Transcript Knees Up Mother Brown

Knees Up Mother Brown!
Marion Richardson
The St Albans and Harpenden
Acupuncture
Knee Clinic
Why acupuncture?
An ancient art
Cost effective
Patient choice
Well tried &
tested
Safe
Local practitioners
A last ditch attempt
Cost-effectiveness

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
Lindell (1999)
o patients in GP setting
o acupuncture OR hospital OP referral or procedure
o acupuncture costs significantly less
o average saving/patient £232
No UK studies specifically focussing on knee pain but
back pain study (Thomas et al, 2005) incremental QALY
costs compared favourably with other NHS approved
treatments
Reinhold et al (2007) Eur J Health Economics
o Acupuncture + usual care cost effective in OA knee
Why acupuncture?
An ancient art
Cost effective
Patient choice
Well tried &
tested
Safe
Local practitioners
A last ditch attempt
Safety

Yamashita et al (2006)
o No serious adverse events reported
o Minor side effects – worsening of pain,
haematoma, dizziness
o May be unrelated to physiological action of
acupuncture per se

White (2007) Evidence from UK
o Negligible risk in hand of competent
practitioners
Why acupuncture?
An ancient art
Cost effective
Patient choice
Well tried &
tested
Safe
Local practitioners
A last ditch attempt
Eastern or Western therapy?
Dampness in the spleen meridian?
OR
Osteoarthritis of the knee?
Why OA knee?



Common
Debilitating
Older population with comorbidity
 NSAIDs can be harmful +
lack of evidence of long-term
effectiveness
 Surgery may be suboptimal ,
has relatively high rates of
complications and is
expensive - £5633 (PBC
tariff 2008/9)
Is there research evidence?


Large cohort, high quality RCTs
o Vas et al (2004) Acupuncture vs a sham needle – better
for pain, improved function and decreased use of
diclofenac
o Berman et al (2004) – Acupuncture improved function
and pain relief compared with sham acupuncture and
education control groups
o Witt C et al 2005 - Acupuncture significantly better than
sham for pain and disability
Systematic Review (White et al, 2007) Acupuncture
significantly superior to sham and to no intervention in
improving pain and function in severe OA knee
How are patients referred?
Via MSK CATS
 Clear criteria

o maximum tolerated analgesia
o woken at night
o restricted walking distance (eg 100 m)
Contacted by MSK CATS ES physio
 Offered acupuncture & choice of surgery
 Appointment made by surgery

The clinics
Nurse led
 Initial personal consultation
 ‘Trial’ session of acupuncture
 Group clinic
 Treatment protocol
 Assessment using MYMOP

The clinics
Nurse led
 Initial personal consultation
 ‘Trial’ session of acupuncture
 Group clinic
 Treatment protocol
 Assessment using MYMOP

The clinics
Nurse led
 Initial personal consultation
 ‘Trial’ session of acupuncture
 Group clinic
 Treatment protocol
 Assessment using MYMOP

The clinics
Nurse led
 Initial personal consultation
 ‘Trial’ session of acupuncture
 Group clinic
 Treatment protocol
 Assessment using MYMOP

Treatment protocol
4 sessions at weekly intervals
 Reassess and either

o continue with manual acupuncture
o add electroacupuncture and reassess
Treatments at extending intervals
 MYMOP assessment at 6 months
 Maintenance every 6 weeks or less
frequently

Treatment protocol
4 sessions at weekly intervals
 Reassess and either

o continue with manual acupuncture
o add electroacupuncture and reassess
Treatments at extending intervals
 MYMOP assessment at 6 months
 Maintenance every 6 weeks or less
frequently
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Is it working?

Numbers treated to end of August
o 63 patients (44F, 19M)
o 98 knees (35 both)
o Age range 48 - 93

Numbers still being treated
o 52 patients
o 80 knees
Success contd.

Those referred back to MSK CA(T)S
o
o
o
o
o
o
o
1 worse after treatment
6 insufficient symptom relief
1 wanted surgery (despite considerable improvement)
1 initial improvement not maintained
2 repeated DNA
1 problems getting to surgery
1 GP disapproved of acupuncture!
Success contd.
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Saving money?
o 1 TKR = 282 treatments
o
o
28 patients for first 6 months
35 patients a year AT LEAST longer term
o Both knees = 1 treatment
o 12 knees maintained for 1 year and avoiding TKR =
an annual saving against tariff of £67,356

Other potential savings
o OPD consultations
o Physiotherapy interventions
o Medications
MYMOP scores

Overall score (max 24, min 0)
o Pain (0-6)
o Stiffness (0-6)
o Activity (0-6)
o Wellbeing (0-6)
Drugs for condition
 Importance of cutting down

MYMOP scores difference at
4 weeks
10
9
8
7
6
5
4
3
2
1
0
Worse
-1
-3
-5
-7+
-14+
What are the perceived benefits?

Reduce the demand for outpatient, inpatient and day
case treatment and so either save the cost of those activities
and/or reduce waiting times

Reduce the need for operative interventions especially
knee surgery
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Reduce referrals to the West Herts physiotherapy
service and thereby reduce waiting times
Promote a Secondary to Primary shift of care in line
with the aims of government, Investing in Your Health and PCTs

Enhance patient choice and ensure a service that is locally
accessible to patients in line with the stated aims of the government
and local health economy

Reduce expenditure on medication
Let the patients speak…

“In 2003 I was diagnosed with severe
osteoarthritis in both knees and was told that the
condition would deteriorate and my only recourse
was painkillers and eventually replacement
knees. The provision of acupuncture on the
NHS has transformed this prognosis.
Acupuncture eased the pain and discomfort to
such an extent that I was able to take up regular
exercise to strengthen my muscles. Nowadays, I
rarely take painkillers and the flexibility in both
knee joints has improved dramatically.
Attending the acupuncture clinic in the GP’s
surgery is beneficial for several reasons: the
surgery is local; the acupuncture is given as
part of a treatment programme particular to
each patient’s medical history; the patient has
confidence that the acupuncturist is well-trained
and has a medical background and patients feel
more comfortable in familiar surroundings.
Group sessions are therapeutic in encouraging
patients to share their experiences.
I feel privileged and lucky to have benefitted
from acupuncture on the NHS and hope that it
will continue and its availability become
widespread throughout the country.”
Valerie Lucien 18 August 2008
Acknowledgements

Dr Jonathan Freedman, Parkbury House
 Pam Richmond – Nurse Acupuncturist
 Drs James Ferguson, Michael Cannell, Andy Cohen –
the Midway Surgery St Albans
 Dr Mike Cummings - BMAS Medical Director
 Dr Saul Berkovitz - Consultant RLHH
 Katrina Power – Commissioning Lead West Herts PCT
 Dr Mark Bevis – MSK CATS GP Lead
 Sally Allan – Extended Scope Practitioner MSK CATS
Any questions?