Kris Clarkson

Implementing the NICE osteoarthritis guidelines: A mixed methods study and cluster randomised trial of a model osteoarthritis consultation in primary care - the Management of OsteoArthritis In Consultations (MOSAICS) study protocol

BackgroundThere is as yet no evidence on the feasibility of implementing recommendations from the National Institute of Health and Care Excellence (NICE) osteoarthritis (OA) guidelines in primary care, or of the effect these recommendations have on the condition. The primary aim of this study is to determine the clinical and cost effectiveness of a model OA consultation (MOAC), implementing the core recommendations from the NICE OA guidelines in primary care. Secondary aims are to investigate the impact, feasibility and acceptability of the MOAC intervention; to develop and evaluate a training package for management of OA by general practitioners (GPs) and practice nurses; test the feasibility of deriving `quality markers’ of OA management using a new consultation template and medical record review; and describe the uptake of core NICE OA recommendations in participants aged 45 years and over with joint pain.DesignA mixed methods study with a nested cluster randomised controlled trial.MethodThis study was developed according to a defined theoretical framework (the Whole System Informing Self-management Engagement). An overarching model (the Normalisation Process Theory) will be employed to undertake a comprehensive `whole-system’ evaluation of the processes and outcomes of implementing the MOAC intervention. The primary outcome is general physical health (Short Form-12 Physical component score [PCS]) (Ware 1996). The impact, acceptability and feasibility of the MOAC intervention at practice level will be assessed by comparing intervention and control practices using a Quality Indicators template and medical record review. Impact and acceptability of the intervention for patients will be assessed via self-completed outcome measures and semi-structured interviews. The impact, acceptability and feasibility of the MOAC intervention and training for GPs and practice nurses will be evaluated using a variety of methods including questionnaires, semi-structured interviews, and observations.DiscussionThe main output from the study will be to determine whether the MOAC intervention is clinically and cost effective. Additional outputs will be the development of the MOAC for patients consulting with joint pain in primary care, training and educational materials, and resources for patients and professionals regarding supported self-management and uptake of NICE guidance.Trial registrationISRCTN number: ISRCTN06984617.

The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care.

Background This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes. Methods and findings We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire–2 for depression, a two-item Generalized Anxiety Disorder–2 questionnaire for anxiety, and a question about current pain intensity [0–10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]). Conclusions In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group. Trial registration ISRCTN registry ISRCTN40721988

Effect of a model consultation informed by guidelines on recorded quality of care of osteoarthritis (MOSAICS): a cluster randomised controlled trial in primary care

Summary Objective To determine the effect of a model osteoarthritis (OA) consultation (MOAC) informed by National Institute for Health and Care Excellence (NICE) recommendations compared with usual care on recorded quality of care of clinical OA in general practice. Design Two-arm cluster randomised controlled trial. Setting Eight general practices in Cheshire, Shropshire, or Staffordshire UK. Participants General practitioners and nurses with patients consulting with clinical OA. Intervention Following six-month baseline period practices were randomised to intervention (n = 4) or usual care (n = 4). Intervention practices delivered MOAC (enhanced initial GP consultation, nurse-led clinic, OA guidebook) to patients aged ≥45 years consulting with clinical OA. An electronic (e-)template for consultations was used in all practices to record OA quality care indicators. Outcomes Quality of OA care over six months recorded in the medical record. Results 1851 patients consulted in baseline period (1015 intervention; 836 control); 1960 consulted following randomisation (1118 intervention; 842 control). At baseline wide variations in quality of care were noted. Post-randomisation increases were found for written advice on OA (4–28%), exercise (4–22%) and weight loss (1–15%) in intervention practices but not controls (1–3%). Intervention practices were more likely to refer to physiotherapy (10% vs 2%, odds ratio 5.30; 95% CI 2.11, 13.34), and prescribe paracetamol (22% vs 14%, 1.74; 95% CI 1.27, 2.38). Conclusions The intervention did not improve all aspects of care but increased core NICE recommendations of written advice on OA, exercise and weight management. There remains a need to reduce variation and uniformly enhance improvement in recorded OA care. Trial registration number ISRCTN06984617.

What does a primary care annual review for RA include? A national GP survey

Sir Patients with rheumatoid arthritis (RA) are at increased risk of comorbidities particularly cardiovascular disease and osteoporosis [1, 2]. NICE standards of care for rheumatoid arthritis (RA) recommend patients should receive a holistic annual review that should include an assessment of disease activity and severity, active screening for and management of comorbidities [3] and assessment of the impact of RA on quality of life. In 2013, RA was included in the Quality Outcomes Framework (QOF) of the UK general practice contract. General practitioners (GPs) were incentivised to provide a face to face annual review for RA patients, including cardiovascular and fracture risk screening, mirroring the routine care for patients with other long-term conditions such as diabetes—a model which improves quality of care and clinically important outcomes [4]. The aims of this study were to investigate what domains GPs report including in their annual review for patients with RA and to determine the role of the multidisciplinary team in providing these reviews. We conducted a national cross-sectional survey in 2013 to investigate the primary care management of RA. Five thousand randomly selected GPs were asked to complete a brief questionnaire investigating their management strategies for patients with RA. Participants were presented with a predefined list of 12 measures that could be included in an annual review (presented in Table 1: including cardiovascular disease, osteoporosis and depression screening) and asked to indicate which measures they routinely included. Furthermore, GPs were asked which screening tools they used for cardiovascular disease and osteoporosis screening and which members of the multidisciplinary team conducted these reviews. One thousand three hundred eighty-eight (27.8 %) completed questionnaires were returned. The majority (1052, 75.6 %) of responders were GP partners, with a mean (SD) age of 47 (9.4) years. Seven hundred five participants (50.8%) were female. The majority of responding GPs (1083, 80.4 %) felt that a primary care annual review was of benefit to their RA patients, although only 712 (51.2 %) GPs felt that RA should be included in the QOF component of the GP contract. Nine hundred thirty-nine (67.7 %) GPs indicated they were aware of the NICE Standards of Care for RA, although only half (693, 49.9 %) felt they impacted on their clinical practice. Only 767 (55.3 %) GPs thought their patients had access to an annual review in secondary care. The individual measures that GPs reported including in their annual review are detailed in Table 1. The most frequently incorporated components were medication review (1232, 88.8 %), followed by cardiovascular risk assessment (1139, 82.1 %). The latter was most commonly performed by practice nurses using QRISK (1214, 87.5 %). Osteoporosis risk assessment was also commonly performed (1118, 80.5 %), usually by GPs themselves (1023, 73.7 %), with a minority of GPs thought osteoporosis screening for their patients was * S. L. Hider s.hider@keele.ac.uk

Cost-effectiveness of a model consultation to support self-management in patients with osteoarthritis

Abstract Objectives The aim of this study was to estimate the cost-effectiveness of a model OA consultation for OA to support self-management compared with usual care. Methods An incremental cost–utility analysis using patient responses to the three-level EuroQoL-5D (EQ-5D) questionnaire was undertaken from a UK National Health Service perspective alongside a two-arm cluster-randomized controlled trial. Uncertainty was explored through the use of cost-effectiveness acceptability curves. Results Differences in health outcomes between the model OA consultation and usual care arms were not statistically significant. On average, visits to the orthopaedic surgeon were lower in the model OA consultation arm by −0.28 (95% CI: −0.55, −0.06). The cost–utility analysis indicated that the model OA consultation was associated with a non-significant incremental cost of £−13.11 (95% CI: −81.09 to 54.85) and an incremental quality adjusted life year (QALY) of −0.003 (95% CI: −0.03 to 0.02), with a 44% chance of being cost-effective at a threshold of £20 000 per QALY gained. The percentage of participants who took time off and the associated productivity cost were lower in the model OA consultation arm. Conclusion Implementing National Institute for Health and Care Excellence guidelines using a model OA consultation in primary care does not appear to lead to increased costs, but health outcomes remain very similar to usual care. Even though the intervention seems to reduce the demand for orthopaedic surgery, overall it is unlikely to be cost-effective.

Cost-utility analysis of routine anxiety and depression screening in patients consulting for osteoarthritis: results from the POST trial

To investigate the cost‐effectiveness (cost‐utility) of introducing general practitioner screening for anxiety and depression in patients consulting for osteoarthritis (OA).

OP0106 Effect of a Model Consultation on Quality of Care of Osteoarthritis: A Primary Care Cluster Randomised Trial

Background Uptake of recommended assessment and management strategies for osteoarthritis (OA) in primary care has not consistently been achieved. Objectives To determine the effect of a model OA consultation, informed by NICE OA recommendations, to support self-management of peripheral joint pain in adults aged ≥45 years on recorded quality of primary care. Methods A two arm cluster-randomised unblinded controlled trial (registration: ISRCTN06984617) [1] used an electronic template [2] to record quality indicators of OA care. This was installed in 8 general practices 6 months (baseline period) before randomisation into intervention (n=4) or usual care (n=4) arms. In intervention practices, GPs and practice nurses received training on core NICE recommendations for OA (diagnosis, written information, exercise & physical activity, healthy eating, pain management) and in a model OA consultation. Patients in those practices received a consultation with the GP for joint pain, an OA guidebook, and up to 4 follow-up consultations with a practice nurse to support self-management. All practices continued with template use. Multilevel logistic regression (patients nested within clinician seen) analysis was performed on all patients aged ≥45 years consulting for OA in a 6 month period post randomisation. Outcomes were i) quality indicators of OA care, ii) routinely recorded management. Results There were 1118 patients in the intervention arm, and 842 patients in the control arm. There was wide variation between practices and clinicians in achieved quality of care prior to randomisation. Uptake of written information on OA increased in intervention practices from 4% at baseline to 28%; written exercise advice from 4% to 22%; and written weight loss advice from 1% to 15%; but remained stable in control practices at 1-3%. At 6 months, patients in the intervention arm were more likely to have received paracetamol (odds ratio 1.74; 95% CI 1.27, 2.38), and physiotherapy referral (5.30; 95% CI 2.11, 13.34) but less likely to have had an x-ray (0.45; 95% CI 0.12, 1.72). There were no differences in any other routinely recorded management. Conclusions The model OA consultation was associated with improvements in recorded quality indicators of OA care for core NICE recommendations. There remains a need to understand and reduce variability between practices and clinicians in primary care management of OA. References Dziedzic KS, Healey EL, Porcheret M, Ong B, Main CJ, Jordan KP, et al. Implementing the NICE osteoarthritis guidelines: a mixed methods study and cluster randomised trial of a model osteoarthritis consultation in primary care - the Management of OsteoArthritis In Consultations (MOSAICS) study protocol. Implement Sci 2014;9(1):95 doi: 10.1186/s13012-014-0095-y Edwards JJ, Jordan KP, Peat G, Bedson J, Croft PR, Hay EM, et al. Quality of care for OA: the effect of a point-of-care consultation recording template. Rheumatology 2014 doi: 10.1093/rheumatology/keu411 Acknowledgements This research was funded by a National Institute for Health Research (NIHR) Programme Grant (RP-PG-0407-10386) and is supported by the NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands. The views expressed in this paper are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Disclosure of Interest J. Edwards Employee of: Provider of general practice services and benefits financially from the Quality & Outcomes Framework, Speakers bureau: Invited speaker, EULAR 2015, K. Jordan: None declared, M. Porcheret: None declared, E. Healey: None declared, C. Jinks: None declared, J. Bedson Employee of: Provider of general practice services and benefits financially from the Quality & Outcomes Framework, K. Clarkson: None declared, E. Hay: None declared, K. Dziedzic: None declared