Background
Methods
Stage 1 - ideas generation round
Initial development
The advisory group
Stage 2 - consensus questionnaire
-
A 57 year old attends the GP for the first time with a knee problem. The problem has worsened over the past few months and the patient has come to ask for help coping with it.
Stage 3 - consensus rounds
Sample size calculation and recruitment of expert groups
Composition and characteristics of expert groups
Characteristic | Number (%) group members |
---|---|
GP Group (n = 15)
| |
Female | 6 (40) |
Qualified as a GP for 5 yrs or longer | 12 (80) |
Undertakes dedicated musculoskeletal sessions | 11 (73) |
Practice type – urban/rural/mixed | 10 (67)/1 (7)/4 (26) |
Practice list size greater than 7 000 | 10 (67) |
Undergraduate or postgraduate training practice | 14 (93) |
Patient Group (n = 14)
| |
Female | 6 (43) |
Reported “having osteoarthritis” | 13 (93) |
Reported ever consulting for osteoarthritis | 11 (79) |
Reported caring for someone with osteoarthritis | 3 (21) |
Undertaking consensus rounds
Analysis of round 2 responses
Stage 4 - defining consensus
Number of statements by level of agreement
Level of agreement for inclusion (%) | GP Group | Patient Group | ||||
---|---|---|---|---|---|---|
No. of statements | Cumulative level of agreement (%) | No. of statements cumulatively included | No. of statements | Cumulative level of agreement (%) | No. of statements cumulatively included | |
100 | 11 | 100 | 11 | 2 | 100 | 2 |
90 – 99 | 14 | > = 90 | 25 | 4 | > = 90 | 6 |
80 – 89 | 4 | > = 80 | 29 | 5 | > = 80 | 11 |
70 – 79 | 5 | > = 70 | 34 | 10 | > = 70 | 21 |
60 – 69 | 8 | > = 60 | 42 | 16 | > = 60 | 37 |
50 – 59 | 3 | > = 50 | 45 | 9 | > = 50 | 46 |
<50 | 16 | 15 |
“Setting the bar”
Results
Statement1
| No. (%) GP Group would include (n = 15) | No. (%) Patient Group would include (n = 14) |
---|---|---|
The GP:2
| ||
Encourages the patient to give a full account of the problem(s), including the reason for coming today | 15 (100) | 11 (79) |
Finds out how long the patient has had the knee problem for and whether the problem comes and goes | 14 (93) | 12 (86) |
Asks specific questions about the amount and type of any pain | 14 (100) | 11 (79) |
Asks about other knee symptoms such as stiffness, locking and giving way | 13 (93) | 12 (86) |
Asks about problems with mobility, such as walking, going up and down stairs, and getting in and out of a chair | 13 (93) | 9 (64) |
Asks if, and how, the knee problem affects activities such as work, hobbies, sports and general leisure activities | 14 (100) | 7 (50) |
Asks about previous problems with the knee, knee operations, knee injections | 13 (93) | 11 (79) |
Asks about problems with other joints, especially the other knee and the hips | 14 (93) | 8 (62) |
Asks about the patient’s ideas, concerns, fears and feelings about the problem | 14 (93) | 7 (54) |
Asks if the patient has tried anything to help the problem, and if yes, what/how used/how effective
|
15 (100)
|
12 (92)
|
Checks if there is anything in the patient’s story to suggest a fracture, cancer, inflammatory or septic arthritis | 14 (93) | 7 (54) |
Examines the knee joint and surrounding tissues | 15 (100) | 11 (85) |
Informs the patient that the most likely reason for the problem is osteoarthritis and explains the reason(s) for coming to this diagnosis
|
15 (100)
|
12 (92)
|
Gives a brief explanation of osteoarthritis
|
14 (93)
|
12 (92)
|
Asks if the patient has any unanswered questions | 15 (100) | 8 (57) |
Hands the guidebook to the patient with the advice to read it | 14 (93) | 8 (62) |
Encourages the patient to consider the use of “NICE core treatments”, increased physical activity/muscle strengthening exercises/dietary changes to lose weight, if needed | 14 (93) | 10 (77) |
Emphasises, when relevant, the benefit of losing weight: that if weight is lost then the pain reduces | 14 (93) | 10 (77) |
Emphasises, when relevant, the benefit of exercise in helping to lose weight in addition to the benefits for osteoarthritis | 14 (93) | 8 (62) |
Enquires about the patient’s need for painkillers
|
15 (100)
|
13 (100)
|
Recommends the use of paracetamol and/or topical NSAIDs (creams or ointments) before the use of other painkillers
|
15 (100)
|
13 (100)
|
Summarises the management plan and re-checks that it is acceptable to the patient | 14 (93) | 9 (64) |
Advises the patient to make a follow up appointment with the specially trained healthcare professional
|
15 (100)
|
13 (93)
|
Uses free-text to record the consultation in the paper/electronic records | 14 (93) | 8 (67) |
In addition to statement above records coded data on the; i) diagnosis and ii) main elements of the consultation, such as the level of pain, the BMI and advice to exercise | 15 (100) | 10 (77) |
Statement | No. (%) GP group would include (n = 15) | No. (%) Patient group would include (n = 14) |
---|---|---|
The GP:* | ||
Assesses the degree of pain using a formal measure, such as rating the pain on a scale from 0 to 10 | 1 (7) | 8 (57) |
Assesses the extent of mobility problems using a formal measure, such as a rating scale from 0 to 10. | 1 (7) | 7 (50) |
Asks about a family history of joint problems | 6 (43) | 4 (29) |
Asks about jobs which may have affected/caused the knee problem, such as those involving a lot of kneeling (for example, carpet fitter, cleaner, joiner, electrician) | 9 (64) | 5 (36) |
Asks about the patient’s expectations of the consultation | 10 (67) | 4 (31) |
Asks which problem, concerning the knee, the patient wants help with most, for example pain, stiffness or climbing the stairs | 9 (60) | 5 (38) |
Asks about who the patient has seen, or asked for help from, about the problem | 10 (71) | 6 (46) |
Assesses the patient’s mood for symptoms of anxiety and depression | 8 (53) | 1 (8) |
Screens the patient for depression using a formal depression screening tool | 0 (0) | 0 (0) |
Asks about other conditions, such as diabetes, heart or kidney disease, which might affect the management of the knee problem | 10 (67) | 9 (64) |
Asks about circumstances, such as unemployment and financial hardship, which might affect the management of the knee problem | 5 (33) | 0 (0) |
Assesses the knee joint by general observation of the patient’s walking pattern, mobility and footwear | 13 (87) | 9 (69) |
Performs a specific test, such as a timed walk test, to assess function | 0 (0) | 3 (21) |
Examines the other knee, hips and hands for signs of osteoarthritis | 11 (73) | 10 (71) |
If not recently done, measures weight and height to calculate the body mass index | 6 (40) | 6 (46) |
Undertakes a full examination of the locomotor system (of the joints and muscles) | 0 (0) | 4 (33) |
Enquires about the patient’s views and understanding of osteoarthritis | 13 (87) | 9 (75) |
In addition to giving a brief explanation explains the likely cause of osteoarthritis | 4 (27) | 9 (69) |
In addition to giving a brief explanation explains the likely outcome for people with osteoarthritis | 9 (60) | 8 (62) |
Explores the patient’s understanding of the information given, and their reaction/beliefs/feelings about it | 8 (53) | 8 (62) |
Tells the patient that they are central to the management of their own condition: that self-management of osteoarthritis is necessary and important | 13 (87) | 11 (85) |
Explains that the central role of the primary healthcare team in the management of osteoarthritis is to support and guide self-management | 7 (47) | 9 (69) |
Explains the purpose of managing osteoarthritis to: improve understanding, reduce pain, improve mobility and reduce the risk of it getting worse | 9 (60) | 12 (86) |
Explains the approach to the treatment of osteoarthritis recommended by NICE | 3 (20) | 8 (62) |
In addition to handing out the guidebook highlights sections in the guidebook relevant to the patient’s problem | 6 (40) | 6 (46) |
Asks if the patient has any views/preferences for what treatment they might want to consider next, and, if they do, what they are | 12 (80) | 6 (43) |
Takes an “exercise history”: the patient’s attitude to taking exercise/physical activity/exercises and their experience of these | 9 (60) | 6 (43) |
Takes a “weight history”: the patient’s attitude to losing weight and their prior experience of doing this | 7 (47) | 9 (69) |
Indicates, if the patient is overweight, where they are on a body mass index chart | 7 (47) | 9 (69) |
Explains that exercise may cause muscle soreness initially and that the benefits of exercise may not be immediate | 9 (60) | 5 (38) |
Explains the risks and benefits of painkillers | 11 (73) | 6 (50) |
Discusses with the patient whether any other extra treatment needs to be considered | 7 (47) | 8 (67) |
Discusses appropriate referrals, for example to; physiotherapy, occupational therapy, podiatry, social services, community pharmacy, district nursing service or work support services | 8 (53) | 10 (71) |
Discusses the option of joint replacement surgery in patients with established severe pain, or severe functional limitation, in addition to core treatments and painkillers | 7 (47) | 7 (54) |
Formulates with the patient a self-management plan | 11 (73) | 10 (77) |
Explains when the patient should re-consult the GP | 11 (73) | 8 (57) |