Is a questionnaire and radiograph-based follow-up model for patients with primary hip and knee arthroplasty a viable alternative to traditional regular outpatient follow-up clinic?

Trochleoplasty Provides Good Outcomes for Recurrent Patellofemoral Dislocations with No Clear Superiority across Different Techniques

Background: Literature is sparse on outcome comparisons between different trochleoplasty techniques in the treatment of patella instability. To date, it is unclear whether there is a technique that offers superior outcomes. This systematic review and meta-analysis aims to compare and evaluate the outcomes of trochleoplasty techniques in the treatment of patellofemoral instability in trochlea dysplasia to establish whether there is an ideal choice of trochleoplasty technique for superior outcomes. Methods: 21 studies involving 880 knees were included. The mean age of the patients was 21.7 years (range 8-49 years). Mean follow-up timeframe of 43.5 months (range 8.8-100 months). Clinical outcomes assessed included rates of recurrence of patellofemoral dislocation, patient satisfaction, Kujala score, International Knee Documentation Committee (IKDC) score, Tegner score, and Lysholm score. Egger's test showed no publication bias across all outcomes assessed. Results: Favourable results were seen across all outcomes assessed and patient satisfaction. Improvements were seen with Kujala, IKDC, and Lysholm scores. Tegner scores showed good return to function. Post-operative dislocation and complication rates were low across the different techniques. Meta-regression for Kujala and IKDC scores showed good outcomes regardless of trochleoplasty technique used (Kujala, p = 0.549, relative risk 492.06; IKDC, p = 0.193, RR 0.001). The exact risk that trochleoplasty poses to the cartilage remains uncertain, as no study had a conservatively managed arm for comparison. Conclusions: Trochleoplasty yielded good outcomes irrespective of technique used with no clear superiority demonstrated in any technique in terms of outcome scores, satisfaction, post-operative dislocation rates or complications.

Remote research burden of follow-up in longitudinal patient-reported outcomes (PROs) data collection: An exploratory sequential mixed-methods study (Preprint).. [DOI: 10.2196/preprints.51290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Longitudinal patient-reported outcomes studies require questionnaire assessments to be administered remotely multiple times, burdening research staff.

OBJECTIVE

To define and quantify the burden that researcher may experience during patient follow-up.

METHODS

Data were collected via interviews and a questionnaire. This study is an exploratory sequential mixed-methods study. Traditional content analysis was used for the qualitative data. Quantitative data were analyzed using Spearman’s correlation, and significance was tested using the chi-square test. Learning curves of healthcare staff regarding follow-up calls were generated using cumulative summation analysis.

RESULTS

We constructed a three-dimension conceptual framework for staff burden: (a) time-related burden, (b) technical-related burden, and (c) emotional-related burden. The quantitative analysis found that follow-up time was significantly correlated with staff experience, workload, and learning curve periods. There was a significant difference between the lost-to-follow-up rate of staff with and without follow-up experience with this program. Staff working on a daily assessment schedule had a higher lost-to-follow-up rate than those on a twice-a-week schedule. Additionally, inexperienced follow-up staff needed 113 calls to achieve stable follow-up time and quality, while experienced staff needed only 55 calls.

CONCLUSIONS

Researchers in longitudinal PROs projects suffer from a multidimensional burden during remote follow-up. Our results may help establish a proper PROs follow-up protocol to reduce the burden on research staff without sacrificing data quality.

Feasibility testing of a standardised virtual clinic for follow-up of patients after hip and knee arthroplasty

INTRODUCTION

Over 200,000 hip and knee total joint arthroplasties (TJAs) are performed annually in England and Wales. UK guidelines recommend regular follow-up because missed early failure can result in complex revision surgery, which places additional burden on overstretched orthopaedic services. This study evaluated the feasibility and acceptability of an expert, consensus-based, standardised virtual clinic (VC) approach for TJA follow-up.

METHODS

Five UK secondary care orthopaedic centres implemented a standardised VC. Feedback was obtained through patient satisfaction questionnaires and telephone interviews with arthroplasty care practitioners. Key stakeholders subsequently attended an expert discussion forum to achieve consensus on the final VC format and to address obstacles identified during testing.

RESULTS

From 19 June 2018 to 11 December 2018, 561 TJA patients [mean age (SD) 70 (9.4) years, 57.8% female, 69.0% hip TJA, 1-28 years postsurgery (median 5 years)] completed a VC. Of these 561 patients, 82.2% were discharged without attending an outpatient appointment and 46 (8.8%) required early face-to-face consultant review. Patient satisfaction with the VC was high (156/188; 83.0%); over 70% of patients indicated a preference for the VC.

DISCUSSION

This feasibility study suggested significant resource savings, including time spent by consultant orthopaedic surgeons in outpatient clinics, hospital transport and an estimated saving of up to two-thirds of usual clinic-allotted time. The expert discussion forum provided helpful feedback for supporting more efficient implementation of the VC.

CONCLUSIONS

A standardised VC is a feasible alternative to outpatient clinics for the follow-up of hip and knee TJA patients, and is acceptable to key stakeholders, including patients.

Mid- to late-term follow-up of primary hip and knee arthroplasty: the UK SAFE evidence-based recommendations

To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty. A programme of work was conducted, including: a systematic review of the clinical and cost-effectiveness literature; analysis of routine national datasets to identify pre-, peri-, and postoperative predictors of mid-to-late term revision; prospective data analyses from 560 patients to understand how patients present for revision surgery; qualitative interviews with NHS managers and orthopaedic surgeons; and health economic modelling. Finally, a consensus meeting considered all the work and agreed the final recommendations and research areas. The UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE) recommendations apply to post-primary hip and knee arthroplasty follow-up. The ten-year time point is based on a lack of robust evidence beyond ten years. The term 'complex cases' refers to individual patient and surgical factors that may increase the risk for arthroplasty failure. For Orthopaedic Data Evaluation Panel (ODEP) 10A* minimum implants, it is safe to disinvest in routine follow-up from one to ten years post-non-complex hip and knee arthroplasty provided there is rapid access to orthopaedic review. For ODEP 10A* minimum implants in complex cases, or non-ODEP 10A* minimum implants, periodic follow-up post-hip and knee arthroplasty may be required from one to ten years. At ten years post-hip and knee arthroplasty, clinical and radiological evaluation is recommended. After ten years post-hip and knee arthroplasty, frequency of further follow-up should be based on the ten-year assessment; ongoing rapid access to orthopaedic review is still required. Complex cases, implants not meeting the ODEP 10A* criteria, and follow-up after revision surgery are not covered by this recommendation.

Associations of the Oxford Knee Score and knee arthroplasty revision at long-term follow-up

BACKGROUND

Self-reported outcome measures are increasingly being collected for healthcare evaluation therefore it is prudent to understand their associations with patient outcomes. Our aims were to investigate: (1) if Oxford Knee Score (OKS) is associated with impending revision at long-term (5 and 10 years) follow-up, and (2) if decreased OKS at subsequent follow-ups is associated with higher risk of revision.

PATIENTS AND METHODS

All total knee (TKAs) and unicompartmental knee arthroplasties (UKAs) between 1999 and 2019 in the New Zealand Joint Registry with an OKS at 6 months (TKA n = 27 708, UKA n = 8415), 5 years (TKA n = 11 519, UKA n = 3365) or 10 years (TKA n = 6311, UKA n = 1744) were included. Logistic regression determined associations of the OKS with revision within 2 years of each score. Change in OKS between timepoints were compared with revision risk.

RESULTS

For every one-unit increase in OKS, the odds of TKA and UKA revision decreased by 10% and 11% at 6 months, 10% and 12% at 5 years and 9% and 5% at 10 years. For both procedures a decrease of seven or more OKS points from previous follow-up was associated with higher risk of revision (5 years: TKA 4.7% versus 0.5%, UKA 8.7% versus 0.9%; 10 years: TKA 4.4% versus 0.7%, UKA 11.3% versus 1.5%; all P < 0.01).

CONCLUSION

The OKS had a strong negative association with risk of impending TKA and UKA revision from early to long-term (10+ years) follow-up. A decrease of seven or more points when compared with the previous follow-up was also associated with higher revision risk.

Virtual Arthroplasty Follow-Up: Better for the Trust, Patients, and the Planet

Background The Virtual Arthroplasty Follow-Up (VARF) Quality Improvement Project was initiated in March 2020 with the aim of improving patient experience while reducing costs to the trust, the patient, and the planet. Methodology This retrospective study was conducted in a district general hospital. Patients were assessed based on their Oxford Hip Score (OHS), University of California, Los Angeles (UCLA) activity score, and an X-ray. A patient satisfaction survey was undertaken via phone call using a 10-point questionnaire. These responses were then correlated to age, distance travelled, and OHS/UCLA scores. The environmental impact was estimated using CO₂ emissions for driving and outpatient clinics taken from relevant literature. Results A total of 132 patients were enrolled in the project. Overall, 75% demonstrated a good outcome from both their X-ray and OHS/UCLA scores. Further, 23% of patients required an additional phone call, of which a further 77% were re-enrolled in the VARF pathway. Only five of 132 (3.8%) patients required a face-to-face review. The patient satisfaction survey enrolled 52 patients, 90% of whom were satisfied with the service. Only one patient stated being dissatisfied with the service. Overall, 77% of patients felt that the service saved them time, money, or both. The strongest predictor of patient satisfaction was the OHS (r = 0.52) where a score of <35 was associated with a nine-fold increase in either responding neutral or dissatisfied with the service. Accounting for both travel and clinic space, approximately 8 tonnes of CO₂ equivalent were saved. Once time and cost-saving from virtual clinics were included, this project saved the trust £21,408 and patients £948. Conclusions VARF has been shown to be an appropriate way to follow up arthroplasty patients which maintains high patient satisfaction while reducing the environmental impact, saving patients' time and money, and freeing up clinic space for other uses. A potential improvement of the process would be to triage those with low OHS to a more intensive follow-up.

Automatic Identification of Failure in Hip Replacement: An Artificial Intelligence Approach

Background: Total hip arthroplasty (THA) follow-up is conventionally conducted with serial X-ray imaging in order to ensure the early identification of implant failure. The purpose of this study is to develop an automated radiographic failure detection system. Methods: 630 patients with THA were included in the study, two thirds of which needed total or partial revision for prosthetic loosening. The analysis is based on one antero-posterior and one lateral radiographic view obtained from each patient during routine post-surgery follow-up. After pre-processing for proper standardization, images were analyzed through a convolutional neural network (the DenseNet169 network), aiming to predict prosthesis failure. The entire dataset was divided in three subsets: training, validation, and test. These contained transfer learning and fine-tuning algorithms, based on the training dataset, and were implemented to adapt the DenseNet169 network to the specific data and clinical problem. Results: After the training procedures, in the test set, the classification accuracy was 0.97, the sensitivity 0.97, the specificity 0.97, and the ROC AUC was 0.99. Only five images were incorrectly classified. Seventy-four images were classified as failed, and eighty as non-failed with a probability >0.999. Conclusion: The proposed deep learning procedure can detect the loosening of the hip prosthesis with a very high degree of precision.

Remote Follow-up of Shoulder Arthroplasty Patients During COVID-19 Pandemic - Is This the way Forward?

Background

The COVID-19 Pandemic has affected the way health care systems function across the globe. Apart from eliminating the risk of being in a vulnerable environment during the pandemic such as a hospital setting, virtual arthroplasty follow-up reduces the demand on funding and resources on the National Health Services (NHS).

Methods

We retrospectively reviewed our shoulder arthroplasty patients (55) operated between October 2018 to November 2020 at both our hospital sites. For remote follow-up, patients were contacted on a scheduled appointment date via telephone by an orthopaedic surgeon to enquire about their wound, pain and function. Patients were questioned as per questionnaire from the Oxford Shoulder Score (OSS) and American Shoulder and Elbow Surgeons (ASES) Standardised Assessment form.

Results

50 patients were included in the final data set after excluding those who had died (5 patients). All patients had had final x-rays with full Covid-19 precautions at the time of final follow-up. No patient had wound problems except one who had concerns of wound appearance. There were no cases of notching, impingement, deep infection, dislocation or nerve injury. Of the 50 patients, 40 (80%) patients were satisfied to have a remote follow-up. 36 (72%) patients said they wouldn't mind a remote follow-up appointment.

Conclusion

Remote follow-up via audio consultation may be an effective alternative to in person visits after shoulder arthroplasty. Patients in this series demonstrated a high level of satisfaction with virtual visits and post-operative complications were effectively identified.

A mixed-methods survey to explore issues with virtual consultations for musculoskeletal care during the COVID-19 pandemic

OBJECTIVE

To explore orthopaedic and musculoskeletal clinicians' views and experiences of legal, safety, safeguarding and security issues regarding the use of virtual consultations (VC) during the COVID-19 pandemic. A secondary objective was to suggest ways to overcome these issues.

METHODS

A mixed method cross-sectional survey was conducted, seeking the views and experiences of orthopaedic and musculoskeletal medically qualified and Allied Health Professionals in the United Kingdom. Descriptive statistical analysis was employed for quantitative data and a qualitative content analysis undertaken for qualitative data. Findings were presented in accordance with the four key issues.

RESULTS

Two hundred and ninety professionals (206 physiotherapists, 78 medically qualified professionals, 6 'other' therapists) participated in the survey. Of the 290 participants, 260 (90%) were not using VC prior to the COVID-19 pandemic, 248 respondents (86%) were unsure whether their professional indemnity insurance covered VC, 136 (47%) had considered how they would handle an issue of safeguarding whilst the remainder had not, 126 (43%) had considered what they would do if, during a virtual consultation, a patient suffered an injury (e.g. bang on their head) or a fall (e.g. mechanical or a medical event like syncope) and 158 (54%) reported they felt the current technological solutions are secure in terms of patient data. Qualitative data provided additional context to support the quantitative findings such as validity of indemnification, accuracy of diagnosis and consent using VC, safeguarding issues; and security and sharing of data. Potential changes to practice have been proposed to address these issues.

CONCLUSIONS

VC have been rapidly deployed since the onset of the COVID-19 pandemic often without clear guidance or consensus on many important issues. This study identified legal, safeguarding, safety and security issues. There is an urgent need to address these and develop local and national guidance and frameworks to facilitate ongoing safe virtual orthopaedic practice beyond the COVID-19 pandemic.

Effectiveness, Patient Satisfaction, and Cost Reduction of Virtual Joint Replacement Clinic Follow-Up of Hip and Knee Arthroplasty

BACKGROUND

Total hip and knee arthroplasties are increasingly performed operations, and routine follow-up places huge demands on orthopedic services. This study investigates the effectiveness, patients' satisfaction, and cost reduction of Virtual Joint Replacement Clinic (VJRC) follow-up of total hip arthroplasty and total knee arthroplasty patients in a university hospital. VJRC is especially valuable when in-person appointments are not advised or feasible such as during the COVID-19 pandemic.

METHODS

A total of 1749 patients who were invited for VJRC follow-up for knee or hip arthroplasty from January 2017 to December 2018 were included in this retrospective study. Patients were referred to VJRC after their 6-week postoperative review. Routine VJRC postoperative review was undertaken at 1 and 7 years and then 3-yearly thereafter. We evaluated the VJRC patient response rate, acceptability, and outcome. Patient satisfaction was measured in a subgroup of patients using a satisfaction survey. VJRC costs were calculated compared to face-to-face follow-up.

RESULTS

The VJRC had a 92.05% overall response rate. Only 7.22% required further in-person appointments with only 3% being reviewed by an orthopedic consultant. VJRC resulted in an estimated saving of £42,644 per year at our institution. The patients' satisfaction survey showed that 89.29% of the patients were either satisfied or very satisfied with VJRC follow-up.

CONCLUSION

VJRC follow-up for hip and knee arthroplasty patients is an effective alternative to in-person clinic assessment which is accepted by patients, has high patient satisfaction, and can reduce the cost to both health services and patients.

Monitoring Patient Recovery After THA or TKA Using Mobile Technology

BACKGROUND

Smartphones offer the possibility of assessing recovery of mobility after total hip or knee arthroplasty (THA or TKA) passively and reliably, as well as facilitating the collection of patient-reported outcome measures (PROMs) with greater frequency.

QUESTIONS/PURPOSES

We investigated the feasibility of using mobile technology to collect daily step data and biweekly PROMs to track recovery after total joint arthroplasty.

METHODS

Pre- and post-operative daily steps were recorded in prospectively enrolled patients (128 THA and 139 TKA) via an app, which uses the phone's accelerometer. During 6-month follow-up, patients also completed PROMs (the pain numeric rating scale, the Hip Disability and Osteoarthritis Outcome Score Joint Replacement [HOOS JR] and the Knee Injury and Osteoarthritis Outcome Score Joint Replacement [KOOS JR]), and HOOS or KOOS JR quality of life domain via a mobile-enabled web link.

RESULTS

At least 6 months of follow-up was completed by 65% for THA and 68% for TKA patients. Reasons for non-completion included time commitment, phone battery, app issues, and health complications. Responses from 78% of requested PROMs were returned with 96% of patients returning at least one post-operative PROM. Step data were available from 92% of days from male patients and 86% of days from female patients. The most robust recovery occurred early, within the first 2 months. The groups with higher pre-operative steps were more likely to recover their maximum daily steps at an earlier time point. Correlations between step counts and PROMs scores were modest.

CONCLUSION

Assessing large amounts of post-TKA and post-THA step data using mobile technology is feasible. Completion rates were good, making the technology very useful for collecting frequent PROMs. Being unable to ensure that patients always carried their phones limited our analysis of the step counts.

An Evaluation of Risk Factors for Patient "No Shows" at an Urban Joint Arthroplasty Clinic

BACKGROUND

Patient physical health and provider financial health are both affected when patients are unable to attend scheduled clinic appointments. The purpose of this study is to identify risk factors for patients missing appointments to better target interventions to improve appointment attendance.

METHODS

We reviewed scheduled arthroplasty appointments at an urban academic orthopaedic clinic over a 3-year period. We collected information including sex, race, distance to clinic, language, insurance, median income of home zip code, appointment day, time, precipitation, and temperature. Mixed-level multiple logistic regression was used to model the odds of missing appointments in Stata v14.

RESULTS

Overall, 8,185 visits for 3,081 unique patients were reviewed and 90.7% of appointments were attended. After controlling for time and day of appointment, distance from the clinic, and the primary language spoken, patients with government insurance were two times as likely to miss an appointment compared with privately insured patients. White patients were two times as likely to attend scheduled appointments compared with black/Hispanic patients. Younger patients (<50 years) and older patients (>73 years) were 2.7 times and 1.8 times, respectively, more likely to miss appointments compared with those aged between 65 and 72 years. Appointments on the most temperate days were more likely to be missed, and those on the coldest days (14°F to 36°F) and warmest days (69°F to 89°F) were less likely to be missed.

DISCUSSION

Appointment no shows are associated with sociodemographic and environmental factors. This information is valuable to help better delineate novel ways to better serve these patient populations.

The burden and utility of routine follow-up at one year after primary arthroplasty

AIMS

Routine surveillance of primary hip and knee arthroplasties has traditionally been performed with office follow-up visits at one year postoperatively. The value of these visits is unclear. The present study aims to determine the utility and burden of routine clinical follow-up at one year after primary arthroplasty to patients and providers.

METHODS

All patients (473) who underwent primary total hip (280), hip resurfacing (eight), total knee (179), and unicompartmental knee arthroplasty (six) over a nine-month period at a single institution were identified from an institutional registry. Patients were prompted to attend their routine one-year postoperative visit by a single telephone reminder. Patients and surgeons were given questionnaires at the one-year postoperative visit, defined as a clinical encounter occurring at nine to 15 months from the date of surgery, regarding value of the visit.

RESULTS

Compliance with routine follow-up at one year was 35%. The response rate was over 80% for all questions in the patient and clinician surveys. Overall, 75% of the visits were for routine surveillance. Patients reported high satisfaction with their visits despite the general time for attendance, including travel, being over four hours. Surgeons found the visits more worthwhile when issues were identified or problems were addressed.

CONCLUSION

Patient compliance with follow-up at one year postoperatively after primary hip and knee is low. Routine visits of asymptomatic patients deliver little practical value and represent a large time and cost burden for patients and surgeons. Remote strategies should be considered for routine postoperative surveillance primary hip and knee arthroplasties beyond the acute postoperative period. Cite this article: Bone Joint J 2020;102-B(7 Supple B):85-89.

Setting up an arthroplasty care practitioner-led virtual clinic for follow-up of orthopaedic patients

This article provides an overview of the set up for an arthroplasty care practitioner (ACP)-led virtual orthopaedic clinic (VOC). Suitable patients attend a local hospital for an X-ray and complete a questionnaire, but do not physically attend a clinic. This has been running successfully in a university teaching hospital and has led to cost savings, a reduction in outpatient waiting times and high levels of patient satisfaction. Similar clinics have the potential to become normal practice across the NHS. This article outlines the steps necessary to implement a successful VOC. The lessons learnt during this exercise may be useful for other ACPs when setting up a VOC.

Developing a standardized approach to virtual clinic follow-up of hip and knee arthroplasty

AIMS

This study aimed to develop a virtual clinic for the purpose of reducing face-to-face orthopaedic consultations.

PATIENTS AND METHODS

Anonymized experts (hip and knee arthroplasty patients, surgeons, physiotherapists, radiologists, and arthroplasty practitioners) gave feedback via a Delphi Consensus Technique. This consisted of an iterative sequence of online surveys, during which virtual documents, made up of a patient-reported questionnaire, standardized radiology report, and decision-guiding algorithm, were modified until consensus was achieved. We tested the patient-reported questionnaire on seven patients in orthopaedic clinics using a 'think-aloud' process to capture difficulties with its completion.

RESULTS

A patient-reported 13-item questionnaire was developed covering pain, mobility, and activity. The radiology report included up to ten items (e.g. progressive periprosthetic bone loss) depending on the type of arthroplasty. The algorithm concludes in one of three outcomes: review at surgeon's discretion (three to 12 months); see at next available clinic; or long-term follow-up/discharge.

CONCLUSION

The virtual clinic approach with attendant documents achieved consensus by orthopaedic experts, radiologists, and patients. The robust development and testing of this standardized virtual clinic provided a sound platform for organizations in the United Kingdom to adopt a virtual clinic approach for follow-up of hip and knee arthroplasty patients. Cite this article: Bone Joint J 2019;101-B:951-959.

French translation and cultural adaptation of a questionnaire for patients with hip or knee prosthesis

INTRODUCTION

The Kingsbury questionnaire offers the possibility of follow-up by means of an X-ray and a simple questionnaire sent to the home address of the patient, who will not need to come in consultation if there are no problems. The questionnaire detects any anomaly in follow-up. In case of anomaly in the questionnaire or radiograph, the patient is contacted and/or seen again, as appropriate. The Kingsbury questionnaire has had no transcultural validation, and we therefore conducted a prospective study in order to 1) translate into French the questionnaire, previously validated in English; 2) adapt it for good understanding according to cultural habits; and 3) assess the translated version on a test-retest procedure.

HYPOTHESIS

The study hypothesis was that the translated questionnaire would show good test-retest reproducibility.

MATERIAL AND METHODS

The exact English version of the questionnaire was obtained directly from the authors of the index publication. A methodology of translation, back-translation and test-retest enabled assessment of the translation and of the reproducibility of the French version. The reference method of cultural adaptation of self-administered questionnaires and patient information documents was used. The questionnaire was tested prospectively.

RESULTS

One hundred patients were contacted, providing 73 clinical tests with radiographic validation and 48 complete test-retests in a representative population of total hip and total knee arthroplasty (THA, TKA). Internal coherence showed a KR-20 coefficient of 0.71 and Cronbach alpha of 0.76: e.g., good internal coherence. Item difficulty, requiring renewed contact, was low for all questions. Mean variance was low on the first 7 questions: 0.08 (range, 0.02-0.16). Correlation was close to 0.5 for each question. Analysis of reproducibility found excellent agreement (>90%) for the first 7 questions, which were binary; for question 8, agreement was good (83.3%) considering that there were 5 possible responses. For 19 of the 73 respondents, the questionnaire results indicated a need for further contact. After analysis of their radiographs, 4 needed to be seen in consultation again. The other 15 had unfavorable responses but without deterioration since the last classical consultation or any radiologic abnormality consultation, and were not called back for consultation.

CONCLUSION

The French version of the Kingsbury questionnaire provided reproducible assessment, avoiding the need to call the patient back for consultation unnecessarily. The questionnaire needs validating in a larger sample before being widely used: the present study was just a first step.

LEVEL OF EVIDENCE

IV, Prospective without control group.

Is virtual clinic follow-up of hip and knee joint replacement acceptable to patients and clinicians? A sequential mixed methods evaluation

Objective

To evaluate the acceptability to key stake holders of a newly introduced virtual clinic follow-up pathway for hip and knee joint replacement.

Design

A service evaluation comprising a questionnaire sent electronically to 115 patients and interviews with 10 individuals.

Setting

A newly introduced virtual clinic follow-up pathway for hip and knee replacement patients in a district general hospital.

Participants

The electronic questionnaire was distributed to all patients treated under the virtual clinic service over a 5-month period (n=115). Purposive sampling from volunteers among respondents, leading to semi-structured interviews with eight patients. Two orthopaedic consultants were also interviewed.

Intervention

Consultant review of web-based patient reported outcome measures and digital radiographs, with feedback to patients via letter, replacing face-to-face outpatient appointments for the follow-up of hip and knee joint replacement.

Results

The response rate to the questionnaire was 40%. 44% indicated they would prefer a virtual appointment over a face-to-face consultation in future. The most common word in the free text comments was ‘good’ (n=107).

Seven main themes were identified from the patient interviews: patient understanding and expectations, patient confidence, patient voice, managing deterioration of condition, patient benefit, patient satisfaction using technology and navigating the website.

Two main themes were identified from the staff interviews: the adapting patient pathway and project management.

Combined analysis elucidated that patients who were doing well liked the ‘click and go’ approach but those with problems were concerned about how to report these and were therefore less satisfied.

Conclusion

The virtual clinic process appears to be well accepted by both patients and clinicians. However, appropriate patient selection and clear pathways of communication to address patient concerns are pivotal to success.

Requesting spinal MRIs effectively from primary care referrals

OBJECTIVE

To define if MRI scans can accurately be requested based on information provided in the primary care referral and, therefore, streamline the patient journey. The demand for outpatient spinal appointments significantly exceeds our services' ability to provide efficient, high-quality patient care. Currently, magnetic resonance imaging (MRI) of the spine is requested following first consultation.

METHODS

During routine vetting of primary care referral letters, three consultant spinal surgeons recorded how likely they thought each patient would be to have an MRI scan. Following the first consultation with the spinal service, the notes of each patient were reviewed to see if an MRI was requested. We measured the positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity of ordering MRI scans based on primary care referral letters.

RESULTS

149 patients were included [101 females, 48 males, mean age 49 (16-87)]. There were 125 routine, 21 urgent, and 3 'urgent-suspected cancer' referrals. The PPV of ordering MRIs before first consultation was 84%, NPV was 56% with the sensitivity and specificity being 82 and 59%, respectively. Ordering MRIs during initial vetting could shorten the patient journey with potential socioeconomic benefits.

CONCLUSIONS

MRI scans can be effectively ordered based on the information provided by the primary care referral letter. Requesting MRI scans early in the patient journey can save considerable time, improve care, and deliver cost savings. These slides can be retrieved under Electronic Supplementary Material.

Two and a half years on: data and experiences establishing a 'Virtual Clinic' for joint replacement follow up

BACKGROUND

We use a 'Virtual Clinic' for follow up of hip and knee replacement patients. The aim of this study was to investigate patient compliance, pain and function, revision rates and surgeon experience using this system.

METHODS

All hip and knee replacements conducted from 2000 onwards were suitable for 'Virtual Clinic' review. Between July 2014 and December 2016, all patients due for follow up (at 1, 5 and 7 years post-operatively, or biennially thereafter) were mailed an Oxford Hip or Knee Score and a request for a radiograph. A surgeon reviewed the questionnaire and radiograph and decided whether face-to-face review was necessary. We calculated compliance as the percentage of eligible patients who completed the 'Virtual Clinic'. We used retrospective review of medical records for all clinic participants to analyse Oxford scores, disposition following appointment, and revision rates. We reviewed all clinic participants in December 2017 to identify any further revisions. Surgeon feedback was assessed by emailed survey.

RESULTS

A total of 2076 patients were due for follow up. 1405 patients were contactable, and 710 completed the process. We calculated a 36% compliance rate. Surgeons decided 162 (23%) patients with a mean Oxford score of 24.2 required face-to-face assessment. This identified 13 patients needing revision. One other patient was revised for loosening which developed between 'Virtual Clinic' appointments. Surgeon feedback indicated the inclusion of a 'comment' section on the questionnaire as particularly useful.

DISCUSSION

We describe our adoption of a 'Virtual Clinic' for joint replacement follow up. We recommend this system as a practical method of following up patients.

Identifying complications requiring re-operation following primary hip or knee arthroplasty: a consecutive series of 98 patients

BACKGROUND

The number of hip and knee arthroplasties completed is expected to double over the next decade. In public hospitals, regular post-arthroplasty orthopaedic review has commonly occurred for the duration of a patient's life, which requires substantial outpatient resources. However, there is limited evidence regarding the utility of these reviews for identifying complications. The current study investigated when and where complications requiring re-operation were identified following primary hip or knee arthroplasty.

METHODS

The medical records of all patients requiring re-operation for complications following primary hip arthroplasty (n = 48, 2004 to 2015) or knee primary arthroplasty (n = 50, 1998 to 2015) at a large regional health service were evaluated. Data were extracted by one of four investigators using a standardised electronic data extraction tool. Variables of interest included the health setting where the complication was initially identified, how long following the original operation the complication was identified and whether the complication was symptomatic.

RESULTS

Routine post-arthroplasty orthopaedic appointments identified 15 (15.3%) complications requiring re-operation; all were identified in the first-year post-surgery. For each complication identified in the first-year post-surgery, approximately 1000 orthopaedic outpatient appointments were required. After the first year, all complications were identified in Emergency Departments (n = 30, 30.6%), General Practice (n = 24, 24.5%) or non-routine orthopaedic outpatient appointments (n = 19, 19.4%). All patients with complications reported symptoms.

CONCLUSIONS

Routine post-arthroplasty review appointments were an inefficient mechanism for identifying complications requiring re-operation more than one year following surgery. Public health services should consider assessing and redesigning post-arthroplasty review services to reduce the burden on patients and the demand for outpatient appointments.

Follow-up after arthroplasty of the hip and knee : are we over-servicing or under-caring?

The number of arthroplasties of the hip and knee is predicted to increase rapidly during the next 20 years. Accompanying this is the dilemma of how to follow-up these patients appropriately. Current guidelines recommend long-term follow-up to identify patients with aseptic loosening, which can occur more than a decade postoperatively. The current guidelines and practices of orthopaedic surgeons vary widely. Existing models take up much clinical time and are expensive. Pilot studies using 'virtual' clinics and advanced-practice physiotherapists have shown promise in decreasing the time and costs for orthopaedic surgeons and patients. This review discusses current practices and future trends in the follow-up of patients who have an arthroplasty. Cite this article: Bone Joint J 2018;100-B:6-10.

Tele-orthopaedics: A snapshot of services in Australia

Health services in the United States and Europe have reported that tele-orthopaedics saves significant patient travel time, reduces time off work, increases satisfaction with care and in some scenarios reduces the cost of care. Less is known about the role of tele-orthopaedics in Australia. The aim of this study was to explore Australian-based tele-orthopaedic services, and to identify the barriers and enablers associated with these services. We used a qualitative case study methodology where specific services were identified from multiple sources and invited to participate in a structured interview. Nine tele-orthopaedic services contributed to the study. Telehealth activity in each service ranged from one to 75 patients per week, and service maturity ranged from three months to 10 years. Services were used predominantly for fracture clinics and peri-operative consultations. The majority (78%) of services used videoconferencing. Two services used asynchronous methods to review radiographs without direct patient involvement. Tele-orthopaedics was found to be disruptive as it required the redesign of many care processes. However, all services found the redesign feasible. Staff resistance was a commonly cited barrier. Further, imaging repositories from multiple imaging providers complicated access to information. Key enablers included clinical champions, picture archiving and communication systems, and the perceived benefit to patients who would avoid the need for travel. Whilst it appears that tele-orthopaedics is not widely utilised in Australia, recognition of the barriers and enablers is important for the development of similar services.

How often is the office visit needed? Predicting total knee arthroplasty revision risk using pain/function scores

BACKGROUND

Most patients have favorable outcomes after primary total knee arthroplasty (TKA). Well-validated methods to predict the risk of poor outcomes have not been developed or implemented. Several patients have annual clinic visits despite well-funcitoning TKA, as a routine practice, to detect early failure requiring revision surgery. It is not known whether assessment of pain and function can be used as a predictive tool for early failure and revision to guide practice. Our objective was to determine whether pain and function can predict revision after TKA.

METHODS

We retrospectively studied data from a large prospectively gathered TKA registry to examine changes in outcome scores for primary TKAs undergoing revision compared to those not requiring revision to determine the factors that are predictive for revision.

RESULTS

Of the 1,012 patients, 721 had had a single-sided primary TKA and had American Knee Society (AKS) Scores for three or more visits. 46 patients underwent revision, 23 acutely (fracture, traumatic component failure or acute infection) and 23 for latent causes (late implant loosening, progressive osteolysis, or pain and indolent infection). Mean age was 70 years for the non-revision patients, and 64 years for those revised. Both AKS Clinical and AKS Function Scores for non-revised patients were higher than in revision patients, higher in acute revision compared to latent revision patients. Significant predictors of revision surgery were preoperative, 3- and 15-month postoperative AKS Clinical Scores and 3-month AKS Function Scores. At 15-month post-TKA, a patient with a low calculated probability of revision, 32 % or less, was unlikely to require revision surgery with a negative predictive value of 99 %.

CONCLUSION

Time dependent interval evaluation post-TKA with the AKS outcome scores may provide the ability to assign risk of revision to patients at the 15-month follow-up visit. If these findings can be replicated using a patient-reported measure, a virtual follow-up with patient-reported outcomes and X-ray review may be an alternative to clinic visit for patients doing well.