Supporting patients to prepare for total knee replacement: Evidence-, theory- and person-based development of a 'Virtual Knee School' digital intervention

INTRODUCTION

Digital delivery of pre-operative total knee replacement (TKR) education and prehabilitation could improve patient outcomes pre- and post-operatively. Rigorously developing digital interventions is vital to help ensure they achieve their intended outcomes whilst mitigating their potential drawbacks.

OBJECTIVE

To develop a pre-operative TKR education and prehabilitation digital intervention, the 'Virtual Knee School' (VKS).

METHODS

The VKS was developed using an evidence-, theory- and person-based approach. This involved a mixed methods design with four phases. The first three focused on planning the VKS. The final phase involved creating a VKS prototype and iteratively refining it through concurrent think-aloud interviews with nine patients who were awaiting/had undergone TKR. Meta-inferences were generated by integrating findings from all the phases. ISRCTN registration of the overall project was obtained on 24 April 2020 (ISRCTN11759773).

RESULTS

Most participants found the VKS prototype acceptable overall and considered it a valuable resource. Conversely, a minority of participants felt the prototype's digital format or content did not meet their individual needs. Participants' feedback was used to refine the prototype's information architecture, design and content. Two meta-inferences were generated and recommend: 1. Comprehensive pre-operative TKR education and prehabilitation support should be rapidly accessible in digital and non-digital formats. 2. Pre-operative TKR digital interventions should employ computer- and self-tailoring to account for patients' individual needs and preferences.

CONCLUSIONS

Integrating evidence, theory and stakeholders' perspectives enabled the development of a promising VKS digital intervention for patients awaiting TKR. The findings suggest future research evaluating the VKS is warranted and provide recommendations for optimising pre-operative TKR care.

PATIENT OR PUBLIC CONTRIBUTION

Patient and Public Involvement (PPI) was central throughout the project. For example, PPI representatives contributed to the project planning, were valued members of the Project Advisory Group, had key roles in developing the VKS prototype and helped disseminate the project findings.

Supporting the parent-to-child transfer of self-management responsibility for chronic kidney disease: A qualitative study

INTRODUCTION

As children with long-term conditions (LTCs) mature, they are usually expected to assume responsibility from their parents for self-management of their condition. Little is known about what supports families with this handover of responsibility, including the role of healthcare professionals (HCPs). This study aimed to explore what supports young people with chronic kidney disease (CKD) to assume self-management responsibility and parents to relinquish control.

METHODS

A qualitative study, using a grounded theory approach was conducted. Individual and dyadic interviews and focus groups were carried out with 16 young people aged 13-17 years old with CKD, 13 parents, and 20 HCPs. Participants were recruited from two UK children's renal units.

FINDINGS

Building and maintaining trust, fostering positivity, learning from mistakes, forming partnerships and individualized support, facilitated the transfer of self-management responsibility. However, HCPs' focus on developing partnerships with young people meant some parents felt excluded, highlighting uncertainty around whether support should be child- or family-centred. Although tailored support was identified as critical, aspects of local service provision appeared to impact on HCPs' capacity to implement individualized approaches.

CONCLUSION

This study has identified what supports the handover of responsibility, and, importantly, HCPs' current, and potential role in helping young people to assume responsibility for managing their LTC. Further research is needed to explore how HCPs' involvement balances child- and family-centred care, and how HCPs can adopt personalized, strengths-based approaches to help ensure the support that families receive is tailored to their individual needs.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public involvement was integrated throughout the study, with young adults with CKD and parents who had a child with CKD actively involved in the study's design and delivery.

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.

Home-Based Health Care Interventions for People Aged 75 Years and Above With Chronic, Noninflammatory Musculoskeletal Pain: A Scoping Review

BACKGROUND AND PURPOSE

Chronic, noninflammatory musculoskeletal pain is common in the aged population and management can be challenging for older people due to multimorbidity, social isolation, and physical frailty. The aim of this scoping review is to summarize and discuss the evidence related to home-based health care interventions for older adults, with chronic, musculoskeletal pain.

METHODS

A review of the literature using 8 electronic databases (Embase, MEDLINE, CINAHL, PubMed, Cochrane Library, Physiotherapy Evidence Database [PEDro], Scopus, and Web of Science) was performed, following the PRISMA-ScR guidelines. English language published studies that assessed home-based health care intervention/s, in men and women 75 years and older, with chronic, noninflammatory musculoskeletal pain where included. Two authors independently reviewed the articles and extracted data into a preformulated chart.

RESULTS AND DISCUSSION

The database search identified 4722 studies of which 7 studies met the inclusion criteria. Six of the 7 studies were randomized controlled trials and 5 studies focused on a single-site pain. The type of home-based interventions in the included studies was physical therapy (n = 2), psychotherapy (n = 3), and multimodal therapy (combination of multiple therapies) (n = 2). Participation completion rate was more than 74% in 6 out of 7 studies. Most studies used pain and/or physical function as their primary outcome (n = 6). Music therapy showed a statistically significant reduction in visual analog scale score for pain, and there was a trend toward improvement of pain and function in the physical therapy studies. No significant differences in outcomes between intervention and control groups were observed in the multimodal studies.

CONCLUSION

This review highlights the scarcity of evidence related to home-based health interventions in older people 75 years and older, living with chronic, noninflammatory musculoskeletal pain. The findings were that physical, psychotherapeutic, and multimodal interventions are usually well tolerated and can be delivered as a safe self-management option. There remains a substantial need for more high-quality research with wider range of home-based interventions and comprehensive assessment of outcomes for this age group.

Self-care support of diet and the gut in the routine care of school-age children with long-term conditions: An integrative review

There is policy impetus for provision of self-care support (SCS) for children with long-term conditions (LTCs). However, it is not clear what SCS should consist of and how it can be delivered in routine care. This review aimed to synthesise the literature, specifically on SCS of diet and the gut as these components are essential for optimal growth and development and enhanced quality of life. Using an integrative review methodology, studies conducted between January 1990 and July 2020 were systematically identified and methodological quality assessed using the Mixed Methods Appraisal Tool. Twenty-five studies were included. SCS of diet and the gut consisted of support in developing and applying specific knowledge and skills and practical help with incorporating the demands of self-care into everyday life. Key requisites for models of SCS in the context of delivery and uptake in routine care were starting early, keeping it going, being flexible and choosing appropriate outcomes. This review contributes new understanding on the provision of SCS of diet and the gut for school-age children with LTCs, including identification of gaps in the literature and further research needs.

Content and delivery of pre-operative interventions for patients undergoing total knee replacement: a rapid review

BACKGROUND

Total knee replacement (TKR) is a common operation typically performed for end-stage knee osteoarthritis. Patients awaiting TKR often have poor health-related quality of life. Approximately 20% of patients experience persistent pain post-TKR. Pre-operative TKR interventions could improve pre- and post-operative outcomes, but future research is required to inform their design. This review aimed to identify and synthesize recent literature on the content and delivery of pre-operative TKR interventions to help guide future research and clinical practice.

METHODS

This rapid review included randomized trials of pre-operative TKR interventions ("outcomes studies") and primary studies exploring patients' and/or health professionals' views of pre-operative TKR interventions ("views studies"). Medline, Embase, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials were searched for English language studies published between January 2009 and December 2020. Eligible studies' reference lists were screened. Studies were appraised using the Mixed Methods Appraisal Tool. The findings were narratively synthesized using a convergent segregated approach.

RESULTS

From 3263 records identified, 52 studies were included (29 outcomes studies, 21 views studies, two outcomes/views studies). The studies' methodological quality varied but was generally highest in qualitative studies. The outcomes studies investigated education (n=5), exercise (n=20), psychological (n=2), lifestyle (n=1), and/or other interventions (n=5). The views studies addressed education (n=20), exercise (n=3), psychological (n=1), lifestyle (n=4), and/or other interventions (n=1). Only three outcomes studies (two randomized controlled trials (RCTs) and a pilot study) compared the effectiveness of intervention components/delivery approaches. The two RCTs' results suggest that pre-operative TKR exercise interventions are equally effective regardless of whether they include strength or strength plus balance training and whether they are hospital- or home-based. Personal tailoring and using more than one delivery format were associated with improved outcomes and/or perceived as beneficial for multiple intervention types.

CONCLUSIONS

Definitive evidence on the optimal design of pre-operative TKR interventions is lacking. Personal tailoring and employing multiple delivery formats appear to be valuable design elements. Preliminary evidence suggests that including balance training and hospital versus home delivery may not be critical design elements for pre-operative TKR exercise interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019143248 FUNDER: National Institute for Health and Care Research (ICA-CDRF-2018-04-ST2-006).

Shifting responsibilities: A qualitative study of how young people assume responsibility from their parents for self-management of their chronic kidney disease

INTRODUCTION

The responsibility for managing a long-term condition (LTC) such as chronic kidney disease (CKD) typically transfers from parent to child, as children become older. However, children can find it challenging to become independent at managing their LTC, and evidence for how healthcare professionals (HCPs) support transfer of responsibility is limited. This study aimed to explore how young people with CKD assume responsibility for managing their condition and the HCP's role during this process.

METHODS

Sampling, qualitative data collection and analysis were guided by a constructivist grounded theory approach. Individual and dyadic interviews, and focus groups, were conducted with 16 young people aged 13-17 years with CKD, 13 parents and 20 HCPs.

FINDINGS

A grounded theory, shifting responsibilities, was developed that provides new insights into how young people's, parents' and HCPs' constructions of the transfer of responsibility differed. These diverse constructions contributed to multiple uncertainties around the role of HCPs, when the process started and was completed and whether the endpoint of the process was young people's self-management or young person-parent shared management.

CONCLUSION

Families would benefit from HCP support over a longer timeframe that integrates assuming self-management responsibility with gaining independence in other areas of their lives and focuses on young people 'doing' self-management.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public involvement was integrated throughout the study, with young adults with CKD and parents who had a child with CKD actively involved in the study's design and delivery.

Evaluation of two electronic-rehabilitation programmes for persistent knee pain: protocol for a randomised feasibility trial

INTRODUCTION

Persistent, knee pain is a common cause of disability. Education and exercise treatment are advocated in all clinical guidelines; however, the increasing prevalence of persistent knee pain presents challenges for health services regarding appropriate and scalable delivery of these treatments. Digital technologies may help address this, and this trial will evaluate the feasibility and acceptability of two electronic-rehabilitation interventions: 'My Knee UK' and 'Group E-Rehab'.

METHODS AND ANALYSIS

This protocol describes a non-blinded, randomised feasibility trial with three parallel groups. The trial aims to recruit 90 participants (45 years or older) with a history of persistent knee pain consistent with a clinical diagnosis of knee osteoarthritis. Participants will be randomly assigned in a 1:1:1 allocation ratio. The 'My Knee UK' intervention arm will receive a self-directed unsupervised internet-based home exercise programme plus short message service support (targeting exercise behaviour change) for 12 weeks; the 'Group E-Rehab' intervention arm will receive group-based physiotherapist-prescribed home exercises delivered via videoconferencing accompanied by internet-interactive educational sessions for 12 weeks; the control arm will receive usual physiotherapy care or continue with their usual self-management (depending on their recruitment path). Feasibility variables, patient-reported outcomes and clinical findings measured at baseline, 3 and 9 months will be assessed and integrated with qualitative interview data from a subset of Group E-Rehab and My Knee UK participants. If considered feasible and acceptable, a definitive randomised controlled trial can be conducted to investigate the clinical effectiveness and cost-effectiveness of one or both interventions with a view to implementation in routine care.

ETHICS AND DISSEMINATION

The trial was approved by the West of Scotland Research Ethics Committee 5 (Reference: 20/WS/0006). The results of the study will be disseminated to study participants, the study grant funder and will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN15564385.

The relationship between multisite peripheral joint pain and physical activity levels in older adults: A cross-sectional survey

INTRODUCTION

Research on levels of physical activity (PA) in those with peripheral joint pain have only focused on single sites, in the knee or hips. This study investigated the levels of PA in adults with single-site and multisite peripheral joint pain compared to adults with no joint pain.

METHODS

Analysis of a cross-sectional population survey mailed to adults aged ≥45 years (n = 28,443) was conducted. Respondents reported any peripheral joint pain in the last 12 months in either the hands, hips, knees or feet; PA levels were self-reported using the short telephone activity rating scale. The association between PA levels, peripheral joint pain and outcomes of health status (physical and mental component scores, using SF-12) pain intensity (10-point scale) and health-related quality of life (HRQoL) (EQ-5D) were investigated using analysis of variance and ordinal regressions.

RESULTS

Compared to those with no joint pain, all pain groups reported lower levels of PA: joint pain in one site (odds ratio = 0.91, 95% CI: 0.83-0.99); two sites (0.74, 0.67-0.81), three sites (0.65, 0.59-0.72) and four sites (0.47, 0.42-0.53). Across all joint pain groups, levels of PA were associated with pain intensity, physical health status, mental health status and HRQoL.

DISCUSSION

Adults with more sites of peripheral joint pain were more likely to report lower levels of PA. Those with more sites of pain and lower levels of PA reported poorer outcomes. Health care providers should be aware that those with multisite joint pain are most likely to have low levels of PA.

Exploring the feasibility, acceptability and value of volunteer peer mentors in supporting self-management of osteoarthritis: a qualitative evaluation

BACKGROUND

Hip and knee osteoarthritis (OA) affect a large and growing proportion of the population. Treatment options are typically conservative making self-management a priority. Using trained peers to support individuals with OA has potential to improve self-management.

PURPOSE

To explore the process of engaging and training volunteers to become peer mentors; and to qualitatively evaluate the feasibility, acceptability and value of being a peer mentor to support others' self-management of OA.

MATERIALS AND METHODS

A qualitative evaluation of a peer mentorship support intervention reporting the processes of recruitment and training; and semi-structured interviews conducted with nine active peer mentors. Transcribed interviews were coded and analysed using framework analysis.

RESULTS

It was possible to recruit, train and retain volunteers with OA to become peer mentors. The peer mentors benefitted from their training and felt equipped to deliver the intervention. They enjoyed social elements of the mentorship intervention and gained satisfaction through delivering valued support to mentees. Peer mentors perceived the mentorship intervention to have a positive impact on self-management of OA for mentees.

CONCLUSION

Training volunteers with OA to become peer mentors was feasible and acceptable. Peer mentors perceived their support benefitted others with OA. They positively rated their experience of providing mentorship support.IMPLICATIONS FOR REHABILITATIONThis study demonstrates that it is possible to recruit, train and engage older volunteers to become peer mentors for people with osteoarthritis.Training should highlight the significance of employing key self-management techniques such as goal-setting.Peer mentors acknowledged that they benefitted from training and delivering the mentorship intervention, and this impacted positively on their own osteoarthritis self-management.Careful consideration of matching mentors and mentees appears to enhance the success of mentorship support.Recognising the impact of mentorship support on mentees' self-management is central to peer mentors' sustained engagement with the intervention.

Understanding peer mentorship in supporting self-management of hip and knee osteoarthritis: A qualitative study of mentees' perspectives

Background

Hip and knee osteoarthritis (OA) are common musculoskeletal conditions. Treatment is usually conservative, making self‐management a priority. We developed and trialled an OA peer mentorship intervention to support self‐management in older people. Our objectives were to gain understanding of the perceived challenges of living with OA and explore how a peer mentorship intervention can support tackling these challenges; and to explore mentees' experiences of receiving the intervention to understand how this affected their OA self‐management.

Methods

Qualitative semi‐structured interviews focussing on acceptability and feasibility of being in the study were conducted with mentees. Transcribed interviews were double coded and subject to framework analysis. To address the objectives of this paper, three main themes were subject to focused analysis: mentees' experiences of OA, experience of peer mentorship support and factors influencing self‐management.

Results

Seventeen mentees participated in an interview following completion of the peer support intervention. Themes emerging from focused analysis were the following: tackling the challenges of living with OA pre‐ and post‐intervention; and the interplay of the peer mentorship intervention and self‐management. Key elements of the latter theme are enabling factors provided by peer mentorship, and mentees' readiness to self‐manage.

Conclusion

To effectively support OA self‐management, peer mentorship interventions should include core educational components and focus on strategies that enhance key enablers of self‐management. Paying attention to the mentor–mentee relationship and timing of intervention engagement can maximise opportunities for older people to adjust and transition from supported to independent self‐management.

Peer mentorship to improve self-management of hip and knee osteoarthritis: a randomised feasibility trial

OBJECTIVE

To determine the feasibility of conducting a randomised controlled trial (RCT) of a peer mentorship intervention to improve self-management of osteoarthritis (OA).

DESIGN

Six-month parallel group non-blinded randomised feasibility trial.

SETTING

One secondary care and one primary care UK National Health Service Trust.

PARTICIPANTS

Fifty adults aged ≥55 years old with hip and/or knee OA.

INTERVENTIONS

Participants were allocated 1:1 to the intervention or control group using an online randomisation service. Intervention group participants received usual care (information resources) and up to eight community-based self-management support sessions delivered by a peer mentor (trained volunteer with hip and/or knee OA). Control group participants received usual care only.

OUTCOME MEASURES

Key feasibility outcomes were participant and peer mentor recruitment and attrition, intervention completion and the sample size required for a definitive RCT. Based on these feasibility outcomes, four success criteria for proceeding to a definitive RCT were prespecified. Patient-reported outcomes were collected via questionnaires at baseline, 8 weeks and 6 months.

RESULTS

Ninety-six individuals were screened, 65 were eligible and 50 were randomised (25 per group). Of the 24 participants who commenced the intervention, 20 completed it. Four participants did not complete the 6-month questionnaire. Twenty-one individuals were eligible for the peer mentor role, 15 were trained and 5 withdrew prior to being matched with a participant. No intervention-related harms occurred. Allowing for 20% attrition, the sample size required for a definitive RCT was calculated as 170 participants. The intervention group showed improvements in self-management compared with the control group.

CONCLUSIONS

The feasibility outcomes achieved the prespecified criteria for proceeding to an RCT. The exploratory analyses suggest peer mentorship may improve OA self-management. An RCT of the OA peer mentorship intervention is therefore warranted with minor modifications to the intervention and trial procedures.

TRIAL REGISTRATION NUMBER

ISRCTN:50675542.

Consensus on pre-operative total knee replacement education and prehabilitation recommendations: a UK-based modified Delphi study

BACKGROUND

Over 90,000 total knee replacement (TKR) procedures are performed annually in the United Kingdom (UK). Patients awaiting TKR face long delays whilst enduring severe pain and functional limitations. Almost 20% of patients who undergo TKR are not satisfied post-operatively. Optimising pre-operative TKR education and prehabilitation could help improve patient outcomes pre- and post-operatively; however, current pre-operative TKR care varies widely. Definitive evidence on the optimal content and delivery of pre-operative TKR care is lacking. This study aimed to develop evidence- and consensus-based recommendations on pre-operative TKR education and prehabilitation.

METHODS

A UK-based, three-round, online modified Delphi study was conducted with a 60-member expert panel. All panellists had experience of TKR services as patients (n = 30) or professionals (n = 30). Round 1 included initial recommendations developed from a mixed methods rapid review. Panellists rated the importance of each item on a five-point Likert scale. Panellists could also suggest additional items in Round 1. Rounds 2 and 3 included all items from Round 1, new items suggested in Round 1 and charts summarising panellists' importance ratings from the preceding round. Free-text responses were analysed using content analysis. Quantitative data were analysed descriptively. All items rated as 'Important' or 'Very important' by at least 70% of all respondents in Round 3 were included in the final set of recommendations.

RESULTS

Fifty-five panellists (92%) (patients n = 26; professionals n = 29) completed Round 3. Eighty-six recommendation items were included in Round 1. Fifteen new items were added in Round 2. Rounds 2 and 3 therefore included 101 items. Seventy-seven of these reached consensus in Round 3. Six items reached consensus amongst patient or professional panellists only in Round 3. The final set of recommendations comprises 34 education topics, 18 education delivery approaches, 10 exercise types, 13 exercise delivery approaches and two other treatments.

CONCLUSIONS

This modified Delphi study developed a comprehensive set of recommendations that represent a useful resource for guiding decision-making on the content and delivery of pre-operative TKR education and prehabilitation. The recommendations will need to be interpreted and reviewed periodically in light of emerging evidence.

Comparison of reliability, construct validity and responsiveness of the IPAQ-SF and PASE in adults with osteoarthritis

BACKGROUND

This study assessed the measurement properties of two commonly used self-report physical activity (PA) measures: the International Physical Activity Questionnaire-Short Form (IPAQ-SF) and the Physical Activity Scale for the elderly (PASE) in adults with osteoarthritis.

METHODS

Secondary analysis of the MOSAICS cluster randomised controlled trial baseline and 3-month follow-up questionnaires, total scores and subdomains of the IPAQ-SF and PASE were compared. Intra-class correlations (ICC) were used to assess test-retest reliability, measurement error was assessed using standard error of measurement (SEM), smallest detectable change (SDC) and 95% limits of agreement (LoA). Responsiveness was assessed using effect size (ES), standard responsive measurement (SRM) and response ratio (RR).

RESULTS

There was moderate correlation (r = 0.56) between the total IPAQ-SF scores (score ranges 0-16,398) and the total PASE scores (score ranges 0-400). Subdomain correlations were also moderate (ranges 0.39-0.57). The PASE showed greater reliability compared to the IPAQ-SF (ICC = 0.68; 0.61-0.74 95% CI and ICC = 0.64; 0.55-0.72, respectively). Measurement errors in both measures were large: PASE SEM = 46.7, SDC = 129.6 and 95% LoA ranges = -117 to 136, the IPAQ-SF SEM = 3532.2 METS^{-1 min-1 week} , SDC = 9790.8 and 95% LoA ranges = -5222 to 5597. Responsiveness was poor: ES -0.14 and -0.16, SRM -0.21 and -0.21, and RR 0.12 and 0.09 for the IPAQ-SF and PASE, respectively.

DISCUSSION

The IPAQ-SF and PASE appear limited in reliability, measurement error and responsiveness. Researchers and clinicians should be aware of these limitations, particularly when comparing different levels of PA and monitoring PA levels changes over time in those with osteoarthritis.

The inter-rater reliability of the Performance Oriented Mobility Assessment tool after brain surgery

Background/Aims

Falls are a significant cause of hospital admissions in the UK and require clinically reasoned intervention from the multidisciplinary team to ensure the patient receives an effective and efficient treatment, including physiotherapy. This study aimed to assess the inter-rater reliability of the Performance Oriented Mobility Assessment in patients who had recently undergone brain surgery.

Methods

A prospective inter-rater reliability study involving 18 male and 12 female patients aged between 27 and 87 years who had recently undergone brain surgery was conducted. Three raters of varying clinical physiotherapy experience assessed participants using the Performance Oriented Mobility Assessment on an acute neurosurgical ward. Inter-rater reliability was measured using Bland–Altman plots and intraclass correlation coefficients.

Results

Bland–Altman plots and intraclass correlation coefficient values demonstrated excellent inter-rater reliability, regardless of the age and sex of the patients or the clinical experience of the rater.

Conclusions

Results suggest that the Performance Oriented Mobility Assessment is a potentially useful tool for assessing patients, particularly for the risk of falls, following brain surgery. Future research is needed to determine other clinimetric properties of this outcome measure before wider implementation.

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.

Impact of Chronic Pain on Patients' Quality of Life: A Comparative Mixed-Methods Study

Background:

Chronic pain has become a common problem within primary care and can negatively impact patients’ lives.

Objective:

To assess and explore the impact of chronic pain on patients’ quality of life (QoL) using quantitative and qualitative data, respectively.

Methods:

A convergent parallel mixed-methods design was used. Chronic pain patients were recruited from a community-based pain clinic located in the North of England. Quality of life was assessed using Short-Form 36 version 2. Quality of life data were also extracted from the Third Oxford and Lifestyles Survey and Welsh Health Survey to allow comparison of QoL of chronic pain patients with that of the general population and patients with long-term conditions. Qualitative interviews were conducted face-to-face using a semistructured topic guide. Quantitative data were analyzed using SPSS version 24 and qualitative data were analyzed thematically.

Results:

Seventy-nine patients participated in the quantitative phase. The mean (standard deviation) age was 46.5 (14.5). Lower back (54; 68.3%) followed by lower limb were the most common pain sites. Compared with the general population and patients with long-term conditions, chronic pain patients had significantly lower mean QoL scores across all domains of SF-36 (All P < .05). Six themes emerged from qualitative data: interference with physical functioning, interference with professional life, interference with relationships and family life, interference with social life, interference with sleep, and interference with mood.

Conclusion:

The multidimensional negative impact of chronic pain leads to poorer QoL among patients with chronic pain compared to the general population and patients with other long-term conditions.

A nurse-led clinic for patients consulting with osteoarthritis in general practice: development and impact of training in a cluster randomised controlled trial

Background

Despite a lack of service provision for people with osteoarthritis (OA), each year 1 in 5 of the general population consults a GP about a musculoskeletal condition such as OA. Consequently this may provide an opportunity for practice nurses to take an active role in helping patients manage their condition. A nurse led clinic for supporting patients with OA was developed for the MOSAICS study investigating how to implement the NICE 2014 OA Guideline core recommendations. This paper has two main objectives, firstly to provide an overview of the nurse-led OA clinic, and secondly to describe the development, key learning objectives, content and impact of the training to support its delivery.

Methods

A training programme was developed and delivered to provide practice nurses with the knowledge and skill set needed to run the nurse-led OA clinic. The impact of the training programme on knowledge, confidence and OA management was evaluated using case report forms and pre and post training questionnaires.

Results

The pre-training questionnaire identified a gap between what practice nurses feel they can do and what they should be doing in line with NICE OA guidelines. Evaluation of the training suggests that it enabled practice nurses to feel more knowledgeable and confident in supporting patients to manage their OA and this was reflected in the clinical management patients received in the nurse-led OA clinics.

Conclusions

A significant gap between what is recommended and what practice nurses feel they can currently provide in terms of OA management was evident. The development of a nurse training programme goes some way to develop a system in primary care for delivering the core recommendations by NICE.

Trial registration

The cluster trial linked to this training was conducted from May 2012 through February 2014 by the Arthritis Research UK Primary Care Centre, Keele University, UK (Trial registration number ISRCTN06984617).

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0568-y) contains supplementary material, which is available to authorized users.

Implementing the NICE osteoarthritis guidelines: a mixed methods study and cluster randomised trial of a model osteoarthritis consultation in primary care--the Management of OsteoArthritis In Consultations (MOSAICS) study protocol

Background

There is as yet no evidence on the feasibility of implementing recommendations from the National Institute of Health and Care Excellence (NICE) osteoarthritis (OA) guidelines in primary care, or of the effect these recommendations have on the condition. The primary aim of this study is to determine the clinical and cost effectiveness of a model OA consultation (MOAC), implementing the core recommendations from the NICE OA guidelines in primary care. Secondary aims are to investigate the impact, feasibility and acceptability of the MOAC intervention; to develop and evaluate a training package for management of OA by general practitioners (GPs) and practice nurses; test the feasibility of deriving ‘quality markers’ of OA management using a new consultation template and medical record review; and describe the uptake of core NICE OA recommendations in participants aged 45 years and over with joint pain.

Design

A mixed methods study with a nested cluster randomised controlled trial.

Method

This study was developed according to a defined theoretical framework (the Whole System Informing Self-management Engagement). An overarching model (the Normalisation Process Theory) will be employed to undertake a comprehensive ‘whole-system’ evaluation of the processes and outcomes of implementing the MOAC intervention. The primary outcome is general physical health (Short Form-12 Physical component score [PCS]) (Ware 1996). The impact, acceptability and feasibility of the MOAC intervention at practice level will be assessed by comparing intervention and control practices using a Quality Indicators template and medical record review. Impact and acceptability of the intervention for patients will be assessed via self-completed outcome measures and semi-structured interviews. The impact, acceptability and feasibility of the MOAC intervention and training for GPs and practice nurses will be evaluated using a variety of methods including questionnaires, semi-structured interviews, and observations.

Discussion

The main output from the study will be to determine whether the MOAC intervention is clinically and cost effective. Additional outputs will be the development of the MOAC for patients consulting with joint pain in primary care, training and educational materials, and resources for patients and professionals regarding supported self-management and uptake of NICE guidance.

Trial registration

ISRCTN number: ISRCTN06984617.

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0095-y) contains supplementary material, which is available to authorized users.

Predictors of outcomes of recovery following total hip replacement surgery: A prospective study

Objectives

To investigate psychosocial and biomedical outcomes following total hip replacement (THR) and to identify predictors of recovery from THR.

Methods

Patients with osteoarthritis (OA) on the waiting list for primary THR in North West England were assessed pre-operatively and at six and 12 months post-operatively to investigate psychosocial and biomedical outcomes. Psychosocial outcomes were anxiety and depression, social support and health-related quality of life (HRQoL). Biomedical outcomes were pain, physical function and stiffness. The primary outcome was the Short-Form 36 (SF-36) Health Survey Total Physical Function. Potential predictors of outcome were age, sex, body mass index, previous joint replacement, involvement in the decision for THR, any comorbidities, any complications, type of medication, and pre-operative ENRICHD Social Support Instrument score, Hospital Anxiety and Depression scores and Western Ontario and McMaster Universities osteoarthritis index score.

Results

The study included 206 patients undergoing THR. There were 88 men and 118 women with a mean age of 66.3 years (sd 10.4;36 to 89). Pain, stiffness and physical function, severity of OA, HRQoL, anxiety and depression all improved significantly from pre-operative to 12-month assessment (all p < 0.001), with the greatest improvement occurring in the first six months (all p < 0.001). The predictors that were found to influence recovery six months after THR were: pain (p < 0.001), anxiety (p = 0.034), depression (p = 0.001), previous joint replacement (p = 0.006) and anti-inflammatory drugs (p = 0.012).

Conclusions

The study identified the key psychosocial and biomedical predictors of recovery following THR. By identifying these predictors, we are able to identify and provide more support for patients at risk of poor recovery following THR.

Cite this article: Bone Joint Res 2013;2:248–54.

Quality of care for individuals with osteoarthritis: a longitudinal study

OBJECTIVES

The objectives of this paper were to investigate quality of care for individuals with osteoarthritis (OA) and to determine if those most in need had the outcome of a total joint replacement (TJR). Key quality indicators were involvement in treatment decisions, appropriate information provision and outcomes of care.

METHODS

A longitudinal study was conducted on individuals newly referred to an orthopaedic specialist at one hospital in North West England. A total of 268 participants were recruited consecutively and followed up at 3, 6 and 12 months. Validated measurement tools such as, a Visual Analogue Scale for pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) assessed pain and physical functioning. Mean scores on the outcome measures were estimated and plotted over time by joint affected and whether or not the participant had a TJR by 12 months.

RESULTS

Most participants (82%) felt that they were involved in the decision about their care, although 21% reported that they had not received a diagnosis of OA. Information was not provided on OA, pain management and exercise to 58%, 65% and 57% of participants, respectively. However, 98% of the 109 having a TJR reported receiving information about the procedure. Among the 118 known not to have had a TJR, pain and physical functioning remained relatively stable over time.

CONCLUSION

It appears that patients with the most severe symptoms of pain and physical functioning were selected for TJR. However, care for individuals with OA could be improved by providing standard information on OA in general and pain management and exercise. In particular, effective strategies for the implementation of the research evidence and guidelines are required to improve quality of care.

Individuals' expectations and challenges following total hip replacement: a qualitative study

PURPOSE

Hip replacements are one of the most common operations for individuals with hip osteoarthritis. There have been numerous quantitative studies investigating the recovery from joint replacement surgery and these show how effective and satisfied patients are. However, little qualitative work has been conducted to explore patients' actual experiences. Therefore, this study aimed to detail the experiences of individuals undergoing a total hip replacement (THR) to determine whether their expectations were met.

METHOD

The qualitative study was nested within a longitudinal study (n = 215) that was investigating biomedical and psychosocial outcomes from THR. We interviewed a purposive sample of individuals (n = 25) 6 months after THR to explore their experiences of having a THR.

FINDINGS

Participants were aged 48-82 years. They felt disabled following the THR and some had unrealistic expectations of recovery. Most of them received minimal information and health professional support. Participants had to overcome a number of challenges such as diminished confidence, frustration over slow progress and reduced physical functioning.

CONCLUSION

Individuals undergoing THR need to have the opportunity to discuss their expectations of THR, so there is no "false optimism". Support requirements, following THR, need to be reviewed as they were often underestimated by patients and health professionals.

The impact of increasing oximetry usage in India: A pilot study

The overall goal of the global oximetry (GO) project was to increase patient safety during anaesthesia and surgery in low and middle income countries by decreasing oximetry costs and increasing oximetry utilisation. Results from the overall project have been previously published. This paper reports specifically on pilot work undertaken in four hospitals in one Indian State. The aim of this work was to assess the impact of increasing oximetry provision in terms of benefits to anaesthetists and in the identification of patient problems during anaesthesia, to identify training needs and to explore perceptions regarding barriers to more comprehensive oximetry coverage. Data collection was by interview with hospital staff, use of a log-book to capture data on desaturation episodes and a follow-up questionnaire at 10 months after the introduction of additional oximeters. Increasing oximetry utilisation in the four hospitals was viewed positively by the anaesthetic staff and enabled improvement in monitoring patients. Of the 939 monitored patients studied, 214 patients (23%) experienced a total of 397 desaturation episodes. For nearly half of the patients undergoing caesarean section under regional anaesthesia following a desaturation event supplementary oxygen was required. In 53 of the 379 female sterilisations (14%) desaturation episodes occurred and in eight patients, there were 17 episodes of desaturation due to obstruction. In the recovery room, 91 of the 939 patients were monitored using the oximeters with 12 patients (13%) requiring oxygen. This study has highlighted that pulse oximetry must be used even in patients having surgical procedures or caesarean section under regional or local anaesthesia as these procedures are associated with hypoxic episodes. Anaesthetists must ensure they are complying with the Indian Society of Anaesthesiologists monitoring standards for anaesthesia and ensure patients are monitored by pulse oximetry.

Nurse prescribing from the community nurse's perspective

Background

Since 1994, district nurses and health visitors in the United Kingdom have been able to prescribe from a limited formulary. Items which are prescribed by these nurses are wound care products, incontinence appliances and medicinal preparations such as paracetamol and emollients. There is a planned expansion of prescribing by nurses, in terms of both the range of products and drugs that are prescribable and the types of nurses eligible for training for this new role.

Objective

To investigate patterns of nurse prescribing among community nurses in three primary care trusts in the United Kingdom.

Methods

Postal survey to 164 community nurses who were qualified to prescribe. Responses were received from 129 (79 per cent) with 35 nurses identifying themselves as not prescribing and excluded from the sample; 93 (72 per cent) of the questionnaires were entered on a database for analysis.

Key findings

Prescribing costs for district nurses ranged from £7.65 to £18,053 (median £2,023.64) and for health visitors from £0.73 to £2,556 (median £42.77) for a 12-month period. Nineteen per cent (n=28) of community nurses had decided not to prescribe even though they were trained to do so. Infrastructures and mechanisms to support nurses with nurse prescribing have been slow to emerge. Nurses perceived that their ability to prescribe was benefiting their patients and that they were providing better care. Community nurses cautiously welcomed the proposed extension of nurse prescribing.

Conclusions

Nurse prescribing has allowed community nurses more autonomy in managing a patient's total care. Our findings suggest that around one-quarter of nurses qualified to prescribe are not doing so. With the imminent extension of nurse prescribing for other nurses, action is needed by primary care trusts to put structures in place to ensure that nurses take on board this extension and challenge to their role.

Specialist community nurses: a critical analysis of their role in the management of long-term conditions

The aim of this narrative review is to identify strategies in use by specialist community and public health nurses in the prevention, care and management of individuals with long-term conditions, specifically chronic obstructive pulmonary disease (COPD) and musculoskeletal disorders. These conditions have been selected as they are highly prevalent; a burden on health services globally and a major public health issue. From a UK policy perspective, specialist community nurses have been placed at the forefront of taking a lead role in the coordination and delivery of more responsive services for individuals with long-term conditions; whether this has been an effective use of skills and resource is questionable. We systematically searched relevant databases between 1999-2009 to identify interventions used by specialist community nurses and critically appraised the studies. This review reports on impact and value of interventions used by specialist community nurses in the prevention and management of COPD and musculoskeletal conditions, and makes recommendations for improving services.

Patients waiting for a hip or knee joint replacement: is there any prioritization for surgery?

OBJECTIVE

To investigate whether patients are prioritized for joint replacement surgery on the basis of severity of osteoarthritis, pain and physical functioning.

METHOD

A total of 105 patients on the waiting list for primary total knee or hip replacement from a UK regional orthopaedic centre were interviewed at baseline and followed up at 3, 6 and 9 months or until joint replacement. Measurement tools were the visual analogue scale (VAS), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index and the Oxford hip or knee score.

RESULTS

Most participants (81, 77%) were categorized on the waiting list as 'routine', despite having high levels of pain according to the measurement scales. There was no significant correlation between the waiting list categorization and the actual waiting time for a hip or knee joint replacement operation (Kendall's tau = 0.17; P = 0.062) and the waiting list categorization did not appear to ensure that patients were operated upon earlier. There were also no significant differences in measures (VAS pain, WOMAC and Oxford hip or knee scores) between those individuals who had their operations earlier (before 6 months) compared with those participants who had their operations later (6 months or greater) or even not at all. Of the 105 patients who were listed for joint replacement, 24 (25%) patients did not have their operation due to: a medical delay (14); self-delay/cancellation (7); arthroscopy instead (2); and death (1).

CONCLUSION

With the expected increase in demand for joint replacement, there needs to be a re-examination of assessment procedures of patients listed for joint replacement. The use of measurement tools to assess symptoms such as pain and physical function would be one way forward.

Pain, physical functioning and quality of life of individuals awaiting total joint replacement: a longitudinal study

OBJECTIVES

To investigate if pain, physical function and the quality of life changed among adults with osteoarthritis while on the waiting list for hip or knee joint replacement.

METHODS

A longitudinal study of patients listed for primary hip or knee joint replacement. Participants were interviewed at baseline (n = 105) and followed up at 3 (n = 84), 6 (n = 47) and 9 months (n = 24), or until their joint replacement. Measurement tools used were a visual analogue scale (VAS), Western Ontario and McMaster's Universities (WOMAC) Osteoarthritis Index and the Medical Outcomes Study Short Form Health Survey (SF-36).

RESULTS

Baseline data indicated high levels of pain as measured by VAS [mean 7.0 (SD 2.2)] and WOMAC pain [mean 11.2 (SD 3.5)]. At baseline, the mean physical function measured by WOMAC was 40.3 (SD 12.1). At the 3-month follow-up, there was significant deterioration in VAS pain scores (0.6; 95% CI mean difference 0.3, 1.0); WOMAC pain scores (1.2; 95% CI mean difference 0.7, 1.8) and WOMAC physical function scores (4.8; 95% CI mean difference 2.8, 6.7) compared with baseline.

CONCLUSION

The often long wait for joint replacement surgery and deterioration in pain and physical function has highlighted the need for active management by health professionals while patients are on the waiting list.

The Global Oximetry initiative

Global Oximetry (GO) is an initiative launched recently in Uganda, India, the Philippines and Vietnam. The overall aims are to promote oximetry utilisation and reduce oximetry costs in lower income countries. Research objectives include studying the feasibility of cost reduction; overcoming non-cost barriers to global oximetry including issues of prioritization; education and guidelines; servicing and access to parts. Promotional objectives include creating new policy, influencing oximetry design, and setting new global standards for safer monitoring.

Quality of care for people with osteoarthritis: a qualitative study

AIM

The overall aim of this qualitative study was to explore within primary care the experiences of management and care of individuals with end-stage lower limb osteoarthritis who are on the waiting list for joint replacement.

BACKGROUND

Osteoarthritis, one of the most common chronic diseases, causes loss of physical function and severe pain among sufferers. Improving quality of care and service provision for individuals with chronic diseases is high on the UK's NHS agenda.

METHODS

Data were collected by semi-structured qualitative interviews with 21 individuals with osteoarthritis who were waiting for a hip or knee replacement operation. Interviews were analysed using framework analysis.

RESULTS

Participants had been suffering with osteoarthritis for between seven months and 38 years. The management by health professionals for people on the waiting list for joint replacement was minimal. However, participants spoke of 'hiding' their symptoms from health professionals and were trying to 'self-manage' their symptoms. Families became more involved in helping individuals with osteoarthritis to manage with everyday life.

CONCLUSION

Management of individuals' osteoarthritis while on the waiting list needs to be given consideration by health professionals in primary and secondary care. Health professionals need to be working with each other to provide more comprehensive care across the primary and secondary care interface.

RELEVANCE TO CLINICAL PRACTICE

Case managers or community matrons could be identified as the co-ordinator and assessor of the needs of patients with osteoarthritis so as to try and improve pain management and service provision for these individuals especially while on the waiting list.

Prescribing by specialist nurses in cancer and palliative care: results of a national survey

BACKGROUND

This study investigates Macmillan nurses' views on nurse prescribing in cancer and palliative care and explores perceived motivators and barriers to training for and the implementation of this extended nursing role.

METHOD

National postal survey of 2252 Macmillan nurses in the UK.

RESULTS

A response rate of 70% (1575) was achieved. Eleven percent (168 of 1575) of Macmillan nurses surveyed were trained as extended formulary independent nurse prescribers. Half (88 of 168) of the Macmillan nurses who could prescribe from the extended formulary were prescribing, representing just 6% (88 of 1575) of the sample. Training deficits highlighted included poor organization and insufficient length, depth and specificity of courses (to meet the needs of nurses working in palliative care) and a lack of medical mentorship. Among Macmillan nurses who had not undergone extended formulary independent nurse prescribing training, 25% (335) perceived that prescribing was not part of their specialist nursing role. A further 40% (538) expressed reluctance to undergo training.

CONCLUSIONS

A clear lack of enthusiasm amongst specialist nurses in cancer and palliative care to undertake prescribing training was identified. It is noteworthy that half of the Macmillan nurses trained as extended formulary independent nurse prescribers were not prescribing. Since government targets for nurse prescribing are not yet being met, these findings raise important questions concerning whether extended nurse prescribing is likely to be a successful initiative in cancer and palliative care.

A longitudinal study exploring pain control, treatment and service provision for individuals with end-stage lower limb osteoarthritis

OBJECTIVE

To investigate the level of pain control, treatment and service provision amongst individuals with end-stage lower limb osteoarthritis who were on the waiting list for hip or knee joint replacement.

METHODS

A total of 105 patients on a waiting list for primary knee or hip replacement from a regional orthopaedic centre in the UK were recruited. The study was longitudinal and based on direct interviews at baseline and 6 months, with a postal questionnaire at 3 months. Data were collected on pain by a visual analogue scale (VAS) and the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index. In addition, medication and the use of services and treatments were recorded.

RESULTS

Participants experienced high levels of pain as measured by VAS [mean 7.0; 95% confidence interval (CI) 6.6-7.5] and WOMAC pain (mean 11.2; 95% CI 10.6-11.9). The majority of participants (78, 74%) was taking analgesics more than once a day. Primary care utilization was variable. Of the 74 (70%) participants who had consulted their GP in the previous 3 months, 41 (55%) had not discussed their pain or osteoarthritis during these consultations. Just below one-third of participants (31, 30%) reported to have received information on osteoarthritis.

CONCLUSIONS

Pain appears to be difficult to manage in individuals with end-stage lower limb osteoarthritis. Individuals appeared not to be taking appropriate levels of analgesia in relation to levels of pain. Improvements are required in the provision of information on pain and osteoarthritis. Patients would benefit from more proactive management by health professionals (especially by GPs).

Supervision and responsibility: The Royal College of Anaesthetists National Audit † †This article is accompanied by Editorial II

BACKGROUND

The Royal College of Anaesthetists audited consultant supervision and responsibility in anaesthesia in the UK during 2003.

METHODS

Consultants (supervising) and non-consultants (supervised) were surveyed on their attitudes to supervision, experience of their own hospital system for supervision and of induction for new starters. Local coordination was achieved through anaesthesia audit coordinators who provided information on local policies, induction programmes and anaesthesia charts. Supervision was audited over a 5-day period.

RESULTS

135 departments of anaesthesia took part (43% of 315 departments), questionnaires being returned by 2297 anaesthetists. Anaesthesia record charts in use do not meet criteria considered desirable locally. Most trainees, but less than half staff grade/associate specialists, received an induction programme, often not supported by written documentation. Consultants find conflicting demands of service and supervision difficult. Many work in systems which do not permit providing direct, immediate support to those supervised. Most anaesthetists think supervision is very important. Around half disagree with national guidance that every NHS patient should have a named consultant. Two per cent of non-consultants during the audit period reported assistance from consultants not being obtainable soon enough.

CONCLUSIONS

This audit found departure from standards and the potential for risk and failure. New standards may be needed regarding anaesthesia record sheets, induction, accountability, when to seek help and care of sick patients. Supervision systems in over 40% of hospitals need review to ensure they provide a named consultant and immediate direct support for elective lists.

Clinical and economic choices in anaesthesia for day surgery: a prospective randomised controlled trial

We compared the cost-effectiveness of general anaesthetic agents in adult and paediatric day surgery populations. We randomly assigned 1063 adult and 322 paediatric elective patients to one of four (adult) or two (paediatric) anaesthesia groups. Total costs were calculated from individual patient resource use to 7 days post discharge. Incremental cost-effectiveness ratios were expressed as cost per episode of postoperative nausea and vomiting (PONV) avoided. In adults, variable secondary care costs were higher for propofol induction and propofol maintenance (propofol/propofol; p < 0.01) than other groups and lower in propofol induction and isoflurane maintenance (propofol/isoflurane; p < 0.01). In both studies, predischarge PONV was higher if sevoflurane/sevoflurane (p < 0.01) was used compared with use of propofol for induction. In both studies, there was no difference in postdischarge outcomes at Day 7. Sevoflurane/sevoflurane was more costly with higher PONV rates in both studies. In adults, the cost per extra episode of PONV avoided was pound 296 (propofol/propofol vs. propofol/ sevoflurane) and pound 333 (propofol/sevoflurane vs. propofol/isoflurane).

Anaesthesia for day case surgery: a survey of adult clinical practice in the UK

BACKGROUND AND OBJECTIVE

In October 2000, we conducted a national postal survey of consultant day case anaesthetists in the UK to explore the range and variation in the practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). The survey was carried out as part of a larger study that comprised a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery). We report the findings of this national survey of adult urology and orthopaedic day case anaesthetic practice in the UK.

METHODS

The survey used a structured postal questionnaire and collected data on the duration of the surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flows used for anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia.

RESULTS

The overall response rate for the survey was 74% (63% for urology, 67% for orthopaedics). The survey indicated the following practice in adult urology and adult orthopaedic day case surgery: 6 and 12% used premedication; propofol was the preferred induction agent (96 and 97%) and isoflurane the preferred maintenance agent (56 and 58%); 32 and 41% used prophylactic antiemetics; 86 and 93% used a laryngeal mask.

CONCLUSIONS

This survey identifies the variation in current clinical practice in adult day surgery anaesthesia in the UK and discusses this variation in the context of current published evidence.

Anaesthesia for day case surgery: a survey of paediatric clinical practice in the UK

BACKGROUND AND OBJECTIVE

In October 2000, we conducted a national postal survey of day case consultant anaesthetists in the UK to explore the range and variation in practice of anaesthetizing a patient for day case surgery (paediatrics, urology and orthopaedics). This paper reports the findings of this national survey of paediatric day case anaesthetic practice carried out as part of a major two-centre randomized controlled trial designed to investigate the costs and outcome of several anaesthetic techniques during day care surgery in paediatric and adult patients (cost-effectiveness study of anaesthesia in day case surgery).

METHODS

The survey used a structured postal questionnaire and collected data on the duration of surgical procedure; the use of premedication; the anaesthetic agents used for induction and maintenance; the fresh gas flow rates used for general anaesthesia; the use of antiemetics; and the administration of local anaesthesia and analgesia.

RESULTS

The overall response rate for the survey was 74 and 63% for the paediatric section of the survey. Respondents indicated that 19% used premedication, 63% used propofol for induction, 54% used isoflurane for maintenance, 24% used prophylactic antiemetics and 85%, used a laryngeal mask. The findings of this national survey are discussed and compared with published evidence.

CONCLUSIONS

This survey identifies the variation in clinical practice in paediatric day surgery anaesthesia in the UK.

What information do anaesthetists provide for patients?

BACKGROUND

Information on anaesthesia interventions, plans and risks is needed by patients and carers alike and is a key component of the Good Practice In Consent initiative. Existing information materials may under-represent what patients are able to contribute.

METHOD

UK anaesthetic departments were surveyed on provision of written patient information. The response rate was 66% (177/267).

RESULTS

Fifty-five per cent of respondents reported providing patient information materials for planned surgical admission, mainly on general anaesthesia, regional analgesia and pain. A minority provided information for children and for critical care patients. Few (32%) had sought feedback from patients, and few used existing sources of guidance. Most (85%) wanted improvements, with a four-to-one majority favouring central resources developed by The Royal College of Anaesthetists.

CONCLUSIONS

Working in parallel does not give our hospitals excellent, effective patient information materials. Demand exists for The Royal College of Anaesthetists to lead in this area. Working in partnership with patients and taking into account existing written guidance is important but has often been overlooked.

The management of pain following day-case surgery

The object of this study was to assess patients' experience of pain management following day surgery. One hundred and two patients agreed to take part in a telephone survey, 2 and 4 days following day surgery. The majority of patients (73%) were broadly satisfied with the quality of pain management they received, however, there was room for improvement. Despite modern anaesthesia and surgery, 17% of patients surveyed reported having severe pain immediately following day-case surgery. The majority (82%) of patients left the day-case ward in pain and an even higher proportion (88%) had pain at some time between 2 and 4 days postoperatively. Severe levels of pain following discharge from hospital were a concern for 21% of patients. It was reported that day-case staff did not always ask patients whether they were in pain. Communication with patients is vital in the delivery of optimal care. More support and more information are needed to manage patients' pain effectively, whilst in the day-case wards and also following discharge, at home.

Anaesthesia clinical directors in the United Kingdom: organisation, objectives and support needs

A postal survey of all 269 acute hospital trusts identified in the United Kingdom was carried out to study the work of Clinical Directors of anaesthesia. Initial responses from 163 Clinical Directors and 129 completed questionnaires were analysed. Four main areas of concern revealed by the survey were contracts and objectives, funding of managerial sessions, access to information and perceived need for support. Most Clinical Directors had no job description and most had no formal written objectives, despite a substantial body of advice that these should be provided. There was generally substantial underfunding of managerial hours compared with those actually worked and approximately 20% of Clinical Directors surveyed had no funding for managerial duties. Clinical Directors' ratings of the information available to assist their decision making were also a cause of concern. Clinical Directors perceived that they need better networking, more training particularly on human resource management and improved management information.