Title: Occupational advice initiated prior to planned surgery for lower limb joint replacement
Funder: Department of Health and Social Care

Abstract: Importance: There are an increasing number of patients of working age undergoing hip and knee replacements. Currently, there is variation in the advice and support given about sickness absence, recovery to usual activities and return to work after these procedures. Earlier return to work improves the health of patients and benefits their employers and society. An intervention that encourages and supports early recovery to usual activities including work has the potential to reduce the health and socioeconomic burden of hip and knee replacements. Objective: To develop an occupational advice manual to support early recovery to usual activities including work which is tailored to the requirements of patients undergoing hip and knee replacement. To test the acceptability, practicality and feasibility of this intervention within current care frameworks. Design: Two phase research programme delivered over 27 months using intervention mapping: Phase 1 (Months 1-13) 1 Needs assessment (rapid evidence synthesis, cohort analysis and stakeholder interviews) 2 Identification of intended outcomes and performance objectives 3 Selection of theory-based methods and practical strategies Phase 2 (Months 10-27) 4 Development of components and materials for the manualised occupational advice intervention using a modified Delphi process 5 Intervention adoption and implementation 6 Evaluation and feasibility testing Setting: Three NHS hospitals in the UK. Participants & Exposures: Phase 1 will commence with an assessment of current practice and an individual needs assessment. A rapid review of existing evidence will supplement a prospective cohort study of patients on the waiting list for hip or knee replacement who are currently working. A minimum of 50 patients will be recruited to the cohort study at each centre during a 3-month period. Information about pre-surgical activity, work roles, absenteeism and work place disability will be collected pre-operatively and at 8, 16 and 24 weeks post operatively using questionnaires. From within this cohort a sample of 10-15 patients that intend to return to work and 3 who do not intend to return to work to from each centre will be selected to participate in individual interviews. Additionally, interviews with surgeons, allied health professionals, GPs and employers will be undertaken. This will provide detailed information about the shortcomings and difficulties in current care and support available and identify possible solutions and improvements to overcome them. We will then be able to identify who and/or what needs to change in order for workers to make a successful return to work following surgery. This will allow us to generate a list of potential intervention components. In Phase 2 the potential intervention components identified during Phase 1 will be reviewed by stakeholder groups using a modified 3-round Delphi consensus process to agree the content of the final intervention. The intervention will then be manualised and an implementation and evaluation plan will be designed. Following implementation at each centre, the intervention will then be evaluated using further stakeholder interviews. This will assess the acceptability, practicality and feasibility of the intervention as a) an intervention for clinical practice and b) a potential trial intervention for any subsequent clinical trial. The final intervention will be revised and refined based on feedback from this process.

Lay abstract: What is the problem? Hip and knee arthritis causes pain which limits physical function and can affect ability to work. Hip and knee replacements are proven to relieve pain and improve function, and can enable many patients of working age to continue working or get back to work. More than 30,000 working age patients have a hip or knee replacement in the UK each year. Time off work after these operations costs the UK approximately £1 billion each year. Why is it important? Prolonged periods of sick leave can lead to general health problems and depression. Early recovery and planned return to work can help to prevent these problems and reduce the financial burden associated with sick leave. This study will benefit: patients by improving health and earnings; employers by increasing productivity; society by decreasing benefits and healthcare costs. What do we intend to do? Currently there is much we do not know about patients returning to usual activities and work following hip and knee replacement: When and how patients return to work Who is helping patents return to work and what advice are they giving? What are the problems with current care? What can we do better? How are fit notes being used to help people return to work? What is the best way to assess return to work? What are the barriers that prevent early return to work? Answering these questions will help us better understand what is currently being done and how we might improve current care. Guided by these answers, we will develop an occupational advice intervention to help patients return to usual activities including work. This will then be turned in to a manual to aid delivery within the NHS. We will then test this manual to see if it works in hospitals in the UK. How do we intend to do it? This project will involve two separate phases and will take 27 months. Phase 1 will answer the questions listed above. It will gather information about return to work after hip and knee replacement and current barriers preventing early return to work. It will do these using 3 complimentary approaches. 1 A review of currently available evidence 2 A questionnaire study of patients waiting for hip and knee replacement who are in work prior to surgery 3 Interviews with patients and their care team (e.g. surgeons, GPs, physio/occupational therapists, employers) Using this information we will identify the problems with current care. This will allow us to create number of tools to overcome these, designed to help patients recover from their surgery and return to work faster. In Phase 2 we will undertake a ‘consensus’ process. This will allow us to collect the opinions of a variety of people involved in the care of hip and knee replacement patients, and patients themselves, about the tools developed in Phase 1. Agreement will be reached about which tools will work and these will be turned in to a manual of occupational ‘return to work’ advice. This will then be tested and tested to tell us whether it could work in UK hospitals and what patients and healthcare workers think about it. What will happen after we finish? We will have developed a manual of occupational advice to help patients return to work after hip and knee replacement. The next step will be to test this intervention in a clinical trial to evaluate whether this manual is better it is at getting patients back to work than what we are doing currently.

Research activity codes: 5.7 PHYSICAL
Health categories: MUSCULOSKELETAL