Does preoperative opioid use predict outcomes to 6 months following primary unilateral knee or hip arthroplasty for osteoarthritis? A data-linked retrospective study.

BACKGROUND: Few Australian studies have examined the incidence of prescribed opioid use prior to primary total knee or total hip arthroplasty (TKA, THA) and whether it predicts post-surgery outcomes. A recent Australian study demonstrated that the prevalence of pre-arthroplasty opioid use was approximately 16%. In the United States, approximately 24% of people undergoing TKA or THA are chronic opioid users preoperatively. PURPOSE: This study aimed to determine (i) the proportion of TKA and THA patients who use prescribed opioids regularly (daily) before surgery (i.e., opioid use reported between the time of waitlisting and any time up to 3 months before surgery), (ii) if opioid use before surgery predicts (a) complication/readmission rates to 6-months post-surgery, and (b) patient-reported outcomes to 6-months post-surgery. METHODS: A retrospective cohort study of patients who underwent TKA or THA between January 2013 and June 2018 from two Australian public hospitals was undertaken utilizing linked individual patient-level data from two prospectively collected independent databases comprising approximately 3,500 and 9,500 people (database contained known opioid usage data within the 5-year time frame). Inclusion criteria included (i) primary diagnosis of osteoarthritis of the index joint, (ii) primary elective THA or TKA, and (iii) age ≥ 18 years. Exclusion criteria included (i) revision arthroplasty, (ii) non-elective arthroplasty, (iii) hip hemiarthroplasty, (iv) uni-compartmental knee arthroplasty, and (v) previous unilateral high tibial osteotomy. RESULTS: Analysis was completed on 1,187 study participants (64% female, 69% TKA, mean (SD) age 67 [9.9]). 30% were using regular opioids preoperatively. Adjusted regression analyses controlling for multiple co-variates indicated no significant association between preoperative opioid use and complications/readmission rates or patient-reported outcomes to 6 months post-surgery. Model diagnostics produced poor discrimination for area under the curves and non-significant goodness of fit tests. Pre-arthroplasty opioid use was associated with lower health-related quality of life (EuroQol-Visual Analogue Scale) compared to non-opioid users undergoing primary THA (mean difference -5.04 [-9.87, -0.22], P = 0.04, Adjusted R2 = 0.06) CONCLUSION: In this study, 30% of patients were using prescribed opioids daily prior to primary TKA or THA. Pre-arthroplasty opioid use was not associated with postoperative adverse events or patient-reported pain, function, or global perceived improvement up to six months post-surgery.

"IT's too much to do alone": A mixed-methods exploration of patient experiences implementing emergency department management plans for chronic pain.

OBJECTIVES: To explore the experiences of socio-culturally diverse community members attempting to manage their chronic pain and enact evidence-based management plans following an index Emergency Department (ED) visit. METHODS: A convergent parallel mixed-methods design with qualitative interviews and descriptive analysis was undertaken in two public hospitals in a multicultural region in Sydney, Australia. Consecutive adults were recruited from culturally and linguistically diverse (CALD: n = 45) or Australian-born (n = 45) backgrounds, who presented to the ED for a chronic neuromusculoskeletal pain condition. Consenting participants were prescribed an individualised chronic pain management plan following examination by a physiotherapist, who collected standardised measures of pain and health literacy. Six months later, participants underwent a structured phone survey regarding their pain status and whether they had actioned management plans. Participants were invited to participate in a semi-structured interview. RESULTS: Six-month data were available for 82 of 90 participants who attended the ED and consented to the baseline assessment (40 CALD and 42 Australian-born). Participants were 52% females, predominately middle-aged (mean age 54.7 years), with an overall mean symptom duration of 10 years (SD 9.0). At 6 months, there were nine representations by six CALD participants and 23 by nine Australian-born participants. Overall, 52% reported unchanged pain, 24% were worse and 23% improved, with similar action plan progress for CALD (58%) and Australian-born (53%) participants. Pain features and health literacy were similar, irrespective of progress with pain management plans. From 41 participants who consented to phone interviews, three themes emerged to explain their progress with recommendations: 'illness model', 'urgency' and 'control orientation'. CONCLUSIONS: Patients presenting to the ED with chronic pain might be more likely to action discharge recommendations if primary care providers identify patient-specific and contextual barriers to implementation.

A mixed methods approach to investigating physical activity in people with obesity participating in a chronic care programme awaiting total knee or hip arthroplasty.

AIMS: To describe patient-reported physical activity and step count trajectory and explore perceived barriers and enablers to physical activity amongst people with obesity participating in a chronic care programme whilst awaiting arthroplasty. DESIGN: Convergent parallel mixed-method study. METHOD: A patient cohort derived from a longitudinal sample of adults with end-stage osteoarthritis and obesity from a chronic care programme whilst awaiting primary total knee or hip arthroplasty (n = 97) was studied. Physical activity was measured at baseline (entry to the wait list) and before surgery (9-12 months waiting time) using the Lower Extremity Activity Scale (LEAS) and activity monitors (activPAL™). A subset of participants completed in-depth semi-structured interviews 6 months after being waitlisted to explore perceived barriers and enablers to physical activity. Themes were inductively derived and then interpreted through the COM-B model. RESULTS: Baseline LEAS and activPAL™ data were available from 97 and 63 participants, respectively. The proportion of community ambulant individuals reduced from 43% (95% CI 33%-53%) at baseline to 17% (95% CI 9%-28%) pre-surgery. Paired activPAL™ data (n = 31) for step count, upright time, and stepping time remained unchanged. Twenty-five participants were interviewed. Five themes underpinning physical activity were mapped to the COM-B model components of capability (physical capability), opportunity (accessibility and social norms), and motivation (self-efficacy and beliefs and physical activity). CONCLUSIONS: Participation in a chronic care programme did not improve physical activity levels for people with obesity awaiting arthroplasty. Programs cognisant of the COM-B model components may be required to address the natural trajectory of declining physical activity levels while awaiting arthroplasty.

The effect of body mass index and preoperative weight loss in people with obesity on postoperative outcomes to 6 months following total hip or knee arthroplasty: a retrospective study.

BACKGROUND: Few studies have investigated the association between obesity, preoperative weight loss and postoperative outcomes beyond 30- and 90-days post-arthroplasty. This study investigated whether body mass index (BMI) and preoperative weight loss in people with obesity predict postoperative complications and patient-reported outcomes 6 months following total knee or hip arthroplasty. METHODS: Two independent, prospectively collected datasets of people undergoing primary total knee or hip arthroplasty for osteoarthritis between January 2013 and June 2018 at two public hospitals were merged. First, the sample was grouped into BMI categories, < 35 kg/m2 and ≥ 35 kg/m2. Subgroup analysis was completed separately for hips and knees. Second, a sample of people with BMI ≥ 30 kg/m2 was stratified into participants who did or did not lose ≥ 5% of their baseline weight preoperatively. The presence of postoperative complications, Oxford Hip Score, Oxford Knee Score, EuroQol Visual Analogue Scale and patient-rated improvement 6 months post-surgery were compared using unadjusted and adjusted techniques. RESULTS: From 3,552 and 9,562 patients identified from the datasets, 1,337 were included in the analysis after merging. After adjustment for covariates, there was no difference in postoperative complication rate to 6 months post-surgery according to BMI category (OR 1.0, 95%CI 0.8-1.4, P = 0.8) or preoperative weight loss (OR 1.1, 95%CI 0.7-1.8, P = 0.7). There was no between-group difference according to BMI or preoperative weight change for any patient-reported outcomes 6 months post-surgery. CONCLUSION: Preoperative BMI or a 5% reduction in preoperative BMI in people with obesity was not associated with postoperative outcomes to 6 months following total knee or hip arthroplasty.

Why do some people with osteoarthritis and obesity awaiting hip or knee arthroplasty achieve successful weight management? A qualitative study.

AIM: To explore perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty. DESIGN: A nested qualitative study within a multi-centre, quasi-experimental pilot study comparing usual care weight management to a dietitian-led weight-loss diet. METHODS: Semi-structured individual interviews were conducted with adults with end-stage osteoarthritis and a body mass index ≥30 kg/m2 waitlisted for primary total knee or hip arthroplasty. Participants with diverse sociodemographic characteristics and varied success with weight management in the pilot study were purposively sampled. Interviews were analysed using inductive thematic analysis, underpinned by constructivist-interpretivist epistemology. The Patient Activation Measure and Health Literacy Questionnaire were used for context when interpreting the findings. RESULTS: Twenty-five participant interviews were conducted with a sociodemographically varied sample (aged 44-80 years, 9 born in Australia, 6 in paid employment and 11 lost ≥5% of their baseline weight). Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Adaptability, the ability to overcome barriers to weight loss, comprised three subthemes; readiness to act, degree of independence and problem-solving skills. Approaches towards navigating healthcare influenced uptake and adherence to weight management recommendations. Importantly, these themes were dependent on social and environmental circumstances, which influenced the type of barriers experienced and resources available to the individual. CONCLUSION: Differences in a person's beliefs, their ability to adapt and navigate healthcare and sociocultural context appear to explain successful weight management among people with end-stage arthritis. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Clinicians should allow for individualisation cognisant of the identified themes when providing advice and treatment to promote adherence to weight management interventions. IMPACT: This study explored perceived barriers and enablers to weight management among people with obesity awaiting total knee or hip arthroplasty. Four identified themes underpinned successful weight management: beliefs, adaptability, navigating healthcare and sociocultural context. Beliefs about whether weight was perceived as a problem, the expectation of weight loss and treatment-related beliefs influenced participants' perspectives towards weight loss. Understanding and assessing the contribution of each factor may guide weight management from clinicians treating patients with obesity and osteoarthritis. REPORTING METHOD: The data are reported using the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: Patients contributed to the data collected.

The feasibility of implementing a cultural mentoring program alongside pain management and physical rehabilitation for chronic musculoskeletal conditions: results of a controlled before-and-after pilot study.

BACKGROUND: Culturally diverse communities face barriers managing chronic musculoskeletal pain conditions including navigation challenges, sub-optimal healthcare provider engagement and difficulty adopting self-management behaviours. OBJECTIVES: To explore the feasibility and trends of effectiveness of implementing a cultural mentoring program alongside clinical service delivery. METHODS: This quasi-experimental controlled before-and-after multiple case study was conducted in three hospital-based services that provide treatment for patients with musculoskeletal pain. Two prospective cohorts, a pre-implementation and a post-implementation cohort, of adults with chronic musculoskeletal pain who attended during the 6-month recruitment phase, were eligible if they self-identified with one of the cultures prioritised for mentoring by the clinic. The pre-implementation cohort received routine care for up to 3-months, while the post-implementation cohort received up to 3-months of cultural mentoring integrated into routine care (3 to 10 sessions), provided by a consumer (n = 6) with lived experience. Feasibility measures (recruitment and completion rates, attendance, satisfaction), and trends of effectiveness (Patient Activation Measure and Health Literacy Questionnaire items one and six) were collated over 3-months for both cohorts. Outcomes were presented descriptively and analysed using Mann-Whitney U-tests for between-group comparisons. Translation and transcription of post-treatment semi-structured interviews allowed both cohorts' perspectives of treatment to be analysed using a Rapid Assessment Process. RESULTS: The cultural mentor program was feasible to implement in clinical services with comparable recruitment rates (66% pre-implementation; 61% post-implementation), adequate treatment attendance (75% pre-implementation; 89% post-implementation), high treatment satisfaction (97% pre-implementation; 96% post-implementation), and minimal participant drop-out (< 5%). Compared to routine care (n = 71), patients receiving mentoring (n = 55) achieved significantly higher Patient Activation Measure scores (median change 0 vs 10.3 points, p < 0.01) at 3-months, while Health Literacy Questionnaire items did not change for either cohort over time. Three themes underpinned participant experiences and acceptability of the mentoring intervention: 'expectational priming', 'lived expertise' and 'collectivist orientation' to understand shared participant experiences and explore the potential differential effect of the mentoring intervention. CONCLUSION: Participant experiences and observations of improved patient activation provide support for the acceptability of the mentoring intervention integrated into routine care. These results support the feasibility of conducting a definitive trial, while also exploring issues of scalability and sustainability.

Effect of weight-loss diets prior to elective surgery on postoperative outcomes in obesity: A systematic review and meta-analysis.

This systematic review investigated the effects of weight-loss diets before elective surgery on preoperative weight loss and postoperative outcomes in people with obesity. Electronic databases were searched from inception to May 2021. Inclusion criteria were prospective cohort or randomised controlled studies that compared effects of weight-loss diets to standard care on postoperative outcomes in adults with obesity awaiting surgery. Participants with cancer or undergoing bariatric surgery were excluded. Data on preoperative weight change, length of stay, postoperative complications and patient-reported outcome measures were extracted and synthesised in meta-analyses. One randomised controlled trial involving total knee arthroplasty and two that investigated general surgery were eligible that included 173 participants overall. Each study compared low-calorie diets using meal replacement formulas to usual care. There is very-low-quality evidence of a statistically significant difference favouring the intervention for preoperative weight loss (mean difference [MD] -6.67 kg, 95% confidence interval [CI] -12.09 to -1.26 kg; p = 0.02) and low-quality evidence that preoperative weight-loss diets do not reduce postoperative complications to 30 days (odds ratio [OR] 0.34, 95% CI 0.08-1.42; p = 0.14) or length of stay (MD -3.72 h, 95% CI -10.76 to 3.32; p = 0.30). From the limited data that is of low quality, weight loss diets before elective surgery do not reduce postoperative complications.

A Mixed-Methods Investigation into Patients' Decisions to Attend an Emergency Department for Chronic Pain.

OBJECTIVE: This study explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born. DESIGN AND METHODS: This mixed-methods study was underpinned by the Behavioral Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy, and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5 focus groups) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilization and contributing factors for both cohorts. RESULTS: ED attendance was a product of escalating distress, influenced by the degree to which participants' perceived needs outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure, and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophizing, lower health literacy, and greater social challenges present for the CALD cohort. CONCLUSION: This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for health care providers to recognize features of higher vulnerability and consider streamlining access to available support services.

Patient factors associated with referral to inpatient rehabilitation following knee or hip arthroplasty in a public sector cohort: A prognostic factor study.

RATIONALE, AIMS AND OBJECTIVES: Inpatient rehabilitation following total knee or hip arthroplasty (TKA, THA) is resource intensive and expensive. Understanding who is referred is integral to the discourse concerning service and cost reform. This study aimed to determine patient prognostic factors associated with referral to inpatient rehabilitation following TKA or THA in a public sector setting. In this setting, surgeon or patient choice does not drive referral. METHOD: Prognostic factor research based on secondary analysis of prospectively collected data. Consecutive people undergo elective, primary TKA, or THA at a high-volume public hospital. The outcome was referral to inpatient rehabilitation after acute care. Patient variables including sociodemographic, comorbidity, and complication details were used in multivariable logistic regression to determine the prognostic factors associated with referral. RESULTS: Five hundred twenty people were included; 9.2% experienced the outcome. In the multivariable model, acute complications (OR 3.6, 95% CI 1.6-7.8), TKA surgery (OR 3.1, 95% CI 1.0-9.4), renal disease (OR 4.4, 95% CI 1.4-13.3), and higher body mass index (OR 1.1, 95% CI 1.0-1.2) were associated with referral; unilateral surgery (OR 0.1 (95% CI 0.01-0.2) and previous arthroplasty (OR 0.3 (95% CI 0.1-0.8) were protective. There were no significant associations found for sociodemographic factors (such as gender and residential status) in the multivariable model. CONCLUSION: In the absence of choice, physical impairment and health factors are associated with referral to inpatient rehabilitation following TKA or THA.

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component.

BACKGROUND: Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care. METHOD: A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol. RESULTS: Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles. CONCLUSION: Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

Health effects of a low-inflammatory diet in adults with arthritis: a systematic review and meta-analysis.

The aim is to systematically assess the health impact of a low-inflammatory diet intervention (full-diet or supplement), compared to usual diet or other dietary interventions, on weight change, inflammatory biomarkers, joint symptoms, and quality of life in adults with osteoarthritis, rheumatoid arthritis or seronegative arthropathy (psoriatic, reactive, ankylosing spondylitis or IBD-related), on outcomes assessed in prospective studies within 6 months of intervention commencement (PROSPERO CRD42019136567). Search of multiple electronic library databases from inception to July 2019, supplemented by grey literature searches, for randomised and prospective trials assessing the above objective. After exclusion of 446 ineligible studies, five randomised and two prospective trials involving 468 participants with either osteoarthritis or rheumatoid arthritis were included. GRADE assessment for all outcomes was very low. Meta-analyses produced the following standardised mean differences (SMD) and 95 % confidence interval (CI) 2-4 months following commencement of the diets favouring the low-inflammatory diet: weight SMD -0⋅45 (CI -0⋅71, -0⋅18); inflammatory biomarkers SMD -2⋅33 (CI -3⋅82, -0⋅84). No significant effects were found for physical function (SMD -0⋅62; CI -1⋅39, 0⋅14), general health (SMD 0⋅89; CI -0⋅39, 2⋅16) and joint pain (SMD -0⋅98; CI -2⋅90, 0⋅93). In most studies, the quality of dietary intervention (dietitian input, use of validated dietary compliance tool) could not be gauged. In conclusion, very low-level evidence suggests that low-inflammatory diets or supplements compared to usual diets are associated with greater weight loss and improvement in inflammatory biomarkers. More high-quality trials are needed to assess the health effects of a low-inflammatory diet more comprehensively and conclusively in arthritic conditions.

Associations between pre-surgical daily opioid use and short-term outcomes following knee or hip arthroplasty: a prospective, exploratory cohort study.

BACKGROUND: Retrospective studies have found that daily opioid use pre-arthroplasty predicts worse longer-term service, clinical and patient-reported outcomes. Prospective studies are needed to confirm these observations. This prospective, exploratory study aimed to determine: the proportion of total knee or hip arthroplasty (TKA, THA) patients who use opioids regularly (daily) pre-surgery; if opioid use pre-surgery is associated with acute and sub-acute outcomes to 12-weeks post-surgery. METHODS: Consecutive patients undergoing primary TKA or THA were prospectively enrolled pre-surgery and followed-up by telephone to 12-weeks post-surgery. Acute-care (oral morphine equivalent dosage (OMED), length of stay, discharge to inpatient rehabilitation, complications) and 12-week outcomes (Oxford Knee or Hip Score, Euroqol 'today' health score, current use of opioids, and complications including readmissions) were monitored. Unadjusted and adjusted Odds Ratios (ORs) (95% Confidence Interval, CI), Rate Ratios and ß coefficients (standard error) were calculated. RESULTS: Five Hundred Twenty-One patients were included (TKA n = 381). 15.7% (95%CI 12.6 to 18.9) used opioids regularly pre-surgery. 86.8% (452/521) were available for follow-up at 12-weeks. In unadjusted analyses, pre-surgical opioid use was significantly associated with higher average acute daily OMED [ß 0.40 (0.07), p <  0.001], presence of an acute complication [OR 1.75 (1.02 to 3.00)], and ongoing use of opioids at 12-weeks [OR 5.06 (2.86 to 8.93)]. After adjusting for covariates, opioid use pre-surgery remained significantly associated with average acute daily OMED [ß 0.40 (0.07), p <  0.001] and ongoing use at 12-weeks [OR 5.38 (2.89 to 9.99)]. CONCLUSION: People who take daily opioids pre-surgery have significantly greater odds for greater opioid consumption acutely and ongoing use post-surgery. Adequately powered prospective studies are required to confirm whether pre-surgical opioid use is or is not associated with poorer joint and quality of life scores or a complication in the short-term.