Audit and investigation suggestions

Medication and monitoring

 Are your patients on biologic drugs, e.g. adalimumab (Humira), etanercept (Enbrel), rituximab? Is this clearly
marked in their records?
 Are your elderly patients who are housebound or in residential care receiving vitamin D supplementation to help
reduce risk of falls and fracture?
 Are your patients on corticosteroids being managed according to the Framework for the development of
guidelines for the management of glucocorticoid-induced osteoporosis (Osteoporos Int (2012) 23:2257–2276)?
 Are your patients on DMARDs being managed according to shared care guidelines and in possession of a
disease-monitoring book?
 Are all patients on DMARDs in your practice having regular blood monitoring which conforms with BSR
guidance?
 Patients on repeat prescriptions of NSAIDs and cox-2 drugs should have an annual record of renal function (eGFR
and creatinine).
 Patients on repeat prescriptions of NSAIDs and cox-2 drugs should have an annual record of blood pressure.

Fibromyalgia and chronic widespread pain

 Look through notes of patients diagnosed with fibromyalgia – were there clues in the past history (depression,
anxiety, somatisation, eating disorders and childhood sexual and physical abuse)?
 Do a computer search on your GP clinical system for fibromyalgia (read codes = N239 and N248). Record the
prevalence for your practice – if this is less than 2% ask yourself why. Could it be that you are underdiagnosing
or undercoding FMS?

Investigations

 Consider performing a retrospective review of patients who have had MRI scans for possible meniscal injuries.
Did your history and examination findings correlate with the MRI report? How will this change your approach?
 Audit the number of patients still taking steroids after two years with a diagnosis of PMR. Have any of these
patients still got raised inflammatory markers? Does the diagnosis need to be re-considered?
 How confident do you feel about diagnosing a prolapsed disc without an MRI scan? What might change your
confidence or approach?
 Review personal use of Rheumatology investigations (e.g. ANF, rheumatoid factor). In patients not referred to
Rheumatology, how much information did the tests add to the clinical picture?

Co-morbidity

 Audit management of cardiovascular disease risk for patients with inflammatory arthritis and connective tissue
diseases (formal risk assessment – QRISk2, annual recording of blood pressure, lipids, smoking cessation advice
etc.)
 Are your patients with arthritis who are receiving regular steroid medication or DMARDs having their annual flu
vaccination and pneumococcal vaccination?
 Annual depression screening for all patients with arthritis and chronic musculoskeletal pain.
 Record of lifestyle advice (smoking cessation, weight management, exercise advice or referral) given to patients
with arthritis.
Gout

 Are your patients with gout being managed according to the BSR 2007/EULAR 2012 guidelines?
(1) Documented frequency and duration of gout flares
(2) The achievement of target reduction in plasma urate levels
(3) Documented lifestyle modification (weight reduction, alcohol intake and dietary adjustment)
(4) The assessment and treatment of co-morbid disorders (diabetes mellitus, hypertension, and cardiovascular
risk).
(5) Have patients with gout had a medication review (especially thiazide/loop diuretics)
 Case find patients with a raised uric acid level on the practice register in the last 12 months.
(www.stampoutgout.co.uk)

Sports and exercise

 Consider ways you can promote physical activity to sedentary patients with chronic disease, and put these into
practice. Consider using validated questionnaires such as the International Physical Activity Questionnaire (IPAQ)
or General Practice Physical Activity Questionnaire (GPPAQ) to record activity levels.
 Perform an audit of the referrals made to secondary care for patients with sporting injuries in the last few
months. What was the outcome of the referrals? Could any more have been done within primary care before
the referral was made?

Upper limb

 Brush up your knowledge of clinically relevant anatomy of the upper limb. Develop a scheme to quickly assess
the myotomes and dermatomes.
 Check that you have ready access to information, either paper-based or online, to give to patients about the
treatment of lateral epicondylitis, especially with respect to self-help exercises.

Osteoarthritis

On average in one year 2% of all people registered with a practice will consult about OA.
 Do a computer search on your GP clinical system to calculate the percentage of patients who had a consultation
for osteoarthritis (read codes = N05...) in the last year. Discuss with your colleagues what you have found and
think about the following:
(1) Does the prevalence seem higher or lower than you thought?
(2) If lower, are patients not being diagnosed, or are symptom codes (such as ‘knee arthralgia’) being used
instead of disease codes?
(3) What sort of care are you providing for this group of patients? Are you routinely documenting pain (e.g. VAS
score) and function?

Osteoporosis

QOF indicators for secondary prevention of fractures

 The practice can produce a register of patients:
1) Aged 50–74 years with a record of a fragility fracture after 1 April 2012 and a diagnosis of osteoporosis
confirmed on DXA scan,
2) Aged 75 years and over with a record of a fragility fracture after 1 April 2012.
  The percentage of patients aged between 50 and 74 with a fragility fracture in whom osteoporosis has been
confirmed on a DXA scan and who are currently being treated with an appropriate bone-sparing agent.
 The percentage of patients aged 75 years and over with a fragility fracture and who are currently treated with an
appropriate bone-sparing agent.

Rheumatoid arthritis

Rheumatoid arthritis is on the QOF menu for the first time from 2013 with the following indicators:
 The practice can produce a register of all patients aged 16 years and over with rheumatoid arthritis
 The percentage of patients with rheumatoid arthritis aged 30–84 years who have had a cardiovascular risk
assessment using a CVD risk assessment tool adjusted for RA in the preceding 15 months.
 The percentage of patients aged 50–90 years with rheumatoid arthritis who have had an assessment of fracture
risk using a risk assessment tool adjusted for RA in the preceding 27 months.
 The percentage of patients with rheumatoid arthritis who have had a face-to-face annual review in the
preceding 15 months. Can you think of what a ‘good’ annual review looks like? What parts of the annual review
can be done in primary care? Which members of the practice team could perform the review? Are there training
needs arising?

Other suggestions

 Review last 10 rheumatology referrals. What was the diagnosis? What was the outcome of the referral? Would
you refer a similar patient again? Could any other appropriate management have been delivered in primary
care?
 Review last 10 orthopaedic referrals. What was the diagnosis? What was the outcome of the referral? Would
you refer a similar patient again? Could any other appropriate management have been delivered in primary
care?
 Review last 10 physiotherapy/musculoskeletal referrals. What was the diagnosis? What was the outcome of the
referral? Would you refer a similar patient again? Could any other appropriate management have been
delivered in primary care?
 Can you build a case for introduction of musculoskeletal clinical quality indicators to the Quality and Outcomes
Framework (QOF)? What indicators would you use and why?
 Patient-based case studies: interesting or unusual cases, examples of effective multidisciplinary team working,
working with expert patient groups.
 Significant event analysis (SEA) forms an important part of the learning curve for all healthcare professionals.
Can you think of an SEA in the musculoskeletal field which has led to changed/improved management?
 Consider performing a significant event analysis on patients presenting with musculoskeletal pain who were
subsequently diagnosed with cancer. Could the diagnosis have been made earlier?
 Given the importance of early diagnosis in inflammatory arthritis, if you have a patient diagnosed with a
connective tissue disease or inflammatory arthritis consider a casenote review to see whether the referral was
organised in a timely manner (i.e. within 6 weeks of developing symptoms).

More on the background to SEA

Significant event analysis provides the opportunity of using events in practice as a personal learning opportunity for the
healthcare professional. By reflecting on a chosen event and learning from the event this should lead to improved
patient care. The chosen event may be to do with patient care (clinical event), something that has happened within the
team (management event), a training event or just an event within your practice that was significant to you and that you
wish to build upon and learn from.