Implementing NICE Osteoarthritis Guidelines › system › files › 10102014... · practise with case histories Living with OA Joint familiarisation / recording procedures Exercise

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

Conaghan, P. G et al. BMJ 2008;336:502-503

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


Self Management

Kennedy, A. et al. BMJ 2007;335:968-970.

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



joint pain


with a GP

MOAC-2 follow up


nurse


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.


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

GP and Practice Nurse Training

Training

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


0% 20% 40% 60% 80%

100%

% of times indicator entered when template used (n=828)

OA Template




joint pain


with a GP

MOAC-2 follow up


nurse


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

Healthy person

Primary Care Centre

• 2002

• Daily diary

• Research User Group

Light bulb moment

• Pain management programme

• Voluntary work

• Part-time employment

Research Users Group

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

OA Guidebook

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

Themes

• Do the findings seem credible?

• What do they say to you?

• Other information

Our Meetings

• Three meetings

• Our own experiences

• What was important to us?

• Fear of loss of independence

Distraction and Exercise

• We could relate to this

• Our own stories

• Physical Activity

Feelings

• Feelings about ageing

• Emotional Impact

• Frustration

• Importance of feeling valued

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

Quality Indicators

• Researchers / Researcher User Group

• MOSAICS Study

• Objectives

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/

http://www.keele.ac.uk/media/keeleuniversity/ri/Primarycare/pdfs/OA_Guidebook.pdf

http://www.keele.ac.uk/media/keeleuniversity/ri/Primarycare/pdfs/OA_Guidebook.pdf

http://www.invo.org.uk/

Acknowledgements

EULAR European League Against Rheumatism

So – can this approach to OA be implemented in day-to-day

practice?

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




joint pain


with a GP

MOAC-2 follow up


nurse


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

http://elearning.rcgp.org.uk/mod/lesson/view.php?id=3101

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

Documents

Implementing NICE Osteoarthritis Guidelines › system › files › 10102014... · practise with case histories Living with OA Joint familiarisation / recording procedures Exercise