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Evidence review for regular follow-up and review
Evidence review L
NICE Guideline, No. 226
1. Follow-up and review
1.1. Review question
Is regular follow-up and review needed for people with osteoarthritis?
1.1.1. Introduction
Primary care is the most common first point of contact for people with osteoarthritis. Although some people may re-present to primary care over many years, some only present once and others never present. Patients with osteoarthritis may be prescribed potentially harmful medication or may have declining function, in which cases, timely review, intervention and reconsideration of the management plan would be beneficial. Adherence to management approaches such as exercise may be improved through follow-up. These issues have led to calls for regular, standardised reviews. However, the symptoms and function of people with osteoarthritis may vary from joint-to-joint and from person-to-person over time, this can necessitate frequent reviews over a short period of time. In such cases, a routine follow-up when the patient’s symptoms have settled may represent an unnecessary use of resource. It is important to have an effective system for achieving the best outcomes for people with osteoarthritis through balancing a proactive and a reactive approach to follow-up.
Current practice for people with osteoarthritis is to have symptom-led reviews and proactive medication reviews. Follow up is limited within NHS physiotherapy services and there can be long waiting times for specialist chronic pain services. There is not a standardised approach for follow up of a patient with osteoarthritis over time.
This review aims to determine if regular follow-up and review is beneficial for people with osteoarthritis. This question aims to answer:
- A)
Is regular or symptom-led follow-up most beneficial?
- B)
If regular follow-up is beneficial, what is the frequency of follow up that is required (for example: more than once a year compared to once a year)?
1.1.2. Summary of the protocol
Table 1
PICO characteristics of review question.
For full details see the review protocol in Appendix A.
1.1.3. Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in Appendix A and the methods document.
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
1.1.4. Effectiveness evidence
1.1.4.1. Included studies
No relevant clinical studies comparing different follow up and review strategies were identified.
See also the study selection flow chart in Appendix C.
1.1.4.2. Excluded studies
See the excluded studies list in Appendix J.
1.1.5. Summary of studies included in the effectiveness evidence
No evidence was identified for this review.
1.1.6. Summary of the effectiveness evidence
No evidence was identified for this review.
1.1.7. Economic evidence
1.1.7.1. Included studies
No health economic studies were included.
1.1.7.2. Excluded studies
No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.
See also the health economic study selection flow chart in Appendix G.
1.1.8. Summary of included economic evidence
There was no economic evidence found.
1.1.9. Economic model
This area was not prioritised for new cost-effectiveness analysis.
1.1.10. Unit costs
Relevant unit costs are provided below to aid consideration of cost effectiveness.
| Resource | Unit costs | Source |
|---|---|---|
| GP cost per consultation lasting 9.22 minutes (including direct care staff costs and qualification costs) | £39 | PSSRU 20202 |
1.1.11. Economic evidence statements
Economic
- No relevant economic evaluations were identified.
1.1.12. The committee's discussion and interpretation of the evidence
1.1.12.1. The outcomes that matter most
The critical outcomes were quality of life, pain and physical function. These were considered critical due to their importance to people with osteoarthritis. The Osteoarthritis Research Society International (OARSI) consider that pain and physical function were the most important outcomes for evaluating interventions. Quality of life gives a broader perspective on the person’s wellbeing, allowing for examination of the biopsychosocial impact of interventions. Psychological distress, osteoarthritis flares, falls, residential service or hospital admission (including disability allowance use) and progression to joint replacement were the important outcomes.
The committee considered osteoarthritis flares to be important in the lived experience and management of osteoarthritis. However, these were also considered difficult to measure with no clear consensus on their definition. The Flares in OA OMERACT working group have proposed an initial definition and domains of OA flares through a consensus exercise; “it is a transient state, different from the usual state of the condition, with a duration of a few days, characterized by onset, worsening of pain, swelling, stiffness, impact on sleep, activity, functioning, and psychological aspects that can resolve spontaneously or lead to a need to adjust therapy.“. However, this has been considered to have limitations and has not been widely adopted. Therefore, the committee included the outcome accepting any reasonable definition provided by any studies discussing the event.
Mortality was considered as a composite of serious adverse events rather than as a discreet outcome and categorised as an important outcome. Osteoarthritis as a disease process is not considered to cause mortality by itself and mortality is an uncommon outcome from osteoarthritis interventions.
No evidence was identified for any of these outcomes in this review.
1.1.12.2. The quality of the evidence
No evidence was identified for this review.
1.1.12.3. Committee consideration of advantages and disadvantages
The committee considered the current use of follow up in the NHS referring to their expert opinion. In current practice, follow up would be symptom led follow up or osteoarthritis will be raised as a concern in consultations for other conditions where regular follow up is normal practice. On discussion, the committee agreed that symptom led follow up is likely to be appropriate in most scenarios, as people with osteoarthritis may be able to self-manage their condition effectively after initial information and guidance is provided to initiate management strategies. They considered the potential opportunity cost that could be generated from regular follow up, which considering the absence of evidence saying that there is benefit from this, reinforced this idea. Based on these factors the committee made recommendation 1.5.1.
However, the committee acknowledged that follow up should be focussed on the person’s needs and so symptom led follow up may not always be the only scenario where follow up is required. The committee noted some scenarios where additional follow up may be required:
- If any new medication or other intervention is started – The committee acknowledged that introducing new medication presented potential risks and benefits for the person, and that it was appropriate to review the medication with the person to ensure that it is appropriate for ongoing use. This includes ensuring that medication is only used for the minimal time period as advised in recommendation 1.4.1. Therefore, the committee recommended that additional follow up should be considered in this case. This follow up could be provided by anyone suitably qualified to provide it (for example: pharmacists, general practitioners). Furthermore, the committee acknowledged the need for follow up for any other intervention, including exercise. The committee agreed that providing effective information to manage expectations of the effects of treatment are important (such as acknowledging that people will initially experience discomfort from exercise, but if they persist then symptoms will likely improve). Reinforcing this idea may require additional follow up, allowing opportunities to emphasise positive behaviours and empathise with the challenges associated with the intervention.
- The circumstances affecting the ability of the patient to seek help for themselves – The committee noted that health inequalities exist where people may not be able to engage with their health and so seek help on this basis (for example: people with learning disabilities, or people with communication difficulties). Therefore, this model of follow up should be adjusted to the person’s needs to ensure that everyone can engage with their care and access the support they require.
- The severity of the patient’s symptoms or functional limitations – People who experience more significant symptoms that are affecting their daily life may require additional consultation to work on management plans which may include complex combinations of therapies and considerations for invasive procedures, such as surgery. The committee wished to ensure this group did not experience an unmet need due to gradual but progressive functional deterioration.
All decisions about follow up should be made according to good practice as a shared decision, incorporating the values of the person with osteoarthritis and any healthcare professionals involved in their care. Additional information and recommendations to support those made in this guidance is available in the NICE guidelines on Shared decision making (NG197) and NICE guidelines on Patient experience in adult NHS services (CG138). Support should be provided in a manner tailored to the individual with their concerns taken into account. With all of this taken into account the committee agreed recommendation 1.5.2.
Furthermore, the committee acknowledged that setting clear times to follow up management strategies, if deemed important in a shared decision, is important. Clearly explaining expectations of what a positive treatment experience is like, and the potential problems that can be experienced, and setting a specific time for people to seek additional help in if the management is not improving their symptoms was agreed to be important. Therefore, the committee made recommendation 1.5.3.
When appointments are made to discuss osteoarthritis, this should be the focus of the appointment. People with osteoarthritis may have other conditions that require consideration. However, people may be experiencing significant problems with their osteoarthritis that could be managed effectively if discussed. Therefore, care should be provided in a holistic manner
The committee discussed the implications of osteoarthritis for patients who have multiple long term conditions and agreed that such individuals were at particular risk of long term deterioration due to polypharmacy, falls and interactions between the long term conditions. They recommended that people should refer to the NICE guidelines on Multimorbidity: clinical assessment and management (NG56) for additional guidance. Based on this the committee agreed recommendation 1.5.2.
1.1.12.4. Cost effectiveness and resource use
There were no published economic evaluations found. In the absence of clinical evidence, cost-effectiveness modelling was not feasible since a model would require good evidence of clinical effectiveness.
The committee used expert opinion to inform the recommendation that symptom-led follow-up is likely to be the most appropriate course of action in most cases, which is a departure from the previous recommendation where regular reviews were offered to all people with symptomatic osteoarthritis and annual reviews considered in people who had persistent/multiple joint problems, comorbidities or were taking regular medication for osteoarthritis. They also acknowledged that follow-up should be focussed on the person’s needs so there are some circumstances where additional follow-up may be required, for example if symptoms are very severe or if the person does not have the ability to seek help for themselves. This is a change from the previous guidelines where regular reviews of symptomatic osteoarthritis and annual reviews in people with joint symptoms/pain, comorbidities or multiple medications were recommended.
The committee’s decision to recommend symptom-led follow-up in place of regular reviews is a more efficient use of healthcare resources and may lead to cost-savings. This course of action also ensures that patients continue to receive the current standard of care.
1.1.12.5. Other factors the committee took into account
The committee noted that the osteoarthritis research in general does not appear to represent the diverse population of people with osteoarthritis. They agreed that any further research should be representative of the population, including people from different family backgrounds, and socioeconomic backgrounds, disabled people, and people of different ages and genders. Future work should be done to consider the different experiences of people from diverse communities to ensure that the approach taken can be made equitable for everyone. With this in mind the committee subgrouped their research recommendation by these protected characteristics where appropriate while suggesting that people from each group should be included in the research to ensure that it is applicable to the entire population.
The committee were aware that there is increasing use of telehealth appointments particularly with covid 19. Evidence comparing in person and telephone appointments was not included in the protocol for this review and therefore no recommendations have been made concerning this.
1.1.13. Recommendations supported by this evidence review
This evidence review supports recommendations 1.5.1 to 1.5.3 and the research recommendation on follow up. Other evidence supporting these recommendations can be found in evidence review L.
1.1.14. References
- 1.
- Ahn YH. Effects and costs of a community-based self-management support program for Korean medical aid beneficiaries with osteoarthritis: 12-month follow-up. Annals of the Rheumatic Diseases. 2016; 75(Suppl 2):1293
- 2.
- Curtis L, Burns A. Unit costs of health and social care 2020. Canterbury. University of Kent, 2020. Available from: https://www
.pssru.ac .uk/project-pages/unit-costs /unit-costs-2020/ - 3.
- Hinman RS, Campbell PK, Lawford BJ, Briggs AM, Gale J, Bills C et al Does telephone-delivered exercise advice and support by physiotherapists improve pain and/or function in people with knee osteoarthritis? Telecare randomised controlled trial. British Journal of Sports Medicine. 2020; 54(13):790–797 [PubMed: 31748198]
- 4.
- National Institute for Health and Care Excellence. Developing NICE guidelines: the manual [updated October 2020]. London. National Institute for Health and Care Excellence, 2014. Available from: http://www
.nice.org.uk /article/PMG20/chapter /1%20Introduction%20and%20overview - 5.
- Ravaud P, Flipo RM, Boutron I, Roy C, Mahmoudi A, Giraudeau B et al ARTIST (osteoarthritis intervention standardized) study of standardised consultation versus usual care for patients with osteoarthritis of the knee in primary care in France: pragmatic randomised controlled trial. BMJ. 2009; 338:b421 [PMC free article: PMC2651104] [PubMed: 19237406]
- 6.
- Smith T, Pickup L, Evans L, Latham S, Conaghan P. How often should i see the physiotherapist? a systematic review and meta-analysis investigating the relationship between number of physiotherapy contacts and efficacy when treating osteoarthritis of the knee. Rheumatology (United Kingdom). 2015; 54 (Suppl 1):i127
- 7.
- Wang Q, Runhaar J, Kloppenburg M, Boers M, Bijlsma JW J, Bierma-Zeinstra SM A et al Diagnosis of early stage knee osteoarthritis based on early clinical course: data from the CHECK cohort. Arthritis Research & Therapy. 2021; 23(1):217 [PMC free article: PMC8375192] [PubMed: 34412670]
- 8.
- Wetzels R, van Weel C, Grol R, Wensing M. Family practice nurses supporting self-management in older patients with mild osteoarthritis: a randomized trial. BMC Family Practice. 2008; 9:7 [PMC free article: PMC2235871] [PubMed: 18226255]
Appendices
Appendix A. Review protocols
Download PDF (238K)
Appendix B. Literature search strategies
- Is regular follow-up and review needed for people with osteoarthritis?
The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.4
For more information, please see the Methodology review published as part of the accompanying documents for this guideline.
B.1. Clinical search literature search strategy
Download PDF (263K)
B.2. Health Economics literature search strategy
Download PDF (211K)
Appendix C. Effectiveness evidence study selection
Download PDF (118K)
Appendix D. Effectiveness evidence
No studies were included.
Appendix E. Forest plots
No studies were included.
Appendix F. GRADE tables
No studies were included.
Appendix G. Economic evidence study selection
Download PDF (203K)
Appendix H. Economic evidence tables
There were no health economic studies found in the review.
Appendix I. Health economic model
No original economic modelling was undertaken.
Appendix J. Excluded studies
Clinical studies
Table 5Studies excluded from the clinical review
| Study | Exclusion reason |
|---|---|
| Ahn 20161 | Conference abstract only |
| Hinman 20203 | Incorrect interventions (follow up for an intervention) |
| Ravaud 20095 | Inappropriate comparison (compares regular follow up to as many follow up appointments in a limited time period, rather than symptom-led follow up) |
| Smith 20156 | Conference abstract only |
| Wang 20217 | Incorrect intervention (predictors for early stage arthritis- all people had imaging. No relevant information for follow-up review) |
| Wetzels 20088 | Inappropriate comparison (compares regular follow up to no follow up) |
Health Economic studies
Published health economic studies that met the inclusion criteria (relevant population, comparators, economic study design, published 2005 or later and not from non-OECD country or USA) but that were excluded following appraisal of applicability and methodological quality are listed below. See the health economic protocol for more details.
None.
Appendix K. Research recommendations – full details
K.1. Research recommendation
What is the clinical and cost effectiveness of patient-initiated follow-up compared with routine follow-up for people with osteoarthritis?
K.1.1. Why this is important
Evidence in lacking as to the optimal follow up strategy for people with osteoarthritis. In most cases patient initiated follow up is likely to be sufficient however there may be instances where this is not appropriate. The committee considered this might apply to those who have communication difficulties or learning disability; in people with multi-morbidities where osteoarthritis is not seen as a priority and for people where clinicians are uncertain the patient will access care when it is needed. In this review the committee investigated the effect of symptom led follow up and routine follow up and identified no evidence. The committee recommended that patient led follow up was likely to be appropriate for most people. However, the committee agreed that further research was required to ensure that the most optimal follow up was provided for people with osteoarthritis.
K.1.2. Rationale for research recommendation
Download PDF (187K)
K.1.3. Modified PICO table
Download PDF (177K)
Final version
Evidence reviews underpinning recommendations 1.5.1 to 1.5.3 and research recommendations in the NICE guideline
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
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- Surgical interventions for symptomatic mild to moderate knee osteoarthritis.[Cochrane Database Syst Rev. 2019]Surgical interventions for symptomatic mild to moderate knee osteoarthritis.Palmer JS, Monk AP, Hopewell S, Bayliss LE, Jackson W, Beard DJ, Price AJ. Cochrane Database Syst Rev. 2019 Jul 19; 7(7):CD012128. Epub 2019 Jul 19.
- New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.[Med J Aust. 2021]New Australian guidelines for the treatment of alcohol problems: an overview of recommendations.Haber PS, Riordan BC, Winter DT, Barrett L, Saunders J, Hides L, Gullo M, Manning V, Day CA, Bonomo Y, et al. Med J Aust. 2021 Oct 4; 215 Suppl 7:S3-S32.
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