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1.  Osteoarthritis and the Rule of Halves 
Osteoarthritis and Cartilage  2014;22(4):535-539.
Summary
Background
Symptomatic osteoarthritis poses a major challenge to primary health care but no studies have related accessing primary care (‘detection’), receiving recommended treatments (‘treatment’), and achieving adequate control (‘control’).
Objective
To provide estimates of detection, treatment, and control within a single population adapting the approach used to determine a Rule of Halves for other long-term conditions.
Setting
General population.
Participants
400 adults aged 50+ years with prevalent symptomatic knee osteoarthritis.
Design
Prospective cohort with baseline questionnaire, clinical assessment, and plain radiographs, and questionnaire follow-up at 18 and 36 months and linkage to primary care medical records.
Outcome measures
‘Detection’ was defined as at least one musculoskeletal knee-related GP consultation between baseline and 36 months. ‘Treatment’ was self-reported use of at least one recommended treatment or physiotherapy/hospital specialist referral for their knee problem at all three measurement points. Pain was ‘controlled’ if characteristic pain intensity <5 out of 10 on at least two occasions.
Results
In 221 cases (55.3%; 95%CI: 50.4, 60.1) there was evidence that the current problem had been detected in general practice. Of those detected, 164 (74.2% (68.4, 80.0)) were receiving one or more of the recommended treatments at all three measurement points. Of those detected and treated, 45 (27.4% (20.5, 34.3)) had symptoms under control on at least two occasions. Using narrower definitions resulted in substantially lower estimates.
Conclusion
Osteoarthritis care does not conform to a Rule of Halves. Symptom control is low among those accessing health care and receiving treatment.
doi:10.1016/j.joca.2014.02.006
PMCID: PMC3988991  PMID: 24565953
Osteoarthritis; Rule of Halves; Primary care
2.  How do GPs use x rays to manage chronic knee pain in the elderly? A case study 
Annals of the Rheumatic Diseases  2003;62(5):450-454.
Objectives: To determine whether clinical signs and symptoms of osteoarthritis influence general practitioners' (GPs) decisions about x raying older patients with knee pain and whether x ray reports alter their initial treatment or referral plan.
Methods: A cross sectional survey of 1000 GPs in England and Wales using "paper cases" in three questionnaires mailed at two-weekly intervals. The first questionnaire assessed GPs' management of patients with knee pain using four case scenarios, two with features of clinical knee osteoarthritis. The second questionnaire contained the same scenarios with information on x ray findings added. The third questionnaire considered management of knee pain in general.
Results: 447 GPs responded to questionnaire 1, 316 (71%) to questionnaire 2, 287 (64%) to questionnaire 3. 106 responders (25%) would have x rayed all four patients and 64 (15%) none. Choosing to carry out an x ray examination was not influenced by the presence of clinical signs and symptoms of osteoarthritis but was linked to other management choices, such as referral to orthopaedics (odds ratio (OR) 2.13; 95% confidence interval (CI) 1.62 to 2.81). The strongest predictor in questionnaire 2 of a treatment or referral was whether it had been chosen in the first survey. However, the x ray report was associated with a significant change in treatment and referrals. Where radiographic osteoarthritis was present, GPs were less likely to refer to a physiotherapist (OR 0.64; 95% CI 0.50 to 0.83) or rheumatologist (OR 0.15; 95% CI 0.08 to 0.28), and more likely to refer to an orthopaedic surgeon (OR 31.34; 95% CI 21.51 to 45.66). Questionnaire 3 showed that GPs' general views on the use of x rays correlated with the frequency of their choosing to x ray in the four individual case scenarios.
Conclusions: A GP's choice to x ray older people with knee symptoms is linked with decisions on treatment and referral even before the x ray result is known, but it does not appear to be influenced by clinical features of osteoarthritis. The presence of radiographic osteoarthritis has a marked impact on the decision to refer to secondary care. More evidence on the outcome of management without x rays is needed to help GPs in decision making.
doi:10.1136/ard.62.5.450
PMCID: PMC1754519  PMID: 12695159
3.  Factors affecting over-the-counter use of aspirin in the secondary prophylaxis of cardiovascular disease. 
The British Journal of General Practice  2001;51(473):1001-1003.
Little is known about the contribution of over-the-counter (OTC) aspirin to cardiovascular prophylaxis. To investigate this, a two-phase cross-sectional study was carried out in nine general practices in North Staffordshire. In the first phase, all patients with cardiovascular disease (CVD) were identified from computer searches using morbidity registers and drug searches. The search also identfied the subgroup receiving prescribed prophylactic aspirin. In the second phase, a questionnaire was posted to all patients with CVD who were not on prescribed aspirin to establish their current use of OTC aspirin. Overall, 69% of the CVD group used aspirin, with 26% of aspirin being OTC. OTC aspirin use was more common in those aged under 65 years, men, and the more affluent. Also, there were significant differences in OTC aspirin use between the various practices. This study shows that a considerable amount of aspirin is used OTC in those with CVD. Its use is influenced by several factors that could be addressed when considering attempts to improve the overall uptake of aspirin.
PMCID: PMC1314169  PMID: 11766849
4.  The association between pain intensity and the prescription of analgesics and non-steroidal anti-inflammatory drugs 
Background
It is not known whether general practitioners (GPs) prescribe analgesic medication according to intensity of pain or a hierarchical prescribing regimen.
Aims
The aim of this study was to assess the association of strength of pain-relief medication prescribed by the GP with the strength of previous prescription and pain level.
Methods
The PROG-RES study collected data on pain intensity in 428 patients aged ≥50 years with non-inflammatory musculoskeletal pain during a consultation with their GP. Prescriptions for analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) were identified on the day of the consultation and in the previous year and were classified as basic, moderate or strong analgesic or NSAID. Regression models were used to assess the association of strength of analgesia and prescription of a NSAID with the strength of previous prescription and the level of pain.
Results
The majority of patients were not prescribed medication for their pain at the index consultation, but had such a prescription the previous year. There was an association between strength of analgesic and intensity of pain: more intense pain resulted in a stronger drug. This association was attenuated by adjustment for prescribed analgesia in the previous year. There was no association between intensity of pain and NSAID prescription, but previous NSAID prescription predicted another such prescription.
Conclusion
GPs do not always issue prescriptions for musculoskeletal pain. In cases where a prescription is issued, this is more strongly influenced by previous prescriptions than the patient's pain level. GPs adopt an individualized approach to the treatment of musculoskeletal pain in older adults.
doi:10.1002/j.1532-2149.2011.00107.x
PMCID: PMC3564413  PMID: 22337613
5.  The effectiveness of national guidance in changing analgesic prescribing in primary care from 2002 to 2009: An observational database study 
Background
Numerous national guidelines have been issued to assist general practitioners’ safe analgesic prescribing. Their effectiveness is unclear. The objective of this study was to examine trends in general practitioners’ prescribing behaviour in relation to national guidelines.
Methods
This was a retrospective observational database study of registered adult patients prescribed an analgesic (2002–2009) from the Consultations in Primary Care Archive – 12 North Staffordshire general practices. Prescribing guidance from the UK Medicines Regulatory Health Authority (MHRA) regarding non-steroidal anti-inflammatory drugs (NSAIDs) and co-proxamol, and the National Institute for Health and Clinical Excellence (NICE) osteoarthritis (OA) management guidelines were considered. Analgesic prescribing rates were examined, arranged according to a classification of six equipotent medication groups: (1) basic analgesics; (2)–(5) increasingly potent opioids and (6) NSAIDs. In each quarter from 2002 to 2009, the number of patients per 10,000 registered population receiving a prescription for the first time from each group was determined. Quarters associated with significant changes in the underlying prescribing trend were determined using joinpoint regression.
Results
A significant decrease in incident co-proxamol and Cox-2 prescribing occurred around the time of the first MHRA advice to stop using them and were rarely prescribed thereafter. The new prescribing of weak analgesics (e.g., co-codamol 8/500) increased at this same time. Initiating topical NSAIDs significantly increased around the time of the NICE OA guidelines.
Conclusions
Significant prescribing changes occurred when national advice and guidelines were issued. The effectiveness of this advice may vary depending upon the content and method of dissemination. Further evaluation of the optimal methods for delivering prescribing guidance is required.
doi:10.1002/j.1532-2149.2012.00189.x
PMCID: PMC3592995  PMID: 22865816

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