Willingness to Undergo Joint Surgery Following a First-Line Intervention for Osteoarthritis: Data From the Better Management of People With Osteoarthritis Register

Income-Related Inequality Changes in Osteoarthritis First-Line Interventions: A Cohort Study

OBJECTIVE

To examine income-related inequality changes in the outcomes of an osteoarthritis (OA) first-line intervention.

DESIGN

Retrospective cohort study.

SETTING

Swedish health care system.

PARTICIPANTS

We included 115,403 people (age: 66.2±9.7 years; females 67.8%; N=115,403) with knee (67.8%) or hip OA (32.4%) recorded in the "Swedish Osteoarthritis Registry" (SOAR).

INTERVENTIONS

Exercise and education.

MAIN OUTCOME MEASURES

Erreygers' concentration index (E) measured income-related inequalities in "Pain intensity," "Self-efficacy," "Use of NSAIDs," and "Desire for surgery" at baseline, 3-month, and 12-month follow-ups and their differences over time. E-values range from -1 to +1 if the health variables are more concentrated among people with lower or higher income. Zero represents perfect equality. We used entropy balancing to address demographic and outcome imbalances and bootstrap replications to estimate confidence intervals for E differences over time.

RESULTS

Comparing baseline to 3 months, "pain" concentrated more among individuals with lower income initially (E=-0.027), intensifying at 3 months (difference with baseline: E=-0.011 [95% CI: -0.014; -0.008]). Similarly, the "Desire for surgery" concentrated more among individuals with lower income initially (E=-0.009), intensifying at 3 months (difference with baseline: E=-0.012 [-0.018; -0.005]). Conversely, "Self-efficacy" concentrated more among individuals with higher income initially (E=0.058), intensifying at 3 months (difference with baseline: E=0.008 [0.004; 0.012]). Lastly, the "Use of NSAIDs" concentrated more among individuals with higher income initially (E=0.068) but narrowed at 3 months (difference with baseline: E=-0.029 [-0.038; -0.021]). Comparing baseline with 12 months, "pain" concentrated more among individuals with lower income initially (E=-0.024), intensifying at 12 months (difference with baseline: E=-0.017 [-0.022; -0.012]). Similarly, the "Desire for surgery" concentrated more among individuals with lower income initially (E=-0.016), intensifying at 12 months (difference with baseline: E=-0.012 [-0.022; -0.002]). Conversely, "Self-efficacy" concentrated more among individuals with higher income initially (E=0.059), intensifying at 12 months (difference with baseline: E=0.016 [0.011; 0.021]). The variable 'Use of NSAIDs' was not recorded in the SOAR at 12-month follow-up.

CONCLUSION

Our results highlight the increase of income-related inequalities in the SOAR over time.

Feasibility of pain informed movement program for people with knee osteoarthritis

Objective

To establish the feasibility of an intervention consisting of neuromuscular exercise, mind-body techniques, and pain neuroscience education (PNE), referred to as Pain Informed Movement in people with knee Osteoarthritis (KOA). This program has the potential to improve our understanding of intrinsic pain modulation and its role in the management of chronic pain.

Methods

This was a single-arm feasibility trial with a nested qualitative component. Primary outcome: complete follow-up. Inclusion criteria: age ≥40 years, KOA clinical diagnosis or meeting KOA NICE criteria, and pain intensity ≥3/10. The program consisted of 8-week in-person and at-home exercise sessions. PNE and mind-body techniques were provided as videos and integrated into the exercise sessions. Participants completed questionnaires and physical assessments including blood draws at baseline and program completion. Secondary feasibility outcomes: acceptability of the intervention, burden, rates of recruitment, compliance and adherence, and adverse events. A priori success criteria were identified. Participants were invited to an online focus group.

Results

19 participants were enrolled, with a complete follow-up rate of 74% (mean age 63.3 years (SD 10.5), 73% female), indicating modifications were necessary to proceed. All other success criteria were met. The focus groups revealed that the video content pertaining to the mind-body techniques would benefit from on screen demonstrations.

Conclusion

The Pain Informed Movement program is deemed feasible, with minor modifications needed to proceed. A pilot two-arm RCT will be conducted to establish the feasibility and explore potential effects of Pain Informed Movement compared to conventional neuromuscular exercise and standard OA education.

Pain Informed Movement for people with knee osteoarthritis: Protocol for a pilot randomized controlled trial

Objective

Conservative pain management strategies for knee osteoarthritis (KOA) have limited effectiveness and do not employ a pain-mechanism informed approach. Pain Informed Movement is a novel intervention combining mind-body techniques with neuromuscular exercise and pain neuroscience education (PNE), aimed at improving endogenous pain modulation. While the feasibility and acceptability of this program has been previously established, it now requires further evaluation in comparison to standard KOA care.

Design

This protocol describes the design of a pilot two-arm randomized controlled trial (RCT) with an embedded qualitative component. The primary outcome is complete follow-up rate. With an allocation ratio of 1:1, 66 participants (33/arm) (age ≥40 years, KOA diagnosis or meeting KOA NICE criteria, and pain intensity ≥3/10), will be randomly allocated to two groups that will both receive 8 weeks of twice weekly in-person exercise sessions. Those randomized to Pain Informed Movement will receive PNE and mind-body technique instruction provided initially as videos and integrated into exercise sessions. The control arm will receive neuromuscular exercise and standard OA education. Assessment will include clinical questionnaires, physical and psychophysical tests, and blood draws at baseline and program completion. Secondary outcomes are program acceptability, burden, rate of recruitment, compliance and adherence, and adverse events. Participants will be invited to an online focus group at program completion.

Conclusion

The results of this pilot RCT will serve as the basis for a larger multi-site RCT aimed at determining the program's effectiveness with the primary outcome of assessing the mediating effects of descending modulation on changes in pain.

Net cost savings arising from patient completion of an active self-management program

OBJECTIVE

The objective of this study is to investigate changes in willingness for total knee replacement (TKR) surgery following a randomised control trial (RCT) of an osteoarthritis management program, and to extrapolate orthopaedic cost consequences for private health insurers (PHI).

METHODS

Willingness for surgery data from the RCT is analysed using a multinomial logistic regression model. A decision analytic model is used to conduct a break-even cost benefit analysis of the intervention from a PHI payer perspective. The analysis estimates the minimum probability of progression to surgery required for the intervention to be cost-neutral when considering savings limited to reduced orthopaedic costs. Cost data and orthopaedic pathway probabilities are sourced from payer data.

RESULTS

At baseline, 39% of participants in the treatment and control group were willing for surgery. At 12 months, 16% of participants in the treatment group remained willing for surgery, versus 36% in the control group. Participants in the treatment group are 2.96 (95% CI: 1.01-8.66) times more likely than those in the control group to move from initially willing for surgery, to unsure or unwilling at 12 months. The analysis indicates that the intervention is likely to be cost saving when at least 60% of initially willing participants progress to surgery over a 5-year time horizon.

CONCLUSION

Our study estimates that an education, exercise and weight loss intervention can deliver both improved participant outcomes and a return on investment to Australian PHIs through a reduction in TKR surgery incidence.

Within-person change in patient-reported outcomes and their association with the wish to undergo joint surgery during a digital first-line intervention for osteoarthritis

AIM

To study the association between within-person changes in patient-reported outcomes (PROMs) and wish for joint surgery during participation in a digital first-line intervention comprising exercise and education for knee/hip osteoarthritis (OA).

METHODS

Retrospective observational registry study. Participants enrolled between June 1, 2018 and October 30, 2021, with follow-up data at three months (n = 13,961). We used asymmetric fixed effect (conditional) logistic regressions to study the association between change in wish to undergo surgery at last available time point (3, 6, 9, or 12 months) and improvement or worsening of PROMs pain (0-10), quality of life (QoL) (EQ5D-5L, 0.243-0.976), overall health (0-10), activity impairment (0-10), walking difficulties (yes/no), fear of movement (yes/no), and Knee/Hip injury and Osteoarthritis Outcome Score 12 Items (KOOS-12/HOOS-12, 0-100) function and QoL subscales.

RESULTS

The proportion of participants wishing to undergo surgery declined by 2% (95% CI: 1.9, 3.0), from 15.7% at the baseline to 13.3% at 3 months. Generally, improvements in PROMs were associated with reduced likelihood of wishing for surgery, while worsening was associated with increased likelihood. For pain, activity impairment EQ-5D and KOOS/HOOS QoL, a worsening led to a change in the probability of wish for surgery of larger absolute magnitude than an improvement in the same PROM.

CONCLUSIONS

Within-person improvements in PROMs are associated with reduced wish for surgery while worsenings with an increased wish for surgery. Larger improvements in PROMs may be needed to match the magnitude of the change in wish for surgery associated with a worsening in the same PROM.

Exploring appropriateness criteria for informing the total knee arthroplasty decision-making process: An interpretive descriptive study

RATIONAL

The Hawker appropriateness criteria for total knee arthroplasty (TKA) are: osteoarthritis symptoms impacting quality of life, evidence of osteoarthritis, trial of conservative treatments, patient's realistic expectations, patient/surgeon agree benefits outweigh risks, and readiness for surgery. Little is known about the barriers and facilitators of using the Hawker et al. appropriateness criteria for TKA in clinical practice.

AIMS AND OBJECTIVES

Explore the barriers and facilitators to using appropriateness criteria for TKA in making decisions for adults with knee osteoarthritis.

METHODS

Interpretive descriptive qualitative study at an academic hospital. Purposive sampling aimed to recruit: (1) healthcare team members at all levels influencing care delivery, and (2) adults with TKA assessed at the hospital clinic. Semi-structured interviews asked about the barriers/facilitators to using the Hawker appropriateness criteria. Data analysis consisted of inductive thematic analysis with themes mapped to the Consolidated Framework for Implementation Research domains.

RESULTS

Nine healthcare professionals and 14 adults with TKA participated and identified common barriers to using the Hawker appropriateness criteria: (a) intervention characteristics domain: difficulty to assess criteria, patients expecting healthcare professionals to decide, limited accessibility to conservative treatments; (b) individuals characteristics domain: no need to change current TKA process, clinical judgement limited to OA severity/age, implicit assessment of subjective criteria; (c) inner setting domain: TKA information received after decision made; and (d) outer setting domain: no timely access to TKA. A facilitator of use was evidence/buy-in fosters programme changes.

CONCLUSION

Barriers to using the criteria relevant to clinical practice and the healthcare system were identified while only one facilitator was revealed. Interventions tailored to these barriers are needed to support the use of the Hawker appropriateness criteria in TKA decision-making.

Use of non-surgical treatments on the journey to knee replacement in patients with knee osteoarthritis: a 10-year population-based case-control study

AIM

To investigate temporal trends in primary care visits, physiotherapy visits, dispensed non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in knee osteoarthritis (OA) patients who have and have not undergone knee replacement.

METHODS

We analysed 5665 OA patients from the Skåne Healthcare Register, Sweden, who underwent knee replacement between 2015 and 2019. Controls were OA patients without knee replacement, matched 1:1 by sex, age, time and healthcare level of initial OA diagnosis, and assigned a pseudo-index date corresponding to their case's knee replacement date. Annual prevalence and prevalence ratio of primary care and physiotherapy visits, dispensed NSAIDs and opioids (all for any cause) in the 10 years before knee replacement were estimated using Poisson regression.

RESULTS

The annual prevalence of all-cause primary care visits, physiotherapy visits and opioid use was similar between cases and controls until 3 years before the index date when it started to increase among the cases. The year before the index date, the prevalence ratio (cases vs controls) for physiotherapy use was 1.8 (95% CI 1.7, 1.8), while for opioid use 1.6 (1.5, 1.7). NSAID use was consistently higher among cases, even 10 years before the index date when the prevalence ratio versus controls was 1.3 (1.2, 1.3), increasing to 1.8 (1.7, 1.9) in the year preceding the index date.

CONCLUSIONS

Management of OA patients who have and have not undergone knee replacement appears largely similar except for higher use of NSAIDs in knee replacement cases. Symptomatic treatments start to increase a few years before the surgery in knee replacement cases.

What Factors Identified in Initial Osteoarthritis Management Are Associated With Poor Patient-reported Outcomes After THA? A Register-based Study

BACKGROUND

Some patients report long-term pain or no improvement in health-related quality of life (HRQoL) or are dissatisfied after THA. However, factors associated with these poorer patient-reported outcomes after surgery are inconsistent and have typically been studied in the late phase of hip osteoarthritis (OA) among patients already eligible for surgery. Earlier identification of risk factors would provide time to address modifiable factors, helping to improve patients' pain, HRQoL, and satisfaction after surgery and reduce the burden on orthopaedic clinics by referring patients who are better prepared for surgery.

QUESTIONS/PURPOSES

We analyzed data from patients with hip OA referred to a first-line OA intervention program in primary healthcare at a stage when they had not been referred for THA, and asked: (1) What percentage of patients who proceed to THA report lack of improvement in pain, lack of improvement in HRQoL as measured by the EQ-5D, or are not satisfied with surgery 1 year after THA? (2) What associations exist between baseline factors at referral to this first-line OA intervention program and these poorer patient-reported outcomes 1 year after THA?

METHODS

We included 3411 patients with hip OA (mean age 67 ± 9 years, 63% [2160 of 3411] women) who had been referred for first-line OA interventions between 2008 and 2015 and subsequently underwent THA for OA. All patients were initially identified through the Swedish Osteoarthritis Register, which follows and evaluates patients in a standardized national first-line OA intervention program. Then, we identified those who were also registered in the Swedish Arthroplasty Register with a THA during the study period. We included only those with complete patient-reported outcome measures for pain, HRQoL, and satisfaction preoperatively and 1-year postoperatively, representing 78% (3411 of 4368) of patients, who had the same baseline characteristics as nonrespondents. Multiple logistic regression was used to assess the associations between 14 baseline factors and the aforementioned patient-reported outcomes of pain, HRQoL, and satisfaction 1 year after THA, adjusted for all included factors.

RESULTS

Five percent (156 of 3411) of the study population lacked improvement in pain, 11% (385 of 3411) reported no improvement in HRQoL, and 10% (339 of 3411) reported they were not satisfied with surgery 1 year after THA. Charnley Class C (multiple-joint OA or another condition that affects the ability to walk) was associated with all outcomes: lack of improvement in pain (OR 1.84 [95% CI 1.24 to 2.71]; p = 0.002), lack of improvement in HRQoL (OR 1.83 [95% CI 1.42 to 2.36]; p < 0.001), and not being satisfied (OR 1.40 [95% CI 1.07 to 1.82]; p = 0.01). Older age was associated with a lack of improvement in pain (OR per year 1.03 [95% CI 1.01 to 1.05]; p = 0.02), lack of improvement in HRQoL (OR per year 1.04 [95% CI 1.03 to 1.06]; p < 0.001), and not being satisfied (OR per year 1.03 [95% CI 1.01 to 1.05]; p < 0.001). Depression was associated with a lack of improvement in pain (OR 1.54 [95% CI 1.00 to 2.35]; p = 0.050) and with not being satisfied (OR 1.50 [95% CI 1.11 to 2.04]; p = 0.01) but not with a lack of improvement in HRQoL (OR 1.04 [95% CI 0.76 to 1.43]; p = 0.79). Having four or more comorbidities was associated with a lack of improvement in HRQoL (OR 2.08 [95% CI 1.39 to 3.10]; p < 0.001) but not with a lack of improvement in pain and not being satisfied.

CONCLUSION

The results of this study showed that older age, Charley Class C, and depression in patients with first-line OA interventions were risk factors associated with poorer outcomes regarding pain, HRQoL, and satisfaction after THA. Screening patients with hip OA for depression early in the disease course would provide increased time to optimize treatments and may contribute to better patient-reported pain, HRQoL, and satisfaction after future THA. Further research should focus on identifying the optimal time for surgery in patients with depression, as well as what targeted interventions for depression can improve outcome of surgery in these patients.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Variation in the utilisation of physiotherapy in patients with advanced knee osteoarthritis prior to total knee arthroplasty a systematic review

INTRODUCTION

Due to demographic changes and increasing knee osteoarthritis (KOA) prevalence, the incidence of total knee arthroplasties (TKA) is constantly rising. Clinical practice guidelines for the treatment of KOA unanimously recommend non-surgical interventions such as exercise, education, and weight reduction in overweight patients. The aim of this systematic review is to determine the proportion of patients with end-stage KOA who attended physiotherapy (PT) prior to TKA.

METHODS

A systematic literature search was carried out in the medical databases MEDLINE (via Pubmed), PEDro, and EBSCO in August of 2022. Studies were included regardless of their design, if they reported the proportion of patients with a diagnosis of primary KOA, who participated in PT prior to undergoing TKA. Study quality assessment was performed by two independent authors using the Joanna Briggs Institutes Checklist for studies reporting prevalence data. Results were presented by using a narrative synthesis.

RESULTS

Eighteen studies, comprising 579,718 patients, were identified in this systematic review. PT utilisation prior to TKA ranged from 10% to 73% for patients with advanced KOA. Only two studies showed PT utilisation rates of 60% or higher. Female gender, higher income, better socioeconomic status, higher education levels, older age were associated with PT utilisation. Data for other predicting factors was conflicting.

DISCUSSION

This review shows substantial variation in the utilisation of PT in patients with end-stage KOA. This is concerning, considering the uniform recommendation from clinical practice guidelines for non-surgical treatments like exercise and education in patients with KOA, which are mostly provided by physiotherapists.

Researchers in rheumatology should avoid categorization of continuous predictor variables

BACKGROUND

Rheumatology researchers often categorize continuous predictor variables. We aimed to show how this practice may alter results from observational studies in rheumatology.

METHODS

We conducted and compared the results of two analyses of the association between our predictor variable (percentage change in body mass index [BMI] from baseline to four years) and two outcome variable domains of structure and pain in knee and hip osteoarthritis. These two outcome variable domains covered 26 different outcomes for knee and hip combined. In the first analysis (categorical analysis), percentage change in BMI was categorized as ≥ 5% decrease in BMI, < 5% change in BMI, and ≥ 5% increase in BMI, while in the second analysis (continuous analysis), it was left as a continuous variable. In both analyses (categorical and continuous), we used generalized estimating equations with a logistic link function to investigate the association between the percentage change in BMI and the outcomes.

RESULTS

For eight of the 26 investigated outcomes (31%), the results from the categorical analyses were different from the results from the continuous analyses. These differences were of three types: 1) for six of these eight outcomes, while the continuous analyses revealed associations in both directions (i.e., a decrease in BMI had one effect, while an increase in BMI had the opposite effect), the categorical analyses showed associations only in one direction of BMI change, not both; 2) for another one of these eight outcomes, the categorical analyses suggested an association with change in BMI, while this association was not shown in the continuous analyses (this is potentially a false positive association); 3) for the last of the eight outcomes, the continuous analyses suggested an association of change in BMI, while this association was not shown in the categorical analyses (this is potentially a false negative association).

CONCLUSIONS

Categorization of continuous predictor variables alters the results of analyses and could lead to different conclusions; therefore, researchers in rheumatology should avoid it.

Patient and public involvement to inform the protocol of a clinical trial comparing total hip arthroplasty with exercise: an exploratory qualitative case study

OBJECTIVE

To explore patient, clinician and decision-maker perceptions on a clinical trial evaluating the effectiveness of total hip arthroplasty (THA) compared with exercise to inform the trial protocol.

DESIGN

This is an exploratory qualitative case study using a constructivist paradigm.

SETTING AND PARTICIPANTS

Participants were enrolled into three key stakeholder groups: patients eligible for THA, clinicians, and decision makers. Focus group interviews were conducted in undisturbed conference rooms at two hospitals in Denmark, according to group status using semi-structured interview guides.

ANALYSIS

Interviews were recorded, transcribed verbatim and thematic analysed using an inductive approach.

RESULTS

We conducted 4 focus group interviews with 14 patients, 1 focus group interview with 4 clinicians (2 orthopaedic surgeons and 2 physiotherapists) and 1 focus group interview with 4 decision-makers. Two main themes were generated. 'Treatment expectations and beliefs impact management choices' covered three supporting codes: Treatment without surgery is unlikely to lead to recovery; Clinician authority impacts the management narrative; The 'surgery vs exercise' debate. 'Factors influencing clinical trial integrity and feasibility' highlighted three supporting codes: Who is considered eligible for surgery?; Facilitators and barriers for surgery and exercise in a clinical trial context; Improvements in hip pain and hip function are the most important outcomes.

CONCLUSIONS

Based on key stakeholder treatment expectations and beliefs, we implemented three main strategies to improve the methodological rigorousness of our trial protocol. First, we added an observational study investigating the generalisability to address a potential low enrolment rate. Second, we developed an enrolment procedure using generic guidance and balanced narrative conveyed by an independent clinician to facilitate communication of clinical equipoise. Third, we adopted change in hip pain and function as the primary outcome. These findings highlight the value of patient and public involvement in the development of trial protocols to reduce bias in comparative clinical trials evaluating surgical and non-surgical management.

TRIAL REGISTRATION NUMBER

NCT04070027 (pre-results).

Co-design of the web-based ‘My Knee’ education and self-management toolkit for people with knee osteoarthritis

Objective

Describe the co-design process and learnings related to developing the web-based Translating Research Evidence and Knowledge (TREK) ‘My Knee’ education and self-management toolkit for people with knee osteoarthritis.

Co-design process

Stage (i): Understand and define; systematically reviewed education interventions in published trials; appraised web-based information about knee osteoarthritis; and used concept mapping to identify education priorities of people with knee osteoarthritis and physiotherapists. Stage (ii): Prototype; created a theory-, guideline- and evidence-informed toolkit. Stage (iii): Test and iterate; completed three co-design workshops with end-users (i.e., people with knee osteoarthritis and health professionals); plus an expert review.

Results

The toolkit is available at myknee.trekeducation.org. Stage (i) identified the need for more accurate and co-designed resources to address broad education needs generated during concept mapping, including guidance on surgery, dispelling common misconceptions and facilitating engagement with exercise therapy and weight management. A theory- and research-informed prototype was created in Stage (ii) to address broad learning and education needs. Stage (iii) co-design workshops ( n =  15 people with osteoarthritis and n =  9 health professionals) informed further content creation and refinement, alongside improvements to optimise usability. Expert opinion review ( n =  8) further refined accuracy and usability.

Conclusions

The novel co-design methodology employed to create the TREK ‘My Knee’ toolkit facilitated the alignment of the content and usability to meet the broad education needs of people with knee osteoarthritis and health professionals. This toolkit aims to improve and facilitate engagement with guideline-recommended first-line care for people with knee osteoarthritis. Future work will determine its effectiveness in improving clinical outcomes in this population.

Assessment of Mobile Health Applications for Management of Knee and/or Hip Osteoarthritis Using the Mobile Application Rating Scale

BACKGROUND

Mobile health applications (apps) can help individuals with knee and/or hip osteoarthritis (OA) learn about, monitor, and manage their condition. These apps have not been formally evaluated.

OBJECTIVE

The aim of this study was to evaluate the publicly available mobile health apps for individuals with knee and/or hip OA using a systematic review.

METHODS

We searched the Apple App Store, Android Google Play, and Amazon Appstore using the terms "arthritis," "osteoarthritis," "hip OA," "knee OA," "hip," "knee," "rehabilitation," "rehab," and "physical therapy" in December of 2021. Applications that met the inclusion/exclusion criteria were reviewed using the Mobile Application Rating Scale (MARS; 29 items across 6 sections, each rated at 1-5).

RESULTS

Among 1104 identified apps, 94 met the inclusion/exclusion criteria for MARS appraisal. Fourteen apps met the predetermined score thresholds for final summary. Of the 14 apps appraised, the total overall mean app score on the MARS ranged from 3.12 to 4.20 (mean, 3.51 ± 0.37). Although app features varied, common features were symptom tracking, exercise recommendations, education, goal setting, and improving well-being. Many apps allowed for sharing with health care providers and included some measures to protect privacy. Jointfully Osteoarthritis was the top-rated app in both the Apple App Store and Android Google Play.

CONCLUSIONS

The majority of the apps we identified for knee and/or hip OA did not meet predetermined score thresholds for final summary. Many failed to provide comprehensive education and deliver management plans and lacked scientific testing. Future research should focus on apps that fit the needs of health care providers and patients including quality information, structured exercise programs tailored to individual needs, secure communication methods, and health information protection.

Progression to arthroplasty surgery among patients with hip and knee osteoarthritis : a study from the Swedish BOA Register

AIMS

The aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.

METHODS

In this longitudinal register-based observational study, we identified 72,069 patients with hip and knee OA in the Better Management of Patients with Osteoarthritis Register (BOA), who were referred for first-line OA intervention, between May 2008 and December 2016. Patients were followed until the first primary arthroplasty surgery before 31 December 2016, stratified into a hip and a knee OA cohort. Data were analyzed with Kaplan-Meier and multivariable-adjusted Cox regression.

RESULTS

At five years, Kaplan-Meier estimates showed that 46% (95% confidence interval (CI) 44.6 to 46.9) of those with hip OA, and 20% (95% CI 19.7 to 21.0) of those with knee OA, had progressed to arthroplasty. The strongest prognostic factors were desire for surgery (hazard ratio (HR) hip 3.12 (95% CI 2.95 to 3.31), HR knee 2.72 (95% CI 2.55 to 2.90)), walking difficulties (HR hip 2.20 (95% CI 1.97 to 2.46), HR knee 1.95 (95% CI 1.73 to 2.20)), and frequent pain (HR hip 1.56 (95% CI 1.40 to 1.73), HR knee 1.77 (95% CI 1.58 to 2.00)). In hip OA, the probability of progression to surgery was lower among those with comorbidities (e.g. ≥ four conditions; HR 0.64 (95% CI 0.59 to 0.69)), with no detectable effects in the knee OA cohort. Instead, being overweight or obese increased the probability of OA progress in the knee cohort (HR 1.25 (95% CI 1.15 to 1.37)), but not among those with hip OA.

CONCLUSION

Patients with hip OA progressed faster and to a greater extent to arthroplasty than patients with knee OA. Progression was strongly influenced by patients' desire for surgery and by factors related to severity of OA symptoms, but factors not directly related to OA symptoms are also of importance. However, a large proportion of patients with OA do not seem to require surgery within five years, especially among those with knee OA. Cite this article: Bone Joint J 2022;104-B(7):792-800.

Evaluating willingness for surgery using the SMART Choice (Knee) patient prognostic tool for total knee arthroplasty: study protocol for a pragmatic randomised controlled trial

BACKGROUND

Approximately 1 in 5 patients feel unsatisfied after total knee arthroplasty (TKA). Prognostic tools may aid in the patient selection process and reduce the proportion of patients who experience unsatisfactory surgery. This study uses the prognostic tool SMART Choice (Patient Prognostic Tool for Total Knee Arthroplasty) to predict patient improvement after TKA. The tool aims to be used by the patient without clinician input and does not require clinical data such as X-ray findings or blood results. The objective of this study is to evaluate the SMART Choice tool on patient decision making, particularly willingness for surgery. We hypothesise that the use of the SMART Choice tool will influence willingness to undergo surgery, especially when used earlier in the patient TKA journey.

METHODS

This is a multicentred, pragmatic, randomised controlled trial conducted in Melbourne, Australia. Participants will be recruited from the St. Vincent's Hospital, Melbourne (SVHM) Orthopaedic Clinic, and the client base of HCF, Australia (private health insurance company). Patients over 45 years of age who have been diagnosed with knee osteoarthritis and considering TKA are eligible for participation. Participants will be randomised to either use the SMART Choice tool or treatment as usual. The SMART Choice tool provides users with a prediction for improvement or deterioration / no change after surgery based on utility score change calculated from the Veterans-RAND 12 (VR-12) survey. The primary outcome of the study is patient willingness for TKA surgery. The secondary outcomes include evaluating the optimal timing for tool use and using decision quality questionnaires to understand the patient experience when using the tool. Participants will be followed up for 6 months from the time of recruitment.

DISCUSSION

The SMART Choice tool has the potential to improve patient decision making for TKA. Although many prognostic tools have been developed for other areas of surgery, most are confined within academic bodies of work. This study will be one of the first to evaluate the impact of a prognostic tool on patient decision making using a prospective clinical trial, an important step in transitioning the tool for use in clinical practice.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12622000072718 . Prospectively registered - 21 January 2022.