Search

Objective: To investigate delays from symptom onset to rheumatology assessment for patients with a new onset of rheumatoid arthritis (RA) or unclassified arthritis., Methods: Newly presenting adults with either RA or unclassified arthritis were recruited from rheumatology clinics. Data on the length of time between symptom onset and first seeing a GP (patient delay), between first seeing a general practitioner (GP) and being referred to a rheumatologist (general practitioner delay) and being seen by a rheumatologist following referral (hospital delay) were captured., Results: 822 patients participated (563 female, mean age 55 years). The median time between symptom onset and seeing a rheumatologist was 27.2 weeks (IQR 14.1-66 weeks); only 20% of patients were seen within the first 3 months following symptom onset. The median patient delay was 5.4 weeks (IQR 1.4-26.3 weeks). Patients who purchased over-the-counter medications or used ice/heat packs took longer to seek help than those who did not. In addition, those with a palindromic or an insidious symptom onset delayed for longer than those with a non-palindromic or acute onset. The median general practitioner delay was 6.9 weeks (IQR 2.3-20.3 weeks). Patients made a mean of 4 GP visits before being referred. The median hospital delay was 4.7 weeks (IQR 2.9-7.5 weeks)., Conclusion: This study identified delays at all levels in the pathway towards assessment by a rheumatologist. However, delays in primary care were particularly long. Patient delay was driven by the nature of symptom onset. Complex multi-faceted interventions to promote rapid help seeking and to facilitate prompt onward referral from primary care should be developed., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Osteoarthritis (OA) is a leading cause of pain and disability. NICE OA guidelines (2008) recommend that patients with OA should be offered core treatments in primary care. Assessments of OA management have identified a need to improve primary care of people with OA, as recorded use of interventions concordant with the NICE guidelines is suboptimal in primary care. The aim of this study was to i) describe the patient-reported uptake of non-pharmacological and pharmacological treatments recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and ii) determine whether patient characteristics or OA diagnosis impact uptake., Methods: A cross-sectional survey mailed to adults aged ≥45 years (n = 28,443) from eight general practices in the UK as part of the MOSAICS study. Respondents who reported the presence of joint pain, a consultation in the previous 12 months for joint pain, and gave consent to medical record review formed the sample for this study., Results: Four thousand fifty-nine respondents were included in the analysis (mean age 65.6 years (SD 11.2), 2300 (56.7%) females). 502 (12.4%) received an OA diagnosis in the previous 12 months. More participants reported using pharmacological treatments (e.g. paracetamol (31.3%), opioids (40.4%)) than non-pharmacological treatments (e.g. exercise (3.8%)). Those with an OA diagnosis were more likely to use written information (OR 1.57; 95% CI 1.26,1.96), paracetamol (OR 1.30; 95% CI 1.05,1.62) and topical NSAIDs (OR 1.30; 95% CI 1.04,1.62) than those with a joint pain code. People aged ≥75 years were less likely to use written information (OR 0.56; 95% CI 0.40,0.79) and exercise (OR 0.37; 95% CI 0.25,0.55) and more likely to use paracetamol (OR 1.91; 95% CI 1.38,2.65) than those aged < 75 years., Conclusion: The cross-sectional population survey was conducted to examine the uptake of the treatments that are recommended in the NICE OA guidelines in older adults with a self-reported consultation for joint pain and to determine whether patient characteristics or OA diagnosis impact uptake. Non-pharmacological treatment was suboptimal compared to pharmacological treatment. Implementation of NICE guidelines needs to examine why non-pharmacological treatments, such as exercise, remain under-used especially among older people.

Background: Patients with inflammatory rheumatic conditions such as rheumatoid arthritis, polymyalgia rheumatica and ankylosing spondylitis are at increased risk of common comorbidities such as cardiovascular disease, osteoporosis and anxiety and depression which lead to increased morbidity and mortality. These associated morbidities are often un-recognized and under-treated. While patients with other long-term conditions such as diabetes are invited for routine reviews in primary care, which may include identification and management of co-morbidities, at present this does not occur for patients with inflammatory conditions, and thus, opportunities to diagnose and optimally manage these comorbidities are missed., Objective: To evaluate the feasibility and acceptability of a nurse-led integrated care review (the INtegrating and improving Care for patients with infLammatory rheUmatological DisordErs in the community (INCLUDE) review) for people with inflammatory rheumatological conditions in primary care., Design: A pilot cluster randomized controlled trial will be undertaken to test the feasibility and acceptability of a nurse-led integrated primary care review for identification, assessment and initial management of common comorbidities including cardiovascular disease, osteoporosis and anxiety and depression. A process evaluation will be undertaken using a mixed methods approach including participant self-reported questionnaires, a medical record review, an INCLUDE EMIS template, intervention fidelity checking using audio-recordings of the INCLUDE review consultation and qualitative interviews with patient participants, study nurses and study general practitioners (GPs)., Discussion: Success of the pilot study will be measured against the engagement, recruitment and study retention rates of both general practices and participants. Acceptability of the INCLUDE review to patients and practitioners and treatment fidelity will be explored using a parallel process evaluation., Trial Registration: ISRCTN12765345., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Evidence on the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis is limited and conflicting. The primary objective of the Hip Injection Trial (HIT) is to compare pain intensity over 6 months, in people with hip OA between those receiving an ultrasound-guided intra-articular hip injection of corticosteroid with 1% lidocaine hydrochloride plus best current treatment with those receiving best current treatment alone. Secondary objectives are to determine specified comparative clinical and cost-effectiveness outcomes, and to explore, in a linked qualitative study, the lived experiences of patients with hip OA and experiences and impact of, ultrasound-guided intra-articular hip injection., Methods: The HIT trial is a pragmatic, three-parallel group, single-blind, superiority, randomised controlled trial in patients with painful hip OA with a linked qualitative study. The current protocol is described, in addition to details and rationale for amendments since trial registration. 204 patients with moderate-to-severe hip OA will be recruited. Participants are randomised on an equal basis (1:1:1 ratio) to one of three interventions: (1) best current treatment, (2) best current treatment plus ultrasound-guided intra-articular hip injection of corticosteroid (triamcinolone acetonide 40 mg) with 1% lidocaine hydrochloride, or (3) best current treatment plus an ultrasound-guided intra-articular hip injection of 1% lidocaine hydrochloride alone. The primary endpoint is patient-reported hip pain intensity across 2 weeks, 2 months, 4 months and 6 months post-randomisation. Recruitment is over 29 months with a 6-month follow-up period. To address the primary objective, the analysis will compare participants' 'average' follow-up pain NRS scores, based on a random effects linear repeated-measures model. Data on adverse events are collected and reported in accordance with national guidance and reviewed by external monitoring committees. Individual semi-structured interviews are being conducted with up to 30 trial participants across all three arms of the trial., Discussion: To ensure healthcare services improve outcomes for patients, we need to ensure there is a robust and appropriate evidence-base to support clinical decision making. The HIT trial will answer important questions regarding the clinical and cost-effectiveness of intra-articular corticosteroid injections., Trial Registration: ISRCTN: 50550256 , 28th July 2015.

Plain English Summary: In the UK, more patients go to primary care than other parts of the health service. Therefore it is important for research into primary care to include the insights and views of people who receive these services. To explore the extent, quality and impact of patient and public involvement (PPI) in primary care research, we examined documents of 200 projects and surveyed 191 researchers.We found that about half of studies included PPI to develop research ideas and during the study itself. Common activities included designing study materials, advising on methods, and managing the research. Some studies did not undertake the PPI activities initially planned and funded for. PPI varied by study design, health condition and study population. We found pockets of good practice: having a PPI budget, supporting PPI contributors, and PPI informing recruitment issues. However, good practice was lacking in other areas. Few projects offered PPI contributors training, used PPI to develop information for participants about study progress and included PPI to advise on publishing findings.Researchers reported beneficial impacts of PPI. Most impact was reported when the approach to PPI included more indicators of good practice. The main cost of PPI for researchers was their time. Many reported difficulties providing information about PPI.In partnership with PPI contributors, we have used these findings to develop:a new Cost and Consequences Framework for PPI highlighting financial and non-financial costs, benefits and harms of PPIFifteen co-produced recommendations to improve the practice and delivery of PPI., Abstract: Background: To improve the lives of patients in primary care requires the involvement of service users in primary care research. We aimed to explore the extent, quality and impact of patient and public involvement (PPI) in primary care research. Methods: We extracted information about PPI from grant applications, reports and an electronic survey of researchers of studies funded by the NIHR School for Primary Care Research (SPCR). We applied recognised quality indicators to assess the quality of PPI and assessed its impact on research. Results: We examined 200 grant applications and reports of 181 projects. PPI was evident in the development of 47 (24%) grant applications. 113 (57%) grant applications included plans for PPI during the study, mostly in study design, oversight, and dissemination. PPI during projects was reported for 83 (46%) projects, including designing study materials and managing the research. We identified inconsistencies between planned and reported PPI. PPI varied by study design, health condition and study population.Of 46 (24%) of 191 questionnaires completed, 15 reported PPI activity. Several projects showed best practice according to guidelines, in terms of having a PPI budget, supporting PPI contributors, and PPI informing recruitment issues. However few projects offered PPI contributors training, used PPI to develop information for participants about study progress, and had PPI in advising on dissemination.Beneficial impacts of PPI in designing studies and writing participant information was frequently reported. Less impact was reported on developing funding applications, managing or carrying out the research. The main cost of PPI for researchers was their time. Many researchers found it difficult to provide information about PPI activities.Our findings informed:a new Cost and Consequences Framework for PPI in primary care research highlighting financial and non-financial costs, plus the benefits and harms of PPIFifteen co-produced recommendations to improve PPI in research and within the SPCR. Conclusions: The extent, quality and impact of PPI in primary care research is inconsistent across research design and topics. Pockets of good practice were identified making a positive impact on research. The new Cost and Consequences Framework may help others assess the impact of PPI., Competing Interests: Ethical approval was obtained from Keele University’s Research Ethics Committee (21st March 2014). Respondents to the survey were informed that a return of a completed questionnaire implied informed consent to participate in the study and share anonymous information publicly.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation-as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely., Competing Interests: Compliance with ethical standardsAll authors declare to have no conflicts of interest.

This is the first national study of public and patient research priorities in osteoporosis and fracture. We have identified new research areas of importance to members of the public, particularly 'access to information from health professionals'. The findings are being incorporated into the research strategy of the National Osteoporosis Society., Purpose: This study aimed to prioritise, with patients and public members, research topics for the osteoporosis research agenda., Methods: An e-survey to identify topics for research was co-designed with patient representatives. A link to the e-survey was disseminated to supporters of the UK National Osteoporosis Society (NOS) in a monthly e-newsletter. Responders were asked to indicate their top priority for research across four topics (understanding and preventing osteoporosis, living with osteoporosis, treating osteoporosis and treating fractures) and their top three items within each topic. Descriptive statistics were used to describe demographics and item ranking. A latent class analysis was applied to identify a substantive number of clusters with different combinations of binary responses., Results: One thousand one hundred eighty-eight (7.4%) respondents completed the e-survey. The top three items overall were 'Having easy access to advice and information from health professionals' (63.8%), 'Understanding further the safety and benefit of osteoporosis drug treatments' (49.9%) and 'Identifying the condition early by screening' (49.2%). Latent class analysis revealed distinct clusters of responses within each topic including primary care management and self-management. Those without a history of prior fracture or aged under 70 were more likely to rate items within the cluster of self-management as important (21.0 vs 12.9 and 19.8 vs 13.3%, respectively)., Conclusion: This is the first study of public research priorities in osteoporosis and has identified new research areas of importance to members of the public including access to information. The findings are being incorporated into the research strategy of the National Osteoporosis Society.

Self-management is recommended by policy and clinical guidelines as a way to contend with the growing incidence of osteoarthritis-related joint pain in an ageing population. Sociologists assert that self-management is as much about lay strategies for dealing with the biographically disruptive qualities of chronic illness as opposed to solely complying with medical regimens. The original concept of biographical disruption coined by Bury is not uncontested. Chronic joint pain has been characterised as featuring 'co-existing meanings' of significance and consequence. The former conferring no biographical disruption due to osteoarthritis being associated with 'normal ageing' and the latter causing biographical disruption due to the corporeal limitations joint pain imparts, which, in turn, can influence whether, why and how self-management is undertaken. This article reports findings from repeat interviews and a diary study completed by 22 participants with chronic knee pain. We explore the co-existing but temporally divergent 'meanings as significance' associated with knee pain. Participants describe the onset and current experience of the pain in terms of biographical normality (retrospective or contemporaneous meanings). Future meanings as significance are mediated by cultural beliefs about ageing and current physical consequences of the condition, and also have a distinct character of their own. Knee pain is associated with the possibility of disability and harbours a distinct risk; potential disruption to everyday social relationships, notably relating to care and dependency. In turn, future meanings of significance influence the preventative self-management strategies that people utilise. We argue for a more cogent theoretical understanding of temporal dimensions of biographical disruption, biographical work and subsequent self-management by utilising and extending the thought of Bury, and Corbin and Strauss. Doing so helps to understand patient self-management strategies and facilitates self-management support in clinical settings for osteoarthritis and potentially other chronic conditions.

Plain English Summary: People with osteoarthritis desire high quality care, support and information. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators can be used to benefit patients by measuring whether minimum standards of quality care are being met from a patient perspective. The aim of this study was to describe how a Research User Group (RUG) worked alongside researchers to co-produce a set of self-reported quality indicators for people with osteoarthritis when visiting their general practitioner or practice nurse (primary care). These were required in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE quality standards for OA. This article describes the public involvement in the MOSAICS study. This was 1) the co-development by RUG members and researchers of an Osteoarthritis Quality Indicators United Kingdom (OA QI (UK)) questionnaire for use in primary care, and 2) the comparison of the OA QI (UK) with a similar questionnaire developed in Norway. This study shows how important and effective a research user group can be in working with researchers in developing quality care indicators for osteoarthritis for use in a research study and, potentially, routine use in primary care. The questionnaire is intended to benefit patients by enabling the assessment of the quality of primary care for osteoarthritis from a patient's perspective. The OA QI (UK) has been used to examine differences in the quality of osteoarthritis care in four European countries., Abstract: Background People with osteoarthritis (OA) desire high quality care, support and information about OA. However, the quality of care for people with OA in general practice is not routinely collected. Quality Indicators (QI) can be used to benefit patients by measuring whether minimum standards of quality care (e.g. NICE quality standards) are being met from a patient perspective. A Research User Group (RUG) worked with researchers to co-produce a set of self-report, patient-generated QIs for OA. The QIs were intended for use in the MOSAICS study, which developed and evaluated a new model of supported self-management of OA to implement the NICE guidelines. We report on 1) the co-development of the OA QI (UK) questionnaire for primary care; and 2) the comparison of the content of the OA QI (UK) questionnaire with a parallel questionnaire developed in Norway for the Musculoskeletal Pain in Ullensaker (MUST) study. Methods Researchers were invited to OA RUG meetings. Firstly, RUG members were asked to consider factors important to patients consulting their general practitioner (GP) for OA and then each person rated their five most important. RUG members then discussed these in relation to a systematic review of OA QIs in order to form a list of OA QIs from a patient perspective. RUG members suggested wording and response options for a draft OA QI (UK) questionnaire to assess the QIs. Finally RUG members commented on draft and final versions of the questionnaire and how it compared with a translated Norwegian OA-QI questionnaire. Results RUG members (5 males, 5 females; aged 52-80 years) attended up to four meetings. RUG members ranked 20 factors considered most important to patients consulting their GP for joint pain. Following discussion, a list of eleven patient-reported QIs for OA consultations were formed. RUG members then suggested the wording and response options of 16 draft items - four QIs were split into two or more questionnaire items to avoid multiple dimensions of care quality within a single item. On comparison of this to the Norwegian OA-QI questionnaire, RUG members commented that both questionnaires contained seven similar QIs. The RUG members and researchers agreed to adopt the Norwegian OA-QI wording for four of these items. RUG members also recommended adopting an additional seven items from the Norwegian OA-QI with some minor word changes to improve their suitability for patients in the UK. One other item from the draft OA QI (UK) questionnaire was retained and eight items were excluded, resulting in a 15-item final version. Conclusions This study describes the development of patient-reported quality indicators for OA primary care derived by members of a RUG group, working in partnership with the research team throughout the study. The OA QI (UK) supports the NICE quality standards for OA and they have been successfully used to assess the quality of OA consultations in primary care in the MOSAICS study. The OA QI (UK) has the potential for routine use in primary care to assess the quality of OA care provided to patients. Ongoing research using both the UK and Norwegian OA-QI questionnaires is assessing the self-reported quality of OA care in different European populations.

Background: The international literature on patient and public involvement (PPI) in research covers a wide range of issues, including active lay involvement throughout the research cycle; roles that patients/public can play; assessing impact of PPI and recommendations for good PPI practice. One area of investigation that is less developed is the sustainability and impact of PPI beyond involvement in time-limited research projects., Methods: This paper focuses on the issues of sustainability, the importance of institutional leadership and the creation of a robust infrastructure in order to achieve long-term and wide-ranging PPI in research strategy and programmes., Results: We use the case of a Primary Care Research Centre to provide a historical account of the evolution of PPI in the Centre and identified a number of key conceptual issues regarding infrastructure, resource allocation, working methods, roles and relationships., Conclusions: The paper concludes about the more general applicability of the Centre's model for the long-term sustainability of PPI in research.

Background: Long-term conditions (LTCs) are important determinants of quality of life and healthcare expenditure worldwide. Whilst multimorbidity is increasingly the norm in primary care, clinical guidelines and the delivery of care remain focused on single diseases, resulting in poorer clinical outcomes. Osteoarthritis, and anxiety and/or depression frequently co-occur with other LTCs, yet are seldom prioritized by the patient or clinician, resulting in higher levels of disability, poorer prognosis, and increased healthcare costs., Objective: To examine the feasibility and acceptability of an integrated approach to LTC management, tackling the under-diagnosis and under-management of osteoarthritis-related pain and anxiety and/or depression in older adults with other LTCs in primary care., Design: The ENHANCE study is a pilot stepped-wedge cluster randomized controlled trial to test the feasibility and acceptability of a nurse-led ENAHNCE LTC review consultation for identifying, assessing, and managing joint pain, and anxiety and/or depression in patients attending LTC reviews. Specific objectives (process evaluation and research outcomes) will be achieved through a theoretically informed mixed-methods approach using participant self-reported questionnaires, a medical record review, an ENHANCE EMIS template, qualitative interviews, and audio recordings of the ENHANCE LTC review., Discussion: Success of the pilot trial will be measured against the level of the primary care team engagement, assessment of training delivery, and degree of patient recruitment and retention. Patient satisfaction and treatment fidelity will also be explored. ISRCTN registry number: 12154418., Competing Interests: The authors have no conflicts of interest to declare.

Background: Early treatment for rheumatoid arthritis (RA) is vital. However, people often delay in seeking help at symptom onset. An assessment of the reasons behind patient delay is necessary to develop interventions to promote rapid consultation., Objective: Using a mixed methods design, we aimed to develop and test a questionnaire to assess the barriers to help seeking at RA onset., Design: Questionnaire items were extracted from previous qualitative studies. Fifteen people with a lived experience of arthritis participated in focus groups to enhance the questionnaire's face validity. The questionnaire was also reviewed by groups of multidisciplinary health-care professionals. A test-retest survey of 41 patients with newly presenting RA or unclassified arthritis assessed the questionnaire items' intraclass correlations., Results: During focus groups, participants rephrased questions, added questions and deleted items not relevant to the questionnaire's aims. Participants organized items into themes: early symptom experience, initial reactions to symptoms, self-management behaviours, causal beliefs, involvement of significant others, pre-diagnosis knowledge about RA, direct barriers to seeking help and relationship with GP. The test-retest survey identified seven items (out of 79) with low intraclass correlations which were removed from the final questionnaire., Conclusion: The involvement of people with a lived experience of arthritis and multidisciplinary health-care professionals in the preliminary validation of the DELAY (delays in evaluating arthritis early) questionnaire has enriched its development. Preliminary assessment established its reliability. The DELAY questionnaire provides a tool for researchers to evaluate individual, cultural and health service barriers to help-seeking behaviour at RA onset., (© 2014 John Wiley & Sons Ltd.)

A multitude of factors can influence the uptake and implementation of complex interventions in health care. A plethora of theories and frameworks recognize the need to establish relationships, understand organizational dynamics, address context and contingency, and engage key decision makers. Less attention is paid to how theories that emphasize relational contexts can actually be deployed to guide the implementation of an intervention. The purpose of the article is to demonstrate the potential role of qualitative research aligned with theory to inform complex interventions. We detail a study underpinned by theory and qualitative research that (a) ensured key actors made sense of the complex intervention at the earliest stage of adoption and (b) aided initial engagement with the intervention. We conclude that using theoretical approaches aligned with qualitative research can provide insights into the context and dynamics of health care settings that in turn can be used to aid intervention implementation., (© The Author(s) 2015.)

Objectives: Some patients spend years with painful osteoarthritis without consulting for it, including times when they are experiencing persistent severe pain and disability. Beliefs about osteoarthritis and what primary care has to offer may influence the decision to consult but their relative importance has seldom been quantified. We sought to investigate the relative importance of perceived service-related and clinical need attributes in the decision to consult a primary care physician for painful osteoarthritis., Design: Partial-profile choice-based conjoint analysis study, using a self-complete questionnaire containing 10 choice tasks, each presenting two scenarios based on a combination of three out of six selected attributes., Setting: General population., Participants: Adults aged 50 years and over with hip, knee or hand pain registered with four UK general practices., Outcome Measures: Relative importance of pain characteristics, level of disruption to everyday life, extent of comorbidity, assessment, management, perceived general practitioner (GP) attitude., Results: 863 (74%) people responded (55% female; mean age 70 years, range: 58-93). The most important determinants of the patient's decision to consult the GP for joint pain were the extent to which pain disrupted everyday life ('most' vs 'none': relative importance 31%) and perceived GP attitude ('legitimate problem, requires treatment' vs 'part of the normal ageing process that one just has to accept': 24%). Thoroughness of assessment (14%), management options offered (13%), comorbidity (13%) and pain characteristics (5%) were less strongly associated with the decision to consult., Conclusions: Anticipating that the GP will regard joint pain as 'part of the normal ageing process that one just has to accept' is a strong disincentive to seeking help, potentially outweighing other aspects of quality of care. Alongside the recognition and management of disrupted function, an important goal of each primary care consultation for osteoarthritis should be to avoid imparting or reinforcing this perception., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Improving the management of people with long-term conditions is a key priority of the UK National Health Service. Whilst the coexistence of two or more long-term conditions in one person is increasingly the norm in primary care, guidelines and delivery of care remain focused on single disease management.Anxiety, depression and osteoarthritis are frequently comorbid with other long-term conditions and with each other, with up to 70 % of people with anxiety and depression also suffering from chronic pain. The relationships between anxiety, depression and pain are reciprocal, with each predicting and worsening the outcome of the others. Where these conditions occur in the context of other long-term conditions, further reduction in health-related quality of life and poorer clinical outcomes for all comorbid conditions is observed. It therefore follows that optimising the management of one comorbid condition should confer benefit to the other/s. Yet despite this, anxiety, depression and chronic pain are seldom prioritised by either patient or clinician, therefore remaining under-recognised and under-treated.Case-finding aims to identify and offer timely treatment to individuals with a given disease in a population at risk, therefore offering one possible solution. Yet case-finding is not without its problems, with well-recognised barriers including lack of time, cultural difficulties and inadequate resources and practitioner skills. So whilst the merits of why to actively seek these conditions is clear, how this may be best achieved is not. We explore the potential role of case-finding for anxiety, depression and osteoarthritis-related joint pain in individuals with comorbid long-term conditions, assessing whether adopting an integrated approach to care may allow opportunistic case-finding therefore promoting identification and timely management of these deleterious conditions.

Self-managing chronic musculoskeletal pain is predominantly framed within a discourse of modifying behaviour, or lifestyle risk factors such as diet, weight loss and exercise by policymakers, researcher and clinicians. Little research has been conducted which explores how 'risk' is understood or encountered by those with joint pain and how it may relate to self-management. Drawing from serial interviews and a diary study with 22 participants, the findings demonstrate that people with chronic pain engage in a process of assessing and adapting to hazardous or pain conferring situations in relation to daily activities. 'Risks' are embedded within a dialectic between corporeal experience and the design features of everyday social environments. Self-management, in this context, is not necessarily solely related to following clinical advice, rather it includes dealing with 'risks' of pain, hazards relating to bodily limitations and the environment, and ensuring the ability to continue with valued activities. Findings contribute to sociological understandings of self-management and risk while demonstrating the limits of viewing self-management as an individualised endeavour of changing behaviour., (© 2015 Foundation for the Sociology of Health & Illness.)

Purpose: Intervention evaluations have not always accounted for long-term implementation of interventions. The purpose of this paper is to explore implementation of a primary care intervention during the lifespan of the trial and beyond., Design/methodology/approach: Eight general practices participated in the trial (four control and four intervention). In-depth interviews (with nine GPs and four practices nurses who delivered the intervention) and observation methods were employed. Thematic analysis was utilized and Normalization Process Theory (NPT) constructs were compared with emergent themes., Findings: Macro-level policy imperatives shaped practice priorities which resulted in the "whole system" new intervention not being perceived to be sustainable. Continued routinization of the intervention into usual care beyond the lifespan of the funded study was dependent on individualized monitoring and taking forward tacit knowledge., Research Limitations/implications: The authors discuss the implications of these findings for sociological theories of implementation and understanding outcomes of research led complex interventions., Originality/value: The study describes the complex interplay between macro processes and individual situated practices and contributes to understanding if, how, and why interventions are sustained beyond initial "research push". The value of the study lies in describing the conditions and potential consequences of long-term implementation, which might be translated to other contexts.

Background: Written information can be of benefit to both practitioners and patients and the provision of quality information is emphasised as a core intervention by United Kingdom National Institute of Clinical Excellence (NICE) OA guidelines. Researchers, patients and HCPs developed an 'OA guidebook' to provide; a) a balanced source of information for patients; b) a resource to aid practitioners when discussing self-management. This study aimed to evaluate the acceptability and usefulness of the OA guidebook as part of complex intervention to deliver NICE OA guidelines in General Practice., Methods: The intervention comprises a series of consultations with GPs and practice nurses in which supported self-management is offered to patients. Eight practices in the West Midlands and North West of England were recruited to take part: four control practices and four intervention practices. Semi-structured interviews were undertaken with patients (n = 29), GPs (n = 9) and practice nurses (n = 4) from the intervention practices to explore experiences of the intervention and use of the guidebook. Data were analysed using thematic analysis and constant comparison of data within and across interviews., Results: GPs thought the guidebook helped provide patients with information about OA aetiology, prognosis and self-management. Thus, it backed up key messages they provided patients during consultations. GPs also found the guidebook helped them 'close off' consultations. Nurses also thought the guidebook helped them describe OA disease processes in consultations. Patients valued the explanations of disease onset, process and prognosis. The use of 'real' people and 'real life' situations contained within the guidebook made self-management strategies seem more tangible. A sense of inclusion and comfort was obtained from knowing other people encountered similar problems and feelings., Conclusion: An OA specific written information guidebook was deemed acceptable and useful to practitioners and patients alike as part of the MOSAICS study. Findings reinforce the utility of this model of patient information as a resource to support patients living with chronic illnesses. An OA guidebook featuring a mixture of lay and professional information developed by professionals and lay people is useful and could effectively be used more widely in usual care.

Background: There is as yet no evidence on the feasibility of implementing recommendations from the National Institute of Health and Care Excellence (NICE) osteoarthritis (OA) guidelines in primary care, or of the effect these recommendations have on the condition. The primary aim of this study is to determine the clinical and cost effectiveness of a model OA consultation (MOAC), implementing the core recommendations from the NICE OA guidelines in primary care. Secondary aims are to investigate the impact, feasibility and acceptability of the MOAC intervention; to develop and evaluate a training package for management of OA by general practitioners (GPs) and practice nurses; test the feasibility of deriving 'quality markers' of OA management using a new consultation template and medical record review; and describe the uptake of core NICE OA recommendations in participants aged 45 years and over with joint pain., Design: A mixed methods study with a nested cluster randomised controlled trial., Method: This study was developed according to a defined theoretical framework (the Whole System Informing Self-management Engagement). An overarching model (the Normalisation Process Theory) will be employed to undertake a comprehensive 'whole-system' evaluation of the processes and outcomes of implementing the MOAC intervention. The primary outcome is general physical health (Short Form-12 Physical component score [PCS]) (Ware 1996). The impact, acceptability and feasibility of the MOAC intervention at practice level will be assessed by comparing intervention and control practices using a Quality Indicators template and medical record review. Impact and acceptability of the intervention for patients will be assessed via self-completed outcome measures and semi-structured interviews. The impact, acceptability and feasibility of the MOAC intervention and training for GPs and practice nurses will be evaluated using a variety of methods including questionnaires, semi-structured interviews, and observations., Discussion: The main output from the study will be to determine whether the MOAC intervention is clinically and cost effective. Additional outputs will be the development of the MOAC for patients consulting with joint pain in primary care, training and educational materials, and resources for patients and professionals regarding supported self-management and uptake of NICE guidance., Trial Registration: ISRCTN number: ISRCTN06984617.

Background: Exercise is consistently recommended for older adults with knee pain related to osteoarthritis. However, the effects from exercise are typically small and short-term, likely linked to insufficient individualisation of the exercise programme and limited attention to supporting exercise adherence over time. The BEEP randomised trial aims to improve patients' short and long-term outcomes from exercise. It will test the overall effectiveness and cost-effectiveness of two physiotherapy-led exercise interventions (Individually Tailored Exercise and Targeted Exercise Adherence) to improve the individual tailoring of, and adherence to exercise, compared with usual physiotherapy care., Methods/design: Based on the learning from a pilot study (ISRCTN 23294263), the BEEP trial is a multi-centre, pragmatic, parallel group, individually randomised controlled trial, with embedded longitudinal qualitative interviews. 500 adults in primary care, aged 45 years and over with knee pain will be randomised to 1 of 3 treatment groups delivered by fully trained physiotherapists in up to 6 NHS services. These are: Usual Physiotherapy Care (control group consisting of up to 4 treatment sessions of advice and exercise), Individually Tailored Exercise (an individualised, supervised and progressed lower-limb exercise programme) or Targeted Exercise Adherence (supporting patients to adhere to exercise and to engage in general physical activity over the longer-term). The primary outcomes are pain and function as measured by the Western Ontario and McMaster Osteoarthritis index. A comprehensive range of secondary outcomes are also included. Outcomes are measured at 3, 6 (primary outcome time-point), 9, 18 and 36 months. Data on adverse events will also be collected. Semi-structured, qualitative interviews with a subsample of 30 participants (10 from each treatment group) will be undertaken at two time-points (end of treatment and 12 to 18 months later) and analysed thematically., Discussion: This trial will contribute to the evidence base for management of older adults with knee pain attributable to osteoarthritis in primary care. The findings will have important implications for healthcare commissioners, general practitioners and physiotherapy service providers and it will inform future education of healthcare practitioners. It may also serve to delay or prevent some individuals from becoming surgical candidates., Trial Registration Isrctn: ISRCTN93634563.

Osteoarthritis-related joint pain is prevalent and potentially disabling. United Kingdom clinical guidelines suggest that patients should be supported to self-manage in primary care settings. However, the processes and mechanisms that influence patient consultation decisions for joint pain are not comprehensively understood. We recruited participants (N = 22) from an existing longitudinal survey to take part in in-depth interviews and a diary study. We found that consultation decisions and illness actions were ongoing social processes. The need for and benefits of consulting were weighed against the value of consuming the time of a professional who was considered an expert. We suggest that how general practitioners manage consultations influences patient actions and is part of a broader process of defining the utility and moral worth of consulting. Recognizing these factors will improve self-management support and consultation outcomes., (© The Author(s) 2014.)

Objectives: Being overweight or obese is a key risk factor for the onset and exacerbation of knee pain. Policy and clinical guidelines encourage lifestyle changes as part of prevention or supported self-management. The present study explores how people who have not consulted for knee pain understand weight in relation to joint pain, if and how they self-manage and potential barriers to doing so., Methods: A qualitative investigation was undertaken using repeat in-depth semi-structured interviews and diary study. Thirteen participants who self-reported moderate to severe pain and had not recently consulted their general practitioner for knee pain were recruited to the study. Thematic analysis of data was conducted., Results: Participants did not recognize the association between being overweight and the onset of joint pain. The findings illuminate understandings of the effect of weight on joint pain, rationales and strategies for losing weight, and how participants' position responsibility for weight gain and loss., Discussion: The present study suggests that clinicians need to account for existing understandings and actions of individuals in relation to weight and joint pain. Supported self-management and public health interventions need to be individually tailored accordingly., (© 2013 The Authors. Musculoskeletal Care published by John Wiley & Sons, Ltd.)

Background: The study aimed to explore the views of general practitioners (GPs), nurses and physiotherapists towards extending the role of sickness certification beyond the medical profession in primary care., Methods: Fifteen GPs, seven nurses and six physiotherapists were selected to achieve varied respondent characteristics including sex, geographical location, service duration and post-graduate specialist training. Constant-comparative qualitative analysis of data from 28 semi-structured telephone interviews was undertaken., Results: The majority of respondents supported the extended role concept; however members of each professional group also rejected the notion. Respondents employed four different legitimacy claims to justify their views and define their occupational boundaries in relation to sickness certification practice. Condition-specific legitimacy, the ability to adopt a holistic approach to sickness certification, system efficiency and control-related arguments were used to different degrees by each occupation. Practical suggestions for the extension of the sickness certification role beyond the medical profession are underpinned by the sociological theory of professional identity., Conclusions: Extending the authority to certify sickness absence beyond the medical profession is not simply a matter of addressing practical and organisational obstacles. There is also a need to consider the impact on, and preferences of, the specific occupations and their respective boundary claims. This paper explores the implications of extending the sick certification role beyond general practice. We conclude that the main policy challenge of such a move is to a) persuade GPs to relinquish this role (or to share it with other professions), and b) to understand the 'boundary work' involved.

Understanding uptake of complex interventions is an increasingly prominent area of research. The interplay of macro (such as changing health policy), meso (re-organisation of professional work) and micro (rationalisation of clinical care) factors upon uptake of complex interventions has rarely been explored. This study focuses on how English General Practitioners and practice nurses make sense of a complex intervention for the management of osteoarthritis, using the macro-meso-micro contextual approach and Normalisation Process Theory (NPT), specifically the construct of coherence. It is embedded in a cluster RCT comprising four control practices and four intervention practices. In order to study sense-making by professionals introduction and planning meetings (N = 14) between researchers and the practices were observed. Three group interviews were carried out with 10 GPs and 5 practice nurses after they had received training in the intervention. Transcripts were thematically analysed before comparison with NPT constructs. We found that: first, most GPs and all nurses distinguished the intervention from current ways of working. Second, from the introduction meeting to the completion of the training the purpose of the intervention increased in clarity. Third, GPs varied in their understanding of their remit, while the practice nurses felt that the intervention builds on their holistic care approach. Fourth, the intervention was valued by practice nurses as it strengthened their expert status. GPs saw its value as work substitution, but felt that a positive conceptualisation of OA enhanced the consultation. When introducing new interventions in healthcare settings the interaction between macro, meso and micro factors, as well as the means of engaging new clinical practices and their sense-making by clinicians needs to be considered., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The literature on patient and public involvement (PPI) in research covers a wide range of topics. However, one area of investigation that appears under developed is the sustainability and impact of PPI beyond involvement in time-limited research projects. This paper presents a case study of PPI development in one primary care research centre in England, and its approach to making this sustainable using documentary sources and material from a formal evaluation. We provide narrative accounts of the set-up, operation and main processes of PPI, and its perceived impact. PPI requires a long-term perspective with participation and trust growing over time, and both users and researchers learning what approaches work best. PPI is a complex interplay of clarity of purpose, defined roles and relationships, organised support (paid PPI staff) and a well-funded infrastructure. 'Soft systems' are equally important such as flexible and informal approaches to meetings, adapting timetables and environments to meet the needs of lay members and to create spaces for relationships to develop between researchers and lay members that are based on mutual trust and respect. This case study highlights that the right combination of ethos, flexible working practices, leadership, and secure funding goes a long way to embedding PPI beyond ad hoc involvement. This allows PPI in research to be integrated in the infrastructure and sustainable.

Background: Service users are increasingly involved in the design of clinical trials and in product and device development. Service user involvement in placebo development is crucial to a credible and acceptable placebo for clinical trials, but such involvement has not yet been reported., Aims: To enhance the design of a future clinical trial of hand splints for thumb-base osteoarthritis (OA), service users were involved in splint selection and design of a placebo splint. This article describes and reflects on this process., Design: Two fora of service users were convened in 2011. Service users who had been prescribed a thumb splint for thumb-base OA were approached about involvement by Occupational Therapy (OT) practitioners., Content of the Fora: A total of eight service users took part in the fora. Service users discussed their experience of OA and their own splints and then tried a variety of alternative splints. Through this they identified the active features of splints alongside acceptable and unacceptable design features. Service users focused on wearability and support with or without immobilization. Fora discussed whether a placebo group ('arm') was an acceptable feature of a future trial, and service users developed a potential design for a placebo splint., Conclusion and Discussion: This is the first project that to involve service users in placebo design. Service users are increasingly involved in product and device design and are ideally placed to identify features to make a placebo credible yet lacking key active ingredients. The future trial will include research into its acceptability., (© 2013 John Wiley & Sons Ltd.)

Objective: We aimed to identify the priorities for joint pain research from a large general population survey and identify characteristics associated with these priorities., Methods: A question about research priorities was developed in collaboration with the Arthritis Research UK Primary Care Centre's Research Users' Group. The question was embedded in a postal survey to an existing cohort of adults with self-reported joint pain, aged ≥56 years, in North Staffordshire. Respondents were asked to rank their top three priorities for research. Factor mixture modelling was used to determine subgroups of priorities., Results: In all, 1756 (88%) people responded to the survey. Of these, 1356 (77%) gave three priorities for research. Keeping active was rated the top priority by 38%, followed by research around joint replacement (9%) and diet/weight loss (9%). Two clusters of people were identified: 62% preferred lifestyle/self-management topics (e.g. keeping active, weight loss) and 38% preferred medical intervention topics (e.g. joint replacement, tablets). Those who preferred the medical options tended to be older and have hip or foot pain., Conclusion: This study has provided population data on priorities for joint pain research expressed by a large cohort of older people who report joint pain. The most popular topics for research were linked to lifestyle and self-management opportunities. Pharmaceutical and invasive interventions, despite being common topics of research, are of less importance to these respondents than non-medical topics. Specific research questions will be generated from this study with collaboration of the patient's group.

Background: The emphasis on prevention in English health policy continues to centre predominantly on major diseases such as coronary heart disease and diabetes. A number of key documents detailing self-management techniques and prevention of osteoarthritis (OA) are currently available, including the NICE guidelines and the Arthritis Foundation's National Public Health Agenda for Osteoarthritis. However, few investigations have explored preventative knowledge of knee OA amongst the population. In particular, asymptomatic members of the population may use further information in considering how to prevent knee pain. This study considers perceptions around the prevention of knee pain amongst an asymptomatic population; this target population may provide alternative insights by which to stimulate preventative behaviours., Methods: A sample of thirteen patients with no current knee pain was selected from responders to a population survey. Each interview was tape recorded and fully transcribed. Qualitative computer software package NVivo8 was used to manage the data. Thematic analysis was conducted using the constant comparative method., Results: The definition and causes of knee pain were interpreted in a multitude of ways. The importance of prevention was recognised by a sub-set, while a small proportion of participants negated the role of prevention. A range of social factors, including early adoption of actions, influenced the implementation and continuation of preventative behaviours. Individual responsibility for prevention was a key theme, although the role of society was also considered. Exercise was cited as a principal preventative strategy, although some participants viewed exercise as a destructive activity. A number of participants deemed pharmacotherapy to be harmful and at odds with normal physiology, instead preferring to adopt preventative behaviour over medication usage., Conclusions: This asymptomatic population exhibit considerable breadth and variation in knowledge of preventative strategies for knee pain. Similarities in perceptions of prevention exist when comparing to the symptomatic population. These range from emphasis on individual responsibility, through to observations on the role of exercise and pharmacotherapy in knee pain. In general individuals are agreeable to act upon recommended treatments in line with NICE guidance. This receptiveness demands a greater consideration of preventative strategies in consultations, as well as wider availability and promotion of preventative strategies in order to improve the musculoskeletal health of the general population.

Background: Sickness certification constitutes daily clinical practice for GPs. In April 2010, the UK sickness certification system changed to reflect the evidence that work is generally good for health and a new Statement of Fitness for Work - the 'fit note' - was introduced. Sickness certification is a contentious topic among GPs and the proposed fit note generated mixed reviews., Aim: To explore GPs' views and use of the fit note during its first year of operation., Design and Setting: Qualitative interview study of GPs based in different geographical locations across the UK., Method: GPs (n = 15), who were recruited from a national sample, participated in semi-structured telephone interviews which were subject to constant comparative analysis., Results: Overall, the fit note was well received. GPs recognised that work is generally good for health and felt the fit note facilitated using an earlier return to work as a negotiation tool. GPs perceive employers as the major obstacle to early return to work. There were reports of scepticism towards the system that negatively impacted on some GPs' operation of sickness certification. Feedback over the fit note's impact on employer behaviour and the return of a mechanism that enables GPs to request early independent assessments would be welcomed., Conclusion: A revised approach is needed to address the scepticism towards the sickness certification system that persists among some GPs. New strategies need to be designed to engage employers in facilitating an early return to work and to enable the objectives of the medical statement reforms to be achieved.

Self-management for chronic illness is a current high profile UK healthcare policy. Policy and clinical recommendations relating to chronic illnesses are framed within a language of lifestyle risk management. This article argues the enactment of risk within current UK self-management policy is intimately related to neo-liberal ideology and is geared towards population governance. The approach that dominates policy perspectives to 'risk' management is critiqued for positioning people as rational subjects who calculate risk probabilities and act upon them. Furthermore this perspective fails to understand the lay person's construction and enactment of risk, their agenda and contextual needs when living with chronic illness. Of everyday relevance to lay people is the management of risk and uncertainty relating to social roles and obligations, the emotions involved when encountering the risk and uncertainty in chronic illness, and the challenges posed by social structural factors and social environments that have to be managed. Thus, clinical enactments of self-management policy would benefit from taking a more holistic view to patient need and seek to avoid solely communicating lifestyle risk factors to be self-managed.

Objective: Current NICE guidelines for Osteoarthritis (OA) identify several core self-management recommendations (exercise and weight loss if overweight/obese) to be supported by Healthcare Professionals. Contemporary research stresses that a patient-centred model of self-management that builds upon existing patient action and belief is essential. The lay beliefs regarding self-management for OA have not been explicitly explored previously., Method: Of the participants, 22 people were recruited to undertake in-depth interviews and a diary study. The constant comparative method and narrative methods were utilized to analyse the data., Results: Making adaptations and using strategies to get on with 'normal' daily life is as much a part of caring for OA as easing painful symptoms. Moreover, participants 'normal' routines ensured that they were able to stay active and keep the knee joint moving. Thus, maintaining everyday social roles and valued activities parallels recommendations from policy and practice. Engaging in exercise is influenced by biography, preferred lifestyle and contextual need., Conclusion: Practitioners and policy need to embrace the complexities of managing chronic OA conditions, by taking onboard the needs and priorities of patients. The findings highlight the disease specific needs of self-management that may be omitted from programmes like the Expert Patients Programme.

Self-management is a key policy initiative in many western countries, and most approaches are designed for people with long-term conditions based upon giving support and advice in order to manage the impact of the condition(s). Less attention has been paid to what people already do themselves. In this paper we focus on the meaning and enactment of self-management in everyday life and the hard work associated with devising and maintaining routine adaptive strategies. This UK-based qualitative study examined how people live with knee pain. From the interviews (22 at baseline, 15 at 6 months) and monthly diaries, it emerged that self-management could be based on implicit and incremental learning from experience or on explicit evaluation of actions. Either way, embodied and emotional hard work was involved in maintaining a daily life that allowed people to fulfil social roles and relationships. This individual and contextualised work needs to be recognised and drawn upon before specific self-management approaches are promoted.

Background: Dahlgren and Whitehead's 'rainbow' outlines key determinants of health and has been widely adopted within public health policy and research. Public understanding regarding the determinants of health is, however, relatively unknown, particularly in relation to common chronic joint problems like knee pain. We aimed to explore individual attitudes to the prevention of knee pain, and assess how people make sense of their lives by using the rainbow model to explore social determinants of health., Methods: Twenty-eight semi-structured interviews were undertaken with older adults living in the community. The format of the interview enabled individuals to first tell their story, then the rainbow picture was used to further prompt discussion. Interviews were digitally recorded and transcripts were fully transcribed. Qualitative computer software package NVivo 2 was used to manage the data. Thematic analysis was undertaken., Results: Individual responsibility for health was a dominant theme although the role of health and statutory services was also recognised. Barriers to uptake of prevention activities included cultural perceptions, attitudes towards work and perceived costs of prevention activities. Participants used the rainbow for locating their personal life within a wider social, economic and policy context., Conclusions: People view individual responsibility as key to maintaining health and draw upon the past, present and future expectations when considering social determinants of their health. The rainbow picture does have relevance at the individual level and can help to formulate more dynamic and contextualised approaches to the prevention of health conditions in community living adults.

Background: Involvement of users in health care research is central to UK health care policy, and guidelines for involvement exist. However, there are limited examples in rheumatology research. The aim of this study was to establish a community knee pain forum aimed at engaging stakeholders in design, dissemination and prioritisation of knee pain research., Methods: Ten people were recruited to the forum representing a wide range of agencies. These included Weight Watchers, the leisure industry, Beth Johnson Foundation, health and social care professionals and the public. Three two-hour meetings over a two-year period were held. Experienced qualitative researchers facilitated each meeting. Written feedback after each meeting was elicited, and a short evaluation form was mailed to all members after the final meeting., Results: Establishing and maintaining a forum of mixed members required careful preparation and ongoing support. Meetings had to be well-structured in order to allow for balanced participation of lay and professional users. Users contributed to the design of methods, provided ideas for dissemination and set priorities for further research. Clear documentation of meetings ensured that users' contributions to the research cycle were transparent., Conclusion: Our knee pain forum illustrates that community engagement can have a positive impact on the development, dissemination and implementation of health research. Engaging with non-academic partners enables mutual learning and this enhances the quality of NHS research.

Background: The new Musculoskeletal Services Framework outlines the importance of health care needs assessment. Our aim was to provide a model for this for knee pain and disability, describing felt need (individual assessment of a need for health care) and expressed need (demand for health care). This intelligence is required by health care planners in order to implement the new Framework., Methods: A multi-method approach was used. A population survey (n = 5784) was administered to adults aged 50+ registered with 3 general practices. The questionnaire contained a Knee Pain Screening Tool to identify the prevalence of knee pain and health care use in the population, and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Survey responders who scored "severe" or "extreme" on at least one item on the pain or physical function scale on the WOMAC were categorised into "severe" groups. Qualitative interviews were undertaken with 22 survey responders to explore in detail the experience of living with knee pain and disability. A sample of interviewees (n = 10) completed an open format patient diary to explore the experience of knee pain in everyday life., Results: The 12-month period prevalence of knee pain was 49.5%, of which half was severe. Severe difficulties were reported with domestic duties, bending, bathing, climbing stairs and getting in or out of a car. Some self-care is occurring. The majority (53%) of responders with severe pain or disability had not consulted their GP in the last 12 months. The qualitative study revealed reasons for this including a perception that knee pain is part of normal ageing, little effective prevention and treatment is available and the use of medications causes side effects and dependency., Conclusion: This study adds to previous work by highlighting a gap between felt and expressed need and the reasons for this mismatch. There is evidence of self-management, but also missed opportunities for effective interventions (e.g. lifestyle advice). A targeted and integrated approach between clinicians and health care planners for primary and secondary prevention is required if aspects of the new Musculoskeletal Services Framework are to be successfully implemented.

Background: Knee osteoarthritis is a highly prevalent condition that can result in disability and reduced quality of life. The evidence suggests that total knee replacement surgery (TKR) is an effective intervention for patients with severe knee problems, but there is also an unmet need for this treatment in the UK. To help understand the reason for this unmet need, the aim of this study was to explore the factors that influence the decision-making process of TKR surgery by synthesising the available evidence from qualitative research on this topic., Methods: A meta-synthesis was undertaken. This involved sevens steps: getting started, deciding what is relevant to the initial interest, reading the studies, determining how the studies are related, translating the studies into one another, synthesising translations, and finally, expressing the synthesis. Second-order and third-order interpretations regarding decision-making in TKR surgery were drawn from the literature., Results: Ten qualitative studies were found and are included in the synthesis. The evidence suggests that social and cultural categories of aging have shaped the expectation of knee osteoarthritis, and this in turn shapes patients' expectations of treatment options. The role of the health care professional was the strongest theme to emerge across all ten studies. Coping strategies and life context determine short and longer-term outcomes of TKR., Conclusion: The decision-making process regarding TKR surgery is extremely complex, as patients have weigh up numerous considerations before they can make a decision about surgery. By synthesising ten qualitative studies, we have illuminated the importance of the health care professional during this process.

Background: Obesity is linked to knee osteoarthritis (OA) and knee pain. These are disabling problems that are more prevalent in older adults. No prospective study has estimated the impact of excess weight avoidance on the occurrence of knee pain in the general older population. The aim of this study was to investigate the influence of overweight and obesity on the onset and progression of knee pain and disability in older adults living in the community., Methods: A prospective cohort study of people aged 50 and over registered with three general practices in North Staffordshire, UK. 5784 people who had responded to a survey in March 2000 were mailed a follow-up questionnaire in March 2003. The main outcome measures were self-reported knee pain and severe knee pain and disability at 3 years measured by the Western Ontario and McMaster Universities Osteoarthritis index., Results: Adjusted response to follow-up was 75%. Among responders with no knee pain at baseline, obesity predicted onset of severe knee pain (relative risk 2.8; 95% CI 1.8, 4.5 compared to normal body mass index (BMI) category). Considering overweight and obese categories together, 19% of new cases of severe knee pain over a 3-year period could potentially be avoided by a one-category shift downwards in BMI; this includes almost half of the new cases that arose in the obese group., Conclusion: Obesity accounts for a substantial proportion of severe disabling knee pain. As knee pain is a common disabling condition in older adults living in the community, effective public health interventions about avoidance of excess weight could have a major impact on future lower limb disability in older adults.

Background: Surveys of the population are commonly used to obtain information on health status. Increasingly, researchers are linking self-reported health status information to primary care consultation data. However, it is not known how participating in a health-related survey affects consultation behaviour. The objective of this study was to assess whether completion of a health-related questionnaire changes primary care consultation behaviour., Methods: Participants were 3402 adults aged 50 and over from the general population in North Staffordshire, UK, who completed a health-related postal survey received in April 2003. The survey was predominantly about occurrence and severity of knee pain in the last year. Primary care attendance for the three months following response was compared to three control periods: i) the three months prior to the survey, ii) the same time period in the previous year and iii) the same time period in the following year. Comparisons were made on consultations for any problem, consultations for musculoskeletal disorders and consultations for knee problems., Results: The percentage of subjects consulting for any condition was marginally higher for the three months directly after receipt of the questionnaire but the difference was only statistically significant in comparison to the three months before the survey (64% v. 62%, p = 0.05). There was little difference in consultation prevalence for musculoskeletal problems immediately after the survey compared to the three control periods. There was an increase of 37% in knee disorder consultations for the three months after the survey compared to the three months directly before the survey (p = 0.02). However, consultation prevalence for knee problems was identical for the three months after the survey to the same time periods in the years prior to and following the survey (both p = 0.94)., Conclusion: The results from this study suggests that questionnaires related to physical health do not affect the standard consulting behaviour of patients, even for the symptom under investigation. This should reassure researchers who wish to link self-reported health status and medical care utilisation and clinicians whose patients are involved in such research.

Objective: To assess reasons for discrepancies between primary care consultation measured from patient self-report and that based on medical records., Methods: Retrospective comparison of recalled consultation in previous 12 months among 2,414 subjects aged 50+ who reported knee pain in a population survey vs. primary care medical records. Record review included (1) all knee morbidity codes and (2) knee problems mentioned in consultation text. It was then extended to: (3) more than 12 months before survey, and (4) consultations for leg or widespread problems (e.g., generalized osteoarthritis)., Results: In those who reported knee pain, recalled consultation prevalence for knee problems "in past year" was 33% compared with 15% based on medical records. Forty percent of those with a recalled consultation had a recorded knee problem in the same time period (kappa = 0.43). Expanding record search to include leg and widespread problems, and knee problems up to 40 months prior to survey, increased "verified" self-reported consulters to 80%., Conclusions: Disparity in estimates of consultation prevalence arose from inaccuracy of: (1) recall in survey responders and (2) recording by general practitioners of specific problems and repeat consultations. Perceived importance of problem in a multiproblem contact and whether it leads to an outcome (e.g., prescription) may influence recording. Implications exist for service provision projections and research.

Objectives: This study aimed to investigate the thoughts and reasoning of respondents in relation to their experience of back and knee pain while they were completing validated health status questionnaires as part of two epidemiological surveys., Methods: Qualitative interviews with 10 participants who were sampled from previous questionnaire responders. Content analysis identified emerging themes. Analysis allowed for a comparison with other research, for a focus on disease-specific questionnaire interpretations, and use of additional survey material (i.e. annotations alongside questionnaire items and accompanying letters)., Results: Adaptation to limitations and comparisons with previous self and/or others changed the way people responded to the standardized questions. The determination of specific periods of pain proved very difficult for respondents because pain, and low back pain in particular, was rarely experienced as a stable phenomenon. In addition, the time frames used in questionnaires were often at variance with the lived reality of pain and its effects on individuals' perceptions of time. Respondents tended to emphasize the context within which they experienced pain, and in the case of knee pain, often ranked this pain in relation to other health issues., Conclusions: In epidemiological studies, differences in interpretations are averaged across large samples, but we argue that a deeper understanding of the range of individual interpretations is important if one is to acknowledge the different meanings of pain within populations. The accounts of pain sufferers are highly complex and variable. Multi-method studies offer an opportunity to explore these using complementary approaches. This may lead to both more patient-centred research and health service provision.

Study Design: Study of interrater reliability., Objective: To assess the interrater reliability of data from pain drawings scored by multiple raters and the consistency of the subsequent classification of cases of widespread pain., Summary of Background Data: In large health surveys, pain drawings used to capture self-reported pain, and to classify cases of widespread pain, are often scored by several raters. The reliability of multiple rater scoring of pain drawings has not been investigated., Methods: As part of a postal survey sent to adults 50 years and older, subjects were asked to shade their pain on a blank body manikin. The first 50 pain drawings in which respondents had shaded pain were selected for this study. Eight nonclinical staff were trained to score pain drawings using transparent templates divided into 50 body areas. Interrater reliability was assessed by comparing the scoring of "pain" or "no pain" for all 50 areas of each pain drawing., Results: Complete scoring agreement among all raters was observed for at least 78% of pain drawings across all body areas (kappa > 0.60). The raters had complete agreement in 42 of 50 areas in 90% or more of pain drawings. From the raters' scoring of pain areas, there was complete agreement on the presence or absence of widespread pain for 49 of 50 pain drawings (98% agreement, Kappa = 0.98)., Conclusions: This study shows that multiple raters, with training and guidelines, can reliably score pain drawings, and high consistency in the subsequent classification of cases of widespread pain can be obtained from such data.

Ethical guidelines in the United Kingdom require written consent from participants in epidemiologic studies for follow-up or review of medical records. This may cause bias in samples used for follow-up or medical record review. The authors analyzed data from seven general population surveys conducted in the United Kingdom (1996-2002), to which over 25,000 people responded. Associations of age, gender, and symptom under investigation with consent to follow-up and consent to review of medical records were examined. Consent to follow-up was approximately 75-95% among survey responders under age 50 years but fell among older people, particularly females. Consent to follow-up was also higher among responders who had the symptom under investigation (pooled odds ratio = 1.61, 95% confidence interval: 1.36, 1.92). Consent to review of medical records followed a similar pattern. Patterns of consent were relatively consistent and represented a high proportion of responders. Males, younger people, and subjects reporting the symptom under investigation were more likely to give consent, and these groups may be overrepresented in follow-up samples or reviews of medical records. Although consent is high among responders, the additive effect of nonresponse and nonconsent can substantially reduce sample size and should be taken into account in epidemiologic study planning.

Computer-assisted data entry procedures for self-completion population surveys are previously unreported. We used Teleform for a questionnaire to registrants (aged 50+) with general practices in North Staffordshire, UK (n=8995). The survey achieved a 77% response rate. 98% (n=6647) of returned questionnaires were scannable. These questionnaires were checked (and corrected) before scanning for entries that may be inaccurately read by the software. Three percent of 1020 scanned questionnaires checked (0.041% of all questionnaire items) had a data entry error. Systematic processes enable accurate survey data transfer to be achieved with Teleform. However, many administrative and technical issues need addressing.

This study has used the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) in an unsolicited postal questionnaire to investigate the impact of knee pain and disability in the general older population. The study provides WOMAC population data for those aged over 50 and demographic and psychosocial associations with severity of WOMAC scores. A pilot survey (n=240) and repeatability study (n=80) were undertaken to test completion of the WOMAC in this new setting. The main questionnaire was mailed to 8,995 men and women aged over 50 registered with three general practices in North Staffordshire, UK. Completion rates for WOMAC items were high. Substantial reliability was found for pain and physical function scales (both >0.80). Fourteen percent of the over 50 population in this study had severe knee pain, 20% had severe difficulty with at least one area of physical functioning, 12% had both. The strongest link with severe difficulty with physical functioning was chronicity (odds ratio (OR)=6.49, 95% CI 4.65, 9.04). Other independent links were age over 75 years (odds ratio (OR)=4.11, 95% confidence interval (CI) 3.03, 5.58), depression (OR=2.80, 95% CI 2.22, 3.54), bilateral knee injury (OR=2.23, 95% CI 1.63, 3.06) and body mass index>30 (OR=2.00, 95% CI 1.51, 2.64). Similar associations were found for severe pain. The findings suggest that the WOMAC is a reliable measure for use in postal surveys. It has advantages over other instruments when measuring pain and physical function difficulty related to the knee. Chronicity, older age, injury, obesity and depression were all linked with higher WOMAC scores for knee pain severity and disability among knee pain sufferers in the general older population.

NHS workforce planning has traditionally ignored the role of doctors and nurses trained in continental Europe and Scandinavia. At present doctors trained in the European Economic Area make up 10 per cent of senior house officers in England and Wales. But the numbers coming to the UK are falling. Falling medical unemployment in Europe will mean these doctors have less incentive to come to the UK, leaving a considerable gap in the NHS workforce. More local research is needed into working patterns and career plans of European-trained nurses and doctors.

In an Escherichia coli strain lysogenic for lambda spc2 transducing phage, an extra copy of ribosomal protein (r-protein) genes in the spc and alpha operons are carried on the phage chromosome. Expression of genes in the spc operon in this merodiploid strain was compared with that in a control "haploid" strain carrying lambda trkA phage. It was found that the synthesis rate of spc mRNA, relative to other reference mRNA in the merodiploid strain, is about 2-fold higher than that in the control strain; yet, no dosage effect was observed in the synthesis rate of r-proteins in the spc or alpha operon. The spc mRNA was found to be more rapidly degraded in the merodiploid strain than in the control strain, and its steady-state amount, relative to reference mRNA, was only slightly higher in the merodiploid strain than in the control strain. Thus, E. coli cells have the ability to regulate the rate of r-protein synthesis regardless of the rate of transcription of r-protein genes, presumably by inactivation of the mRNA followed by its degradation. A model is proposed which involves selective inactivation of r-protein mRNA by a feedback mechanism. The model can explain coordinated synthesis of r-proteins and other observations related to selective expression of certain alleles in diploid strains.