A soft tissue and joint injection clinic is easy to set up, popular with patients, and brings valuable extra income to the practice, as Dr Rob Wicks explains


   

Before the new GMS contract came into force many GPs provided joint and soft tissue injections, but were not remunerated for the activity – the Prescription Pricing Authority (PPA) merely reimbursed GPs for the injections.

Minor surgery clinics, which include clinics for joint and soft tissue injections, are among the six directed enhanced services that PCOs are obliged to commission.

Setting up a clinic

The most important requirement when setting up a clinic for soft tissue and joint injections is that the healthcare professionals involved have the skill to perform the injections. Because the corticosteroids, syringes and needles come in sealed sterile vials there are no sterilisation procedures to follow.

We have been running a clinic at our practice for 6 years. One partner, who had experience as an SHO in rheumatology and was a clinical assistant for 2 years at the local district general hospital, was already doing most of the joint injections in the practice. When a physiotherapist joined the team it made sense to hold an injection clinic at the same time as the physiotherapy sessions.

Clinics are held approximately every 2 weeks, when a maximum of 10 patients are given appointments lasting 10 or 15 minutes.

Patients are generally assessed first by their own GP who makes the appointment and often indicates the possible diagnosis.

The ‘specialist’ GP taking the clinic can often proceed quickly to treatment, although there is plenty of time during the clinic for a more detailed examination if necessary.

Evidence for corticosteroid joint injection

For such a common treatment the evidence base is fairly slim. A recent edition of Clinical Evidence cited evidence that knee and carpal tunnel corticosteroid injections were likely to improve symptoms, but only limited evidence for short-term improvement in tennis elbow.1

There are no randomised controlled trials supporting shoulder joint injection, and of the studies that do exist, few have been carried out in general practice.

The most frequently cited general practice trial comparing corticosteroid injection with physiotherapy in the treatment of shoulder pain claims a 77% success rate for injection as opposed to 46% for physiotherapy. 2 However, the paper does not give any specific diagnoses, for which it was criticised at the time.

There is some debate about whether injection helps range of movement and pain. An analysis of two trials showed improved abduction but not pain relief in tendon lesions.3 Other evidence suggests that steroid injections can provide sufficient pain relief to obviate surgical treatment in some patients with tendinopathy without rotator cuff tears.4 This is supported by a 40-patient study that showed improved pain relief and range of movement for up to 6 months following injection, when compared with local anaesthetic alone.5

The natural history of many shoulder conditions is resolution with time, which may explain the lack of firm evidence for a ‘best’ treatment. Anecdotally, injections help many of my patients and they return, often at intervals of many months, for repeat treatments. My own shoulder injury resulting from a skiing mishap was certainly helped.

Claiming payment

In the clinic we perform three broad categories of injections:

  • Injection of carpal tunnel, trigger fingers and tennis/golfer’s elbow
  • Shoulder joint injections
  • Knee joint injections.

The Read codes covering these three categories are:

  • Injection of steroid into subcutaneous tissue, 7G2A1
  • Injection of steroid into shoulder joint, 7K6z5
  • Injection of steroid into knee joint, 7K6z7.

After each procedure the appropriate Read code is entered in the computer record and a prescription generated for the PPA. This gives us an easy way of counting the number of procedures done, and the number of prescriptions written provides a check. As one doctor does all the injections we are confident that we are not missing any claims.

Our local PCT has agreed to fund this activity at the rate of £40 per injection. A typical clinic earns the practice £360, and this should add up to something in the region of £7000 over the year. The PPA continues to reimburse the prescribing costs of the injections.

Advantages of the clinic

There are several advantages to running a soft tissue and joint clinic:

  • Referral and treatment of common conditions is rapid.
  • The clinic is cheap to run and helps to ensure that the practice is claiming the maximum possible for enhanced services.
  • The number of referrals to secondary care is reduced. Recently published figures for the PCT show that our practice has among the lowest number of rheumatology referrals.
  • Reduced prescribing for musculoskeletal conditions. PACT data show that our practice is a consistently low prescriber of drugs in this category.

The disadvantages, meanwhile, are few:

  • Practice partners who do not take part in the clinic may lose their skills in joint injection.
  • Time spent on clinic work means that there is less time for the routine work of general practice.

Conclusion

Enhanced services offer us a chance to be paid for the additional work we do. The format of our clinic works for our practice and is popular with patients. We also offer limited acupuncture and manipulation in the clinic.

Although the evidence base for corticosteroid joint injections is not robust, it is difficult to deny patients a treatment that is so generally accepted and useful as an adjunct in the treatment of common rheumatological conditions.

References

  1. CE Concise. Issue 11, June 2004. London: BMJ Publishing, 2004. www.clinicalevidence.org
  2. van der Windt, Koes BW, Deville W et al. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. Br Med J 1998; 317: 1292-6.
  3. Speed CA. Corticosteroid injections in tendon lesions. Br Med J 2001; 323: 382-6.
  4. Mellor SJ, Patel VR. Steroid injections are helpful in rotator cuff tendinopathy. Br Med J 2002; 324: 51 (Letter).
  5. Blair B, Rokito AS, Cuomo F et al. Efficacy of injections of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg 1996; 78-A: 1685-9.

Guidelines in Practice, December 2004, Volume 7(12)
© 2004 MGP Ltd
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