Feasibility and acceptability of integrating case finding and initial management for osteoarthritis, anxiety and depression into routine primary care nurse-led long-term condition reviews: results from the ENHANCE Pilot Trial
Co-morbid osteoarthritis (OA), anxiety and depression are undermanaged in primary care yet have significant impact on pain, disability and outcomes of other long-term conditions (LTCs). This study aimed to test the feasibility and acceptability of integrating case-finding and initial management for OA, anxiety and depression within extended primary care practice nurse (PN)-led LTC review consultations.
A stepped wedge pilot trial with process evaluation. PNs gave a study pack to patients age ≥45 years attending routine LTC reviews (asthma, COPD, hypertension, ischaemic heart disease, diabetes). The intervention included case finding questions (Generalized Anxiety Disorder (GAD2), Whooley 2-item depression, diagnosing OA clinically (hands, hips, knees or feet)) followed by further assessments (anxiety (GAD7), depression (PHQ9), joint examination). PNs completed an electronic patient record and initiated management. Pre-determined success criteria were to recruit 4 practices; deliver training to 2 PNs per practice, recruit 50% of those invited, ensure 75% follow up (6 week, 6 month), and the satisfaction (GPAQ) of intervention patients to be at least as acceptable as that of control patients. 24 audio recorded consultations provided insight into fidelity of intervention delivery.
Four practices were recruited. PNs were sequentially trained in practice prior to switching to intervention. Of the 474 people invited, 319 responded (207 control, 112 intervention) (67%). 83% and 79% of participants returned 6 week and 6 month questionnaires respectively. Demographic characteristics, general health, pain intensity, anxiety and depression scores were similar across arms. Overall, self-reported health (EQ5D5L) was high (median 0.84; IQR 0.72, 0.94). 14% of participants reported moderate to severe depression (PHQ9). Median GPAQ scores were similar (control 1.00 (IQR: 1.00, 1.29), intervention 1.00 (IQR: 1.00, 1.14)). 96% of those in the intervention arm reported being asked about joint pain, 93% reported being asked about mood. Audio recordings revealed that case finding questions were used as intended in most consultations (joint pain 20/24 consultations, anxiety 15/24, depression 6/24). One referral to physiotherapy and none to primary care mental health services were recorded by the PNs.
Investigating feasibility and acceptability is an important stage in the development and evaluation of complex interventions as randomised controlled trials in primary care are often unsuccessful due to suboptimal intervention and/or trial design. In this study, recruitment and follow up were good. However, to target those who may benefit from the intervention, changes to the target population and eligibility criteria are required. There was reasonable delivery of the case finding questions, but limited referral and signposting, highlighting areas to further optimise ahead of a main trial.