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.

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.

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.

Implementing core NICE guidelines for osteoarthritis in primary care with a model consultation (MOSAICS): a cluster randomised controlled trial.

OBJECTIVE: To determine the effectiveness of a model osteoarthritis consultation, compared with usual care, on physical function and uptake of National Institute for Health and Care Excellence (NICE) osteoarthritis recommendations, in adults ≥45 years consulting with peripheral joint pain in UK general practice. METHOD: Two-arm cluster-randomised controlled trial with baseline health survey. Eight general practices in England. PARTICIPANTS: 525 adults ≥45 years consulting for peripheral joint pain, amongst 28,443 population survey recipients. Four intervention practices delivered the model osteoarthritis consultation to patients consulting with peripheral joint pain; four control practices continued usual care. The primary clinical outcome of the trial was the SF-12 physical component score (PCS) at 6 months; the main secondary outcome was uptake of NICE core recommendations by 6 months, measured by osteoarthritis quality indicators. A Linear Mixed Model was used to analyse clinical outcome data (SF-12 PCS). Differences in quality indicator outcomes were assessed using logistic regression. RESULTS: 525 eligible participants were enrolled (mean age 67.3 years, SD 10.5; 59.6% female): 288 from intervention and 237 from control practices. There were no statistically significant differences in SF-12 PCS: mean difference at the 6-month primary endpoint was -0.37 (95% CI -2.32, 1.57). Uptake of core NICE recommendations by 6 months was statistically significantly higher in the intervention arm compared with control: e.g., increased written exercise information, 20.5% (7.9, 28.3). CONCLUSION: Whilst uptake of core NICE recommendations was increased, there was no evidence of benefit of this intervention, as delivered in this pragmatic randomised trial, on the primary outcome of physical functioning at 6 months. TRIAL REGISTRATION: ISRCTN06984617.

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.

Global oximetry: an international anaesthesia quality improvement project.

Pulse oximetry is mandatory during anaesthesia in many countries, a standard endorsed by the World Health Organization 'Safe Surgery Saves Lives' initiative. The Association of Anaesthetists of Great Britain and Ireland, the World Federation of Societies of Anaesthesiologists and GE Healthcare collaborated in a quality improvement project over a 15-month period to investigate pulse oximetry in four pilot sites in Uganda, Vietnam, India and the Philippines, using 84 donated pulse oximeters. A substantial gap in oximeter provision was demonstrated at the start of the project. Formal training was essential for oximeter-naïve practitioners. After introduction of oximeters, logbook data were collected from over 8000 anaesthetics, and responses to desaturation were judged appropriate. Anaesthesia providers believed pulse oximeters were essential for patient safety and defined characteristics of the ideal oximeter for their setting. Robust systems for supply and maintenance of low-cost oximeters are required for sustained uptake of pulse oximetry in low- and middle-income countries.

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.

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.

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 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.

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.

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.