Knee and hip pain in Primary Care - Health Innovation...
Transcript of Knee and hip pain in Primary Care - Health Innovation...
Knee and hip pain in Primary Care Mike Hurley, Andrea Carter
16 April 2014
Setting the scene
Guidance on the management of osteoarthritis in adults was updated by NICE in February 2014.
As part of our MSK Programme, we conducted a simple audit using the EMIS database at a local
GP Practice to investigate the extent to which the NICE guidance is being followed.
This presentation shows the feedback shared with Practice staff.
Further work to interview patients and implement service improvements is now planned.
• Health Innovation Network is the Academic Health Science Network
(AHSN) for South London
• The Government has established 15 AHSNs nationally
• AHSNs have 4 key objectives:
About Academic Health Science Networks
Focus on the needs of patients and local
populations
Speed up the adoption of
innovation into practice to
improve clinical outcomes and
patient experience
Build a culture of
partnership and
collaboration
Create wealth through co-
development, testing,
evaluation, early adoption and spread of new products and
services
Our work
We are focusing on 5 clinical areas of work, chosen for their
public health importance and relevance to member organisations:
diabetes, dementia, musculoskeletal, alcohol and cancer
All of these Programmes:
• Have a strong public health ethos, considering integration of
mental, physical and social care
• Build on local academic expertise, with a rigorous approach to
evaluation
• Involve patients and public and the third sector
• Forge new industry relationships
• We work in partnership with a diverse membership of health and social
care providers, primary/secondary/tertiary care, higher education
institutions, public health, commissioners – and with patients, the
public and the third sector
• We also aim to forge new and productive relationships with commercial
partners, supporting the local economy
Our members
Musculoskeletal Programme
5 key Musculoskeletal projects
• Enhancing care of osteoarthritis in Primary Care
• Promoting the spread of ESCAPE-knee pain
• Identifying MSK education and training needs and
implementing solutions
• Improving employee musculoskeletal health
• Promoting best practice for common MSK surgical
pathways
NICE guidance
Supports
& braces Heat & Cold
Paracetamol
Education; advice;
exercise/physical activity;
weight loss if required
Topical NSAIDs
Manual therapy
TENS
Insoles
Capsaicin
Oral NSAID/COX-2 Opioids
I/A
steroid
injection
Assistive
devices
Arthroplasty
Clinical practice – highly variable
Audit of EMIS database – key findings
‘Knee osteoarthritis’ n = 80 NICE guidance Number % Percentage of knee
osteoarthritis population
Exercise advice provided 44 55
Evidence of exercise undertaken 22 28
Declined exercise 2 3
Referral to physiotherapy 18 23
Weight advice offered 10 13
Weight management referral 11 14
Referral to osteopathy 13 16
Referral to MSK clinic (since Apr 12) 10 -
Referral to T&O 23 29
Audit of EMIS database – key findings
‘Knee osteoarthritis’ n = 80
NICE guidance Number % Percentage of knee
osteoarthritis population
Paracetamol oral 73 91
Ibuprofen oral 35 44
Ibuprofen topical 24 30
Diclofenac 42 53
Diclofenac + PPI 32 40
Naproxen 24 30
Naproxen + PPI 23 29
Audit of EMIS database – key findings
‘Knee pain’ n = 330
NICE guidance Number % Percentage of knee
pain population
Exercise advice provided 79 24
Evidence of exercise undertaken 57 17
Declined exercise 6 2
Referral to physiotherapy 49 15
Weight advice offered 37 11
Weight management referral 33 10
Referral to osteopathy 55 17
Referral to MSK clinic (since Apr 12) 45 -
Referral to T&O 86 26
Audit of EMIS database – key findings
‘Knee pain’ n = 330
NICE guidance Number % Percentage of knee
pain population
Paracetamol oral 272 82
Ibuprofen oral 90 27
Ibuprofen topical 86 26
Diclofenac 144 44
Diclofenac + PPI 73 22
Naproxen 87 26
Naproxen + PPI 63 19
Audit of EMIS database – key findings
‘Hip osteoarthritis’ n = 50 NICE guidance Number % Percentage of hip
osteoarthritis population
Exercise advice provided 27 54
Evidence of exercise undertaken 11 22
Declined exercise 2 4
Referral to physiotherapy 16 32
Weight advice offered 5 10
Weight management referral 6 12
Referral to osteopathy 9 2
Referral to MSK clinic (since Apr 12) 11 22
Referral to T&O 19 38
Audit of EMIS database – key findings
‘Hip osteoarthritis’ n = 50
NICE guidance Number % Percentage of hip
osteoarthritis
population
Paracetamol oral 42 84
Ibuprofen oral 19 38
Ibuprofen topical 9 18
Diclofenac 19 38
Diclofenac + PPI 10 20
Naproxen 15 30
Naproxen + PPI 12 24
Audit of EMIS database – key findings
‘Hip pain’ n = 139 NICE guidance Number % Percentage of hip
pain population
Exercise advice provided 68 49
Evidence of exercise undertaken 31 22
Declined exercise 2 1
Referral to physiotherapy 17 12
Weight advice offered 12 9
Weight management referral 21 15
Referral to osteopathy 32 23
Referral to MSK clinic (since Apr 12) 19 -
Referral to T&O 32 23
Audit of EMIS database – key findings
‘Hip pain’ n = 139
NICE guidance Number % Percentage of hip
pain population
Paracetamol oral 106 76
Ibuprofen oral 46 33
Ibuprofen topical 32 23
Diclofenac 57 41
Diclofenac + PPI 35 25
Naproxen 38 27
Naproxen + PPI 21 15
Review of EMIS records – key themes
• Under-recording of knee/hip OA?
• Majority of patients managed in primary care
• Pharmacological management usually first line
treatment - paracetamol used widely first (meets NICE)
• Higher referral rates to exercise, physiotherapy and
dietetics might have been expected, particularly early in
the patient pathway?
Patient A: Male, 63
Oct 02: hip pain
Jun 06: bilateral knee pain, given leaflet
Oct 06: knee pain, referred to osteopath
Jun 07: still knee pain, considering when to have surgery
Mar 11: BMI= 30
Sep 13: requested referral for surgery
Nov 13: MCATS, noted doing exercises previously
Jan 14: radiology shows OA both knees, awaiting surgery. On naproxen, no PPI< advserse reaction to coocadamol
14 consultations since 2006. Note also: hyperlipidaemia
Patient B: Male, 59
Jun 94: OA multiple joints
May 10: R knee v troublesome
June 10 referred to Lewisham MCATS OA/obesity
Feb 11 L knee replacement
Nov 11 R knee debridement BMI=40+
Dec 11 r knee arthroscopy May 2012 r knee replacement
Jan 13 declined dietitian referrals
Jan 13 foot problems
31 consultations since June 2010
Patient C: Female, 52
Feb 08 knee OA diagnosis, referred to physio
Jan 09 injection, worked well
Apr 09 severely obese BMI 40+
Apr 12 patient requested referral to dietitian
Jun 12 MCATS referral
Sep 12 arthroscopy/debridement
Jun 13 referred to Kings orthopaedic, unhappy with local provider
Oct 13 Kings orthopaedics will do knee replacement once patient has lost weight
51 consultations since Feb 08 Note also: goitre, hysterectomy, shoulder
pain, vertigo, acne, hypertension
Patient D: Female, 82 1991: obese
1996 ‘knees painful for a long time’, ref community therapy – can’t get out of bath
Nov 01 Requested OT referral for help with stairs and bath. Cocodamol started
Feb 02 seen in hospital, recommended exercise referral
Feb 02 GP consult: knee pain at night 2005: BMI = 44
Feb 09 : diagnosis knee OA, Mar 09: hospital admission corticosteroid injections
Nov 09: diclofenac, cocadamol, tramadol, declined surgery
Feb 10 T&O referral, Jun 10 total L knee replacement - post-op complications (spinal cord compression, MRSA)
Jun 11 wheelchair bound, ‘contemplating other knee replacement’
Oct 12 Stanmore appointment: plan R knee, then L knee one week later
30 consultations since Feb 2009: Note also: cardiac problems, hypertensive
disease
Patient E: Female, 51
2007 left knee arthroscopy
2007 severely obese BMI 40+
Feb 12 joint pain
July 12 changed diclofenac to codrydamol
? What next?
18 consultations since July 2012 Note also anxiety, depression, smoking
cessation referral
Patient F: Female Jun 08 knee pain
X-ray referral, OA diagnosis, managing on voltarol
Feb 09 constant ache day/night, DLA assessment
Aug 09 still on diclofenac
Mar 10 weight management advice
Oct 10 diagnosis multiple joint OA
Dec 10 prescribed PPI for problems with diclofenac
Mar 11 Hip pain, referred for scan
May 12 OA multiple sites, increased PPI - ‘only diclofenac works’
Mar 13 MSK referral ; on codeine
Apr 13 T&O appointment, Jul 13 total hip replacement
Jul 13 Brief intervention for physical activity
Post op review, v happy with hip outcome, lots of pain still on diclofenac
Review of individual patient pathways – key
themes
• obvious link between obesity and osteoarthritis
• pharmacological management first choice for
management, other available options potentially
underused
• resource-intensive condition – multiple consultations
What next?
Further exploratory work e.g.
• Talk to patients to seek their views on Osteoarthritis management
• Identify education and training needs in primary care
And
Testing improvements e.g.
• Widespread use of OA ‘checklist’ (via EMIS)
• Introduce annual review for OA patients
• Refer to the ESCAPE-knee pain programme
• Introduce a Care Plan for OA patients to help them self-manage their
condition
• Facilitate appropriate education packages for GPs and Practice
Nurses
Thank you for your time
www.hin-southlondon.org