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


‘Knee osteoarthritis’ n = 80

NICE guidance Number % Percentage of knee


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


‘Knee pain’ n = 330


pain population











‘Knee pain’ n = 330


pain population




Diclofenac 144 44


Naproxen 87 26



‘Hip osteoarthritis’ n = 50 NICE guidance Number % Percentage of hip









Referral to MSK clinic (since Apr 12) 11 22



‘Hip osteoarthritis’ n = 50

NICE guidance Number % Percentage of hip

osteoarthritis

population




Diclofenac 19 38


Naproxen 15 30



‘Hip pain’ n = 139 NICE guidance Number % Percentage of hip

pain population











‘Hip pain’ n = 139

NICE guidance Number % Percentage of hip

pain population




Diclofenac 57 41


Naproxen 38 27


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

knee and hip pain in primary care - health innovation...

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