Complex organisational factors influence multidisciplinary care for patients with hip fractures: a qualitative study of barriers and facilitators to service delivery

BACKGROUND

Hip fractures are devastating injuries, with high health and social care costs. Despite national standards and guidelines, substantial variation persists in hospital delivery of hip fracture care and patient outcomes. This qualitative study aimed to identify organisational processes that can be targeted to reduce variation in service provision and improve patient care.

METHODS

Interviews were conducted with 40 staff delivering hip fracture care in four UK hospitals. Twenty-three anonymised British Orthopaedic Association reports addressing under-performing hip fracture services were analysed. Following Thematic Analysis of both data sources, themes were transposed onto domains both along and across the hip fracture care pathway.

RESULTS

Effective pre-operative care required early alert of patient admission and the availability of staff in emergency departments to undertake assessments, investigations and administer analgesia. Coordinated decision-making between medical and surgical teams regarding surgery was key, with strategies to ensure flexible but efficient trauma lists. Orthogeriatric services were central to effective service delivery, with collaborative working and supervision of junior doctors, specialist nurses and therapists. Information sharing via multidisciplinary meetings was facilitated by joined up information and technology systems. Service provision was improved by embedding hip fracture pathway documents in induction and training and ensuring their consistent use by the whole team. Hospital executive leadership was important in prioritising hip fracture care and advocating service improvement. Nominated specialty leads, who jointly owned the pathway and met regularly, actively steered services and regularly monitored performance, investigating lapses and consistently feeding back to the multidisciplinary team.

CONCLUSION

Findings highlight the importance of representation from all teams and departments involved in the multidisciplinary care pathway, to deliver integrated hip fracture care. Complex, potentially modifiable, barriers and facilitators to care delivery were identified, informing recommendations to improve effective hip fracture care delivery, and assist hospital services when re-designing and implementing service improvements.

Development of a novel intervention to improve sleep and pain in patients undergoing total knee replacement

Background

Up to 20% of patients experience long-term pain and dissatisfaction after total knee replacement, with a negative impact on their quality of life. New approaches are needed to reduce the proportion of people to go on to experience chronic post-surgical pain. Sleep and pain are bidirectionally linked with poor sleep linked to greater pain. Interventions to improve sleep among people undergoing knee replacement offer a promising avenue. Health beliefs and barriers to engagement were explored using behaviour change theory. This study followed stages 1–4 of the Medical Research Council’s guidance for complex intervention development to develop a novel intervention aimed at improving sleep in pre-operative knee replacement patients.

Methods

Pre-operative focus groups and post-operative telephone interviews were conducted with knee replacement patients. Before surgery, focus groups explored sleep experiences and views about existing sleep interventions (cognitive behavioural therapy for insomnia, exercise, relaxation, mindfulness, sleep hygiene) and barriers to engagement. After surgery, telephone interviews explored any changes in sleep and views about intervention appropriateness. Data were audio-recorded, transcribed, anonymised, and analysed using framework analysis.

Results

Overall, 23 patients took part, 17 patients attended pre-operative focus groups, seven took part in a post-operative telephone interview, and one took part in a focus group and interview. Key sleep issues identified were problems getting to sleep, frequent waking during the night, and problems getting back to sleep after night waking. The main reason for these issues was knee pain and discomfort and a busy mind. Participants felt that the sleep interventions were generally acceptable with no general preference for one intervention over the others. Views of delivery mode varied in relation to digital move and group or one-to-one approaches.

Conclusion

Existing sleep interventions were found to be acceptable to knee replacement patients. Key barriers to engagement related to participants’ health beliefs. Addressing beliefs about the relationship between sleep and pain and enhancing understanding of the bidirectional/cyclical relationship could benefit engagement and motivation. Individuals may also require support to break the fear and avoidance cycle of pain and coping. A future intervention should ensure that patients’ preferences for sleep interventions and delivery mode can be accommodated in a real-world context.

995 MULTIPLE ORGANISATIONAL FACTORS IMPROVE MULTI-DISCIPLINARY CARE DELIVERY TO PATIENTS WITH HIP FRACTURES: A QUALITATIVE STUDY

Introduction

Hip fractures are devastating injuries which incur high healthcare costs. Despite national standards and guidelines, there is substantial variation in hospital delivery of hip fracture care and in patient outcomes. This study aimed to understand organisational processes that facilitate successful delivery of hip fracture services.

Method

Forty qualitative interviews were conducted with healthcare professionals involved in delivering hip fracture care at four English hospitals. Interview data were supplemented with documentary analysis of 23 anonymised British Orthopaedic Association hospital-initiated peer-review reports of services. Data were analysed thematically, with themes transposed onto key components of the care pathway.

Results

We identified multiple aspects of service organisation that facilitated good care delivery. At admission, standardisation of training in nerve block administration impacted care delivery. During hospital stays, service delivery was improved by integrated, shared-care between orthopaedics and orthogeriatrics, and by strategies to improve trauma list efficiency. Adequately staffed orthogeriatric services and the ‘right’ skills and seniority mix were important to holistic care provision. Placing patients on designated hip fracture wards concentrated staff expertise. Collaborative working was achieved through multi-disciplinary team (MDT) meetings between key staff, protocols and care pathways that defined roles and responsibilities, MDT documentation, ‘joined-up’ IT systems within hospitals and with primary care, and shared working spaces such as shared offices and onwards. Trauma and hip fracture coordinators organised care processes and provided a valuable central point of contact within teams. Nominated leads, representing diverse specialties, worked together in MDT planning meetings to develop joint protocols, establish audit priorities, and agree shared goals. Routine, comprehensive monitoring and evaluation of service delivery, with findings shared throughout the MDT, was beneficial.

Conclusion

Our study has characterised potentially modifiable elements of successful hip fracture service delivery. Findings are intended to help services overcome organisational barriers towards delivery of high-quality hip fracture services.

946 MULTIPLE ORGANISATIONAL FACTORS ARE ASSOCIATED WITH ADVERSE PATIENT OUTCOMES POST HIP FRACTURE IN HOSPITALS IN ENGLAND & WALES

Introduction

Older adults who sustain a hip fracture require complex multidisciplinary care, which can challenge organisational structures within hospitals. Despite standards and guidelines, substantial variation remains in hip fracture care delivery across the UK. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the post injury period.

Method

A cohort of 178,757 patients aged 60+ years in England and Wales (2016–19) who sustained a hip fracture was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality data were linked to metrics from 18 hospital-level organisational audits/reports/series. Multilevel models determined the organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality, and emergency 30-day readmission.

Results

Overall LOS was mean 21 days (standard deviation, 20); 13,126 (7.3%) died within 30-days; and 25,239 (15.3%) were readmitted. 25 organisational factors independently predicted LOS: for example, a hospital’s ability to promptly mobilise ≥90% of patients was associated with a 2-day (95%CI:1.3–2.7) shorter LOS, and hospitals where all patients received orthogeriatric assessment within 72 hours of admission had mean 1.5-day (95%CI:0.6–2.3) shorter LOS. Ten organisational factors independently predicted 30-day mortality: providing prompt surgery (≤36 hours from admission) to >80% patients was associated with the same 10% reduction in mortality (95%CI:4–15%), as was discussion of ‘patient experience’ feedback at clinical governance meetings (95%CI:5–15%). Nine organisational factors independently predicted readmission: knowledge of time from discharge to start of community therapy was associated with 17% (95%CI:9–24%) lower readmission rates. Organisational delivery of clinical governance, surgery, and physiotherapy were associated with all outcomes.

Conclusion

Multiple, potentially modifiable, organisational factors are associated with important patient outcomes post-hip fracture. These factors, if causal, indicate auditable components of hospital care where interventions can be targeted to reduce variability in hip fracture care delivery, to improve patient outcomes.

POS1514-HPR UNDERSTANDING AND CHARACTERISING PATIENT PATHWAYS TO TREATMENT FOR VERTEBRAL FRACTURES: A QUALITATIVE STUDY

Background

Osteoporosis involves thinning of the bones, making them more prone to break. The most common osteoporotic fracture is a vertebral fracture (OVF). People with OVFs are at high risk of further fractures. To reduce this risk, guidelines recommend prescription of bone protection therapies to people who have experienced a fracture. However, many patients do not receive diagnosis. Understanding patient pathways to treatment for OVFs will provide information to improve practice and aid in effective identification and management.

Objectives

To understand and characterise patient pathways to treatment for OVFs.

Methods

Twenty-three semi-structured qualitative interviews were conducted with patients aged ≥50 years with diagnosis of OVF. Patients were recruited through two hospitals in England and were purposively sampled to capture variation in pathways to diagnosis, sex, age, comorbidities and other relevant characteristics. Interviews were audio-recorded, transcribed and analysed thematically, with themes transposed onto key stages of the patient pathway.

Results

Several factors influenced patient pathways to treatment:

Patient appraisal and self-management: Characteristics and attitudes towards back pain impacted treatment-seeking behaviour. Patients who appraised their pain as ‘different’, severe or disruptive, or associated with an injury such as a fall, were more likely to seek help. Limited availability of information about OVFs and risk factors meant most patients did not associate symptoms with a potential OVF. Factors contributing to delayed consultation included the normalisation of back pain and prioritisation of comorbid conditions. Several misappraised their symptoms as a “pulled muscle” or other minor injury. Many adopted strategies to manage pain, including use of painkillers, lying flat or resting. For some, a lack of improvement in symptoms over time, combined with worsening pain, created a ‘tipping point’ in seeking care. There was a moral dimension for some patients who did not want to “bother” healthcare professionals.

Healthcare professional appraisal: Differential diagnosis was a barrier to treatment and healthcare professionals interpreted OVF pain as broken ribs, muscular pain, kidney pain or sciatica. GPs tended to instigate watchful waiting, in which patients were asked to re-consult if pain did not improve. Feeling disbelieved caused some patients to become disillusioned and reluctant to re-consult and a small number of patients presented at Accident and Emergency. Those already having treatment for musculoskeletal conditions with access to specialist care, were more likely to receive timely diagnosis.

Communication of diagnosis: Patients discussed multiple methods of communication, including written communication and clinical conversations. Several expressed confusion around the use of unfamiliar medical terminology, the implications of OVFs, how many OVFs they had experienced and how they had been identified.

Treatment initiation: Bone protection therapies were not consistently prescribed after diagnosis. Patients who were familiar with these therapies were unsure whether treatment should be initiated in primary or secondary care. Patients described how they felt a need to be proactive by arranging appointments and asking for treatment.

Conclusion

The study provides novel findings about patient pathways to treatment and will be used to identify targeted solutions to improve management of OVFs. This work addresses stages of the Model of Pathways to Treatment[1] and provides detailed understanding of patients’ experiences of these stages. Further work with healthcare professionals in primary care is underway to identify additional system-level factors that may impact patients’ journeys to treatment.

References

[1]Scott, S.E., et al., The model of pathways to treatment: conceptualization and integration with existing theory. Br J Health Psychol, 2013. 18(1): p. 45-65.

Acknowledgements

This study is funded by the National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) programme NIHR201523. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Disclosure of Interests

None declared

Value, transparency, and inclusion: A values-based study of patient involvement in musculoskeletal research

Background

Patient and public involvement work (PPI) is essential to good research practice. Existing research indicates that PPI offers benefits to research design, conduct, communication, and implementation of findings. Understanding how PPI works and its value helps to provide information about best practice and highlight areas for further development. This study used a values-based approach to reporting PPI at a Research Unit focused on musculoskeletal conditions within a UK medical school.

Methods

The study was conducted between October 2019 and January 2020 using Gradinger’s value system framework as a theoretical basis. The framework comprises three value systems each containing five clusters. All PPI members and researchers who had attended PPI groups were invited to participate. Participants completed a structured questionnaire based on the value system framework; PPI members also provided further information through telephone interviews. Data were deductively analysed using a framework approach with data mapped onto value systems.

Results

Twelve PPI members and 17 researchers took part. Views about PPI activity mapped onto all three value systems. PPI members felt empowered to provide their views, and that their opinions were valued by researchers. It was important to PPI members that they were able to ‘give back’ and to do something positive with their experiences. Researchers would have liked the groups to be more representative of the wider population, patients highlighted that groups could include more younger members. Researchers recognised the value of PPI, and the study highlighted areas where researchers members might benefit from further awareness.

Conclusions

Three areas for development were identified: (i) facilitating researcher engagement in training about the value and importance of PPI in research; (ii) support for researchers to reflect on the role that PPI plays in transparency of healthcare research; (iii) work to further explore and address aspects of diversity and inclusion in PPI.

Optimising recruitment into trials using an internal pilot

Background

Recruitment to trials can be difficult. Despite careful planning and research that outlines ways to improve recruitment, many trials do not achieve their target on time and require extensions of funding or time.

Methods

We describe a trial in which an internal pilot with embedded qualitative research was used to improve recruitment processes and inform recruitment projections for the main trial. At the end of the pilot, it was clear that the sample size would not be met on time. Three steps were taken to optimise recruitment: (1) adjustments were made to the recruitment process using information from the qualitative work done in the pilot and advice from a patient and public involvement group, (2) additional recruiting sites were included based on site feasibility assessments and (3) a projection equation was used to estimate recruitment at each site and overall trial recruitment.

Results

Qualitative work during the pilot phase allowed us to develop strategies to optimise recruitment during the main trial, which were incorporated into patient information packs, the standard operating procedures and training sessions with recruiters. From our experience of feasibility assessments, we developed a checklist of recommended considerations for feasibility assessments. For recruitment projections, we developed a four-stage projection equation that estimates the number of participants recruited using a conversion rate of the number randomised divided by the number screened.

Conclusions

This work provides recommendations for feasibility assessments and an easy-to-use projection tool, which can be applied to other trials to help ensure they reach the required sample size.

Trial registration

ISRCTN, ISRCTN92545361. Registered on 6 September 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3296-5) contains supplementary material, which is available to authorized users.

An observational cohort study to produce and evaluate an improved tool to screen older women with back pain for osteoporotic vertebral fractures (Vfrac): study protocol

The aim of this study is to produce an easy to use checklist for general practitioners to complete whenever a woman aged over 65 years with back pain seeks healthcare. This checklist will produce a binary output to determine if the patient should have a radiograph to diagnose vertebral fracture.

PURPOSE

People with osteoporotic vertebral fractures are important to be identified as they are at relatively high risk of further fractures. Despite this, less than a third of people with osteoporotic vertebral fractures come to clinical attention due to various reasons including lack of clear triggers to identify who should have diagnostic spinal radiographs. This study aims to produce and evaluate a novel screening tool (Vfrac) for use in older women presenting with back pain in primary care based on clinical triggers and predictors identified previously. This tool will generate a binary output to determine if a radiograph is required.

METHODS

The Vfrac study is a two-site, pragmatic, observational cohort study recruiting 1633 women aged over 65 years with self-reported back pain. Participants will be recruited from primary care in two sites. The Vfrac study will use data from two self-completed questionnaires, a simple physical examination, a lateral thoracic and lateral lumbar radiograph and information contained in medical records.

RESULTS

The primary objective is to develop an easy-to-use clinical screening tool for identifying older women who are likely to have vertebral fractures.

CONCLUSIONS

This article describes the protocol of the Vfrac study; ISRCTN16550671.

Correction to: Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures and those with back pain due to degenerative changes

This article was originally published under a CC BY-NC-ND 4.0 license, but has now been made available under a CC BY 4.0 license. The PDF and HTML versions of the paper have been modified accordingly.

Systematic review of management of chronic pain after surgery

Background

Pain present for at least 3 months after a surgical procedure is considered chronic postsurgical pain (CPSP) and affects 10–50 per cent of patients. Interventions for CPSP may focus on the underlying condition that indicated surgery, the aetiology of new‐onset pain or be multifactorial in recognition of the diverse causes of this pain. The aim of this systematic review was to identify RCTs of interventions for the management of CPSP, and synthesize data across treatment type to estimate their effectiveness and safety.

Methods

MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library were searched from inception to March 2016. Trials of pain interventions received by patients at 3 months or more after surgery were included. Risk of bias was assessed using the Cochrane risk‐of‐bias tool.

Results

Some 66 trials with data from 3149 participants were included. Most trials included patients with chronic pain after spinal surgery (25 trials) or phantom limb pain (21 trials). Interventions were predominantly pharmacological, including antiepileptics, capsaicin, epidural steroid injections, local anaesthetic, neurotoxins, N‐methyl‐d‐aspartate receptor antagonists and opioids. Other interventions included acupuncture, exercise, postamputation limb liner, spinal cord stimulation, further surgery, laser therapy, magnetic stimulation, mindfulness‐based stress reduction, mirror therapy and sensory discrimination training. Opportunities for meta‐analysis were limited by heterogeneity. For all interventions, there was insufficient evidence to draw conclusions on effectiveness.

Conclusion

There is a need for more evidence about interventions for CPSP. High‐quality trials of multimodal interventions matched to pain characteristics are needed to provide robust evidence to guide management of CPSP.

Flimsy evidence base

Selecting, assessing and interpreting measures of function for patients with severe hip pathology: The need for caution

INTRODUCTION

It is not always possible to use a combination of patient-reported outcome measures (PROMs), performance tests and clinician-administrated measures to assess physical function prior to hip surgery. We hypothesised that there would be low correlations between these three types of measure and that they would be associated with different patients' characteristics.

MATERIALS AND METHODS

We conducted a cross-sectional analysis of the preoperative information of 125 participants listed for hip replacement. The WOMAC-function subscale, Harris Hip Score (HHS) and walk, step and balance tests were assessed by questionnaire or during a clinic visit. Participant's socio-demographics and medical characteristics were also collected. Correlations between functional measures were investigated with correlation coefficients. Regression models were used to test the association between the patient's characteristics and each of the three types of functional measures.

RESULTS

None of the correlations between the PROM, clinician-administrated measure and performance tests were very high (<0.90). Associations between patient's characteristics and functional scores varied by type of measure. Psychological status was associated with the PROM (P-value<0.0001) but not with the other measures. Age was associated with the performance test measures (P-value ranging from ≤0.01 to <0.0001) but not with the PROM. The clinician-administered measure was not associated with age or psychological status.

DISCUSSION

Substantial discrepancies exist when assessing hip function using a PROM, functional test or a clinician-administered test. Moreover, these assessment methods are influenced differently by patient's characteristics. Clinicians should supplement their pre-surgery assessment of function with patient-reported measure to include the patient's perspective.

LEVEL OF EVIDENCE

III, observational cross-sectional study.

Central sensitization as a determinant of patients' benefit from total hip and knee replacement

Background

Discrepancies exist between osteoarthritic joint changes and pain severity before and after total hip (THR) and knee (TKR) replacement. This study investigated whether the interaction between pre‐operative widespread hyperalgesia and severity of radiographic osteoarthritis (OA) was associated with pain severity before and after joint replacement.

Methods

Data were analysed from 232 patients receiving THR and 241 receiving TKR. Pain was assessed pre‐operatively and at 12 months post‐operatively using the WOMAC Pain Scale. Widespread hyperalgesia was assessed through forearm pressure pain thresholds (PPTs). Radiographic OA was evaluated using the Kellgren and Lawrence scheme. Statistical analysis was conducted using multilevel models, and adjusted for confounding variables.

Results

Pre‐operative: In knee patients, there was weak evidence that the effect of PPTs on pain severity was greater in patients with more severe OA (Grade 3 OA: ß = 0.96 vs. Grade 4: ß = 4.03), indicating that in these patients higher PPTs (less widespread hyperalgesia) was associated with less severe pain. In hip patients, the effect of PPTs on pain did not differ with radiographic OA (Grade 3 OA: ß = 3.95 vs. Grade 4: ß = 3.67).

Post‐operative: There was weak evidence that knee patients with less severe OA who had greater widespread hyperalgesia benefitted less from surgery (Grade 3 OA: ß = 2.28; 95% CI −1.69 to 6.25). Conversely, there was weak evidence that hip patients with more severe OA who had greater widespread hyperalgesia benefitted more from surgery (Grade 4 OA: ß = −2.92; 95% CI −6.58 to 0.74).

Conclusions

Widespread sensitization may be a determinant of how much patients benefit from joint replacement, but the effect varies by joint and severity of structural joint changes.

Significance

Pre‐operative widespread hyperalgesia and radiographic osteoarthritis (OA) severity may influence how much patients benefit from joint replacement. Patients undergoing knee replacement with less severe OA and greater widespread hyperalgesia benefitted less from surgery than patients with less hyperalgesia. Patients undergoing hip replacement with more severe OA and greater widespread hyperalgesia benefitted more than patients with less hyperalgesia.

Secondary prevention of fractures after hip fracture: a qualitative study of effective service delivery

There is variation in how services to prevent secondary fractures after hip fracture are delivered and no consensus on best models of care. This study identifies healthcare professionals' views on effective care for the prevention of these fractures. It is hoped this will provide information on how to develop services.

INTRODUCTION

Hip fracture patients are at high risk of subsequent osteoporotic fractures. Whilst fracture prevention services are recommended, there is variation in delivery and no consensus on best models of care. This study aims to identify healthcare professionals' views on effective care for prevention of secondary fracture after hip fracture.

METHODS

Forty-three semi-structured interviews were undertaken with healthcare professionals involved in delivering fracture prevention across 11 hospitals in one English region. Interviews explored views on four components of care: (1) case finding, (2) osteoporosis assessment, (3) treatment initiation, and (4) monitoring and coordination. Interviews were audio-recorded, transcribed, anonymised and coded using NVivo software.

RESULTS

Case finding: a number of approaches were discussed. Multiple methods ensured there was a 'backstop' if patients were overlooked. Osteoporosis assessment: there was no consensus on who should conduct this. The location of the dual energy X-ray absorptiometry (DXA) scanner influenced the likelihood of patients receiving a scan. Treatment initiation: it was felt this was best done in inpatients rather request initiation in the post-discharge/outpatients period. Monitoring (adherence): adherence was a major concern, and participants felt more monitoring could be conducted by secondary care. Coordination of care: participants advocated using dedicated coordinators and formal and informal methods of communication. A gap between primary and secondary care was identified and strategies suggested for addressing this.

CONCLUSIONS

A number of ways of organising effective fracture prevention services after hip fracture were identified. It is hoped that this will help professionals identify gaps in care and provide information on how to develop services.

Using self-reports of pain and other variables to distinguish between older women with back pain due to vertebral fractures and those with back pain due to degenerative changes

Women with back pain and vertebral fractures describe different pain experiences than women without vertebral fractures, particularly a shorter duration of back pain, crushing pain and pain that improves on lying down. This suggests a questionnaire could be developed to identify older women who may have osteoporotic vertebral fractures.

INTRODUCTION

Approximately 12 % of postmenopausal women have vertebral fractures (VFs), but less than a third come to clinical attention. Distinguishing back pain likely to relate to VF from other types of back pain may ensure appropriate diagnostic radiographs, leading to treatment initiation. This study investigated whether characteristics of back pain in women with VF are different from those in women with no VFs.

METHODS

A case control study was undertaken with women aged ≥60 years who had undergone thoracic spinal radiograph in the previous 3 months. Cases were defined as those with VFs identified using the algorithm-based qualitative (ABQ) method. Six hundred eighty-three potential participants were approached. Data were collected by self-completed questionnaire including the McGill Pain Questionnaire. Chi-squared tests assessed univariable associations; logistic regression identified independent predictors of VFs. Receiver operating characteristic (ROC) curves were used to evaluate the ability of the combined independent predictors to differentiate between women with and without VFs via area under the curve (AUC) statistics.

RESULTS

One hundred ninety-seven women participated: 64 cases and 133 controls. Radiographs of controls were more likely to show moderate/severe degenerative change than cases (54.1 vs 29.7 %, P = 0.011). Independent predictors of VF were older age, history of previous fracture, shorter duration of back pain, pain described as crushing, pain improving on lying down and pain not spreading down the legs. AUC for combination of these factors was 0.85 (95 % CI 0.79 to 0.92).

CONCLUSION

We present the first evidence that back pain experienced by women with osteoporotic VF is different to back pain related solely to degenerative change.

Assessment of physical function following total hip arthroplasty: Inertial sensor based gait analysis is supplementary to patient-reported outcome measures

BACKGROUND

Functional outcome assessment after total hip arthroplasty often involves subjective patient-reported outcome measures whereas analysis of gait is more objective. The study's aims were to compare subjective and objective functional outcomes after total hip arthroplasty between patients with low and high self-reported levels of pre-operative physical function.

METHODS

Patients undergoing total hip arthroplasty (n=36; m/f=18/18; mean age=63.9; SD=9.8 years; BMI=26.3; SD=3.5) were divided into a low and high function subgroup, and prospective measures of WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) function score and gait were compared at baseline and 3 and 12 months post-operatively.

FINDINGS

WOMAC function scores significantly improved in both low and high function subgroups at 3 months post-operatively whereas gait parameters only improved in patients with a low pre-operative function. Between 3 and 12 months post-operatively, WOMAC function scores had not significantly further improved whereas several gait parameters significantly improved in the low function group. WOMAC function scores and gait parameters were only moderately correlated (Spearman's r=0.33-0.51).

INTERPRETATION

In a cohort of patients undergoing total hip arthroplasty, pre-operative differences in mean WOMAC function scores and gait parameters between low and high function subgroups disappeared by 3 months post-operatively. Gait parameters only improved significantly during the first 3 post-operative months in patients with a low pre-operative function, highlighting the importance of investigating relative changes rather than the absolute changes and the need to consider patients with high and low functions separately.

Pathways Through Care for Long-Term Pain After Knee Replacement: A Qualitative Study With Healthcare Professionals

BACKGROUND

Chronic pain after total knee replacement is experienced by around 20% of patients in the UK. Ensuring that services are designed to best meet the needs of patients requires a foundation of empirical work. The present study sought to describe healthcare professionals' experiences and views on the assessment and care of patients with chronic pain after total knee replacement.

METHODS

We undertook a qualitative focus group study with healthcare professionals at a large acute NHS hospital trust, all of whom came into contact with patients experiencing chronic pain after total knee replacement. Snowball sampling was used to recruit participants to four focus groups. Transcripts of the audio-recorded groups were analysed thematically.

RESULTS

Eighteen healthcare professionals from a range of disciplines took part. Participants found it difficult to conceptualize chronic pain; its character varied between patients, and its origins and progress were often ambiguous. In the first of two superordinate themes, participants recognized chronic pain as a possible outcome of total knee replacement, but felt that patients may be unprepared for this. In the second superordinate theme, apparent complexities in assessing and managing patients with chronic pain after total knee replacement and a lack of explicit access points meant that healthcare professionals often saw no clear way to help patients. Participants agreed that a multidisciplinary approach that adapts to individual patient context was an ideal approach.

CONCLUSION

The present study illustrated potential obstacles to 'best practice' in the management of chronic pain after total knee replacement, identified through research with healthcare professionals. There is a need to improve access to services and develop well-defined and flexible care pathways that can accommodate complexities inherent to chronic pain, such as an unpredictable course. Copyright © 2015 John Wiley & Sons, Ltd.

Assessment of chronic post-surgical pain after knee replacement: development of a core outcome set

Background

Approximately 20% of patients experience chronic post-surgical pain (CPSP) after total knee replacement (TKR). There is scope to improve assessment of CPSP after TKR, and this study aimed to develop a core outcome set.

Methods

Eighty patients and 43 clinicians were recruited into a three-round modified Delphi study. In Round 1, participants were presented with 56 pain features identified from a systematic review, structured interviews with patients and focus groups with clinicians. Participants assigned importance ratings, using a 1–9 scale, to individual pain features; those features rated as most important were retained in subsequent rounds. Consensus that a pain feature should be included in the core outcome set was defined as the feature having a rating of 7–9 by ≥70% of both panels (patients and clinicians) and 1–3 by ≤15% of both panels or rated as 7–9 by ≥90% of one panel.

Results

Round 1 was completed by 71 patients and 39 clinicians, and Round 3 by 62 patients and 33 clinicians. The final consensus was that 33 pain features were important. These were grouped into an 8-item core outcome set comprising: pain intensity, pain interference with daily living, pain and physical functioning, temporal aspects of pain, pain description, emotional aspects of pain, use of pain medication, and improvement and satisfaction with pain relief.

Conclusions

This core outcome set serves to guide assessment of CPSP after TKR. Consistency in assessment can promote standardized reporting and facilitate comparability between studies that address a common but understudied type of CPSP.

Assessment of the impact of flares in ankylosing spondylitis disease activity using the Flare Illustration

OBJECTIVES

Many AS patients report periods of perceived higher disease activity (flares). This pilot study aims to document disease activity patterns reported by AS patients and examine associations with disease-specific health status measures.

METHODS

Consecutive AS patients (n = 114) were asked whether they experience flares, and if they experience symptoms of AS between flares. They were shown the Flare Illustration of disease patterns over time and asked to select the pattern that best described their disease (i) since symptom onset and (ii) in the past year. Associations between reported disease pattern and disease activity (Bath AS Disease Activity Index, BASDAI); functional impairment (Bath AS Functional Index, BASFI); AS Quality of Life (ASQoL); Back Pain (Nocturnal and Overall) and demographic features were assessed in a subsample (n = 83) (statistical significance defined at P <or= 0.05).

RESULTS

Since disease onset 108/113 patients (96%) reported flares, and 82/99 (83%) reported symptoms of AS between flares. Flares typically lasted days or weeks. When patients were asked to characterize their disease pattern using the Flare Illustration, patterns with constant symptoms predominated (>70% of patients) and patterns with constant symptoms since onset (vs intermittent symptoms) were associated with worse health status (ASQoL: P = 0.007; BASDAI: P = 0.029; BASFI: P = 0.013, overall back pain: P = 0.025).

CONCLUSIONS

Almost all AS patients report flares in disease activity: 70-80% report constant symptoms with single/repeated flares, while 20-30% report flares with no intermittent symptoms. The former is associated with a significantly poorer health status. These findings will be validated in a prospective study.

Understanding the pain experience in hip and knee osteoarthritis--an OARSI/OMERACT initiative

OBJECTIVE

To examine the pain experience of people with hip or knee osteoarthritis (OA), particularly changes over time and most distressing features.

METHOD

Focus groups in individuals aged 40+ years with painful hip or knee OA obtained detailed descriptions of OA pain from early to late disease. A modified Patient Generated Index (PGI) was used to assess the features of OA pain that participants found most distressing. Content analysis was performed to examine response patterns; descriptive statistics were used to summarize PGI responses.

RESULTS

Mean age of the 143 participants (52 hip OA; 91 knee OA) was 69.5 years (47-92 years); 60.8% were female and 93.7% Caucasian. Participants described two distinct types of pain - a dull, aching pain, which became more constant over time, punctuated increasingly with short episodes of a more intense, often unpredictable, emotionally draining pain. The latter, but not the former, resulted in significant avoidance of social and recreational activities. From PGI responses, distressing pain features were: the pain itself (particularly intense and unpredictable pain) and the pain's impact on mobility, mood and sleep.

CONCLUSIONS

Two distinct pain types were identified. Intermittent intense pain, particularly when unpredictable, had the greatest impact on quality of life.

Predicting catastrophic decline in mobility among older people

OBJECTIVE

to investigate the associations between chronic health conditions, psychosocial and environmental factors and catastrophic decline in mobility among older people.

DESIGN

longitudinal cohort.

SETTING

national sample living in private households.

PARTICIPANTS

nine hundred and ninety-nine adults aged > or = 65 years at initial interview, of which 786 agreed to take part in a follow-up survey 12 months later, and 531 responded to the questionnaire.

MEASUREMENTS

catastrophic decline in mobility: inability to do any of the three activities of daily living items-walking 400 yards, climbing up and down stairs or steps and getting on a bus-having been capable of independently doing all three one year earlier.

RESULTS

similar annual rates of catastrophic decline were reported for men and women: 4.8 [95% confidence interval (CI) 2.7-8.3] and 4.6% (2.4-8.6), respectively. Strong associations were found between catastrophic decline and age > 70 years, hearing problems and health deterioration, odds ratio (OR) 3.7 (95% CI 1.1-11.8), 2.8 (1.1-7.3) and 4.3 (1.2-14.7), respectively. Poor perceptions of health, loss of control and feeling fearful also appeared to be important: below average summary psychological status, OR 6.5 (1.9-22.3). Inability to do heavy housework, carry heavy shopping or bend to cut own toenails, indicating poor functional reserve capacity, was strongly associated with decline, OR 6.8 (2.2-20.8).

CONCLUSION

psychosocial factors are as strongly associated with catastrophic decline as deterioration in health status. Interventions to reduce the risk of catastrophic decline may require management of psychosocial problems as well as health condition components.