Patient pathways, systems and management

Optimising care pathways has the potential to increase patient satisfaction and treatment outcomes, ensure more consistent, appropriate and timely referrals, improve multidisciplinary team (MDT) capabilities, and reduce the burden on our healthcare services. Patients can often feel lost in a system they are struggling to navigate. These patients often have multiple comorbidities, and therefore need holistic management – which means they may need to be referred multiple times between different healthcare professionals. It is therefore no surprise that patients report being ‘not very satisfied with the support they had received from healthcare services’, and feel like they are being ‘passed between specialties’.Patients with osteoarthritis (OA) deserve better; through incremental change, care provision in OA can be improved.

What are the opportunities to improve pathways for patients with OA?

In general practice:

  • Optimise referral pathways and ensure that ‘gatekeeper’ roles in the pathway refer the right patients at the right time, to the right person2
  • Reduce delays and increase access to appropriate specialist input.5

For intermediary musculoskeletal (MSK) services and First Contact Practitioners (FCP):

  • Simplify MSK and FCP pathways by optimising the referral process4
  • Support appropriate specialist input with minimal delays whenever possible
  • Ensure a holistic approach to care, which includes both pharmacological and non-pharmacological options5

In hospitals:

  • Reduce patient load on hospital capacity4
  • Aim for lower hospital waiting times4,6
  • Provide strong and visionary leadership at the specialist level4
  • Increase secondary care resources available to patients with OA, alongside other core specialty priorities

What are the opportunities to improve pathways for patients with OA?

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A redesign of the OA pathway and a review of workforce capabilities can help ensure patients receive optimal treatment in every care setting. Change should be driven at a system level to support the National Health Service (NHS) ambition to create efficiencies through optimally integrated care and a well-equipped OA workforce;7 but change should also be driven by individuals, with care providers and commissioners taking an active approach to manage change in their local areas. Increased MDT and community-based working with access to specialist care will be key to this, and will help improve outcomes for patients.4,8

Beyond the challenges with pathways and systems, there are also only limited pharmacological management options for chronic pain in OA. These include topical and oral non-steroidal anti-inflammatory drugs (NSAID), paracetamol and opioids. However, the effectiveness of paracetamol can be low for this type of pain, while chronic use of non-steroidal anti-inflammatory drugs (NSAID) is associated with side effects; the efficacy of opioids for chronic use is unclear – and opioids are associated with common toxicities such as drowsiness, and carry a risk of addiction.9 Due to a lack of viable alternatives, opioids continue to be used for patients with OA-related pain, despite the benefits generally not outweighing the risks.10

What can I do now?

Understanding why a best practice approach to OA management, underpinned by MDT care, is key to optimising a patient’s treatment journey through the pathway.

1. ARMA. Chronic pain – this is how it feels. October 2019. http://arma.uk.net/wp-content/uploads/2019/10/Chronic_Pain_Report_V8_APPROVED-07102019.pdf. Accessed August 4, 2020. 2. Musila N, Underwood M, McCaskie AW, Black N, Clarke A, van der Meulen JH. Referral recommendations for osteoarthritis of the knee incorporating patients’ preferences. Fam Pract. 2011;28(1):68-74. 3. Zhang W, Ouyang H, Dass CR, Xu J. Current research on pharmacologic and regenerative therapies for osteoarthritis. Bone Res. 2016;4:15040.
4. NHS. The NHS long term plan. January 2019. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf. Accessed February 26, 2020. 5. NICE. Osteoarthritis: care and management CG177. February 2014. https://www.nice.org.uk/guidance/cg177. Accessed August 4, 2020. 6. Versus Arthritis. Versus Arthritis position statement on the Clinically-led Review of NHS Access Standards. November 2019. https://www.versusarthritis.org/media/21674/clinical-standards-review-nov19.pdf. Accessed August 4, 2020. 7. Public Health England. Musculoskeletal health: A 5 year strategic framework for prevention across the lifecourse. June 2019. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/810348/Musculoskeletal_Health_5_year_strategy.pdf. Accessed August 4, 2020. 8. Conaghan PG, Porcheret M, Kingsbury SR, Gammon A, Soni A, Hurley M, Rayman MP, Barlow J, Hull RG, Cumming J, Llewelyn K, Moscogiuri F, Lyons J, Birrell F. Impact and therapy of osteoarthritis: the Arthritis Care OA Nation 2012 Survey. Clin Rheumatol. 2014;34(9):1581-1588. 9. Conaghan P, Abraham L, Graham-Clarke P, Viktrup L, Cappelleri JC, Beck C, Bushmakin A, Williams N, Mellor J, Jackson J. Poster: Current treatment patterns among European patients with osteoarthritis: analysis of a real-world dataset. Presented at: 11th Congress of the European Pain Federation (EFIC), Valencia, Spain, September 4-7, 2019. https://www.morressier.com/article/current-treatment-patterns-among-european-patients-osteoarthritis-analysis-realworld-dataset/5d402fa68f2158d25ec131dc?.
10. Fuggle N, Curtis E, Shaw S, Spooner L, Bruyère O, Ntani G, Parsons C, Conaghan PG, Corp N, Honvo G, Uebelhart D, Baird J, Dennison E, Reginster JY, Cooper C. Safety of opioids in osteoarthritis: outcomes of a systematic review and meta-analysis. Drugs Aging. 2019;36(Suppl 1):129-143.

Patients with OA deserve better; through incremental change, care provision in OA can be improved

Please note that some of the following resources are not created or sponsored by Pfizer. Where this is the case, using the links will direct you to external, third-party sites.
Further reading
Current guidelines and patient-centred management
The UK guidance by National Institute for Health and Care Excellence (NICE) recommend a holistic approach to osteoarthritis (OA) assessment and management.1 Key to holistic management is a holistic assessment of the patient’s overall situation; NICE encourages assessment…
Best practice in pathways and multidisciplinary team working
Osteoarthritis (OA) treatment pathways require effective partnerships between primary and secondary care services and across multidisciplinary teams (MDTs), to ensure that services are available to all patients who need them – and when they need them.

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PP-INT-GBR-0214 February 2021