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

This paper is one component of the ‘Management of OSteoArthritis In ConsultationS’ (MOSAICS) study [8, 9]. The data were derived from a cross-sectional population survey. A linked medical record review was conducted in order to estimate morbidity burden and identify the presence of any formal OA diagnosis. The findings are reported in line with the STROBE guidelines [10].

A 12 month period for diagnosis and consultation was selected to maximise accurate recall, to reflect those who had recently sought health care, and to include experience since the NICE guidelines had been published.

The study population was described in terms of socio-demographic factors, health status, recorded formal OA diagnosis in the last 12 months, morbidity burden, and number of self-reported joint pain sites (dichotomised into single or multiple). Uptake of recommended treatments was described in the study population, stratified by responder age-group.

Descriptive statistics were used, with mean and standard deviation (SD), frequency counts and percentages (as appropriate) presented. Age was grouped by decades and skewed data such as the SF12-PCS and SF12-MCS were categorised based on quartile scores to determine any association between health status and uptake of recommended treatments. A chi-squared test-for-trend was employed to estimate relationships between uptake of recommended treatments and age group.

Multivariable logistic regression analyses were carried out to estimate associations between participants’ socio-demographic and health factors and the uptake of non-pharmacological and pharmacological treatments. The multivariate model was fully inclusive of all variables listed in Table 3. Results are shown as fully-adjusted odds ratios (AOR) with 95% confidence intervals (CI).

Data analysis was performed using IBM SPSS Statistics version 21 (Armonk, NY, USA) and STATA version 13 (StataCorp, 2013).

This study examined one example of a national guideline of best primary care for OA and found evidence that those with OA report a lack of guideline-based advice and treatment; a finding that was particularly predominant in the oldest ages. This is similar to treatment patterns for knee pain demonstrated prior to 2008 [15]. Semi-structured interviews with older adults with knee pain in a 2008 study had identified an early reliance on pharmacological treatments and underuse of non-pharmacological interventions in early treatment choices [15]. Exercise of any type for OA has also previously been found to be under-used in primary care [16].

A strength of this survey is the large sample size achieved ensuring greater precision in estimates and sufficient power to test statistical associations. Use of self-reported information has some advantages to medical record use as non-pharmacological interventions and over-the-counter drug use are poorly-recorded in medical records. The heterogeneity of practice characteristics across the sample increases the generalisability of the findings to the UK population as a whole. Due to the nature of the data collection, one potential limitation of this study is recall bias. A recall period of up to 12 months may have affected participants’ ability to accurately self-report information about their consultation behaviours and treatments used. As the study focused on treatments over the previous 12 months, it was also impossible to determine whether other treatments had been tried prior to moving onto further treatments (e.g. a trial of non-pharmacological treatments prior to first-line pharmacological options). It is not known whether people reporting use of treatments were responding to clinical recommendations or acting independently; for those not using treatments, they may not have been advised to do so or chosen not to. Although we performed multiple comparisons, the main conclusions rest on plausible and consistent associations across ages and comparable aspects of care. The NICE 2008 guidelines have been updated in 2014 [17]. Although the patient survey data were collected before the 2014 update, there is no reason to suspect that clinical practice would be particularly different since the guideline update, especially since the emphasis on non-pharmacological strategies is retained in the 2014 update. The issues raised by the findings of this survey remain very relevant.

This survey considered everyone with a self-reported consultation for joint pain in the previous 12 months. Only 12.4% of the study population had a recorded OA diagnosis in their medical record during this period, though study participants may have received an OA diagnosis prior to this. People with recorded peripheral joint pain have previously been identified to have a similar preponderance of radiographic OA compared to those with an OA diagnosis [18] and so it is reasonable to consider that the OA guidelines would apply to the whole study population.

In the adjusted models, which accounted inter alia for sex, age, morbidity burden, and clinical severity (through the SF-12 PCS and multi-site pain variable, as multi-site pain is associated with symptom severity [19]), the main variable associated with lower likelihood of use of the core non-pharmacological treatments was older age. The association between older age and reduced use of information may reflect a duration effect, if older people had used it previously, though it could also be due to other factors.

It is possible that the lower use of exercise was due to patient or clinician beliefs about the appropriateness of exercise in the elderly. It has previously been identified that only 16% of men and 12% of women aged ≥65 in the general population achieve recommended physical activity levels [20], therefore while this finding is not surprising, it is in contrast to the NICE universal recommendation for exercise in people with OA despite age.

Increasing age was also associated with greater use of paracetamol. Strauss et al. [21] demonstrated that patients with a preference towards the pharmacological options were generally older, though in this study it is not known if greater paracetamol use is influenced by patient- or clinician-level management. Clinical severity, measured by the SF-12 PCS and the multisite pain variable, appears to be associated with greater use of information. Worse physical function was also associated with greater use of exercise and first-line pharmacotherapy. The latter finding is unsurprising but it is encouraging that people with worse physical function reported greater use of exercise.

This study indicates the potential importance of an OA diagnosis. People with such a diagnosis recently recorded were more likely to report having used treatments recommended in the NICE OA guidelines, i.e. certain core non-pharmacological treatments (exercise and provision of written information) and the first-line pharmacological treatments. This corresponds with previous work by our group which showed that those with an OA diagnosis were more likely to have clinician-recorded quality indicators of care than those with a joint pain symptom code [22]. It raises the possibility that, when GPs themselves are clearer about the diagnosis, there may be better uptake of the treatments that are recommended in the NICE OA guidelines by the patient, which reflects other findings about the nature of OA consultations in primary care [23].

Clinically, the known benefits of exercise [24] and weight loss [25] for hip and knee OA need to be better integrated into routine clinical practice to help reduce the apparent suboptimal uptake in the population with joint pain at large, and in the elderly in particular. Patients and clinicians need to be aware of the benefits of non-pharmacological interventions, to access these early in the course of OA and avoid reliance on pharmacological management.

A particular challenge will be to determine how to maximise patient participation in and adherence to exercise in the long-term. Evidence of barriers and facilitators of exercise adherence related to OA is not strong, although systematic reviews have highlighted the importance of educational and behavioural strategies as well as regular individualised exercise, supervision and follow-up [26, 27]. Future interventions incorporating these components should be tested to find the best way of increasing and maintaining exercise levels in this population in the long-term.