Evaluation of the Burden and Management of Musculoskeletal Diseases

Date of ISAC Approval: 
22/05/2018
Lay Summary: 
Arthritis is a common cause of joint pain and stiffness, affecting everyday movements. It is treated with long-term medication and regular monitoring. However, the burden of arthritis is not fully understood and management guidelines are not always followed. This study will describe the burden of disease and changes in management for four forms of arthritis that affect the joints: gout, rheumatoid arthritis, spondyloarthritis and psoriatic arthritis. It will describe: 1. Time from symptoms to diagnosis, how common each condition is and how they are managed. For some conditions we know little about how many people in the UK are affected and what care they receive. We will describe the characteristics of people affected, complications and use of medicine and services. 2. Use of older and newer, more effective and safer medicines. We will describe changes in medicine prescribing and side-effects over time. For example, gout, where crystals form in joints, can be treated with anti-inflammatories or a newer medicine, allopurinol, which has fewer side effects. 3. Quality of diagnosis and management. For example, monitoring patients at risk of inflammatory arthritis is recommended. We will describe the quality of care using key indicators (e.g. proportion of patients referred to a rheumatologist).
Technical Summary: 
There is incomplete understanding of the burden of inflammatory musculoskeletal diseases and variation in management in terms of spatio-temporal and demographic factors. For example, English studies of ankylosing spondylitis have evaluated risk factors, comorbidities and the validity of diagnostic codes, but the incidence and prevalence of disease, sick-leave rate and pattern of resource-use and management in routine primary care is unknown and we will examine this. Where the distribution and burden of diseases such as psoriatic arthritis are better known, the quality of routine care remains largely unstudied. We will apply quality indicators for timely diagnosis and management to describe current practice and care quality. We will also examine spatio-temporal variation in relation to patient characteristics and local guidelines. Where quality has been measured there is great variance, for example the steadily increasing use of effective treatment with DMARDs for rheumatoid arthritis, compared to the consistently suboptimal use of ULTs for gout. We will assess spatio-temporal and patient-related prescribing patterns and adverse events among incident and prevalent cohorts and the impact of more effective therapy on prescribing rates for traditional therapy including NSAIDs. This will inform understanding of the burden and variation in management of musculoskeletal diseases.
Health Outcomes to be Measured: 
- Routes to diagnosis: screening, referral, symptoms (fatigue, hyperuriceamia, stiffness, back pain, hip pain, joint pain, itchy rash, scalp rash) related auto-inflammatory diseases (achilles tendinitis / tendinopathy, plantar fasciitis, apical lung fibrosis, anterior uveitis, psoriasis) - Prevalence and incidence of disease from 1998: rheumatoid arthritis, ankylosing spondylitis, gout, psoriatic arthritis, psoriasis - Health resource utilisation rates: GP consultation (face-to-face, telephone, video), sick leave, referral to orthopaedic, rheumatology or dermatology, joint aspiration, prescription exemption, total hip or knee replacement, over the counter aspirin therapy - Prescribing rates/timing/duration of drugs from BNF list including: non-steroidal anti-inflammatories (NSAIDs), colchicine, urate lowering therapy (ULT), disease-modifying anti-rheumatics (DMARDs), analgesics, steroids, calcium and vitamin D supplements, bisphosphonates, statins, diuretics, low-dose aspirin, proton pump inhibitors, H2-receptor antagonists, capecitabine, azapropazone, ciclosporin, anti-hypertensives, lipid-lowering, opioids, canakinumab - Adverse drug reactions: drug sensitivity to NSAIDs, steroids, ULT or DMARDs, peptic ulcer (including perforation or bleed) - Other management / quality indicators: duration from joint symptom to diagnosis, drug monitoring, disease review, DAS28, comorbidity screening (CVD, depression, tuberculosis), lifestyle advice (smoking, alcohol, diet, weight/BMI), lifestyle factors (smoking, alcohol, weight/BMI), tests (full blood, white cell, neutrophil, platelet, glucose, lipid, urate, liver function, urea and electrolytes, C-reactive protein, rheumatoid factor, creatinine kinase, ESR, anti-CCP, ECG), blood pressure, joint evaluation, live vaccinations (BCG, influenza - nasal, MMR, polio, rotavirus, typhoid, varicella-zoster, yellow fever), influenza and pneumococcal vaccines - Prevalence and incidence of complications / comorbidities: hypertension, hyperlipidaemia, hypercholesterolemia, hypertriglyceridemia, CHD, heart failure, stroke, depression, diabetes, anterior uveitis, inflammatory bowel disease (undifferentiated, Crohn's, ulcerative colitis), osteoporosis, sleep apnoea, valvular heart disease, reactive arthritis, renal disease, psoriasis - All-cause mortality and the following specific causes of death (coronary heart disease, heart failure, sudden cardiac death, stroke) from 1998.
Collaborators: 

Philip Conaghan - Chief Investigator - University Of Leeds
Gillian Libby - Collaborator - University Of Leeds
Dr Mar Pujades Rodriguez - Collaborator - University Of Leeds
Oras Alabas - Collaborator - University Of Leeds
Owen Johnson - Collaborator - University Of Leeds
Paul David Baxter - Collaborator - University Of Leeds
Samantha Crossfield - Corresponding Applicant - University Of Leeds
Samantha Sykes - Collaborator - University Of Leeds
Sarah Kingsbury - Collaborator - University Of Leeds

Linkages: 
Patient IMD;Practice IMD (Standard)