Title: Improving patients' experience and outcome of total joint replacement
Funder: Department of Health (England)

Abstract: Aims To improve the experience and outcomes of people undergoing primary total hip or knee joint replacement (TJR) for osteoarthritis (OA). Specific objectives: 1) To update reviews of the relevant literature. 2) To understand and assess the patient experience of and 'journey' through total joint replacement in current routine NHS care. 3) To complete the development and testing of new outcome measures of pain and disability. 4) To carry out a randomised controlled trial (RCT) of enhanced peri-operative pain control. 5) To assess the acceptability and feasibility of enhanced pre-operative pain control. 6) To design and pilot a 5-component package of peri-operative care. 7) To assess the economic implications of our strategy and trial results. 8) To develop consensus statements on best practice for TJR within the NHS. Background TJR is the end-stage surgical intervention for severe OA, aimed at relieving chronic joint pain. Over 100,000 TJRs are performed annually in the UK, making it one of the most common elective surgical procedures performed in the NHS. For many people TJR is a successful intervention, but approximately 20% of patients continue to experience significant long-term pain and disability post-operatively. Traditionally, research into TJR has focused on implant survivorship and surgical techniques and therefore relatively little research has been undertaken on improving patients experiences and outcomes. However, literature reviews by ourselves and others, accompanied by empirical data suggest that there are several determinants of poor outcomes after TJR that can be addressed with specific interventions, namely pain control, physiotherapy, patient education, occupational therapy and medical co-morbidities. Research Plans The methods by which the research plans to fulfil the 8 research objectives are outlined below: 1) Literature reviews will be conducted on determinants of outcomes after TJR, with a focus on peri-operative pain control. 2) Qualitative interviews will be conducted with approximately 40 patients, along with health care professionals, and their significant others. These interviews will explore the experience of TJR and provision of care, from pre-surgery appointment to 12-months post surgery. 3) We are currently developing new outcome measures of pain and disability, based on the theoretical framework of the International Classification of Function (ICF). These measures will be validated and compared with other standard measures in a cohort of 300 TJR patients who will be followed-up throughout the duration of the program. 4) An RCT of peri-operative pain control will compare standard care with multi-modal analgesia in 600 TJR patients. 5) The acceptability and feasibility of the treatment options in the pain control RCT will be explored using qualitative interviews. 6) Pilot and feasibility work will lead to the development of a complex package of care designed to optimise patient outcomes after TJR, with patient choice as a central feature. The components will include: education, management of co-morbidities, occupational therapy and home assessments, physiotherapy and pain control. 7) An economic evaluation will assess the cost-effectiveness and implications of trial results. 8) Consensus statements and research recommendations will be developed and disseminated to provide advice to health care providers on the best practice care for TJR patients. Research Team The Research Team includes academic Orthopaedic Surgeons and Rheumatologists, a research group (the 'MOBILE' programme) formerly funded by the MRC and now based at the University of Bristol, and specialists in health economics, clinical trials, pain control, physiotherapy, occupational therapy and rehabilitation, as well as Arthritis Care and Trust Management. Research Enviroment The research will be based at the Avon Orthopaedic Centre, a large regional centre with a high through-put of TJRs. This environment is enhanced by the links with the Universities of Bristol, Oxford and Birmingham and the NCRI accredited Bristol Randomised Trials Collaboration. Anticipated Outputs We intend to develop guidelines for best practice, as well as academic outputs. We will work with the public, healthcare professionals and with government organisations, including the Department of Health, in both the production and dissemination of our guidelines and findings. Public Involvement Arthritis Care is a co-applicant on this grant providing intrinsic representation of the patient's voice in the programme's design and conduct. In addition, patients will guide the work through their involvement in focus groups, membership of an advisory group and their central role in shaping interventions. Ethics The programme will adhere to sound, ethical and safe research practice. Resources The majority of costs incurred will be salaries for research staff and therapists.


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