Title: Missed opportunities to improve care for people with musculoskeletal disorders in primary care
Funder: Department of Health and Social Care

Abstract: Primary care provides first contact, patient-focused healthcare in the community, with more than 70% of people consulting their general practitioner (GP) every year. Over 90% of all NHS contacts (including>300 million GP consultations) take place in primary care, through a range of health professionals including GPs, nurses and physiotherapists. This volume of demand creates key opportunities for primary care, including the efficient delivery of accessible services, the provision of comprehensive and continuous care throughout life, and the co-ordination of services for people with multimorbidity. 1 in 6 general practice consultations are for musculoskeletal problems. The commonest musculoskeletal conditions seen in primary care are osteoarthritis in older adults, and back pain in working age. However, primary care, is also the first point of contact for patients with early inflammatory rheumatological disorders and the main setting for the management of some of these, notably gout. Primary care, therefore, provides unique opportunities for improving the diagnosis and management of these conditions, and to significantly improve the health and well-being of patients, and reduce the health and economic impact of these conditions on individuals and society. This Fellowship focuses on two musculoskeletal conditions which pose significant, but different challenges for primary care diagnosis and management, namely osteoarthritis and gout. For both of these conditions, my prior research and that of others already provides considerable observational evidence on patterns of suboptimal management in primary care and existing opportunities for improvement. This Fellowship represents a concerted approach to intervention to address these. It consists of two distinct but complementary themes. The first theme Missed opportunities in the management of Osteoarthritis is concerned with improving care for patients with the most common and disabling musculoskeletal complaint seen in older adults. Theme 2 addresses the primary care management of chronic gout: chosen because it illustrates challenges that GPs face when managing a relatively uncommon (in terms of day to day workload) yet serious and potentially curable condition, and one which we know is currently poorly managed resulting in long term morbidity and increased mortality. This research focuses on clinical studies that have the potential to rapidly impact on improving patient care by enhancing the use of effective but underutilised interventions and by taking novel technology into the consulting room. The first workpackage in theme 1 takes advantage of the fact that many patients with osteoarthritis already attend primary care for the management of other comorbid long-term conditions. Practice nurses will be trained to opportunistically identify people who are struggling with osteoarthritis-related pain, and to identify those with concurrent anxiety or depression: comorbidities which are known to contribute significantly to increased disability. A pilot trial will evaluate the feasibility of this approach. Workpackage 2 will plug identified gaps' in the current evidence base, developing and testing interventions to address these, thus improving care for patients with osteoarthritis. The first funded trial in this workpackage will investigate the effectiveness of corticosteroid hip injections for patients with hip osteoarthritis with other clinical trials being developed over the duration of the fellowship. Theme 2 is based within a programme of research aimed at optimising the management of chronic gout by addressing key questions highlighted by the European League Against Rheumatism gout guidelines group. Two clinical trials will be developed addressing the role of self-management/self-titration of urate lowering therapy in the management of chronic gout; and investigating whether prophylaxis against acute attacks of gout is needed when initiating urate lowering therapy in primary care settings. The evidence generated by this fellowship will directly impact on patient care, inform new commissioning pathways for musculoskeletal problems and influence clinical guidelines for primary care.

Lay abstract: Arthritis and other musculoskeletal conditions are common, often highly disabling and largely managed in primary care. However, care for these conditions is frequently suboptimal and there are many missed opportunities to improve patient outcomes. This fellowship identifies gaps in our current knowledge about the optimal management of two common chronic musculoskeletal problems and proposes a series of randomised controlled trials to provide evidence on new approaches to managing osteoarthritis and gout. The evidence generated from these studies will inform future clinical guidelines and improve the range of options available to patients and clinicians in primary care.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MUSCULOSKELETAL