Title: Towards UK poSt Arthroplasty Follow-up rEcommendations: UK SAFE
Funder: Department of Health and Social Care

Abstract: In the current economic climate there is increasing pressure to identify cost-saving measures across the NHS. Our recent work suggests that many centres are curtailing primary hip and knee arthroplasty follow-up services to deal with the growing pressure on their services. However, such disinvestment is without evidence-base and raises questions of the consequences to patients. This project will examine the requirements for arthroplasty follow-up and produce evidence and consensus-based recommendations as to how, when and on whom follow-up should be conducted. This project will make use of routine data from 5 national datasets (National Joint Registry, Hospital Episode Statistics, Patient Reported Outcome Measures, Clinical Practice Research Database and TPP SystmOne/ResearchOne) together with prospective data collected on patients presenting for revision surgery and evidence gathered through a comprehensive literature search. 1) NJR-HES-PROMS data will be used to model time to revision to determine when follow-up should occur. A smoothed Nelson-Aalen cumulative hazard rate will be used to identify any peak in the mid-long term revision risk. 2) NJR-PROMS-HES linked data, together with CPRD-HES and R1-HES to understand primary care involvement, will be used to examine which patients are most likely to require intervention. We will use cox proportional hazards regression modelling to identify pre, peri- and post-operative predictors of mid-late term revision (5 or more years post primary surgery). 3) Prospective data collected on 675 patients presenting for elective or emergency revision across 25 NHS centres will determine how patients currently present for revision surgery. 4) Markov modelling will be used to simulate long-term costs and quality adjusted life years associated with different follow-up care models to determine how follow-up should occur. 5) Together with a systematic literature review, this work will inform a Delphi-consensus process, involving all stakeholders, to develop a policy document which includes a stratification algorithm to determine appropriate follow-up for an individual patient. We have assembled a highly experienced multi-disciplinary team from the Leeds and Oxford NIHR Musculoskeletal Biomedical Research Units with the necessary academic expertise to tackle the methodological challenges in undertaking this work to ensure the project yields meaningful results that are accepted by key stakeholders. We have support for the conduct and dissemination of this project from all relevant stakeholders, including major national and international orthopaedic bodies, clinical commissioning groups, general practitioners and patients. This research, by making use of large routinely collected, observational datasets and prospective data collection will establish what constitutes the most effective and cost-effective arthroplasty follow-up care pathways, thereby ending the current confusion over how, when and on whom follow-up should be carried out. Novel, evidence-based care pathways for hip and knee arthroplasty follow-up will have major immediate effect on national NHS planning and budgeting, potentially saving millions of pounds per year, and on patient well-being. The national and global impact will be to reduce the burden on patients and health services in terms of outpatient visits and clinical tests that do not add benefit, while optimising detection of potential problems.

Lay abstract: Most people now understand the need for a cost-effective NHS, but seek reassurance that this will not reduce the standard of care. This is particularly true of older people, who are the group most likely to be affected by this research. This research seeks to demonstrate that good after-care is not necessarily expensive, in terms of time and money on the part of both patient and hospital staff, and that individual patient-centred follow-up can better identify potential problems in a timely fashion, to the benefit of all concerned. Total joint replacement provides considerable improvement in quality of life to people suffering with severe joint damage and in 2013 over 150,000 total hip and knee replacements were conducted. Due to increasing ageing and obesity in the UK population, this number is likely to increase each year. Sometimes, problems can develop with the replaced joint over time and a small percentage of people require further surgery. Because joint failure is not always associated with symptoms, follow-up care is provided to ensure that problems are identified as early as possible. Providing this care for everyone in the years after their surgery is extremely expensive and the NHS is under increasing pressure to reduce its costs. Many hospitals have dramatically reduced the amount of follow-up provided and some provide no follow-up at all. There is very little research evidence to determine whether not providing follow-up care may be causing harm to people by missing the opportunity to pick up a problem with a replaced joint before serious damage occurs. This study will enable us to look at the routine data from the National Joint Registry on a large group of people admitted for revision surgery. We will also ask people how they came to be admitted for revision surgery, their symptoms and previous hospital and GP visits. We will compare those who needed emergency surgery, with those who have more timely revision surgery. This will help us to understand when people are most likely to develop problems with their joint replacement and to identify whether some are more likely to develop problems than others. It is vital that a decision to stop providing follow-up is not made just to save costs to the NHS, but is based on precise evidence, which includes understanding potential benefit and harm to people. At the end of the study an expert panel, including those who have undergone joint replacement, will consider the results to develop guidelines about how follow-up should be conducted to ensure no harm is caused. This project brings together highly experienced teams from the Leeds and Oxford NIHR Musculoskeletal Biomedical Research Units with the necessary expertise to successfully undertake the project. We have three PPI members, including one co-applicant, who were involved in developing this proposal and will support the design of patient material and interpretation of results. We have support from all relevant major national and international orthopaedic societies in this undertaking. The resources requested to support this study have been carefully calculated and are in line with studies of similar complexity and duration. This study has potential for huge impact, by reducing the burden on patients and the NHS in terms of outpatient visits and clinical tests that do not add benefit, whilst optimising detection of potential problems.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MUSCULOSKELETAL