NICE has published Referral Advice - guide to approriate referral from general to specialist services, which deals with 11 common complaints. Last month we covered menorrhagia. In this issue we reproduce the advice on osteoarthritis of the hip.

The referral advice is set out in consensus statements based on the best available evidence. It is designed to help clinicians determine how urgently particular patients need to be referred.

For a summary of the consensus statements click here.

Osteoarthritis of the hip

Osteoarthritis of the hip presents with pain, stiffness, a reduced range of movement and occasionally a feeling that the joint will give way.

The pain, which is typically felt in the groin and also sometimes in the thigh and knee, may be sharp and brought on by particular movement or activity (climbing stairs, standing up). It may also present as a dull ache occurring particularly after activity, or during the night.

Pain may be exacerbated by minor trauma such as a knock or a fall. Stiffness tends to be worse after periods of immobility, and usually improves for a while with use.

Findings on examination will include a painful restriction of hip movement. Osteoarthritis is not associated with systemic illness.

Osteoarthritis is common and its prevalence increases with age. In most patients with radiological changes, symptoms are not sufficiently troublesome to prompt a general practice consultation. In some patients symptoms may be intermittent but in others they can be relentless and debilitating.

The underlying joint changes of osteoarthritis are generally irreversible and management aims at relieving symptoms and reducing disability.

In the NHS in England and Wales, around 39,000 primary hip replacement operations were undertaken in 1999/2000.

Primary care

Initial management strategies for patients with osteoarthritis of the hip include reassurance and patient education, weight reduction in patients who are obese, walking aids, help with patient-specific exercise programmes, and assessment and advice on cushion-soled footwear.

Drug treatment typically includes courses of simple analgesics or non-steroidal anti-inflammatory drugs.

If the patient has had a hip X-ray, a copy of the report should be enclosed with any subsequent referral letter.

Specialist services

These are in a position to:

  • confirm or establish the diagnosis
  • provide management advice coupled with physical therapies
  • assess the need for, and undertake, hip surgery and rehabilitation.
  • Referral Advice

    The majority of the management of patients with osteoarthritis of the hip can be undertaken in primary care. However, referral to a specialist service is advised if:

    there is evidence of infection in the joint

    symptoms rapidly deteriorate and are causing severe disability

    the symptoms impair quality of life. Referral should be based on an explicit scoring system that should be developed locally in a partnership involving patients together with healthcare professionals in primary and secondary care. Referral criteria should take into account the extent to which the condition is causing pain, disability, sleeplessness, loss of independence, inability to undertake normal activities, reduced functional capacity or psychiatric illness

    The starring system developed by NICE to identify referral priorities

    Arrangements should be made so that the patient:

    is seen immediately1
    is seen urgently2
    is seen soon2
    has a routine appointment2
    is seen within an appropriate time depending on his or her clinical circumstances (discretionary)

    1 within a day

    2 health authorities, trusts and primary care organisations should work to local definitions of maximum waiting times in each of these categories. The multidisciplinary advisory groups considered a maximum waiting time of 2 weeks to be appropriate for the urgent category.

Reproduced with kind permission from: Referral Advice - A Guide to Appropriate Referral from General to Specialist Services. London: NICE, December 2001. The complete document can be downloaded from the NICE website

eGuidelines (last updated: November 14, 2003 )
© 2002 MGP Ltd