So looking at this, you look like you’ve got some issues going on with your joints: Exploring case-finding in long-term condition review consultations (the ENHANCE pilot trial)

Background: The ENHANCE pilot trial aimed to test the feasibility and acceptability of integrating case-finding for osteoarthritis, anxiety and depression within extended primary care nurse-led long-term condition (LTC) review consultations. Training was delivered to general practice nurses (PNs) to deliver ENHANCE reviews, supported by an adapted EMIS LTC computer template. This paper reports findings from a process evaluation exploring the ways in which PNs delivered ENHANCE LTC reviews, focusing on what aspects of the ENHANCE approach were delivered and how PNs integrate the ENHANCE approach within an LTC review consultation.

Methods: Twenty-four patients and seven PNs from four general practices gave consent for their ENHANCE consultations to be audio-recorded and transcribed. A checklist was developed and used to assess the extent to which each intended component was included in ENHANCE consultations. Thematic analysis of transcripts enabled a rich description of the ways in which PNs conducted ENHANCE reviews.

Results: Familiarity with the use and access of the ENHANCE template was high, and in more than half of the audio-recorded consultations PNs had integrated new ENHANCE components and not simply added them on at the end. In the majority of consultations PNs explained there would be additional questions about joint pain or mood, though this was often not prefixed with an explanation that many people with LTCs have low mood or joint pain. Although there were some inconsistencies in the wording used, the audio-recordings demonstrated that PNs were asking the initial case-finding questions. However, PNs did not always follow the intended consultation pathway to ask further questions as a result of positive answers to initial case-finding. In some cases, PNs used additional prompts that appeared to influence patients’ responses, and both patients and PNs attempted to normalize or dismiss responses to questions about anxiety and depression. Particular challenges for PNs included the involvement of family members in the consultation, patient understanding and interpretation of case-finding questions and delivering a person-centred approach that integrated standardized case-finding questions.

Conclusion: Data demonstrate variation in the ways PNs incorporated aspects of the ENHANCE approach within LTC review consultations. PNs were asked to record patient responses on a new EMIS computer template, while maintaining a patient-centred dialogue and completing an integrated ENHANCE review within the available timeframe, so it is unsurprising that there were inconsistencies in the use of case-finding questions and following the ENHANCE consultation pathway. PNs were comfortable with using and accessing the template, and there was integration during the review, suggesting that these elements of the approach were feasible. We have identified challenges around interpreting responses to case-finding questions and explaining the approach and outcomes of case-finding to patients that will need to be addressed through PN training in a future main trial.