Narrative synthesis of exemplar indicators and their feasibility for use in primary care
| Overarching theme (source) | ‘Exemplar’ indicator | Reproducibility (other sources of similar indicators) | Implementation references and comment on feasibility |
|---|---|---|---|
| Holistic Assessment: Pain (EULAR (all sites), NICE) | IF a vulnerable elder has symptomatic OA of the knee or hip, THEN pain should be assessed when new to a primary care or musculoskeletal disease practice and annually… (ACOVE-3)46–48 | RAND QA,29 ACOVE-1,32 33 and as adapted (ELSA,41 HPCQI45), Arthritis Foundation,51 52 PCPI,54 EUMUSC.net55 | 12 13 30 31 34 35 38 40 Requires change in routine coding to improve capture of this information |
| Holistic Assessment: Function (ACR (hand), EULAR (all sites), NICE ) | IF a vulnerable elder has symptomatic OA of the knee or hip, THEN functional status should be assessed when new to a primary care or musculoskeletal disease practice and annually…(ACOVE-3)46–48 | RAND QA,29 ACOVE-1,32 33 and as adapted (ELSA,41 HPCQI45), Arthritis Foundation,51 52 PCPI54 | 12 13 30 31 35 38 40 Requires change in routine coding to improve capture of this information |
| Education (EULAR (all sites), NICE, OARSI) | IF a patient has had a diagnosis of symptomatic OA of the knee or hip for >3 months, THEN education about the natural history, treatment, and self-management of OA should have been given or recommended at least once…(Arthritis Foundation)51 52 | ACOVE-1 (2 variations—new and pre-existing disease),32 33 and as adapted (ELSA41), EUMUSC.net55 | 12–14 34 38 40 Requires change in routine coding to improve capture of this information |
| Exercise 1 and 2 (ACR (hip, knee), EULAR (all sites), NICE, OARSI | IF an ambulatory vulnerable elder has symptomatic OA of the knee or hip for longer than 3 months and is able to exercise, THEN a directed or supervised muscle strengthening or aerobic exercise program should be recommended and activity reviewed annually…(ACOVE-3)46–48 | Initial recommendation RAND QA,29 ACOVE-1 (indicators for new and pre-existing disease),32 33 and as adapted (ELSA,41 ACOVE/NH,42 HPCQI45), Arthritis Foundation,51 52 PCPI,54 EUMUSC.net55 Annual review RAND QA,29 ACOVE-132 33 | Initial recommendation 14 30 31 34 37 38 40 43 53 Annual review 53 Requires change in routine coding to improve capture of this information |
| Weight loss 1 (ACR (hip, knee), NICE, OARSI | IF a vulnerable elder is obese (body mass index (BMI) ≥30 kg/m2), THEN he or she should be advised annually to lose weight… (ACOVE-3)46–48 | Arthritis Foundation51 52 | No implementation studies identified for this indicator. Should be captured from existing weight and health promotion records |
| Weight loss 2 (ACR (hip, knee), NICE, OARSI | IF a patient has symptomatic OA of the knee or hip and is overweight (as defined by body mass index of ≥27 kg/m2), THEN the patient should be advised to lose weight at least annually AND the benefit of weight loss on the symptoms of OA should be explained to the patient…(Arthritis Foundation)51 52 | EUMUSC.net55 | 40 53 Consider a lower BMI threshold of 25 kg/m2 for consistency with the usual definition of ‘overweight’. Should be captured from existing weight and health promotion records. |
| Aids and devices 1 (ACR (hip, knee), EULAR (hip, knee), NICE, OARSI) | IF a vulnerable elder has symptomatic OA of the hip or knee and has difficulty walking that makes ADL difficult for longer than 3 months, THEN the need for ambulatory assistive devices should be assessed…(ACOVE-3)46–48 | Arthritis Foundation,51 52 EUMUSC.net55 | 40 53 Requires change in routine coding to improve capture of this information |
| Aids and devices 2 (ACR (hand), NICE) | IF a vulnerable elder has symptomatic OA and has difficulty with non-ambulatory ADL, THEN the need for ADL assistive devices should be assessed… (ACOVE-3)46–48 | Arthritis Foundation,51 52 EUMUSC.net55 | 40 53 Requires change in routine coding to improve capture of this information |
| Paracetamol 1 (ACR (hip, knee), EULAR (all sites), NICE, OARSI) | IF a vulnerable elder is started on pharmacological therapy to treat OA, THEN acetaminophen should be tried first… (ACOVE-3)46–48 | RAND QA,29 ACOVE-1,32 33 and as adapted (ELSA,41 ACOVE/NH,42 HPCQI45), QIGP,49 Arthritis Foundation,51 52 | 12–14 30 31 34 36–38 40 43 50 Requires change in routine coding to capture over-the-counter drug use |
| Paracetamol 2 (ACR (hip, knee), EULAR (all sites), NICE, OARSI) | IF oral pharmacological therapy for OA is changed from acetaminophen to a different oral agent, THEN there should be evidence that the patient has had a trial of maximum dose acetaminophen (suitable for age/comorbidities)….(Arthritis Foundation)51 52 | ACOVE-1,32 33 and as adapted (ELSA,41 ACOVE/NH,42 HPCQI45) | 12 13 34 36 43 Requires change in routine coding to capture over-the-counter drug use |
| Oral NSAIDs 1 (all guidance) | If NSAIDs are considered, ibuprofen should be considered for first-line treatment unless contraindicated or intolerant.* (QIGP)49 | Modifications exist in implementation studies: Steel et al,12 Broadbent et al13 to include use of COX-2 selective drugs | 12 13 50 Requires change in routine coding to capture over-the-counter drug use. |
| Oral NSAIDs 2 (all guidance) | Percentage of patients aged 21 years and older with a diagnosis of OA on prescribed or OTC NSAIDs who were assessed for GI and renal risk factors. (PCPI)54 | Two indicators from ACOVE-3 refer to risks from NSAIDs and aspirin to be ‘discussed and documented’,46–48 EUMUSC.net55 | 12 13 Requires change in routine coding to capture over-the-counter drug use |
| Gastroprotection (EULAR (all sites), NICE, OARSI) | IF a vulnerable elder with a risk factor for GI bleeding (aged ≥75, peptic ulcer disease, history of GI bleeding, warfarin use, chronic glucocorticoid use) is treated with a non-selective NSAID, THEN he or she should be treated concomitantly with misoprostol or a PPI. (ACOVE-3)46–48 | ACOVE-1,32 33 ACOVE-3 46–48 (NSAIDs, and aspirin), QIGP,49 PCPI54 | 34–39 44 50 Should be captured from existing electronic prescribing records |
| Specialist referral (EULAR (all sites), NICE, OARSI) | IF a VE has severe symptomatic OA of the knee or hip despite non-surgical therapy, THEN a referral to an orthopaedic surgeon should be made, BECAUSE joint surgery may reduce pain and improve functional status and quality of life. (ACOVE-3)46–48 | RAND QA,29 ACOVE-1,32 33 and as adapted (ELSA41), Arthritis Foundation,51 52 QIGP,49 EUMUSC.net55 | 12–14 37 38 40 50 It would be feasible to capture the presence of non-surgical therapy indicators in the record, though routine data sources cannot be used to determine the need for a surgical opinion reliably |
*It should be noted that different sources of guidance offer varying recommendations about the use of specific NSAIDs; in the UK, NICE recommend a standard NSAID or COX-2 inhibitor (other than etoricoxib 60mg) to be coprescribed with a PPI.8
ACOVE, Assessing Care of Vulnerable Elders; ACR, American College of Rheumatology; ADL, activities of daily living; COX, cyclooxygenase, ELSA, English Longitudinal Study of Ageing; EULAR, European League Against Rheumatism; EUMUSC.net, European Musculoskeletal Conditions Surveillance and Information Network; GI, gastrointestinal; HPCQI, Home-based Primary Care Quality Initiative; NH, nursing home; NICE, National Institute for Health and Care Excellence; NSAIDs, non-steroidal anti-inflammatories; OA, Osteoarthritis; OARSI, Osteoarthritis Research Society International; OTC, over the counter; PCPI, Physician Consortium for Performance Improvement; PPI, proton-pump inhibitor; QA, Quality Assessment; QIGP, Quality Indicators for General Practice; VE, vulnerable elder.