Study aims to test extended review of LTCs to improve management of OA and anxiety/depression
Joint pain, anxiety and depression commonly co-exist with other long-term conditions, yet are seldom prioritised, resulting in under-detection and sub-optimal treatment in primary care. Can practice nurses take the lead on detecting and guiding treatment for those with multi-morbidity?
Researchers at The Research Institute for Primary Care and Health Sciences, Keele University are embarking on a pilot trial called the ‘ENHANCE study’ to test the acceptability and feasibility of a new model of care embedded within long-term condition (LTC) reviews (diabetes, asthma, COPD and hypertension/ischemic heart disease).
The intervention will be delivered by practice nurses who will receive additional training to identify (case-find) and initially manage OA related joint pain and anxiety and/or depression as part of their routine LTCs review, aided by an extended review (the ENHANCE review) and an amended LTC EMIS template (the ENHANCE template).
The aim of the ENHANCE review is to tackle the under-recognition and under-management of OA related joint pain and anxiety and/or depression in patients with LTCs.
A number of complementary methods have been used to develop the ENHANCE review, including an evidence synthesis of the most recent, high quality reviews, clinical guidelines and policy documents relating to case-finding and treatment of OA and anxiety and depression. A practice nurse focus group further informed the requirements for training and investigated views on barriers and enablers to implementation.
A training package is being developed, and a pilot stepped wedge randomised controlled trial (RCT) will be undertaken to examine the acceptability and feasibility of this new practice nurse-led model of care.
Over a quarter of the population in England (15.4 million people) have LTCs that account for around half of all GP appointments.1 Primary care is seen as the optimal setting to deliver care for people with these conditions, with practice nurses taking the lead in many cases.
The majority of NICE guidelines focus on a single condition, but multi-morbidity, defined as the co-occurrence of two or more LTCs in the same person,2 is increasing, and the number of people with three or more LTCs is expected to rise from 1.9 million in 2008 to 2.9 million in 2018.1 Furthermore, management of many LTCs is incentivised by the Quality and Outcomes Framework (QOF) but for LTCs not included in QOF (e.g. osteoarthritis, anxiety), or those conditions with more subjective outcomes (e.g. depression), care frequently remains suboptimal and health care needs often go unidentified.3,4
Musculoskeletal conditions and mental health problems are common and frequently co-exist, both with each other and with other LTCs.5 Osteoarthiritis is the most common musculoskeletal condition in older adults and is commonly found as a comorbid condition with other LTCs.6 People with osteoarthritis are twice as likely to suffer from heart disease as those in the general population,7 and commonly experience anxiety and depression symptoms.5
People with co-morbid joint pain and mental health problems, such as anxiety and depression, will have higher levels of disability, poorer prognosis and increased health care costs. The NICE guideline for generalised anxiety disorders suggests that primary care practitioners should consider the diagnosis of anxiety or depression in people with a LTC who frequently attend primary care.8 Despite this, anxiety symptoms remain under-diagnosed and under-treated in primary care.9
Although practice nurses manage a range of LTCs, there is evidence to suggest that practice nurses do not have access to the training needed to manage musculoskeletal conditions and as such may lack the skills and confidence to deal with these conditions.10,11 And historically, the management of anxiety and depression has been considered the role of the GP and/or Mental Health Team.12 To take a pro-active role in the recognition and treatment of these co-morbidities, practice nurses require specialised training to build on their many transferable skills.
CONCLUSION
The prevalence of multi-morbidity in people with LTCs is increasing and practice nurses are increasingly being recognised as the ‘gatekeepers’ of care for those with such conditions. OA related joint pain, anxiety and depression often co-exist with many LTCs and with targeted training practice nurses may be in a prime position to lead on the recognition and initial management for these specific conditions. The ENHANCE study will test a new practice nurse-led intervention, to examine the feasibility and acceptability of this integrated approach to the management of patients with LTCs, tackling the under-diagnosis and under-management of OA-related joint pain and anxiety and/ or depression in primary care.
Disclaimer
The ENHANCE study is funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care West Midlands and a NIHR Research Professorship in General Practice (NIHR-RP-2014-04-026). The paper presents independent research and the views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
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