Implementing NICE Osteoarthritis Guidelines: From research to clinical practice

Transcription

1 Implementing NICE Osteoarthritis Guidelines: From research to clinical practice Krysia Dziedzic, Adele Higgingbottom, Helen Duffy Institute of Primary Care Sciences, Keele University

2 Mapping the journey via 3 steps A model of OA care Patient & Public Involvement (PPI) New innovation Open discussion Painting Mark Elsmore

3 Drivers for change Physical activity Obesity 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 Gomes and Higginson PallMed 2008;22:33-41 Age

4 Conaghan, P. G et al. BMJ 2008;336:

5 OA.. Past Cartilage, Joint Failure, Degeneration, Specific joint site Tertiary, Secondary Care Medical model, x-ray Nothing can be done, damage, wear & tear Limited evidence OA. Today Joint complex, Dynamic Remodelling, Multisite Primary Care, Support for Self Management Person with OA, Bio-psychosocial model Something can be done, wear & repair, remodelling NICE OA Guidelines

6 Pre-clinical Clinical trials Health services research Knowledge mobilisation Healthcare delivery 1 st Gap in Translation 2 nd Gap in Translation

7 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, 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

8 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

9 Kennedy, A. et al. BMJ 2007;335: Four key innovations Self Management

10 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 Sep;7(3): Grime J, Dudley B. Developing written information on osteoarthritis for patients: facilitating user involvement by exposure to qualitative research. Health Expect Apr;17(2):

11 Model OA Consultation Model OA Consultation 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

12 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 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 Dec 20;14:195.

13 Model OA Consultation 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 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 Jun; 65(6):

14 Practice Nurse Consultation Consultation 1 Patient s story Consultation with the GP The OA Guidebook Brief joint screen Core treatment options Goal setting Consultation 2 & 3 Revisit goals Positive reinforcement The OA Guidebook Provide specific advice Other treatment options Local opportunities Consultation 4 Revisit goals Positive reinforcement The OA Guidebook Provide specific advice Local opportunities When & who to re-consult

15 GP and Practice Nurse Training Training

16 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 Apr 3;9(1):42.

17 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

18 Practice Nurse training DAY 1 Recap on knowledge from practice-based training The WHAT and the HOW of all 4 consultations Style and content of 1 st consultation / explaining OA 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 4 Exercise demonstration Simulated patient session discussion and practising Opinion leaders through out (Sarah Ryan, Chris Main)

19 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 Nov 27.

20 OA Template Quality Indicators of Care % of times indicator entered when template used (n=828) 100% 80% 60% 40% 20% 0%

21 OA Template

22 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

23 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? Training at the end of the study Control practices

24 Quality Indicators of Care Quality Indicators of Care

25 Making Sense of MOSAICS 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). 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 Apr;106:101-9.

26 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 Apr;106:101-9.

27 MOSAICS Conference has been co-created in partnership investigates the feasibility, acceptability & impact of implementing a new approach to supporting selfmanagement for OA in primary care

28 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

29 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

30 A few numbers 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 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

31 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 ) 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

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33 Patient and Public Involvement in the MOSAICs Study My story Research User Group OA Guidebook Quality Indicators

34 Healthy person

35 Primary Care Centre 2002 Daily diary Research User Group

36 Light bulb moment Pain management programme Voluntary work Part-time employment

37 Research Users Group

38 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

39 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

40 OA Guidebook

41 History Janet Grime & Pauline Ong Reviewed relevant research papers Reviewed leaflets on OA Grime JC, Ong BN Musculoskeletal Disorders 2007; 8:34

42 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

43 Themes Do the findings seem credible? What do they say to you? Other information

44 Our Meetings Three meetings Our own experiences What was important to us? Fear of loss of independence

45 Distraction and Exercise We could relate to this Our own stories Physical Activity

46 Feelings Feelings about ageing Emotional Impact Frustration Importance of feeling valued

47 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.

48 Differences of opinion Discuss in an adult manner Frustration Who would be reading the guidebook?

49 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

50 Quality Indicators Researchers / Researcher User Group MOSAICS Study Objectives

51 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

52 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

53 European-funded study Compare OA quality Indicators across Europe Similar expectations between researcher and patients Patient involved in this study

54 Conclusion Patient involvement is valuable to researchers and patients LINKS arycare/pdfs/oa_guidebook.pdf

55 Acknowledgements EULAR European League Against Rheumatism

56 So can this approach to OA be implemented in day-to-day practice?

57 Enhancing Primary Care Management of OA in South Shropshire Dr Colin Stanford, Dr Vincent Cooper, Dr Mark Porcheret, Professor Krysia Dziedzic, Mrs Helen Duffy

58 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

59 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

60 From research study to day-to-day practice MOSAICS study - investigated the feasibility, acceptability & impact of implementing a new approach to supporting selfmanagement 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

61 OA Regional Innovation Funded Proposal 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.

62 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 GP/PN clinical champions, venues, practice nurse training workshops, travel.

63 MOAC-1 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 GP consultation MOAC-2 Nurse-led OA clinic

64 Patient report & medical records Routine data Weight records Medication Investigation X-ray records (Referral) New data TEMPLATE

65 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

66 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)

67 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

68 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

69 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

70 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

71 Project Timeline: September Launch event Practice Teams 10 th September 2014 Template Installation throughout Sept. On Line Training RCGP 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

72 Improving the management of OA NICE MOSAICS Dissemination & implementation Tools & resources Integrated care

73 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

74 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 ) 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