Implementing NICE guidelines in primary care with a model
osteoarthritis consultation: a cluster randomised controlled trial
Dziedzic K, Healey EL, Porcheret M, Afolabi E, Oppong R, Ong BN, Morden A, Jinks C, Lewis AM,
McHugh GA, Ryan S, Finney A, Main CJ, Pushpa-Rajah A, Handy J, Jowett S, Hay EM.
Research Institute for Primary Care & Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, UK
email: [email protected]
INTRODUCTION
RESULTS
In the UK most individuals with osteoarthritis (OA) are managed in
general practice. The National Institute for Health and Care
Excellence’s (NICE, CG177) recommendations for OA are not
currently implemented in primary care. Evidence for the feasibility
of implementing NICE OA guidelines in primary care, and the
effect on the course and impact of the condition is unknown.
Of eligible participants, 288 were recruited from intervention
practices and 237 from control practices . The mean age (SD) was
67.3 (10.5) and 59.6%, were female. Study recruitment and
follow-up are detailed in Table 1.
AIM
To determine the clinical, cost effectiveness and acceptability of a
model OA consultation (Figure 1) as a method of implementing
core NICE recommendations.
Figure 1. Model Osteoarthritis Consultation (MOAC)
Patient
presenting
with joint pain
45 years and
over
GP makes,
gives, explains
diagnosis,
analgesia,
promotes selfmanagement
Practice
Nurse
supports selfcare; goal
setting,
exercise,
weight loss,
pain control
Table 1. Study flow
4 Practices
Intervention
0 months:
n=288
3 months:
n=260 (90.3%)
6 months:
n=239 (83.0%)
12 months: n=212 (73.6%)
4 Practices
Control
0 months:
n=237
3 months:
n=210 (88.6%)
6 months:
n=185 (78.1%)
12 months: n=172 (72.6%)
There were no statistically significant differences in SF-12 and
EQ-5D scores between arms. Uptake of NICE recommendations
was statistically significantly greater (p<0.05) in the intervention
arm compared with control group at 6 months (Table 2.). All
participants interviewed described liking the guidebook.
How things
are going?
Type and
amount of
pain? Regular
analgesia?
“I know you talk to a layman and you say, ‘Oh, I’ve got arthritis.’ It means
nothing, you know, but when you talk to somebody that it does mean
something to it’s a comfort, really, in a way, because it’s a real illness, as such.
It’s a real problem” (Participant)
Visits to an orthopaedic surgeon were lower in the intervention
arm compared with the usual care arm (p=0.02). Time off work
and associated productivity costs were lower in the intervention
arm. No statistically significant cost effectiveness was identified
over 12 months for NHS costs, productivity loss or QALYs.
GPs and practice nurses in the intervention practices received training on core NICE
recommendations for OA
Table 2. Quality indicators by study groups at 6 months
METHODS
Design: Two arm cluster Randomised Controlled Trial with initial
health survey design and semi structured interviews.
Population: 15,083 (53%) eligible responders 45 years and over
from eight general practices; 525 patients consulting for peripheral
joint pain during the 6 month recruitment period of the cluster
trial (4 intervention, 4 control practices).
Practices randomised to the intervention arm delivered a
consultation with the GP for joint pain, an OA guidebook
(http://www.keele.ac.uk/media/keeleuniversity/ri/primarycare/pd
fs/OA_Guidebook.pdf) and up to 4 consultations with a practice
nurse. Practices in the control arm delivered usual care.
Clinical effectiveness was measured by the SF-12 physical
component score (PCS) at 6 months; uptake of NICE
recommendations was measured by self report Quality Indicators
of OA care; cost-consequence and cost-utility analyses were
undertaken.
Intervention
n=288
Control
n=237
n (%)
n (%)
*Difference
P-value
OA quality indicators
Support to self-manage joint
problem
173 (70.0)
125 (62.5) 12.1 (0.9,20.8)
0.036
Info/Advice on exercises, muscle
strengthening, physical activities
220 (83.3)
138 (67.9) 14.9 (5.1,21.7)
0.005
**Referral to services for losing
weight
32 (23.0)
15 (12.8)
0.003
Information about drug effect
provided
185 (69.8)
19.1 (5.1,37.4)
162 (74.7) -11.2 (-23.2,-0.2) 0.045
*(intervention - control) adjusted for age, sex and practice size **applicable to participants who are overweight or
obese (“Clustering” accounted for in the mixed model)
CONCLUSION
A model OA consultation can increase the uptake of NICE
recommendations in primary care, and is well-received by
patients. Implementing core NICE recommendations for OA can
reduce the number of visits to an orthopaedic surgeon and time
off work, but does not improve health status or quality of life.
This poster presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research
Programme (Grant Reference Number: RP-PG-0407-10386.) The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR
or the Department of Health. Acknowledgements: Arthritis Research UK, Primary Care Consortium Board, the OA Research User Group, the Network,
nursing, health informatics and administrative staff at the Arthritis Research UK Primary Care Centre, the participating general practices and GP facilitators.
CJ, AF, EH, MP, KD are part funded by Collaborations for Leadership in Applied Health Research and Care West Midlands (CLAHRC WM).