Evaluating an 'incident control' approach to non-communicable disease.

OBJECTIVES: This article evaluates the application of 'incident control' methodology usually applied in communicable disease control to an 'incident' of unexplained deaths, specifically to resolve a significant difference in 1-year survival after a lung cancer diagnosis observed between two Clinical Commissioning Groups and the England national average, 2011-14. The purpose of the evaluation was to assess whether a formalised incident control approach is feasible and effective in improving outcomes for non-communicable diseases. STUDY DESIGN: Descriptive, qualitative, process evaluation. METHODS: There were two components to the evaluation: a document review against identified phases of a non-communicable disease incident control framework and a qualitative analysis of semi-structured interviews with stakeholders who had been involved in implementation. RESULTS: The findings indicate feasibility of the incident control model, with some limitations. Identified strengths of the model included the articulation of a clear case and incident definition. The structure and stepped phased approach facilitated partner engagement, robust data analysis, action planning and communication strategies. Delays in data publication and the lack of comparable data across different non-communicable diseases present challenges in timely response and prioritisation of 'incidents'. CONCLUSIONS: The evaluation indicates value in applying defined incident control methodology to management of non-communicable diseases, especially where there is identification of a potential outlier or a measurable variation, i.e. there is a definable 'incident' and 'case'.

Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons.

INTRODUCTION: Patient decision aids could facilitate shared decision-making in joint replacement surgery. However, patient decision aids are not routinely used in this setting. METHODS: With a view to developing a patient decision aid for UK hip/knee joint replacement practice, we undertook a systematic search of the literature for evidence on the use of shared decision-making and patient decision aids in orthopaedics, and a national survey of consultant orthopaedic surgeons on the potential acceptability and feasibility of patient decision aids. RESULTS: We found little published evidence regarding shared decision-making or patient decision aids in orthopaedics. In the survey, 362 of 639 (57%) randomly selected consultant orthopaedic surgeons responded. Respondents appear representative of consultant orthopaedic surgeons in the UK. Of 272 valid responses, 79% (95% CI, 73-85%) thought patient decision aids a good or excellent idea. There was consensus on the potential helpfulness of patient decision aids and core content. A booklet to take home was the preferred medium/practice model. CONCLUSIONS: Despite the increased emphasis on patient involvement in decision-making, there is little evidence in the medical literature relating to shared decision-making or the use of patient decision aids in orthopaedic surgery. Further research in this area of clinical practice is required. Our survey shows that consultant orthopaedic surgeons in the UK are generally positive about the use of patient decision aids for joint replacement surgery. Survey results could inform future development of patient decision aids for joint replacement practice in the UK.

A randomised controlled trial of cemented versus cementless press-fit condylar total knee replacement: 15-year survival analysis.

We report the long-term survival of a prospective randomised consecutive series of 501 primary knee replacements using the press-fit condylar posterior cruciate ligament-retaining prosthesis. Patients received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. Altogether, 44 of 501 knees (8.8%) underwent revision surgery (24 cemented vs 20 cementless). For cemented knees the 15-year survival rate was 80.7% (95% confidence interval (CI) 71.5 to 87.4) and for cementless knees it was 75.3% (95% CI 63.5 to 84.3). There was no significant difference between the two groups (cemented vs cementless; hazard ratio (HR) 0.83, 95% CI 0.45 to 1.52, p = 0.55). When comparing the covariates there was no significant difference in the rates of survival between the side of operation (HR 0.58, p = 0.07), age (HR 0.97, p = 0.10) and diagnosis (HR 1.25 p = 0.72). However, there was a significant gender difference, with males having a higher failure rate with cemented fixation (HR 2.48, p = 0.004). Females had a similar failure rate in both groups. This single-surgeon series, with no loss to follow-up, provides reliable data of the revision rates of one of the most commonly-used total knee replacements. The survival of the press-fit condylar total knee replacement remained good at 15 years, irrespective of the method of fixation.

Outcome of Charnley total hip replacement across a single health region in England. The results at ten years from a regional arthroplasty register.

Using the Trent regional arthroplasty register, we analysed the survival at ten years of 1198 consecutive Charnley total hip replacements carried out across a single health region of the United Kingdom in 1990. At ten years, information regarding outcome was available for 1001 hips (83.6%). The crude revision rate was 6.2% (62 of 1001) and the cumulative survival rate with revision of the components as an end-point was 93.1%. At five years, a review of this series of patients identified gross radiological failure in 25 total hip replacements which had previously been unrecognised. At ten years the outcome was known for 18 of these 25 patients (72%), of whom 13 had not undergone revision. This is the first study to assess the survival at ten years for the primary Charnley total hip replacement performed in a broad cross-section of hospitals in the United Kingdom, as opposed to specialist centres. Our results highlight the importance of the arthroplasty register in identifying the long-term outcome of hip prostheses.

Tensions in public health policy: patient engagement, evidence-based public health and health inequalities.

This paper examines the proposition that there are considerable tensions between key strategies in health policy--namely, evidence-based approaches to population health improvement, reduction of health inequalities, and public and patient engagement--using (1) a critical analysis of the intersection of evidence-based public health, patient and public engagement, and health inequalities policies from a social constructionist perspective and (2) mathematical modelling of paternalistic and shared decision making in the management of hypertension in a random age and sex stratified community sample of residents of south east Northumberland, UK. It is concluded that there may be unintended effects on population health of incongruities in major components of public health policy. Greater public and patient engagement may militate against the disease prevention goals of evidence-based policy, and may better engage sections of the population who already benefit from greater access and better health associated with social status and opportunity, serving to increase inequalities by further marginalising those already suffering from relative exclusion.

A randomised, controlled trial of cemented versus cementless press-fit condylar total knee replacement. Ten-year survival analysis.

We have carried out a long-term survival analysis of a prospective, randomised trial comparing cemented with cementless fixation of press-fit condylar primary total knee replacements. A consecutive series of 501 replacements received either cemented (219 patients, 277 implants) or cementless (177 patients, 224 implants) fixation. The patients were contacted at a mean follow-up of 7.4 years (2.7 to 13.0) to establish the rate of survival of the implant. The ten-year survival was compared using life-table and Cox's proportional hazard analysis. No patient was lost to follow-up. The survival at ten years was 95.3% (95% CI 90.3 to 97.8) and 95.6% (95% CI 89.5 to 98.2) in the cemented and cementless groups, respectively. The hazard ratio for failure in cemented compared with cementless prostheses was 0.97 (95% CI 0.36 to 2.6). A comparison of the clinical outcome at ten years in 80 knees showed no difference between the two groups. The survival of the press-fit condylar total knee replacement at ten years is good irrespective of the method of fixation and brings into question the use of more expensive cementless implants.

Survival analysis of cemented Press-Fit Condylar total knee arthroplasty.

We performed a survival analysis on 354 cemented primary Press-Fit Condylar (PFC) total knee arthroplasties (TKA) in 277 patients with prospective follow-up (mean, 6 years; range, 2-11.7 years). No patient was lost to follow-up. Using revision for all causes as the endpoint, the cumulative survival rate at 10 years was 95.5% (95% confidence interval, 90.1%-98.1%). The 10-year clinical outcome available on 41 patients was good, with significant improvement in pain and mobility assessments using the Nottingham data collection system. Our results indicate that the cemented PFC TKA has good long-term survival based on revision as the endpoint. Revision for implant failure is rare and brings to question modifications to this prosthesis.

Ulceration of the lower leg after total knee replacement a five-year review.

Ulceration of the lower leg is considered to be a hard' clinical endpoint of venous thrombosis. Total knee replacement (TKR) is a significant risk factor for venous thrombosis of the leg and therefore potentially for ulceration. We sent a postal questionnaire to 244 patients at a minimum of five years after TKR enquiring about the development of ulceration since their TKR. The overall incidence of ulceration, both active and healed, was 8.67% which is similar to that in the age-matched general population (9.6% to 12.6%), as was the prevalence of active ulceration. We also identified no clear association between venographically-confirmed postoperative deep-venous thrombosis (DVT) and the incidence and prevalence of ulcers at five years. We suggest that after TKR DVT is not a significant risk factor for ulceration of the leg and that perioperative chemical thromboprophylaxis may not be justified on these grounds.

The appearance on MRI of vertebrae in acute compression of the spinal cord due to metastases.

We studied MR images of the spine in a consecutive series of 100 patients with acute compression of the spinal cord due to metastases. All patients had documented neurological deficit and histologically proven carcinoma. MRI was used to localise bony metastatic involvement and soft-tissue impingement of the cord. A systematic method of documenting metastatic involvement is described. A total of 43 patients had compression at multiple levels; 160 vertebral levels were studied. In 120 vertebrae (75%), anterior, lateral and posterior bony elements were involved. Soft-tissue impingement of the spinal cord often involved more than one quadrant of its circumference. In 69 vertebrae (43%) there was concomitant anterior and posterior compression. Isolated involvement of a vertebral body was observed in only six vertebrae (3.8%). We have shown that in most cases of acute compression of the spinal cord due to metastases there is coexisting involvement of both anterior and posterior structures.

The incidence of fatal pulmonary embolism after knee replacement with no prophylactic anticoagulation.

We made a prospective study of the incidence of fatal pulmonary embolism in patients after total knee replacement with no prophylactic anticoagulation. There were 499 consecutive patients having 527 knee replacements. They all wore anti-thromboembolic stockings and were mobilised 48 hours after surgery. No patient was lost to follow-up. One patient died of pulmonary embolism 22 days after operation. There were no other deaths within three months of operation. The incidence of fatal pulmonary embolism was 0.19% (95% confidence interval: 0 to 0.6%). Fatal pulmonary embolism is rare after total knee replacement without prophylactic anticoagulation and the routine anticoagulation of these patients is of doubtful value.