title: 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.
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.
  
  
  RESULTS
  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.
  
  
  BACKGROUND
  ISRCTN registry ISRCTN40721988.
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.|NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, Keele, United Kingdom.
authors.forename: Christian D
authors.identifier: http://orcid.org/0000-0002-2677-1028
authors.initials: CD
authors.lastname: Mallen
authors.affiliation: General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
authors.forename: Barbara I
authors.identifier: http://orcid.org/0000-0001-5639-0130
authors.initials: BI
authors.lastname: Nicholl
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Martyn
authors.initials: M
authors.lastname: Lewis
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Bernadette
authors.identifier: http://orcid.org/0000-0002-8557-6222
authors.initials: B
authors.lastname: Bartlam
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Daniel
authors.initials: D
authors.lastname: Green
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Sue
authors.identifier: http://orcid.org/0000-0001-8936-3745
authors.initials: S
authors.lastname: Jowett
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Jesse
authors.initials: J
authors.lastname: Kigozi
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: John
authors.initials: J
authors.lastname: Belcher
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Kris
authors.initials: K
authors.lastname: Clarkson
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Zoe
authors.initials: Z
authors.lastname: Lingard
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Christopher
authors.identifier: http://orcid.org/0000-0002-1372-218X
authors.initials: C
authors.lastname: Pope
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.|NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, Keele, United Kingdom.
authors.forename: Carolyn A
authors.initials: CA
authors.lastname: Chew-Graham
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: Peter
authors.initials: P
authors.lastname: Croft
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.|NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, Keele, United Kingdom.
authors.forename: Elaine M
authors.initials: EM
authors.lastname: Hay
authors.affiliation: Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom.
authors.forename: George
authors.identifier: http://orcid.org/0000-0002-9008-0184
authors.initials: G
authors.lastname: Peat
mesh_terms: D000368:Aged; D003863:Depression / Q000150:complications / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D003955:Diagnostic Tests, Routine; D001330:Electronic Data Processing / Q000379:methods; D005260:Female; D006284:Health Plan Implementation / Q000458:organization & administration / Q000592:standards; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods / Q000592:standards; D008875:Middle Aged; D010003:Osteoarthritis / Q000150:complications / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D019095:Point-of-Care Systems / Q000458:organization & administration* / Q000592:standards; D011320:Primary Health Care / Q000379:methods / Q000592:standards; D012017:Referral and Consultation; D011795:Surveys and Questionnaires