After reviewing the 2014 publication of NICE clinical guidance 177 (CG177) for Osteoarthritis: care and management in adults, a way of introducing the key points of education, self-management and non-pharmacological interventions into our management of lower limb osteoarthritis was developed.
The aim was to create a cost effective yet high quality and efficient treatment pathway. A six week programme was formed focusing on education with a holistic approach to each person, and exercises to improve an individual’s strength and fitness.
The overall objective was that the person is able to self-manage their condition more effectively. A mini audit of the effectiveness of the 2015 OASIS group has confirmed an improvement in functional outcomes in over 70% of patients, over 60% reported reduced pain levels and the DNA rate is less than 6%. The CQC inspectors also commented that with the OASIS group incorporated national guidelines and exhibit “evidence and quality into clinical practice”.
Example
Aims and objectives
Aims:
- To facilitate the rehabilitation and self-management of patients with lower limb OA through exercise and education.
- Provide a cost effective and time efficient treatment pathway for patients with lower limb OA.
- Create an empowering and enjoyable patient journey from diagnosis to self-management.
Objectives:
- To increase function and to reduce pain based on validated outcome measure scores.
- To reduce the numbers of referrals on to secondary care for arthroplasty.
- To empower patients to confidently self-manage their condition in its current state and in the future.
- Provide a suite of documentation and patient education leaflets/hand-outs/posters to facilitate understanding.
- To implement an evidenced based exercise regime targeted at improving muscle strength, aerobic fitness and function.
- Create an ever evolving service based on new evidence, outcomes, and patient satisfaction and feedback.
Reasons for implementing your project
Osteoarthritis is the primary cause of disability in the elderly. Each year £250 million is spent on community and social services for osteoarthritis-related problems. AposTherapy UK1 states that if you mix together the demographic time bomb that faces us with an ageing population that wants to remain active, you have the potential for this problem to become the climate change of the health economy.
The Integrated Physiotherapy Orthopaedic and Pain Service (IPOPS) covers the Lichfield, Tamworth and Burntwood areas, with a combined population of approximately 180,000 people based on 2015 Public Health England data2, which also showed a slightly above average life expectancy compared to the national average leading to potential increased costs in the future. In 2014, an audit was published on the OA Lower Limb rehab group, looking at the functional outcome measure trends for groups that had been undertaken between 2011 and 2013. The results showed that for patients who attended all 6 sessions in the programme had a 6.33 times greater chance of improving in all functions than those who did not.
The opportunity presented itself to reform the group with the release of the NICE clinical guidelines in 2014. A steering group was therefore formed to act upon audit data and patient/clinician feedback to analyse and ensure that current practice was aligned with the new guidelines, whilst providing a cost-effective and efficient pathway that meets the Clinical Commissioning Group targets.
NICE Guidance CG177 states that exercise should be the core treatment for people with osteoarthritis and include local muscle strengthening and general aerobic fitness. However it is unclear as to how and in what setting this is best delivered. We should also aim to enhance the patients understanding of the condition and its management.
Based on this guidance, we built upon the foundations of the rehab group already in place to develop a programme with appropriate and progressive exercise at its core, alongside key education about osteoarthritis to heighten the patient’s confidence in self-management through learning and understanding to create a holistic approach to treatment. The benefit of incorporating NICE guidance has been shown with 95% of patients improving in at least one functional measure and 91% improving in at least 2. Pain levels also reduced in 52% of patients.
How did you implement the project
Following the initial audit in 2014, the steering group was formed, which included all physiotherapy assistants who provide the keystone in implementing the programme, physiotherapists and invited patients feedback related to any improvement/changes. The group met to analyse and critique latest evidence and guidance to form the basis of the patient centred education.
This information was delivered in dedicated teaching session within the group format and specifically created supplementary hand-outs and included:
- Background information on OA to increase knowledge of the condition.
- Lifestyle factors including weight management and smoking.
- Pain management with use of pain relief and the theory of pain sciences.
- Pacing and grading strategies to incorporate into activities of daily living.
- Managing flare-ups to help decrease the fear of pain and reliance on health services in the future.
- Self-management for long term conditions.
The core component that the group addressed was the implementation of an evidenced based exercise regime. Following a review of the literature, a new functional circuit was introduced to the session to incorporate general ADL’s in to one gym setting. However, patient feedback reported that a 10-station circuit was preferred. Therefore a new set of 10 functional exercises were introduced with the goals of the patients in mind. This then evolved to include a graded approach to each station to create a more bespoke style for each individual, based on their personal ability.
To ensure that this programme was as cost effective as possible, the education and exercise were combined into a 60 minute session, once weekly over a 6 week period. The group can accommodate up to 10 individuals and is overseen by 1-2 physiotherapy assistants. This in-house set up has incurred no additional costs, and results in OASIS creating a cost saving of £87.89 per patient compared to a course of individual outpatient physiotherapy. It is also identified that potential future cost savings can result from a better patient understanding of the condition and management of flare-ups, meaning a reduction in ‘revolving-door’ patients.
The combination of these factors theoretically helps to reduce numbers of referrals on to secondary care. A Sustainability Assessment Tool has given a total score of 92 for this model which gives significant reason for optimism. This process also highlighted areas of focus to ensure effective change for continued sustainability.
Key findings
The project has been closely monitored with a mix of audit, PDSAs (Plan, Do, Study, Act), data, patient satisfactions and stories to give a rich insight into the projects effectiveness. Pre- and post-group data was collected with baseline functional and pain scores recorded and compared.
Current data for 2016 has shown that 64.7% of attending patients were female and 76.5% of total referrals were for knee OA, which conforms to common trends. The mean age of attendees was 70 years old, showing the tendency towards an aging population.
Data analysis has shown:
- Reported pain scores reduced in 52% of patients.
- Oxford Knee/Hip outcome scores improved in 64%.
- The service implemented Patient Specific Functional Scores improved for 52% of patients, however this was not fully introduced until late in the year.
- Total step ups and sit-stands in 60 seconds improved in 79% and 66% of cases respectively.
- 95% of patients improved in at least 1 functional measure and 91% in at least 2 measures.
Impact on patient outcomes and satisfaction has been unquestionably positive with feedback showing:
- “I now feel more confident and I am managing the pain well”.
- “Helped me to understand the importance of continued exercise”.
- “Now I feel a different person”
Cost saving is a major factor for the current NHS. With positive outcomes from the OASIS group it can be seen as a valid and sustainable tool to reduce costs. With an average group size of 6 patients for the 6 week course, the cost saving made per year is £3691.38 (based on running 7 courses per year) versus a normal course of 1:1 physiotherapy for the same duration.
With reduced physiotherapist contact time for lower limb OA; this has increased capacity for other patients resulting in shorter waiting times in the IPOPS service and therefore a better productivity and utilisation of resources. OASIS set out to improve strength, flexibility, function and quality of life. Based on the data the outcomes met expectations with regards to improvements in function and pain levels. The cost savings were also as expected based on the average of 6 patients per session. However this has the potential to significantly exceed expectations if the model is taken to other sites/areas.
The future for OASIS is to increase the uptake of all appropriate patients so that it is offered as the main treatment for patients with lower limb OA, thus increasing self-management and reducing ‘frequent flyers’ and referrals to secondary care.
Key learning points
From first conception in 2011, and the introduction of new NICE guidance in 2014, the group has grown significantly to its current state. However, we have a vision that it will continue to evolve, and based on what we have learnt from its most recent incarnation, there are a number of key points that need to be highlighted for future.
- Although outcomes are promising, there was difficulty getting patients to ‘buy-in’ to the course. Options were limited to only one time slot at one location per week. Therefore, if they had other commitments, patients were unable to attend. Opening up more times and/or locations would create a higher workload, however would potentially increase numbers and commitment from service users.
- A clear inclusion criteria was developed to result in appropriate patients being referred into the group. However, based on early analysis of patient journeys, a number need further intervention, which was felt to be related to the lower improvements in pain scores compared to function. Pain management is therefore vital to success of long-term management. Updates to the pathways will be made based upon intended NICE clinical guidance on pharmacological management when released. Adjuncts such as intra-articular injections can also be considered as a pre-referral treatment for those patients with high pain levels.
- Feedback has been exceptional from those that have completed the course. A frequent comment received is ‘it’s a shame its only 6-weeks, I wish I could carry on’. Therefore, a post course pack is in the process of development that will draw together information on local activities/gyms and maps for walking routes that will aim to encourage patients to self-manage their long term condition. Other services/trusts have already made contact wishing to develop their own pathways and implement a similar structure, and we encourage others to do the same if they wish to hear more about the potential benefits of the OASIS group.