Title: Support and treatment after joint replacement (STAR): translation into practice and long-term follow up
Funder: Department of Health and Social Care

Abstract: Background Treatment of osteoarthritis with total knee replacement (TKR) aims to reduce pain, functional limitations and associated disability. Over 100,000 primary TKRs are performed annually by the NHS. Despite good outcomes for many, about 20% of patients report chronic pain after TKR, defined as pain present for at least three months. To address this, we conducted the STAR research programme from 2015-2020 (RP-PG-0613-20001). We developed the STAR care pathway in which people with chronic pain after TKR are assessed and referred to appropriate care. In our multi-centre randomised controlled trial comparing patient outcomes after the STAR care pathway with usual care, there was convincing evidence that this approach was clinically important at one-year follow up and that implementation should be explored. A programme development grant will enable us to translate the STAR findings into clinical practice through work with stakeholders, including the NHS and patients, and conduct longer-term follow up of trial participants to describe their outcomes and use of secondary healthcare resources. Aim To improve outcomes for patients with chronic pain after TKR by implementing new research findings into the NHS and understanding long-term outcomes. Objectives: 1. Mobilise knowledge about the STAR care pathway into practice by collaboration with commissioners and healthcare providers 2. Assess longer term outcomes and healthcare use after TKR and receipt of the STAR care pathway by following up trial participants at a median of four years after randomisation into the trial Development workplan The development work comprises two workstreams, which map onto the study objectives. Workstream 1: Work with stakeholders (professionals and patients) to mobilise findings and enable implementation of the STAR care pathway and other aspects of the STAR findings into the NHS. This will deliver a structured package of knowledge mobilisation to embed STAR results into NHS practice. Workstream 2: Follow-up STAR trial participants at a median of four years after randomisation to collect information about long-term pain and secondary healthcare use. This will deliver information on the long-term experiences of patients with chronic pain after TKR (STAR care pathway and usual care) and cost-effectiveness of the STAR care pathway Patient involvement will be embedded in the work, through a PPI group and collaboration with Versus Arthritis. Timeline for delivery The development work will last 24 months. Workstreams 1 and 2 will run in parallel during months 1-24. Impact and dissemination The work will deliver knowledge mobilisation and translation relating to the STAR pathway which has been shown to be clinically important. We will produce resources and publications for patients and professionals.

Lay abstract: Knee osteoarthritis is a common condition causing pain and difficulties with daily activities. If non-surgical treatments do not help, then an operation called knee replacement may be provided. This is where the knee joint is removed and replaced with an artificial joint. Around 100,000 of these operations take place in the NHS each year, but around one-in-five people who have this operation have ongoing pain afterwards and around 20,000 people each year in the UK have this kind of pain. Our research has tried to find ways to improve the situation for those people who have ongoing pain after knee replacement. Between 2015 and 2020 we ran the STAR Research Programme. The programme has provided important findings for patients and healthcare professionals, including ten research publications in clinical journals. As a large team of researchers and clinicians, we want to put these findings into practice. In STAR we conducted several research projects. We reviewed existing research evidence, analysed results from large scale UK studies, and designed a new NHS care pathway for people with pain after knee replacement. We talked with patients and healthcare professionals to understand their experiences of the care pathway and why some people with pain after knee replacement do not seek healthcare. We conducted a randomised controlled trial in eight hospitals in the UK. The trial tested whether the new STAR care pathway provided benefit to people with ongoing pain three months after knee replacement compared with people receiving usual care. We screened over 5,000 people to identify people with pain after their knee operation and 363 people took part in the trial, with 313 completing all of the questionnaires. After one year, we asked participants to tell us about the severity of their pain and the amount to which it interfered in their lives. We found that people who received the STAR care pathway had better outcomes in terms of their pain and how they recovered from their operation. To maximise the value of the STAR programme to patients and the NHS, we will deliver two new projects: In-depth work with healthcare commissioners, professionals and expert patients to work out how to put the STAR care pathway into practice. Follow-up of STAR trial participants to assess the longer-term experiences of people with ongoing pain after knee replacement and the effect of the STAR care pathway four years later. This work will enable us to introduce the care pathway into the NHS. Now that we know that the STAR care pathway provides benefit to patients, we need to ensure people are offered this treatment. We have included patients voices in every aspect of our work and will continue to do so.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.1 INDIVIDUAL CARE NEEDS
Health categories: MUSCULOSKELETAL