Title: Reducing the Rate of Unnecessary Arthroscopic Surgery in the NHS – Developing an Evidence-Based NHS Treatment Pathway for Patients with Degenerative Meniscal Tears
Funder: Department of Health and Social Care

Abstract: Background The meniscus is an important structure in the knee and damage to it can produce disabling symptoms. Arthroscopic meniscectomy is an established surgical treatment for this problem; 150,000 NHS knee arthroscopies are performed annually and the rate is increasing. However, trial evidence suggests surgical treatment is not beneficial in a large proportion of these patients who are being exposed to unnecessary surgery. The current pathway and clinical practice does not reflect the new evidence and significant unwarranted variation exists.There are clear deficiencies in the current clinical pathway that must be addressed: (1) there are no nationally agreed guidelines regarding optimal indications for surgery, allowing variation in care as the appropriate intervention rate is unknown, (2) the true risk to patients from surgery is unknown, (3) within the NHS, there is no routine collection of patient reported outcomes following arthroscopic meniscectomy to drive evidence-based commissioning of care.Aims and Questions To determine the trend and geographic variation in the rate of arthroscopic meniscectomy and the factors underlying this. What are the risks and complications? To deliver evidence-based, expert consensus, patient selection criteria (national guidelines) for meniscectomy. To investigate the application of the consensus guidelines in clinical practice. What proportion of patients referred to secondary care are optimal candidates for surgery? To investigate the measurement and appraisal of digitally collected patient reported outcome for meniscectomy. Plan of Investigation 1. Using the Hospital Episode Statistics (HES) data, I will investigate factors underlying the increasing rates of arthroscopic meniscectomy and geographic variation, focussing on two groups (1) patients aged over 60 and (2) patients subsequently undergoing joint replacement within 1 year, suggesting inappropriate surgery on a background of advanced osteoarthritis. I will use HES Inpatient, Outpatient, and ONS Mortality data to determine the true serious complication rate (venous thromboembolism, heart attack, stroke, death).2. Collaborating with The British Association for Surgery of the Knee (BASK), I will use a modified Delphi method to define the important clinical features of meniscal tears. Then, using the RAND/UCLA Appropriateness Method (RAM), I will determine the expert consensus regarding the features represented in optimal patient candidates for surgery versus those best treated non-operatively. I will produce a national guideline, endorsed by BASK, which will be publicised to change practice.3. Based on the consensus guideline, I will estimate the appropriate population surgical intervention rate using a combination of (1) retrospective review of our regional knee MRI database including all meniscal tear patients referred to secondary care (2) a smaller prospective cohort of patients (Meniscal Tear Outcome Cohort MenTOC). This work will estimate the expected impact of the new pathway on rates of surgery in the NHS.4. For the patients undergoing arthroscopic meniscectomy, I will create the evidence for a follow-up methodology including collection of patient reported outcome measures (PROMs). Firstly, I will complete a systematic review of PROMs currently validated for use in patients with meniscal tears and assess the quality of the validation studies using COSMIN (COnsensus-based Standards for the selection of health Measurement Instruments). I will then test up-take and acceptability of an electronic system for monitoring outcome using these PROMs. This work will inform recommendations on monitoring patient outcome and follow-up that will be endorsed by BASK within the proposed NHS treatment pathway.Summary of potential benefits My work will deliver an evidence-based clinical pathway based on consensus derived indications, a better understanding of the risks of surgery and a methodology for monitoring outcome. Patient care will improve, with effective resource allocation driven by outcome led commissioning that aims to prevent up to approximately 75,000 patients per year undergoing unnecessary surgery.

Lay abstract: Background The meniscus is an important cartilage structure in the knee. With increasing age, the meniscus is prone to weakening and tearing; a torn meniscus may cause severe knee pain and other disabling symptoms. At least one in three people over the age of 50 develop a meniscus tear and up to 150,000 people have surgery for a torn meniscus every year in the UK. Recent research, however, has shown that for many of these patients, physiotherapy and other non-surgical treatment may be as effective as surgery in treating a meniscus tear and avoids the risk associated with surgery. Currently, many patients are undergoing unnecessary surgery and, unlike for patients undergoing a hip or knee replacement, there is no routine recording or monitoring of outcome' (improvement in symptoms) after surgery for a meniscal tear.Aims It is clear the current assessment of patients with meniscal tears in the NHS is failing to identify the large group of patients that would benefit from non-surgical treatment. My work proposes to produce treatment guidelines and drive improved patient care. I will ensure we can identify patients who should and should not undergo surgery, and estimate the number of patients expected to need surgery in the population each year. I will also ensure we can monitor the outcome' of surgery effectively and ensure we identify patients not improving as expected.Key questions: What is the trend in the rate of surgery for meniscal tears and what factors are driving this? What are the risks and complications of surgery? What is the expert consensus, based upon the latest evidence, for when meniscus surgery should and should not be recommended? Applying these expert consensus guidelines, how many people are suitable for surgery each year in the UK? What is the rate of unnecessary surgery? How should we measure the outcome and experience of patients after treatment? Design & Methods First, national healthcare databases will be used to determine the number of patients having surgery for meniscus tears each year. I will report how the number of operations has changed over time and any variation in the frequency of surgery in different areas of the UK. I will also determine the rate of serious complications that occur following surgery.Alongside this, I have established a group of experts, supported by the national British Association for Surgery of the Knee (BASK), to produce a guideline on which people with meniscus tears are suitable for surgery and when surgery should be avoided. Consensus will be gained based on agreed classifying criteria and based on the latest published research.Next, I will ensure the treatment guideline can be used by surgeons when reviewing patients in hospital clinics. By assessing the patients attending the hospital, in combination with a review of knee scan records, I will estimate the expected number of patients likely to require surgery nationally. This will enable me to estimate the potential rate of inappropriate surgery in the UK.Patients undergoing surgery will be invited to complete a range of outcome questionnaires electronically (via email or a website) before and after their surgery. In focus groups, patients will then be asked about their acceptance of this electronic approach to collecting this information and their general expectations regarding their treatment and follow-up. The results will be fed into an amended BASK consensus treatment guideline that will now also include recommendations on how the outcome of treatment can be monitored.Patient and Public Involvement The research topic is supported by a recent James Lind Alliance Priority Setting Partnership as an area of key treatment uncertainty and importance. Patients have been actively involved in designing this project proposal and a group will meet at least twice a year to steer the work.Dissemination My findings will be fed back at public involvement meetings that are established in our research unit and I will publish a freely available online summary. Our findings will also be widely disseminated to clinicians.Intended benefits My project aims to ensure people with meniscus tears get appropriate treatment and avoid the risks of unnecessary surgery. Treatment guidelines will be produced to clearly define when surgery should be avoided and when it is likely to be beneficial. Surgeons and the public will be informed of the findings throughout and this should result in a change in practice and safer, more effective treatment in the NHS. Initial estimates suggest around 75,000 people per year may avoid unnecessary surgery and the NHS may save 1.5 million per year.

Research activity codes: 6.4 SURGERY
Health categories: MUSCULOSKELETAL