Implementing and evaluating a pilot physiotherapist-led osteoarthritis clinic in general practice
Joint pain due to osteoarthritis (OA) is a major cause of disability, work-loss and reduced quality of life in older adults. NICE clinical guidelines recommend core OA treatment should include education, exercise and weight-loss (when applicable). However, despite the evidence-base, many people with OA do not currently receive these treatments. This report describes and evaluates the implementation of a clinical-academic physiotherapist OA clinic embedded into a general practice.
The Managing OSteoArthritis In ConsultationS [MOSAICS] trial tested a GP and practice nurse model of OA care designed to enhance the uptake of NICE guidelines and self-management in primary care. This model was adapted to be delivered by a clinical-academic physiotherapist and implemented in a general practice as part of the linked JIGSAW-UK implementation project.
Setting up the in-practice physiotherapy OA clinic involved: stakeholder meetings; practice visits and training; NHS contract and mentor organisation; service evaluation planning, and public engagement including co-produced clinic advertising. Four key innovations were delivered: i) training of practice clinicians, ii) a model OA consultation, iii) recording of high-quality care within electronic health records using an e-template, and iv) provision of patient information using the Keele Osteoarthritis Guidebook. Following OA diagnostic consultation, patients received up to four follow-up consultations with the physiotherapist who supported self-management by providing education, exercise and weight-loss advice, goal setting, written information provision, ongoing monitoring and referrals as required.
After 10 months, a service evaluation was undertaken using routinely-collected electronic health record data and a patient questionnaire. Data regarding patient referrals, attendance, recorded achievement of NICE OA quality indicators, onward referrals and narrative service feedback from practice staff and patients were captured. Quality indicator data were compared with the outcomes from the empirical MOSAICS intervention practices. Additional self-reported musculoskeletal health data was captured during the first assessment and on discharge using the Musculoskeletal Health Questionnaire (MSK HQ). The MSK HQ provides a score between 0 and 56 with a higher score indicating better musculoskeletal health status. A change of 4.5 points is considered to be a minimally clinically important difference (MCID).
181 new patients were referred to the physiotherapist clinic, filling 84% of appointment slots (referrals to the clinic built up in the first few weeks and two days of snow reduced service access). Onward referrals included reviews for medication (n=20), depression (n=7) and consideration of joint replacement (n=3). Twenty-six discharged patients returned completed questionnaires, all reported receiving information about managing OA, advice and support about how to manage joint pain and, information and advice about physical activity and exercise for joint pain. Of those who were overweight or obese 76% reported being advised to lose weight.
Across the whole practice, high-achievement of provision of written information was recorded about: OA (73%); weight management (49%) and; exercise (69%). These proportions were higher than achieved with a GP-practice nurse model within the MOSAICS trial (53%, 30% and 44% respectively).
Although the MSK HQ questionnaire was filled in during the first session in a sample of 54 patients only 13 provided data at the discharge consultation due to time constraints and prioritising other patient care quality questionnaire data. Mean scores were higher on discharge (38.1) compared to baseline (28.2) suggesting discharged patients on average had better musculoskeletal health with a difference of 9.9 points between data at the two time points (pairwise analysis on complete case data showed a mean change improvement of 9.3 points). This score exceeded the MSK HQ MCID.
Practice staff and patients valued the in-practice physiotherapy service quality, written information and service access. GPs also reported reduced requests for onward referrals and interventions and valued the validation of OA diagnosis.
Cost and savings
My involvement in this project was funded through a NIHR Academic Clinical Lecturer Award and was not costed separately.
We did not carry out a formal cost-effectiveness analysis for this service evaluation. Cost-effectiveness analysis of the similar MOSAICS GP and practice nurse model of care has been shown to improve quality indicators of OA care, reduce NSAIDS and orthopaedic visits at no additional cost (Oppong et al 2018).
Embedding a clinical-academic physiotherapy OA champion into a general practice was effective in improving recorded quality of OA care, with only a minority of patients seen within this new service being referred on to other clinicians.
An embedded clinical-academic physiotherapist appears to be a feasible and acceptable way to implement an empirically-tested model of care, and improve quality of recorded care, in a real-world general practice. Furthermore, it facilitated buy-in for local future physiotherapy service solutions in primary care. Future projects will involve externally validating the clinic and developing then evaluating first-contact and extended scope clinical components.
Top three learning points
JQ is funded by a NIHR Clinical Lectureship in Physiotherapy, awarded as part of Professor Christian Mallen's NIHR Research Professorship (NIHR-RP-2014-026). EC and JE are NIHR Academic Clinical Lecturers in Primary Care. KD is part funded by the NIHR Collaborations for Leadership in Applied Research and Care West Midlands and by a Knowledge Mobilisation Research Fellowship (KMRF-2014-03-002) from the NIHR.
The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. European Institute for Innovation and Technology Health. Arthritis Research UK.
This work was presented at Physiotherapy UK 2018.
This work was part of a wider international project for implementing NICE osteoarthritis guidelines into clinical practice across Western Europe (JIGSAW-E). Further details, resources and publications linked to this wider project can be found at: https://jigsaw-e.com/
For further information contact Jonathan Quicke.