23 June 2015

Reducing Variation in the Care of People with Osteoarthritis

NICE’s latest quality standard on osteoarthritis includes eight statements designed to tackle variation in the care of people with osteoarthritis.

Osteoarthritis is the most common form of arthritis and a leading cause of pain and disability. It has a higher prevalence in women than men and affects around 7.3 million people in England with– a figure that is likely to rise due to an ageing population and increasing rates of obesity.

The condition causes pain which can severely impact on a person’s life and their ability to carry out daily activities.

Symptoms are often inadequately controlled, and research published in 2014 by the Royal College of Surgeons revealed variation in the rates of referral for hip replacement among CCGs. It showed that nearly three-quarters are not following NICE guidance or having a commissioning policy for this procedure.

The NICE quality standard on osteoarthritis aims to reduce variation in care through eight statements which cover the diagnosis, assessment, management, ongoing review and referral for joint surgery of adults who have osteoarthritis

Diagnosing and assessing osteoarthritis

There is a poor link between the symptoms of arthritis and the changes that can be seen through X-rays, MRIs and ultrasound. Minimal changes to joints can lead to substantial pain and modest structural changes can occur that have minimal symptoms.

Consequently the first statement says that adults aged 45 or over should be diagnosed with osteoarthritis clinically without investigations if they have activity-related joint pain and any morning joint stiffness lasts no longer than 30 minutes.

Reducing the need for further investigations will reduce the harm from X-ray exposure and limit unnecessary imaging procedures.

The second statement says that adults newly diagnosed with osteoarthritis should have an assessment that includes pain, its impact on daily activities and quality of life.

This will support self-management among patients and allow healthcare professionals to give advice and support that is positive and constructive, which has been shown to both increase patient satisfaction and effectiveness.

Exercise and weight loss

Exercise is a core treatment for osteoarthritis that will improve joint pain and function.

NICE recommends that adults with osteoarthritis are  advised to participate in muscle strengthening and aerobic exercise.

As weight loss is also a core treatment that will improve joint pain and function, the fifth statement says that adults with osteoarthritis who are overweight or obese are offered support to lose weight.

Referral for surgery

Information about osteoarthritis, activity, exercise and weight loss, are classed as core treatments that support people with arthritis to self-manage their condition and relieve their symptoms.

The seventh statement says adults with osteoarthritis should be supported with non-surgical core treatments for at least 3 months before any referral for consideration of joint surgery.

This will help reduce referrals that may not be needed, as currently a relatively low proportion of people referred for possible joint surgery progress to hip or knee replacements.

The quality standards advises against the use of scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery. While there is considerable variation in the criteria used to decide whether an adult should be considered, there is no evidence to support the scoring tools used and decisions made.

Instead, healthcare professionals should offer support and advice to patients to help reach a shared decision. This should be based on the severity of their symptoms, their general health, their expectations of lifestyle and activity, and the effectiveness of any non-surgical treatments.