MSK Recommended Indicator Set for people with arthritis

The indicators below describe the value, quality and cost of musculoskeletal services, aimed at those who are responsible for shaping services (commissioners and providers) and also relevant and meaningful to clinicians and patients.

Download the Recommended MSK Indicator Set report (PDF, 1MB). The long list from which the final set of indicators derive (PDF, 1.4MB) can also be downloaded.

Explanation

This indicator looks at how much is being spent locally on musculoskeletal services compared with local spend on all NHS services.

Interpretation

Total spend on its own doesn't determine quality – a service could spend a lot because of high local need, or spend less because it’s very efficiently run. Comparing musculoskeletal spend between similar populations would be useful, as an unexpected figure (high or low) needs looking at. It could also be useful to look at trends – whether local spend is going up, or falling – and trying to understand why.

Explanation

This indicator looks at the balance between different types of health professionals, specifically between specialist doctors, and other professions that support people with musculoskeletal conditions, such as physiotherapists, podiatrists and others.

Interpretation

It's important to make sure there's a good mix of professionals available locally so that people with musculoskeletal conditions can get the treatment and support they need. Over-reliance on one particular type would be unexpected (though it could be for very good reasons) and is worth investigating.

Explanation

This indicator looks at how much is being spent by general practitioners (GPs) on prescriptions for second-line medicines for treating pain.

Interpretation

Many people living with painful musculoskeletal conditions can benefit from pain-relieving medication and this should be provided. However, there are also other important aspects to pain-management, and overreliance on second-line pain medications can suggest these are being overlooked.

Explanation

This indicator looks at whether people have a care plan – a summary of their personal health problems and goals and the plan to address them, mutually agreed between them and their clinician and usually reviewed annually.

Interpretation

Care plans are an important way of enabling coordinated, personalised care. People with long-term conditions who want one are entitled to have a care plan as part of their NHS care. Low uptake of care planning suggests that people are not being offered this opportunity to participate in decisions about their health and care.

Explanation

This indicator looks at how long people are waiting to see a physiotherapist (or other allied health professional such as podiatrist, or hand therapist) after the initial referral, whoever makes the referral (including in areas where people can refer themselves directly to physiotherapy).

Interpretation

A long waiting time to see a physiotherapist (or other allied health professional) is usually sub-optimal healthcare. People have troublesome symptoms they need help with and may be unable to work or participate in their usual activities during that time, and problems left for longer become harder to treat.

Explanation

This indicator looks at how much obesity there is among people with two of the most common forms of arthritis (BMI compares height to weight to estimate overweight/obesity).

Interpretation

People who are overweight and obese generally have more severe arthritis symptoms than people of a healthy body weight, and tend to respond less well to treatment. Good musculoskeletal care systems will support people with arthritis to maintain healthy body weight to minimise symptoms and improve their response to treatment.

Explanation

This indicator looks at whether people with two of the most common forms of arthritis are receiving the information they need about improving their symptoms through physical activity.

Interpretation

Appropriate physical activity reduces symptoms for people with arthritis. Clinicians should routinely offer brief advice about physical activity to tackle myths that exercise is bad for joints and that people with arthritis should rest, and to support people to improve their own musculoskeletal health.

Explanation

This indicator looks at how likely it is that people with severe hip osteoarthritis have their hip replaced.

Interpretation

Hip replacement surgery is a very effective treatment for people with hip osteoarthritis. Low rates of surgery could mean that people who could benefit are being left in severe pain. High rates of surgery could suggest that other, non-surgical treatment options, are unavailable or not being explored with patients. There's no “correct” rate of surgery and, as always, it's essential to explore the local reasons for any variation, rather than making assumptions about the cause.

Explanation

This indicator looks at how likely it is that people with severe hip osteoarthritis have their knee replaced.

Interpretation

Knee replacement surgery is a very effective treatment for people with knee osteoarthritis. Low rates of surgery could mean that people who could benefit are being left in severe pain. High rates of surgery could suggest that other, non-surgical treatment options, are unavailable or not being explored with patients. There's no “correct” rate of surgery and, as always, it's essential to explore the local reasons for any variation, rather than making assumptions about the cause.

Explanation

This indicator looks at the number of days on average that a patient spends in hospital after being admitted as an inpatient to have either their hip or their knee replaced.

Interpretation

For most people, it’s good to be back on their feet and home as soon as possible after a joint replacement and this promotes a good recovery – many providers have implemented “enhanced recovery” programmes to achieve this. Longer stays generally aren’t good for patients and they may indicate a lack of best clinical practice and/or treatment that's less cost effective.

Explanation

This indicator looks at how likely it is that a person who has had either their hip or knee replaced needs to be readmitted to hospital as an emergency within 28 days of being discharged after their operation. It only includes people who have had their original joint removed and replaced, not the replacement of an artificial one that has worn out.

Interpretation

If the surgery and after-care goes well, then there shouldn’t be any reason why people need to be back in hospital within a month. Being readmitted as an emergency suggests a problem or a complication, such as an infection or a blood clot in the leg.

Explanation

This indicator looks at how many people aged over 60 years have had keyhole surgery (arthroscopy) for their knee.

Interpretation

Keyhole surgery (arthroscopy) for normal knee osteoarthritis is relatively ineffective. High rates of this procedure in people aged over 60 years suggests poor use of resources.

Explanation

This indicator looks at how likely it is that a person with back pain will attend A&E because of their back pain.

Interpretation

People only go to A&E for their back pain if things have become extremely bad or if they've been unable to access appropriate services elsewhere – both of which shouldn't be common if there are good community musculoskeletal services for people with back pain, including self-management support. A high level of A&E attendance for back pain suggests a problem with these services.

Explanation

This indicator looks at how likely people with back pain are to have specialist injections into one of the small joints in the spine.

Interpretation

Although facet joint injections for back pain are sometimes appropriate, for example to make a diagnosis, for most people as a treatment they're ineffective. Very low numbers could suggest that some people that need them aren’t getting them. High numbers suggest overuse of this procedure and may imply ineffective community back pain services.

Explanation

This indicator looks at how likely it is that someone is seen by a specialist within three weeks of referral if they're suspected to have developed rheumatoid arthritis.

Interpretation

Rheumatoid arthritis is a rapidly progressive condition that causes irreparable damage to the joints. People who develop this need urgent, intensive therapy to prevent long-term pain, disability and joint damage.

Explanation

This indicator looks at how likely it is that a person with rheumatoid arthritis will receive a regular injection with a specialist biological therapy as their treatment.

Interpretation

Biological therapies are high-cost, injected treatments that are used when other approaches haven't worked. Conventional, relatively inexpensive, drugs (DMARDs) for rheumatoid arthritis are most effective when used intensively, very early on in the course of rheumatoid arthritis. So low use of biological therapies could be due to very effective use of DMARDs, or because of a failure of a service to start them in people who really need them.

Explanation

This indicator looks at how likely it is for an older person to fall and break their hip.

Interpretation

People over 70 years old who have osteoporosis (a condition which causes the bones to become thin) are at much greater risk of breaking bones such as the hip from seemingly minor falls. A broken hip can greatly impact mobility, independence and quality of life.

Explanation

This indicator looks at how likely it is that someone with a broken hip gets all the components of best practice care.

Interpretation

There are a number of actions which should occur during the treatment and hospital care of the patient, for example, surgery within 36 hours of admission and specialist older persons’ assessment. People getting all these components are more likely to have a good health outcome following their broken hip.

Explanation

This indicator looks at how likely it is for someone living in their own home when they broke their hip to return to live in their own home within a month.

Interpretation

The goal of care for a person with a broken hip is to restore them to their previous health. Low numbers of people managing to return home within a month of their fracture, for example because they have had to be admitted to a care home, or are needing prolonged inpatient rehabilitation, suggests poorer care.

Explanation

This indicator looks at how much additional “health” people gain from the services and treatments they receive.

Interpretation

Musculoskeletal services aim to improve health for people with arthritis. The Musculoskeletal Health Questionnaire (MSK-HQ) is a short questionnaire that asks people to rate their symptoms – pain/stiffness, independence, mobility, mood, sleep, ability to take part in usual activities. (EQ-5D is similar but shorter and not specific for musculoskeletal problems.) Scores should improve with treatment, and the better the improvement the bigger the change in scores.

Explanation

This indicator looks at how likely it is that people are receiving state benefits because they're unable to work due to a musculoskeletal condition.

Interpretation

An important goal for musculoskeletal services is to support people to carry out their usual daily activities. For people of working age, this includes remaining in (or returning to) employment. High levels of ESA suggest this aspect of musculoskeletal care isn't being effectively provided.

Explanation

This indicator looks at the quality of experience for people using musculoskeletal services.

Interpretation

As well as improving musculoskeletal health, services should be pleasant and acceptable for those who use them. Questionnaires, such as the rheumatic conditions care patient service experience scores, ask individual patients about their experiences. Services that rate highly are generally providing their patients with a good experience.