Title: Hip arthroplasty surveillance: is it really necessary?
Funder: Health Education England

Abstract: Background and research question The UK government is committed to improving the healthcare of patients with long term conditions including arthritis. The treatment of hip arthritis with a joint replacement is a well-established and successful method of reducing pain and increasing mobility but approximately 10% of patients will require revision surgery, the majority of which are for aseptic loosening of the joint. Long term clinical follow up of hip arthroplasty is often provided to identify asymptomatically failing hip replacements through expert review because patients are unaware of changes or the significance of symptoms.Hip arthroplasty surveillance services are being cut in many areas of the United Kingdom, as they are not considered essential. There is a significant annual cost to the NHS of revision hip arthroplasty but a lack of economic evidence for hip arthroplasty surveillance. It is hypothesised that, without surveillance, there will be a greater deterioration of the hip joint before the patient is referred for surgery with potentially higher pain levels pre-operatively and more complex surgery and rehabilitation. The question, Is hip arthroplasty surveillance really necessary?' will be addressed and the aim is to explore the evidence for the existence of hip arthroplasty surveillance services. Plan of investigation The research will commence with a systematic review of the literature and then proceed to a series of concurrent studies using a mixed methods design. This design is suited to pragmatic investigations of existing problems, and the combination of quantitative and qualitative research draws on the strengths of each and minimises the weaknesses of both. The research will take the form of four projects. The first will be a systematic review of the literature to describe the existing clinical evidence for long term surveillance of hip arthroplasty. This will be followed by a qualitative study of the patient view on long term hip arthroplasty surveillance, using focus groups. There will be purposive sampling of patients with experience of primary and revision hip arthroplasty, some of whom have had hip arthroplasty surveillance and some who have not. The third project is a survey of contemporary health professional views on hip arthroplasty surveillance, including medical and non-medical orthopaedic staff. The fourth project is an observational feasibility study of a clinical cohort to explore the effect of hip arthroplasty surveillance on the health economics and the health related quality of life at revision hip arthroplasty.Potential benefits Hip arthroplasty surveillance is threatened by service cuts as it is viewed as non-essential by service providers which leads to disinvestmentThe evidence gathered through this research will be used to inform practice about the cost effectiveness, clinical effectiveness and patient view of hip arthroplasty surveillance services.The clinical feasibility study will provide evidence for the cost effectiveness of this type of service, and, if there is seen to be a significant benefit, a multicentre trial can be designed using information gained in the preliminary study. The evidence for clinical effectiveness of hip arthroplasty surveillance, gathered though the feasibility study and the survey of health professionals, will provide comprehensive knowledge that is useful to managers and clinicians. The qualitative project will provide evidence of patient views, which is important to present to commissioners for service planning alongside the evidence that emerges from the study of the costs involved. If the evidence gathered through the proposed research supports hip arthroplasty surveillance, then non-medical health practitioners will be in a position to further develop their advanced role in this specialised orthopaedic service. This has potential to enhance the future career development of allied health professionals and orthopaedic nurses.

Lay abstract: Treatment with a hip replacement is effective but over time, many deteriorate, often without symptoms, and some will require further surgery. This study explores the need for long-term surveillance of this patient group using a literature review, discussions and interviews with patients, a survey of health professionals and an analysis of the costs and health related quality of life around the time of revision hip surgery. A range of journal papers, presentations and reports will be produced for professional and public audiences. The results will provide evidence to assist future service planning in orthopaedics for patients with a hip replacement.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: MUSCULOSKELETAL