Can we integrate case-finding and management of joint pain, anxiety and depression into long-term condition reviews?
Osteoarthritis (OA) and mental health problems are common and often co-exist in patients with other long term conditions (LTCs), but are under-detected and sub-optimally managed in primary care. The aim of the ENHANCE pilot trial is to develop and test the feasibility and acceptability of a practice nurse-led ‘enhanced’ LTC review for identifying, assessing and supporting the management of joint pain, anxiety and/or depression in patients attending routine LTC reviews. We report analysis of audio recorded ENHANCE consultations undertaken as part of a process evaluation within the pilot trial.
Practice nurses (PNs) at four GP practices participated in training to deliver the ENHANCE review. A computer template incorporating case-finding questions for joint pain and anxiety and depression was provided for use in the consultation. PNs, had the option of verbal advice, referral to relevant services (e.g. physiotherapy and mental health services) and/or provision of information booklets. Patients and nurses were asked to give consent for ENHANCE consultations to be audio-recorded. 24 consultations, with 7 PNs across the four practices were audio-recorded and transcribed. Thematic analysis was undertaken. The ENHANCE trial received NHS ethical approval.
ENHANCE LTC review recordings ranged between 10 and 50 minutes. The way and extent to which PNs integrated the ENHANCE components varied. Reference to the research study was given by PNs, as justification for departure from the usual LTC consultation. PNs and patients normalised symptoms of low mood, anxiety and pain, there were missed opportunities to respond to patient cues, and sometimes help or resources were offered but not given. However, there were examples of highly integrated consultations where PNs did incorporate ENHANCE case-finding questions within a patient-centred discourse and offer further management. Pain management for OA was discussed, and in particular, topical medication was promoted as useful, particularly when patients expressed resistance/reluctance towards the idea of taking tablets. The importance of exercise was emphasised, and nurses handed out information booklets (and in some cases talked patients through particular exercises). Information booklets for anxiety and depression were handed out and some patients were referred to their GP, but referral to the IAPT service was not discussed. There was no evidence of the ENHANCE summary cards being used at the end of consultations, though some PNs did verbally summarise discussions or actions at the end. The findings have been fed into topics guides for interviews with patients and PNs as part of the ongoing process evaluation.
The complexity of LTC reviews poses a challenge for integrating identification and assessment of OA, anxiety and/or depression within these consultations. Despite the challenges, integration can be achieved, but further work around countering normalisation of OA and mental health symptoms within Primary Care consultations is required.