Dr Elspeth Wise discusses how a focus on self-management, core treatments, and regular review can improve outcomes for patients with osteoarthritis
Read this article to learn more about:
- why OA should be managed in the same manner as other long-term conditions
- how patients with the condition can to reduce their pain from OA
- the advantages of regular reviews to assess the patient’s condition and help with self-management and core treatments.
Osteoarthritis (OA) is a common cause of pain and disability in the UK with around 8.5 million people living with the condition.1 It is expected that this figure may rise yet further as the population ages and the obesity epidemic continues. The most commonly affected peripheral joints are the knees, hips, and hands.2 The natural history of arthritis in the different joints varies, with prognosis and symptomatic outcome depending on location of the OA:3
- outcomes are mostly good in the hand
- variable outcomes are found in the knee
- OA of the hip tends to progress.
The need for a quality standard
Osteoarthritis has a considerable impact on patients’ lives, with pain tending to be the worst problem. Classically it occurs on movement/use of the joint but many people with OA suffer with persistent pain. It can therefore not only affect their mobility but also their sleep, mood, and coping abilities. It has a significant impact on health services with around two million adults visiting their GP each year with OA and around £405 million being spent on hip and knee replacements in 2000.3
There are several misconceptions surrounding OA. Many people affected may not present to their GP as it can be perceived to be a ‘normal part of ageing’. It is also often felt that ‘nothing can be done’,4 even though effective treatments such as joint replacement surgery exist.
NICE Quality Standard 87
NICE Quality Standard 87 (QS87) for osteoarthritis was published in June 2015.5 It contains eight quality statements (see Table 1, below) based on key recommendations from NICE Clinical Guideline 177 on Osteoarthritis: care and management in adults (a summary of the guideline can be found here on the Guidelines website).2 The aim of all NICE quality standard statements is to stimulate improvements in patient safety, patient experience, and clinical effectiveness in a particular field.5
This set of standards is expected to be predominantly used in primary care as this is where the majority of OA management takes place. The eight quality statements focus on diagnosing OA, encouraging self-management, reviewing patient care on a regular basis, the use of core treatments, and referring patients for joint surgery appropriately.
|1||Adults aged 45 or over are diagnosed with osteoarthritis clinically without investigations if they have activity-related joint pain and any morning joint stiffness lasts no longer than 30 minutes.|
|2||Adults newly diagnosed with osteoarthritis have an assessment that includes pain, impact on daily activities and quality of life.|
|3||Adults with osteoarthritis participate in developing a self-management plan that directs them to any support they may need.|
|4||Adults with osteoarthritis are advised to participate in muscle strengthening and aerobic exercise.|
|5||Adults with osteoarthritis who are overweight or obese are offered support to lose weight.|
|6||Adults with osteoarthritis discuss and agree the timing of their next review with their primary healthcare team.|
|7||Adults with osteoarthritis are supported with non-surgical core treatments for at least 3 months before any referral for consideration of joint surgery.|
|8||Healthcare professionals do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.|
NICE (2015) QS87. Osteoarthritis. NICE, 2015. Available at: www.nice.org.uk/guidance/qs87 Reproduced with permission
Diagnosing and assessing patients with OA—statements 1 and 2
Osteoarthritis can be safely diagnosed from a clinical history if the patient:
- is 45 years or over and
- has persistent joint pain that is worse on use and
- experiences no or minimal morning stiffness (lasting less than half an hour).
X-rays are not needed to confirm the diagnosis; they do not provide any additional benefit above the clinical diagnosis and involve exposing the patient to radiation. There is good evidence to show that changes demonstrated by X-ray do not necessarily correlate to symptoms: there are many people with OA apparent on radiography who have no symptoms; while minimal changes visible on X-ray could be associated with significant joint pain and vice versa.3 The prevalence of OA on X-ray examination depends on the images obtained and the definitions of OA used and so relying on a clinical diagnosis is both safe and reasonable. However, if there is doubt as to the diagnosis, for example if symptoms are atypical or the presentation is unusual, then requesting an X-ray may be a useful investigative option.
A holistic initial assessment should cover not only a history of joint pain, but also the impact on the patient’s mood, daily activities, and quality of life.2
Self-management and core treatments—statements 3, 4, and 5
As with any long-term condition, supporting patients with OA to manage their condition themselves can have significant benefits. It can improve outcomes and the overall patient experience.6 Patients with OA who self-manage may notice less pain and an improvement in wellbeing;1 they therefore need the techniques and sufficient information to enable them to feel confident in managing and taking control of their condition.
Two quality statements (statements 4 and 5, see Table 1, above) focus on encouraging the use of core treatments. When the term ‘core treatments’ is used in connection with OA, it is referring to the treatments shown in the inner circle of the target diagram in Figure 1 (see below):7 education; exercise; and weight loss, if appropriate. These treatments are considered to be ‘core’ in the management of OA as they are simple and also cost effective.
There is good evidence that exercise reduces joint pain and stiffness and improves function; however, just under one-half of people with OA do no exercise or activity at all.1 It is a common misconception that exercise ‘wears out’ joints, but strengthening the muscles surrounding and supporting the affected joint can significantly ease pain.
Excess/abnormal loading of any joint is a recognised risk factor for the development and progression of OA, especially at the knee. Again, there is good evidence that losing weight improves pain and function. As OA is a dynamic process of wear and repair, reducing or taking away a significant risk factor can allow for the repair process to occur.
The aim of quality statements 4 and 5 on core treatments is to remind healthcare professionals to encourage and provide appropriate support to people with OA to participate in exercise or lose weight depending on their readiness to change/self-motivation. A national survey of patients with OA reported that only one-third of respondents talk to their medical practitioner about self-management, including changing their diet and being more active.1
Timing of reviews—statement 6
As one of many chronic diseases that can affect patients, OA is often forgotten about or dealt with as an aside. Almost one half of patients with OA report that they feel that the NHS does not see OA as a priority.1 Other chronic conditions such as diabetes, ischaemic heart disease, or chronic kidney disease generally have specific reviews with time dedicated to ensuring that their management is optimal.
Ensuring that patients with OA have an appropriate opportunity to have their condition and treatment reviewed was highlighted in NICE CG1772 and is also the focus in quality statement 6.5 Many people never visit their GP about their problem or may often wait until their pain is unbearable,1 and the natural history of OA can vary widely so it is difficult to be too proscriptive about how often patients should be seen.
The NICE Guideline Development Group for CG177 and the Quality Standards Advisory Committee felt that regularly reviewing people with OA can support self-management, encourage their uptake of core treatments, and allow a review of their analgesic usage (both prescribed and over-the-counter).2,5
The evidence review for CG177 highlighted a reduced effectiveness of paracetamol in the management of chronic OA pain than was previously thought, but any changes to the recommendations were delayed until the results of the MHRA safety review into over-the-counter analgesics is completed.2
Non-steroidal anti-inflammatory drugs can have effects on blood pressure and renal function, especially in older people, and can also cause anaemia. A regular review of a patient’s OA treatment can allow these factors to be addressed.
Joint replacement surgery— statements 7 and 8
Osteoarthritis is the commonest reason for joint replacement surgery; these highly successful and cost-effective procedures have the potential to ‘cure’ a patient’s joint pain and improve function. However, healthcare professionals should not refer for joint surgery until the patient has been supported with 3 months of core treatments (see Figure 1, above).
Surgery is not without risk, including a possible risk of death,8 infection, dislocation, fracture, loosening of the prosthesis, and deep vein thrombosis (DVT)/pulmonary embolism (PE), hence the recommendation that patients first undergo a 3-month trial of non-surgical treatments. Probably as a result of the increased use of thromboprophylaxis, the risk of death and DVT/PE has reduced over the years that the National Joint Registry has been collecting data.
Patients can be surprised that the prosthesis does not behave the same as a native joint: the movement is not the same. Kneeling can be uncomfortable after a total knee replacement and is not recommended on a regular basis, nor is squatting after a total hip replacement.
Not everyone is satisfied with the results of their operation with figures suggesting that about 1 in 5 patients are dissatisfied following a total knee replacement.9 Replacements may only last about 10–15 years and so it is important that patients maximise the effects of core treatments before considering surgery.
Losing weight and improving exercise tolerance may actually help improve the outcomes of surgery and so it is in the patient’s best interests to give them a try.
A report by the Royal College of Surgeons highlighted significant variations in access to hip replacements across 52 of the 211 CCGs in England.10 Of particular concern was that 44% of these CCGs had specific criteria for referring: using either Oxford Hip Scores or body mass index levels. This is a direct contravention not only of the NICE guidelines, but also of British Hip Society, British Orthopaedic Association, and Royal College of Surgeons’ recommendations. Quality statement 8 should therefore ensure equity of access to an orthopaedic opinion for all patients in England and Wales.
Implementing the quality standard in primary care
NICE QS87 for osteoarthritis is directed at primary care with many of the quality statements focusing on achieving equity for OA management alongside that of other chronic diseases. It continues the general push towards encouraging self-management and empowering patients to take control of their health. It is to be hoped that this will result in patients using the simple but effective core treatments to their best ability.
Challenges for primary care
Fully implementing the standard will potentially involve GPs having to review more patients (i.e. increase their workload). A number of these patients will be presenting with other chronic conditions, and so hopefully it will not entail a significant increase.
Clinical commissioning groups may have to look at commissioning a self-management programme, e.g. the escape programme. Some CCGs will have to stop using body mass index and Oxford Hip/knee scores as a means of ‘controlling’ referrals. Hopefully, if the effect of core treatments could be maximised then patients outcomes may improve, which could have a positive effect elsewhere.
- Taking a clinical history is normally sufficient to diagnose OA
- It is not necessary to use X-ray as a diagnostic tool for OA
- Assessment should cover not only a history of joint pain, but also the impact on the patient’s mood, daily activities, and quality of life
- Patients should be encouraged to exercise self-management of their OA
- The use of core treatments—exercise and weight loss—are beneficial in reducing the pain of OA by strengthening muscles and reducing load on joints
- As with other long-term conditions, patients with OA should have a regular review with their GP
- Joint replacement and surgery can be an effective treatment for OA, but risks and benefits should be discussed with the patient
- Patient referral for surgery should not depend on scoring tools to decide eligibility.
- The number of people diagnosed with OA in the past year:
- with an X-ray,
- without an X-ray.
- The number of cases where:
- weight/BMI has been documented, particularly in cases of hip/knee OA, and whether this was acted on
- an active recommendation about exercise has been made
- patients on NSAIDs for OA get their BP and bloods checked.
OA=osteoarthritis; BMI=body mass index; NSAID=non-steroidal anti-inflammatory drugs; BP=blood pressure
GP commissioning messages
written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead
- This new quality standard re-emphasises the recommendations in the NICE guideline on osteoarthritis and sets priorities for implementation
- Commissioners should look to review and remove any scoring systems or ‘gateway’ processes that limit access to surgery but should encourage exercise and self-management
- There is very good evidence that weight loss and exercise limits the need for surgery and also improves outcomes afterwards, so CCGs should ensure that appropriate schemes are available to patients either through GPs or via direct access for patients with early osteoarthritis:
- physiotherapy is likely to be a key part of this process and CCGs should ensure sufficient capacity is commissioned.
- Local care pathways should help define the need for any investigations and referral and when alternative diagnoses, such as inflammatory arthritis, need to be explored
- Local formularies should identify analgesics of low acquisition cost for use in osteoarthritis although there is some uncertainty about the efficacies of some of these, e.g. paracetamol.
- Arthritis Care. OA nation. Arthritis Care, 2012. Available at: arthritiscare.org.uk
- NICE. Osteoarthritis: care and management in adults. Clinical Guideline 177. NICE, 2014. Available at: nice.org.uk/cg177
- National Clinical Guideline Centre. Osteoarthritis: Care and management in adults. Clinical Guideline CG177. NCGC, 2014. Available at: nice.org.uk/cg177/evidence
- Sanders C, Donovan J, Dieppe P. Unmet need for joint replacement: a qualitative investigation of barriers to treatment among individuals with severe pain and disability of the hip and knee. Rheumatology 2004; 43 (3): 353–357.
- NICE. Osteoarthritis.. Quality Standard 87. NICE, 2015. Available at: www.nice.org.uk/guidance/qs87
- Naylor C, Imison C, Addicott R et al. Transforming our health care system. The King’s Fund, 2015. Available at: www.kingsfund.org.uk/publications/articles/transformingour-health-care-system-ten-prioritiescommissioners
- Conaghan P, Dickson J, Grant R. Care and management of osteoarthritis in adults: summary of NICE guidance BMJ 2008; 336: 502–503.
- Hunt L, Ben-Shlomo Y, Clarke E et al on behalf of the National Joint Registry for England, Wales and Northern Ireland. 90-day mortality after 409 096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis. Lancet, 2013; 382 (9898): 1097–1104.
- Clement N. Patient factors that influence the outcome of total knee replacement: a critical review of the literature. OA Orthopaedics 2013;1 (2): 11–15.
- The Royal College of Surgeons of England. Is access to surgery a postcode lottery? London: RCS Publishing, 2014. Available at: www.rcseng.ac.uk/news/many-ccgs-are-ignoring-clinicalevidence-in-their-surgical-commissioningpolicies