MuSculoskeletal paiN durIng the COVID-19 PandEmic: an observational study of UK national primary care electronic health records (the SNIPE Study)

Date of ISAC Approval: 
20/10/2020
Lay Summary: 
Since the beginning of the covid pandemic, most people who needed healthcare advice about symptoms not related to covid either spoke to their doctor on the telephone or via video-call. Most specialist services were paused to reduce the spread of the virus and to prioritise care for people with covid. GPs could only refer for very urgent or emergency reasons. Aches and pains can be managed in many ways, including education, physical therapy, exercises and painkilling medication. It is important that GPs recognize aches and pains that might be due to conditions like rheumatoid arthritis. If a GP thinks that a person might have rheumatoid arthritis, it is important that they refer the person to see a specialist very quickly, as the sooner treatment can be started, the better. We think that over the course of the pandemic, the numbers of people contacting their GP for help with aches and pains will change. Also, as GPs can’t refer to specialists for anything but emergencies, they might be more likely to prescribe stronger painkillers, which can be harmful. In other conditions such as cancer, it has been noticed that the number of people who are found to have a new cancer has fallen during the pandemic. We want to see if this is the same for rheumatoid arthritis. This is important because we can give clearer advice to the public urging them to seek help for aches and pains that might indicate rheumatoid arthritis, despite the pandemic. We will also be able to give guidance to health care professionals about when to refer to specialists.
Technical Summary: 
The SNIPE study builds on observations from practising clinicians and patients that the COVID-19 pandemic has substantially affected the care delivered to patients with musculoskeletal disorders in primary care. Patients are being managed remotely with no access to routine specialist services. Instead, they may be prescribed analgesia at increasing strength and thus are at risk of harm. There are also concerns that, as with cancer, reluctance to consult, remote consulting and a hold on routine referral pathways may lead to delayed diagnosis of inflammatory arthropathies (IA) (for example, rheumatoid arthritis and Juvenile Idiopathic Arthritis). The SNIPE study objective is to investigate the impact of the pandemic on the care of adults and children with musculoskeletal disorders. Three hypotheses will be addressed: 1) that the COVID-19 pandemic has affected the numbers of patients consulting in primary care with musculoskeletal conditions from any cause; 2) that analgesic prescribing for these patients has changed; 3) that the time to diagnosis of IA has been affected by the pandemic. The study population includes all primary care users whose electronic records are included in CPRD Aurum. Prevalence and incidence of consultations for all musculoskeletal conditions and associated analgesic prescribing, and time to diagnosis of IA, will be measured throughout the pandemic periods and differences presented; To overcome difficulties defining fluid time periods, Joinpoint regression will be used to identify significant changes in trends. The study will be conducted in two workstreams to enable timely delivery of results to guide swift action in preparation for future pandemic phases. Workstream 1 will investigate the pre-pandemic peroid and the current COVID-19 wave; Workstream 2 will investigate the time period following the current COVID-19 phase. Workstream findings will be developed with stakeholders including public involvement (PI) and disseminated through PI activities, digital platforms and traditional methods.
Health Outcomes to be Measured: 
Hypothesis 1: Prevalence and incidence of primary care consultations for musculoskeletal disorders per 10,000 persons in the registered population. Hypothesis 2: Prevalence and incidence of analgesic prescribing (paracetamol, NSAIDs (non-steroidal anti-inflammatory drugs), opioids, amitriptyline, gabapentinoid and duloxetine) per 10,000 registered population and per 10,000 population with an associated musculoskeletal-related consultation. Hypothesis 3: Period prevalence of referrals in musculoskeletal consulters, incidence of inflammatory arthropathies (e.g. RA and JIA), time in days between incident musculoskeletal consultation and i) referral and ii) incident RA / JIA diagnosis. All of these outcomes will be measured before throughout the pandemic period.
Collaborators: 

Victoria Welsh - Chief Investigator - Keele University
Christian Mallen - Collaborator - Keele University
Claire Burton - Collaborator - Keele University
James Bailey - Collaborator - Keele University
Kayleigh Mason - Collaborator - Keele University
Kelvin Jordan - Collaborator - Keele University
Martin Frisher - Collaborator - Keele University
Ram Bajpai - Collaborator - Keele University
Victoria Welsh - Corresponding Applicant - Keele University

Linkages: 
Patient IMD