Uptake of the NICE osteoarthritis guidelines in primary care: a survey of older adults with joint pain

Background Osteoarthritis (OA) is a leading cause of pain and disability. NICE OA guidelines (2008) recommend that patients with OA should be offered core treatments in primary care. Assessments of OA management have identified a need to improve primary care of people with OA, as recorded use of interventions concordant with the NICE guidelines is suboptimal in primary care. The aim of this study was to i) describe the patient-reported uptake of non-pharmacological and pharmacological treatments recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and ii) determine whether patient characteristics or OA diagnosis impact uptake. Methods A cross-sectional survey mailed to adults aged ≥45 years (n = 28,443) from eight general practices in the UK as part of the MOSAICS study. Respondents who reported the presence of joint pain, a consultation in the previous 12 months for joint pain, and gave consent to medical record review formed the sample for this study. Results Four thousand fifty-nine respondents were included in the analysis (mean age 65.6 years (SD 11.2), 2300 (56.7%) females). 502 (12.4%) received an OA diagnosis in the previous 12 months. More participants reported using pharmacological treatments (e.g. paracetamol (31.3%), opioids (40.4%)) than non-pharmacological treatments (e.g. exercise (3.8%)). Those with an OA diagnosis were more likely to use written information (OR 1.57; 95% CI 1.26,1.96), paracetamol (OR 1.30; 95% CI 1.05,1.62) and topical NSAIDs (OR 1.30; 95% CI 1.04,1.62) than those with a joint pain code. People aged ≥75 years were less likely to use written information (OR 0.56; 95% CI 0.40,0.79) and exercise (OR 0.37; 95% CI 0.25,0.55) and more likely to use paracetamol (OR 1.91; 95% CI 1.38,2.65) than those aged < 75 years. Conclusion The cross-sectional population survey was conducted to examine the uptake of the treatments that are recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and to determine whether patient characteristics or OA diagnosis impact uptake. Non-pharmacological treatment was suboptimal compared to pharmacological treatment. Implementation of NICE guidelines needs to examine why non-pharmacological treatments, such as exercise, remain under-used especially among older people

Effect of a model consultation informed by guideline on recorded quality of care of osteoarthritis (MOSAICS): a cluster randomised controlled trial in primary care

Objective To determine the effect of a model osteoarthritis (OA) consultation (MOAC) informed by National Institute for Health and Care Excellence (NICE) recommendations compared with usual care on recorded quality of care of clinical OA in general practice. Design Two-arm cluster randomised controlled trial. Setting Eight general practices in Cheshire, Shropshire, or Staffordshire UK. Participants General practitioners and nurses with patients consulting with clinical OA. Intervention Following six-month baseline period practices were randomised to intervention (n = 4) or usual care (n = 4). Intervention practices delivered MOAC (enhanced initial GP consultation, nurse-led clinic, OA guidebook) to patients aged ≥45 years consulting with clinical OA. An electronic (e-)template for consultations was used in all practices to record OA quality care indicators. Outcomes Quality of OA care over six months recorded in the medical record. Results 1851 patients consulted in baseline period (1015 intervention; 836 control); 1960 consulted following randomisation (1118 intervention; 842 control). At baseline wide variations in quality of care were noted. Post-randomisation increases were found for written advice on OA (4–28%), exercise (4–22%) and weight loss (1–15%) in intervention practices but not controls (1–3%). Intervention practices were more likely to refer to physiotherapy (10% vs 2%, odds ratio 5.30; 95% CI 2.11, 13.34), and prescribe paracetamol (22% vs 14%, 1.74; 95% CI 1.27, 2.38). Conclusions The intervention did not improve all aspects of care but increased core NICE recommendations of written advice on OA, exercise and weight management. There remains a need to reduce variation and uniformly enhance improvement in recorded OA care

A breakup model for transient Diesel fuel sprays

In this paper a breakup model for analysing the evolution of transient fuel sprays characterised by a coherent liquid core emerging from the injection nozzle, throughout the injection process, is proposed. The coherent liquid core is modelled as a liquid jet and a breakup model is formulated. The spray breakup is described using a composite model that separately addresses the disintegration of the liquid core into droplets and their further aerodynamic breakup. The jet breakup model uses the results of hydrodynamic stability theory to define the breakup length of the jet, and downstream of this point, the spray breakup process is modelled for droplets only. The composite breakup model is incorporated into the KIVA II Computational Fluid Dynamics (CFD) code and its results are compared with existing breakup models, including the classic WAVE model and a previously developed composite WAVE model (modified WAVE model) and in-house experimental observations of transient Diesel fuel sprays. The hydrodynamic stability results used in both the jet breakup model and the WAVE droplet breakup model are also investigated. A new velocity profile is considered for these models which consists of a jet with a linear shear layer in the gas phase surrounding the liquid core to model the effect of a viscous gas on the breakup process. This velocity profile changes the driving instability mechanism of the jet from a surface tension driven instability for the currently used plug flow jet with no shear layers, to an instability driven by the thickness of the shear layer. In particular, it is shown that appreciation of the shear layer instability mechanism in the composite model allows larger droplets to be predicted at jet breakup, and gives droplet sizes which are more consistent with the experimental observations. The inclusion of the shear layer into the jet velocity profile is supported by previous experimental studies, and further extends the inviscid flow theory used in the formulation of the classic WAVE breakup model

Cost-effectiveness of a model consultation to support self-management in patients with osteoarthritis

Objectives: The aim of this study was to estimate the cost-effectiveness of a model OA consultation for OA to support self-management compared with usual care. Methods: An incremental cost-utility analysis using patient responses to the three-level EuroQoL-5D (EQ-5D) questionnaire was undertaken from a UK National Health Service perspective alongside a two-arm cluster-randomized controlled trial. Uncertainty was explored through the use of cost-effectiveness acceptability curves. Results: Differences in health outcomes between the model OA consultation and usual care arms were not statistically significant. On average, visits to the orthopaedic surgeon were lower in the model OA consultation arm by -0.28 (95% CI: -0.55, -0.06). The cost-utility analysis indicated that the model OA consultation was associated with a non-significant incremental cost of £-13.11 (95% CI: -81.09 to 54.85) and an incremental quality adjusted life year (QALY) of -0.003 (95% CI: -0.03 to 0.02), with a 44% chance of being cost-effective at a threshold of £20 000 per QALY gained. The percentage of participants who took time off and the associated productivity cost were lower in the model OA consultation arm. Conclusion: Implementing National Institute for Health and Care Excellence guidelines using a model OA consultation in primary care does not appear to lead to increased costs, but health outcomes remain very similar to usual care. Even though the intervention seems to reduce the demand for orthopaedic surgery, overall it is unlikely to be cost-effective

Relationship of anxiety with joint pain and its management: A population survey

Objectives The aims of the present study was to examine the associations between the severity of pain and anxiety in a community population reporting joint pain, and to investigate the management of joint pain in the presence of comorbid anxiety. Methods A population survey was carried out of people aged ≥45 years, registered with eight general practices in Cheshire, Shropshire and Staffordshire, UK. Respondents were asked to report pain intensity in their hands, hips, knees and feet (on a numerical rating scale), anxiety symptoms (Generalized Anxiety Disorder seven‐item [GAD‐7] scale) and guideline‐recommended treatments used to manage pain. Clinical anxiety was defined by a GAD‐7 score of 10 or more. Results A total of 11,222 respondents with joint pain were included in the analysis, with 1,802 (16.1%) reporting clinical anxiety. Respondents reporting more severe pain were more likely to report clinical anxiety (severe versus mild pain, odds ratio [OR] 5.36, 95% confidence interval [CI] 4.56 to 6.31). The number of pain sites was also positively associated with clinical anxiety (four versus one site; OR 3.64, 95% CI 3.09 to 4.30). Those with clinical anxiety were less likely to undertake general fitness exercises (OR 0.60, 95% CI 0.52 to 0.70), but more likely to diet (OR 1.43, 95% CI 1.21 to 1.69), use walking aids (OR 1.53, 95% CI 1.32 to 1.77) and assistive devices (OR 1.24, 95% CI 1.04 to 1.49), and more likely to use opioids (OR 1.34, 95% CI 1.18 to1.52). Conclusions Anxiety is common among patients presenting to primary care with joint pain. Patients with anxiety are likely to manage their joint pain differently to those without. Case‐finding to identify and treat anxiety would be appropriate in this population, with caution about opioid prescribing and consideration of exercise as an intervention

Arginine deprivation alters microglia polarity and synergises with radiation to eradicate non arginine auxotrophic glioblastoma tumors

New approaches for the management of glioblastoma (GBM) are an urgent and unmet clinical need. Here, we illustrate that the efficacy of radiotherapy for GBM is strikingly potentiated by concomitant therapy with the arginine depleting agent ADI-PEG20 in a non-arginine auxotrophic cellular background (Arginine Succinate Synthetase 1 positive). Moreover, this combination led to durable and complete radiological and pathological response with extended disease-free survival in an orthotopic immune competent model of GBM with no significant toxicity. ADI-PEG20 not only enhances the cellular sensitivity of Arginine succinate synthetase 1 positive GBM to ionising radiation by elevated production of nitric oxide (NO) and hence generation of cytotoxic peroxynitrites, but also promotes glioma-associated macrophages/microglia infiltration into tumors and turns their classical anti-inflammatory (pro-tumor) phenotype into a pro-inflammatory (anti-tumor) phenotype. Our results provide an effective, well-tolerated and simple strategy to improve GBM treatment which merits consideration for early evaluation in clinical trials

World Heart Federation Roadmap on Atrial Fibrillation - A 2020 Update

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world’s population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great

Implementing core NICE guidelines for osteoarthritis in primary care with a model consultation (MOSAICS): a cluster randomised controlled trial

Objective: To determine the effectiveness of a model osteoarthritis consultation, compared with usual care, on physical function and uptake of NICE osteoarthritis recommendations, in adults ≥45 years consulting with peripheral joint pain in UK general practice. Method: Two-arm cluster-randomised controlled trial with baseline health survey. Eight general practices in England. Participants: 525 adults ≥45 years consulting for peripheral joint pain, amongst 28,443 population survey recipients. Four intervention practices delivered the model osteoarthritis consultation to patients consulting with peripheral joint pain; four control practices continued usual care. The primary clinical outcome of the trial was the SF-12 physical component score (PCS) at six months; the main secondary outcome was uptake of NICE core recommendations by six months, measured by osteoarthritis quality indicators. A Linear Mixed Model was used to analyse clinical outcome data (SF-12 PCS). Differences in quality indicator outcomes were assessed using logistic regression. Results: 525 eligible participants were enrolled (mean age 67.3 years, SD 10.5; 59.6% female): 288 from intervention and 237 from control practices. There were no statistically significant differences in SF-12 PCS: mean difference at the 6-month primary endpoint was -0.37 (95% CI -2.32, 1.57). Uptake of core NICE recommendations by six months was statistically significantly higher in the intervention arm compared with control: e.g. increased written exercise information, 20.5% (7.9, 28.3). Conclusion: Whilst uptake of core NICE recommendations was increased, there was no evidence of benefit of this intervention, as delivered in this pragmatic randomised trial, on the primary outcome of physical functioning at six months. Trial registration: ISRCTN06984617