A model consultation for osteoarthritis: the effect on the recorded
quality of primary care
Edwards JJ, Jordan KP, Jinks C, Bedson J, Clarkson K, Hay EM, Dziedzic KS.
Research Institute for Primary Care & Health Sciences, Keele University, Staffordshire, ST5 5BG, UK
Background
• Various sources of guidance exist for the management of
osteoarthritis (OA), for example
Patients in the intervention practices consulting for a working
diagnosis of OA received
• EULAR knee OA guidelines 2003
• a consultation with a GP for joint pain
• National Institute for Health & Care Excellence (NICE) in 2008,
updated in 2014
• up to 4 follow-up consultations with a practice nurse
• There is evidence from the UK and internationally that the
quality of care delivered for OA, as measured by quality
indicators, is not concordant with management guidelines
• a guidebook to support self-management of OA
http://www.keele.ac.uk/media/keeleuniversity/ri/primarycare/pdfs/
Control
Control practices continued with usual care, with written materials
to support consultations as required (the Arthritis Research UK
pamphlet Osteoarthritis).
Aim
To determine the effect of a model OA consultation informed by
NICE recommendations on the recorded quality of primary care.
Methods
A two-arm cluster randomised controlled trial used an electronic
consultation recording template (e-template) in both arms for a 6month run-in period (baseline) [1]. Practices were then randomly
allocated to intervention (n=4) or control (n=4) arms.
Intervention
Intervention practices received
• training in a model OA consultation for GPs and practice nurses,
based on NICE OA recommendations
• funding for additional nursing time for follow-up consultations
Analysis
Outcomes were measured at the level of the individual patient for
the 6 months after randomisation and training, using indicators of
quality of care derived from a systematic review [2] and from the
NICE guidelines.
Indicators were measured either from routinely-recorded data or
through the e-template. Analysis compared quality achievement
between intervention and control arms, adjusted for baseline
achievement.
The quality of information and advice given was considered
hierarchically, with written advice as the optimum method,
followed by verbal advice alone, and then no record of advice.
Baseline period
Intervention arm
Trial period
Control arm
Intervention arm
Control arm
All consulters Patients consulting a nurse
Number of consulters (n)
981
749
1061
220
757
Written information (%)
4
1
28
89
2
Written exercise advice (%)
4
1
22
80
1
Written weight loss advice (%)
1
0.2
15
44
0.5
Table 1: Written advice provision in intervention and control arms before and after the intervention delivery with intention-to-treat and treatment fidelity (patients
consulting a nurse for a follow-up OA consultation).
Results
Conclusions
• 1118 patients consulting for OA in the intervention arm and
842 in the control arm
The model OA consultations were associated with
improvements in recorded quality indicators for some core NICE
OA management strategies. The best adherence to NICE
recommendations was associated with a nurse follow-up
consultation for OA.
• Wide variation in quality achievement was noted between
practices and clinicians
• Patients in the intervention practices were found to be
significantly more likely to have
- been prescribed paracetamol (OR 1.74, 95% CI 1.27, 2.38)
- a record of physiotherapy referral (OR 5.30, 95% CI 2.11,
13.34)
• Patients in intervention practices were less likely to have a
recorded X-ray within 14 days after a consultation (OR 0.45,
95% CI 0.12, 1.72)
• Written advice for education, exercise, and weight loss where
relevant improved substantially as shown in Table 1
• Other routinely recorded and template-derived quality
indicators did not change significantly
There remains a need to understand why there is substantial
variation between clinicians in the recorded management and to
develop strategies to encourage all clinicians to improve
management and recording of OA consultations.
References
1.
2.
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.
Edwards JJ, Khanna M, Jordan KP, Jordan JL, Bedson J, Dziedzic KS. Quality indicators
for the primary care of osteoarthritis: a systematic review. Ann Rheum Dis 2013
(Published On-line First: 27 November 2013) doi: 10.1136/annrheumdis-2013-203913.
Contact
Dr John Edwards, GP Research Fellow, Research Institute for Primary Care & Health Sciences
Tel.: 01782 733977 email: [email protected]
This poster presents independent research arising from an In-Practice Fellowship (JE) funded by the National Institute for Health Research (NIHR) as well as support
from its Programme Grants for Applied Research Programme (Grant Reference Number: RP-PG-0407-10386). The views expressed are those of the authors and not
necessarily those of the NHS, the NIHR or the Department of Health. CJ and KD are part-funded by Collaborations for Leadership in Applied Health Research and Care
West Midlands (CLAHRC WM). 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.