute to the implementation of SOC for RA and OA. These SOC had been developed in a previous part of the EUMUSC.NET project.11 All 11 examined facilitators were endorsed in a broad survey among patients, clinicians and policymakers, as well as in focus groups.

Participation in the survey was low as often observed in internet surveys, and unevenly distributed throughout Europe, possibly affected by the complexity of the questions asked, uneven distribution of contact persons in different countries, combined with a lack of translations. Prior research on facilitators in RMDs is limited, but implementation trials have shown that educational approaches can improve implementation,15 ,16 and that access to care,17 communication18 and personal characteristics19 are important facilitators. These factors are all included in the facilitators acknowledged by the survey participants.

The qualitative interviews were undertaken in five countries representing mixed socioeconomic levels and varying percentage of the gross domestic product spent on healthcare. Evidence of existing inequality was emphasised by the focus groups, for example, the lack of multidisciplinary resources available to meet the standards that affects the possibilities of implementing the SOC.

As a conclusion, implementation of SOC for RA and OA will benefit if identified facilitators are considered and enhanced in clinical practice. This will improve care of patients with RA and OA in Europe.


The authors acknowledge all the members of the working group consisting of researchers, clinicians and patients who kindly collaborated through mail correspondence and two 2-day workshops in Oslo. The authors thank all patients, clinicians and policymakers who participated in the survey and the qualitative interviews. A special thanks to Aubrege A, Baumann C, Boini R, Carton L, Greiff R, Guillemin F, Mangin F, Rat AC, Sander C, Udrea G, Valentin N, Vancon G, Wiek D and Østvik C for contributing to the qualitative interviews, and Groenhaug G for coordinating data collection.


Supplementary materials

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  • Handling editor Hans WJ Bijlsma

  • Collaborators Other members of the EUMUSC.NET working group. Katie Edwards, Jim Howarth, Annelies Boonen, Babette Anhalt, Maxime Dougados, Josef Smolen and Tanja A Stamm.

  • Contributors All authors have contributed to the design, interpretation of data, revising and finally approving the manuscript.

  • Funding This project was funded by the European Community (EC Community Action in the Field of Health 2008–2013) and by the European League Against Rheumatism (EULAR). The views of the funding body did not influence the content of the work.

  • Competing interests RHM, LC, RG, FG, GU, EL, MdW, DW, TVV, ADW and TU report no conflicting interests regarding this work. MAS has received speaker fees from MSD; none of them relates to this work. IFP has received speaker fees from Pfizer, Abbvie and UCB Pharma; none of them relates to this work.

  • Provenance and peer review Not commissioned; externally peer reviewed.