oa guildlines
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Implementing NICE Osteoarthritis Guidelines:
From research to clinical practice
Krysia Dziedzic, Adele Higgingbottom, Helen Duffy
Institute of Primary Care Sciences,
Keele University
• Mapping the journey via 3 steps
– A model of OA care
– Patient & Public Involvement (PPI)
– New innovation
• Open discussion
Painting © Mark Elsmore
People will die increasingly at older ages….the percentage of deaths among those aged 85 … expected to rise from 32% in 2003 to 44% in 2030….. Gomes and Higginson PallMed 2008;22:33-41
Age
Obesity
Physical activity
Drivers for change
OA ………….. Past OA .…………Today
Cartilage, Joint Failure, Degeneration, Specific joint site
Joint complex, Dynamic Remodelling, Multisite
Tertiary, Secondary Care Primary Care, Support for Self Management
Medical model, x-ray Person with OA, Bio-psycho-social model
‘Nothing can be done’, damage, wear & tear
‘Something can be done’, wear & repair, remodelling
Limited evidence NICE OA Guidelines
Pre-clinical Clinical trials Health
services research
Knowledge mobilisation
Healthcare delivery
1st Gap in Translation 2nd Gap in Translation
MOSAICS
8 General Practices
• North West Midlands and South Cheshire
• NIHR CRN Primary Care West Midlands, Keele CTU
• OA Research Users Group [PPI]
Population survey
• N=30,000 45 years and over
• Consent to follow up
• Permission for medical record review
Self reported joint pain
• Hip, Knee, Hand, Foot
• Consultation for joint pain (OA or at risk of OA)
• Uptake of core NICE recommendations
Four key innovations
Self Management Model OA Consultation Training Quality Indicators of Care
Patient presenting with
joint pain
MOAC-1 first consultation
with a GP
MOAC-2 follow up
consultation(s) with a practice
nurse
MOAC-3 Opportunistic consultation
HCPs
OA Guidebook
Self Management
Self management happens outside of primary care consultations
Own experiences and lay networks are equally valid
Knowledge embedded in the clinical experience
Morden A, Jinks C, Bie Nio Ong. Lay models of self-management: how do people manage knee osteoarthritis in context? Chronic Illn. 2011 Sep;7(3):185-200.
Grime J, Dudley B. Developing written information on osteoarthritis for patients: facilitating user involvement by exposure to qualitative research. Health Expect. 2014 Apr;17(2):164-73.
Model OA Consultation
Model OA Consultation
Patient presenting with
joint pain
MOAC-1 first consultation
with a GP
MOAC-2 follow up
consultation(s) with a practice
nurse
MOAC-3 Opportunistic consultation
HCPs
Experiences of OA consultations
• negative talk may occur in the consultation
• patients want their joint pain to be taken seriously and validated
• patients keen on non-pharmacological options
• GPs frustrated by their own lack of knowledge around lifestyle change
Paskins Z, Sanders T, Hassell AB. Comparison of patient experiences of the osteoarthritis consultation with GP attitudes and beliefs to OA: a narrative review. BMC Fam Pract. 2014 Mar 19;15:46. Paskins Z, Sanders T, Hassell AB. What influences patients with osteoarthritis to consult their GP about their symptoms? A narrative review. BMC Fam Pract. 2013 Dec 20;14:195.
Patient presenting with joint pain 45 years and over
GP makes, gives, explains diagnosis, analgesia, promotes self-management
Practice Nurse supports self-care;
goal setting, exercise, weight loss,
pain control
How things are going? Type and amount of pain?
Regular analgesia?
Porcheret M, Grime J, Main C, Dziedzic K. Developing a model osteoarthritis consultation: a Delphi consensus exercise. BMC Musculoskelet Disord. 2013 Jan 16;14:25.
Finney A, Porcheret M, Grime J, Jordan KP, Handy J, Healey E, Ryan S, Jester R, Dziedzic K. Defining the content of an opportunistic osteoarthritis consultation with primary health care professionals: a Delphi consensus study. Arthritis Care Res. 2013 Jun; 65(6): 962-8.
Model OA Consultation
Practice Nurse Consultation
Consultation 4
Revisit goals Positive
reinforcement The OA
Guidebook Provide specific
advice Local
opportunities When & who to
re-consult
Consultation 2 & 3
Revisit goals Positive
reinforcement The OA
Guidebook Provide specific
advice Other treatment
options Local
opportunities
Consultation 1
Patient’s story Consultation with
the GP The OA
Guidebook Brief joint screen
Core treatment options
Goal setting
Development of concrete proposal for change
Analysis of performance: target group and setting
Development/selection of strategies and measures to change practice / behaviour
Development testing and execution of implementation
plan
Evaluate and if needed adapt
Porcheret M, Main C, Croft P, McKinley R, Hassell A, Dziedzic K. Development of a behaviour change intervention: a case study on the practical application of theory. Implement Sci. 2014 Apr 3;9(1):42.
GP Training Four Intervention Practices
• 4 practice-based sessions (2hrs x3, 1hr)
• Practice mapping
• OA Update (diagnosis, epidemiology, patient stories)
• New approach (NICE, self-management support)
• Skills training x2 (discussion, simulated patients – reflection, rehearsal and feedback)
• Consultation aide-memoire
• Simulated consultations
Practice Nurse training
DAY 4
Exercise demonstration Simulated patient session – discussion and
practising Opinion leaders through out (Sarah Ryan,
Chris Main)
DAY 2 & 3
Goal setting – theory and practise with case
histories Living with OA
Joint familiarisation / recording procedures
Exercise and physical activity – demonstrations
++
Weight / pain / overcoming obstacles –
discussion ++
DAY 1
Recap on knowledge from practice-based training
The WHAT and the HOW of all 4 consultations
Style and content of 1st consultation / explaining OA
OA Template
Quality Indicators of Care
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 Nov 27.
OA Template
Quality Indicators of Care
0% 20% 40% 60% 80%
100%
% of times indicator entered when template used (n=828)
Four key innovations
Self Management Model OA Consultation Training Quality Indicators of Care
Patient presenting with
joint pain
MOAC-1 first consultation
with a GP
MOAC-2 follow up
consultation(s) with a practice
nurse
MOAC-3 Opportunistic consultation
HCPs
MOSAICS CLUSTER TRIAL
8 General Practices
• Six month consultation survey
• Clinical & cost effectiveness
• Medical record review & OA template
Intervention practices
• Interviews and observations
• How acceptable is the new model?
• What does it mean for patients and health care professionals?
Control practices
• Training at the end of the study
Making Sense of MOSAICS
Ong BN, Morden A, Brooks L, Porcheret M, Edwards JJ, Sanders T, Jinks C, Dziedzic K. Changing policy and practice: Making sense of national guidelines for osteoarthritis. Soc Sci Med. 2014 Apr;106:101-9.
“I think first of all it made you try to take a more positive approach rather than just say “Well, you've got arthritis”. And I think it also gives you a few more strings to your bow, really, in terms of what you can tell a patient, what you can inform them, what we'd be able to offer …….” (GP). “You need to try and form a standard way of the process of treating osteoarthritis, to implement the NICE guidance, and empower the patients to look after themselves more and inform them better.” (GP).
Holistic Care “….she asked me about some nodes on her hand and it was, you know, the shape of her hand and arthritic pain and you could see that it was arthritis. So I was able to tell her a bit about it and even give her a couple of exercises to do.” (PN) “It gives you sort of the evidence base for things that you're actually doing in that clinic, you know, it gives you the knowledge and the skills.” (PN) “….if you've got a patient coming in who's diabetic, coming for his annual review and he's limping a bit, he's not doing a lot of exercise, we're not focusing on the OA […] whereas now we're looking at it a whole lot differently.” (PN)
Ong BN, Morden A, Brooks L, Porcheret M, Edwards JJ, Sanders T, Jinks C, Dziedzic K. Changing policy and practice: Making sense of national guidelines for osteoarthritis. Soc Sci Med. 2014 Apr;106:101-9.
MOSAICS Conference • has been co-created in partnership
• investigates the feasibility, acceptability & impact of implementing a new approach to supporting self-management for OA in primary care
80 year old lady
‘She said her husband wouldn’t let her do anything. If the doorbell rang .. ‘sit there you mustn’t move you’ve got osteoarthritis’. When she came to me and I said I want to get you moving she was over the moon it was like a new lease of life..’
‘She’d got her guidebook - she used it quite a lot’
‘At her final consultation she virtually skipped into the room. It was just brilliant to see her because she’d done so well.’
Julie Broad, Nurse Practitioner, Autumn Conference 2013
80 year old lady
‘She said her husband wouldn’t let her do anything. If the doorbell rang .. ‘sit there you mustn’t move you’ve got osteoarthritis’. When she came to me and I said I want to get you moving she was over the moon it was like a new lease of life..’
‘She’d got her guidebook - she used it quite a lot’
‘At her final consultation she virtually skipped into the room. It was just brilliant to see her because she’d done so well.’
Julie Broad, Nurse Practitioner, Autumn Conference 2013
• 40 members of the MOSAICS team
• 8 practices
• 23 PPI members
• 70+ practice visits
• 100+ hours of GP and nurse training
• 65 Health Care Professionals attended training sessions
• 11 317 consented to be contacted if they consulted
• 525 recruited to consultation survey over 6m
• 9 million consultation variables downloaded at baseline
• 8 individual consultation interviews
• 27 practice nurse consultations observations
A few numbers
This presentation 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
This presentation references recommendations from the NICE clinical guideline 177 Osteoarthritis: care and management in adults. The views expressed in this presentation are those of the author and not necessarily those of the Institute.
Acknowledgements: NIHR CRN Primary Care West Midlands, Arthritis Research
UK, Arthritis Care, Primary Care Consortium Board, the OA Research Users Group, the network, nursing, health informatics and administrative staff at the Arthritis
Research UK Primary Care Centre, the participating general practices, GP facilitators and MOSAICS team
Patient and Public Involvement in the MOSAICs Study
• My story
• Research User Group
• OA Guidebook
• Quality Indicators
Research Users Group
• Recruited via GPs, word of mouth
• Involvement in studies
• Currently over 71 members in over 61 projects
• Involvement in most stages of research process
Examples of Involvement
• Co-applicants on a Grant Applications
• Identifying Research Priorities
• Members of Project Advisory Groups or Steering Committees
• Commenting and developing Patient Information Leaflets
History
• Janet Grime & Pauline Ong
• Reviewed relevant research papers
• Reviewed leaflets on OA
Grime JC, Ong BN Musculoskeletal Disorders 2007; 8:34
Lay Advisors
• 6 Members from Telford and Wrekin Arthritis Support Group ages 45 to 80 years
• 5 Members from the Research Users Group, Keele University ages 46 to 67 years
Our Meetings
• Three meetings
• Our own experiences
• What was important to us?
• Fear of loss of independence
Quotes
• Helpful to reader
• Personal experience
“If there’s a change in the weather, if I do too much or more than usual shall we say, sometimes if I just put too much pressure on a joint it’ll start it up.”
Differences of opinion
• Discuss in an adult manner
• Frustration
• Who would be reading the guidebook?
Quality Indicators What are they?
– measure quality of care – relate to how health is provided to
patients
Who uses? – Health organisations and managers,
clinicians, patients, carers
How the PPI group developed the questionnaire
• Selected 20 most important indicators of quality of care
• Suggested wording for 14 draft questions
• Reviewed and revised questionnaire
Comparison of UK questionnaire with a Norwegian questionnaire
• PPI group feedback:
– Both included the same or very similar indicators of quality
– Eight questions were almost identical
European-funded study
• Compare OA quality Indicators across Europe
• Similar expectations between researcher and patients
• Patient involved in this study
Conclusion
Patient involvement is valuable to researchers and patients
LINKS
www.keele.ac.uk/media/keeleuniversity/ri/Primarycare/pdfs/OA_Guidebook.pdf
www.invo.org.uk/
Enhancing Primary Care Management of OA in
South Shropshire Dr Colin Stanford, Dr Vincent Cooper, Dr
Mark Porcheret, Professor Krysia Dziedzic, Mrs Helen Duffy
Why choose OA?
• OA is common in older people
• It has a major impact on quality of life, function and independence
• NICE guidelines for OA are implemented inconsistently
• Possible over-use of clinical imaging/referral
What do health care professionals and patients want?
• consistency of care
• more information and education
• continuity and proactive follow-up
• integrated care
• support for self-management
Mann et al, 2011
From research study to day-to-day practice
• MOSAICS study - investigated the feasibility, acceptability &
impact of implementing a new approach to supporting self-management for OA in primary care
• NHS Shropshire – could we roll out this approach to support
patients?
• Link to Orthopaedic Review
• Opportunity for Regional Innovation Funding 2013
Osteoarthritis – Regional Innovation Fund Joint Implementation of Guidelines for
oSteoArthritis in the West Midlands (Jigsaw)
‘The MOSAICS study generated grass roots interest and support, with GPs and practice nurses reporting greater confidence in
managing OA and patients feeling that their joint problems are taken seriously. In addition, the health professionals realised that the core management principles for OA are the same as those for
other long-term conditions (LTCs) and that the knowledge and skills they developed were transferable across a range of LTCs.’
OA Regional Innovation Funded Proposal
Aim of Innovation Project
To adopt an evidence-based, proactive approach to the management of OA in line with NICE
recommendations in primary care practices and spread this out to all South Shropshire Locality
practices
Regional Innovation Funding January 2014 - £££ - GP/PN clinical champions, venues, practice nurse training workshops, travel….
Key tasks
1. Make / give / explain the diagnosis
2. Provide analgesia advice / prescription
3. Promote and support self-management
4. Give the guidebook
Key skills
• Clinical diagnosis OA
• Patient centred approach
Practice Nurse Appointments
• Guided Self Management
MOAC-1
GP consultation
MOAC-2
Nurse-led OA clinic
Patient report & medical records • Routine data
– Weight records
– Medication
– Investigation
• X-ray records
– (Referral)
• New data TEMPLATE
Four key innovations
Self Management Model OA Consultation Training Quality Indicators of Care
Patient presenting with
joint pain
MOAC-1 first consultation
with a GP
MOAC-2 follow up
consultation(s) with a practice
nurse
MOAC-3 Opportunistic consultation
HCPs
Components of the project
• OA template within clinical computer system
• Purpose designed patient information resources
• 2 practice-based development sessions with a Clinical Champion plus e-Learning module
• Support from GP and Practice Nurse Clinical Champions
• 2 days of training for Practice Nurses/HCSWs
• Audit support from CCG
Clinical Champion Training
Launch Event to member practices
Practice based training by clinical champions
Nurse workshops (Education for Health)
Our aspiration for GPs
• Greater confidence to diagnose OA clinically
• Better explanations of OA and more positive messages for patients
• Access to better written information for patients
• Readiness to promote self-management by patients, with practice nurse support
Our aspiration for practice nurses
• Greater understanding of OA and its natural history
• Confidence to explain OA to patients
• Harnessing their knowledge and skills of chronic disease management to manage OA
• Confidence to advise on exercise and pain control, set goals and work with patients to achieve them
And for patients:
• Being given a clear diagnosis and explanation of OA
• Knowing what to expect
• Receiving good written information
• Gaining the confidence to manage their symptoms and limitations in the most effective way
• Being supported and empowered
Progress to date:
• Recruited 4 GP champions, 2 practice nurse champions – training event and core materials given
• Launch event
• Developed nurse workshops in conjunction with Arthritis Research UK/Education for Health
• PPI group – updated OA guidebook, developing plans for patient dissemination
Project Timeline:
September
Launch event
•Practice Teams 10th September 2014
•Template Installation throughout Sept.
On Line
Training
•RCGP http://elearning.rcgp.org.uk/mod/lesson/view.php?id=3101
•GPs/Practice Nurses
Practice Meeting with clinical champions
•On site lunch time practice meeting – GPs & PN
•On site GP education lunchtime meeting – GPs
Practice Nurse Training
•2 days training
• November 2014
Implementation of nurse led clinics
• Clinical champion site visits
•Audit of implementation - template
Improving the management of OA
MOSAICS
Tools & resources
Integrated care
Dissemination & implementation
NICE
The research implementation challenge!
• What can be done within the resources available
• Securing funding opportunities
• Implementation activities may skew research projects!
• Willing adoption vs mandating
• Moving from the local to the national
• Identifying implementation priorities
Acknowledgements: Primary Care Research Consortium Regional Innovation Fund NHS England Shropshire Clinical Commissioning Group This presentation 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 This presentation references recommendations from the NICE clinical guideline 177 Osteoarthritis: care and management in adults. The views expressed in this presentation are those of the authors and not necessarily those of the Institute This paper presents independent research which is part-funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health Arthritis Research UK, Arthritis Care, the Research User Group, the network, nursing, health informatics and administrative staff at the Arthritis Research UK Primary Care Centre, the participating general practices, physiotherapists, Primary Care Rheumatology Society, GP facilitators and MOSAICS team
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