The Effects of Implementing a Point-of-Care Electronic Template to Prompt Routine Anxiety and Depression Screening in Patients Consulting for Osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

Christian D. Mallen, Barbara I. Nicholl, Martyn Lewis, Bernadette Bartlam, Daniel Green, Sue Jowett, Jesse Kigozi, John Belcher, Kris Clarkson, Zoe Lingard, Christopher Pope, Carolyn A. Chew-Graham, Peter Croft, Elaine M. Hay, George Peat

Abstract

Background

This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes.

Methods and findings

We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire–2 for depression, a two-item Generalized Anxiety Disorder–2 questionnaire for anxiety, and a question about current pain intensity [0–10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health.

During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]).

Conclusions

In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group.

Citation: Mallen CD, Nicholl BI, Lewis M, Bartlam B, Green D, Jowett S, et al. (2017) The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care. PLoS Med 14(4): e1002273. https://doi.org/10.1371/journal.pmed.1002273

Academic Editor: Alexander C. Tsai, Massachusetts General Hospital, UNITED STATES

Received: September 23, 2016; Accepted: February 20, 2017; Published: April 11, 2017

Copyright: © 2017 Mallen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data are available subject to the study's pre-determined ethics approval and the Centre's data sharing policies (http://www.keele.ac.uk/pchs/publications/datasharingresources/). Applications for access to anonymised data from our research databases can be sent to the Centre's data manager at primarycare.datasharing@keele.ac.uk. As per the Participants section of METHODS, code lists are available from www.keele.ac.uk/mrr.

Funding: This study was funded by National Institute for Health Research (NIHR) Programme Grant (RP-PG-0407-10386) and will be published in full and was also funded by Christian Mallen's Arthritis Research UK Clinician Scientist Award (19634). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: CCG and CDM are supported by the NIHR Collaborations for Leadership in Applied Health Research and Care West Midlands. CDM is also funded by the NIHR School for Primary Care Research and an NIHR Research Professorship in General Practice (NIHR-RP-2014-04-026). EMH is a NIHR Senior Investigator. DG was a NIHR School for Primary Care Research Doctoral Training Fellow.

Abbreviations: GAD, Generalized Anxiety Disorder; GP, general practitioner; GPRF, general practitioner research facilitator; NHS, National Health Service; NICE, National Institute for Health and Care Excellence; NRS, numerical rating scale; OA, osteoarthritis; PCRN, Primary Care Research Network; PHQ, Patient Health Questionnaire