OPUS CRE Research Streams
Work plan#1: Appropriateness of care
A prognostic tool to support decision making for total joint replacement
Chief Investigators: Peter Choong, Jane Gunn.
Associate Investigators: Jasvinder Singh, Maria Inacio, Michael Kattan.
Currently there is no prognostic tool in the outpatient and primary care setting allowing differentiation of patients who are likely or unlikely to benefit from Total Joint Replacement (TJR). Our group has identified important risk factors for poor patient outcomes of TJR that will inform the development of such a tool.
In 615 consecutive cases, we identified that 15% of these individuals were non-responders to surgery at 12 months after knee TJR. A preliminary comparative study of 1,419 patients conducted with the Swedish Knee Registry confirmed a similar level of non-responder rates of 14.2%. Independent prognostic correlates of post-operative non-response were completed from which we developed a nomogram designed to predict the probability of non-response to knee TJR. The concordance index for this model was 0.74. This is the first nomogram ever applied in TJR, which includes patient related outcome measures.
We will test the predictive probabilities of the nomogram across centres representative of the broader knee TJR population. We will also collaborate with senior researchers from the Health Economics Research Centre at Oxford University who have a strong history of collaboration with Professor Philip Clarke of the University of Melbourne, including over 10 co-authored publications. These researchers are co-investigators on a National Institute for Health Research (NIHR) funded project to develop an ‘arthroplasty candidacy help tool’ for the UK. Specifically, this collaboration will assist with international external validation of the patient selection nomogram.
Dr Darshini Ayton will then assess the nomogram based on patient/clinician views, useability and suitability through interviews and focus groups. Further content analysis methods will be applied to validate the nomogram, surveying for existing or new trends. This will provide insight into patient and clinician views towards the nomogram, which will guide best practice towards developing a program of better care and improving communication between patients and doctors.
Final assessment the acceptability of the nomogram will be completed amongst user groups through the Australian Orthopaedic Association, the Musculoskeletal Clinician Leadership Group and other associated advisory bodies. Other similar forums will be used to assess the useability of the nomogram with international user groups. The nomogram will inform the development of a feedback intervention for surgeons as outlined in Workplan#2 and for targeting patients with a high probability of poor response to surgery as outlined in Workplan#3. While we have elected to target knee TJR for a nomogram in the first instance, future work is planned for the development of a hip TJR nomogram.
Expected outcomes and significance:
The outcome of this work plan will be a prognostic tool for use in the primary care setting by allied health and general practitioners and specialist orthopaedic surgeons in outpatient and private settings. This unique tool will enhance the ability to predict successful patient outcomes. Moreover, this nomogram will identify modifiable risk factors to target for mitigation prior to surgery (e.g. obesity, mental health). This will have direct impact on specialist referrals and ultimately lead to containment of elective surgery waiting list numbers.
Workplan#2 Behaviour and Social Science
Decision making in total joint replacement
Chief Investigators: Anthony Scott, Michelle Dowsey.
Associate Investigators: Michael Kattan, Darshini Ayton, Ian Incoll.
Patients’ and surgeons’ assessments of the risks and benefits of TJR surgery don’t always align. We will investigate factors which might influence decisions, expectation and why surgeons offer surgery to inappropriate candidates have not been subjected to rigorous evaluation. Research indicates complex influences on clinicians’ decisions but few studies are based on a theoretical understanding of what drives decision-making, therefore interventions have not been carefully designed and consequently are not effective. Previous reviews of feedback interventions have shown that feedback and changes in information provided to doctors can influence their behaviour, but that their effects are variable depending on the context and the characteristics of intervention. This includes the timing and frequency of feedback, who delivers the feedback, the content of the feedback, and planned actions taken following feedback.
We are currently conducting a first of its kind NHMRC funded study (Application 1058438 - MARKA) that examines and compares benefit and risk preferences of patients with end-stage Osteoarthritis (OA) undergoing knee TJR with surgeon preferences. The study uses discrete choice experiments (DCEs) to explore how patients balance risks and benefits, determine the extent these align with surgeons’ expectations, and explores whether guiding patients through a decision making process prior to surgery improves patient expectations, health outcomes and satisfaction. We aim to determine patient and surgeon characteristics that correlate with willingness to undergo (patients) or offer (surgeons) knee TJR through a series of structured questionnaires, administered to patients and orthopaedic surgeons including measures of personality, control, risk attitudes and optimism. The role of individual and institutional knee TJR volume and whether employed at a tertiary, rural or community facility are also being examined. The design of the DCE has been finalised with patient input, pre-tested for understanding and piloted in patients and surgeons.
Results illustrate that despite the risk of poor outcome such as moderate or severe pain at 12 months and complication rates approaching 20% in some scenarios, 95% of patients stated they would undergo knee TJR. In contrast, when surgeons were faced with the same scenarios, the opt-out rate for providing surgery was as high as 80%.
Presenting accurate unbiased information may significantly impact patient and surgeon decision making and alter behavioural biases in surgeons who may be overconfident and believe that these outcomes would not occur for ‘their’ patients.
While the MARKA study includes a patient-level intervention to reduce patients’ expectations, it is clear that an intervention to address surgeon behaviours and beliefs is also required. Given our group’s expertise and current research, as well as our collaboration with the Australian Orthopaedic Association, we are in a unique position to extend this research to develop and test the impact of an intervention directed at surgeons to influence surgeon-patient decision making and informed consent for knee TJR. These approaches are unique and would provide a significant insight into decision-making never before considered in TJR.
Changing surgeon behaviour requires an in-depth understanding of what determines their behaviour in order to develop a theory-based intervention. This will be achieved using participatory action research.
Discrete choices experiments will reveal the extent to which surgeon’s focus on surgical risks or post-operative patient outcomes, and the extent to which these influence their decision to recommend surgery. It will also examine how surgeons’ preferences vary according to the volume of knee TJRs performed, their personality, and locus of control, risk aversion, optimism and overconfidence. Feedback methods will be implemented and data pooled to determine how and at what point final consent is justified. The role of technology and data visualisation will also be explored in designing the feedback intervention.
After determining the design and intervention method(s), we will assess the usefulness of these changed methods with surgeons and registrars through various forums prior to implementation. In addition to the MARKA study, we have recently been awarded a University of Melbourne Faculty of Business & Economics and Medicine, Dentistry & Health Sciences Collaboration Grant to aid in this research program. This will be critical for our proposed cluster RCT to evaluate the effect of a feedback intervention on patient pain and function, alongside other associated evaluations.
Expected Outcomes and significance
Workplan #2 will provide new knowledge of the clinical and economic benefits of this feedback intervention. Ultimately, evidence-based decision-making has the potential to minimise inappropriate surgery with the potential to save millions of dollars in healthcare expenditure.
Workplan#3: Developing non-surgical alternatives for end-stage osteoarthritis
Chief Investigators: Peter O’Sullivan, Anne Smith, Michelle Dowsey.
Associate Investigator: Peter Kent, Kieran O’Sullivan.
There is an imperative to find alternative care pathways/interventions for the 15% of people who are unlikely to benefit from TJR. While multidisciplinary osteoarthritis (OA) chronic care programs have been shown to improve pain and function, even for those awaiting TJR, they have not been tested specifically on this group and so whether they would benefit from this traditional approach is unknown. Chronic low back pain (CLBP), shares a similar multi-dimensional risk profile to joint OA. Much effort has been directed to developing targeted treatment to subgroups of people with CLBP who have poor prognosis based on their group profiles. In keeping with this, our group has developed an individualised model of care for CLBP that effectively targets the multidimensional complexity of the disorder. While this has been adapted to OA knee, to date it is not known whether this approach is also applicable to people with end stage OA who are at risk of poor outcome from knee TJR. As knee OA appears to share similar multidimensional complexity with CLBP, such an approach may offer a promising alternative to knee TJR in those patients at risk of poor outcome with the procedure.
We have developed and tested a promising personalised therapy approach in a small-scale, efficacy RCT in CLBP. The approach is termed ‘cognitive functional therapy’ (CFT), and is best briefly described as an integrated, personalised, behavioural approach to the identification and management of modifiable multidimensional factors underlying a person’s pain and disability. CFT comprehensively operationalises and integrates a self-management program, targeting psychological, physical and lifestyle factors. The intervention addresses these targets using a tailored plan depending on which factors are dominant for each individual. It has been proposed that patients with knee OA be considered similar to other chronic pain populations in that the pain experience may be present depending on genetic, structural, psychological, physical and lifestyle factors, which in turn influence the body and mind of the individual – Illustrated in our NHMRC (APP1035810) to date.
Work will focus on the development and testing of personalised therapy approach for those at risk of poor outcome after knee TJR. We have adapted a personalised CFT approach from CLBP for the management of end-stage OA and will assess the effectiveness of this approach, offering a promising alternative to knee TJR in those patients at risk of poor outcome with the procedure. Whilst the significant body of evidence for existing non-surgical management options for knee OA is acknowledged, we seek to build upon this best practice, with key points of difference being, drawing on relevant models of health behaviour such as the Fear Avoidance Model and Common Sense Model to facilitate development of the patients understanding of their condition, the drivers of their pain and disability as well as opportunities for change.
Lead by Senior researchers who have developed and tested the CFT intervention in CLBP, they will provide experience in prognostic and subgrouping methodology. A post-doctoral fellow will also apply experience in mixed methods and models of health behaviour in CLBP to play a key role in understanding the application of CFT from several clinical angles in a 2 phase approach:
Phase 1: Development of an understanding of factors driving pain and disability
Phase 2: Development of a CFT intervention
Expected Outcomes and Significance
This body of work will lead to new knowledge about treatment alternatives for those patients at risk of no benefit for knee TJR that can be further tested in RCT’s. Significant reductions in healthcare costs can be expected through provision of alternatives to the primary surgical procedure and elimination of costly ongoing care after surgery.
Workplan#4 - Hospital Services Coordinated Care
Developing an enhanced recovery program for TJR
Chief Investigators: Nicholas Taylor, Peter Choong, Trisha Peel.
Associate Investigators: Michael Barrington, Stefan Lohmander.
The McKeon Review highlighted that practice inefficiencies and preventable surgical complications are major cost drivers in the healthcare system. The impact of enhanced recovery programs, and multidisciplinary care pathways on preventable surgical complications, on patient satisfaction and on hospital and societal costs has not been established, limiting the wider adoption of such pathways. This Workplan will address these important knowledge gaps, applying mixed methods research to develop and refine a multimodal enhanced recovery program; forming the basis for a concerted effort to improve the delivery of TJR services nationally and internationally.
A pilot cohort study to inform this Workplan undertaken at SVHM, examining the impact of day of mobilisation on length of stay and complications. Overall, a third of patients who mobilised within the first 24 hours following TJR had a significantly shorter mean length of stay compared to patients mobilised after 24 hours. 23% experienced one or more post-operative complications. And there were significantly fewer post-operative complications in the early mobilisation group. Overall, early mobilisation was associated with a 45% reduction in post-operative complications. Our NHMRC (Application 1057736 and 502021) supported work to date has demonstrated post-operative complications occur in 24.3% of patients after TJR and were a major driver of costs.
Workplan #4 will develop a multidisciplinary care bundle to optimise patient care following TJR using mixed methods in a staged approach to test and refine the bundle. This pragmatic research program will be rolled out in five major interlinked avenues of investigation spanning multimodal enhanced recovery, clinical and economic impact, randomised trials, tailor approaches, modelled health economic analysis, RCT and multimodal stakeholder feedback sessions.
We have received private funding to undertake a large part of this study. In addition to examining the impact on length of stay and cost-effectiveness, this portion of research is critical in informing the final stages, examining the impact of the enhanced recovery program on post-operative complications. This will happen through networks established by the research team and will be enriched by data from early stage trials. This research will be conducted in the ‘real-world’ comparing the clinical and cost-effectiveness of an enhanced recovery program to the Medical Research Council Framework.
Expected Outcomes and significance:
Workplan#4 will provide new knowledge about the clinical and health economic benefits of and lead to the development of evidence-based guidelines for patient care following TJR. In addition, enhanced recovery programs may be associated with significant reductions in healthcare costs through decreased length of stay and reduced post-operative complications.
Transfer Theme (5)
Promote effective transfer of research outcomes into health policy and/or practice
Quality of the plan for research translation
Testing implementation models to develop new knowledge of effective approaches
Working with the Stakeholder Advisory Council, and led by our implementation expert (Prof Gunn) and Quali-expert (Dr Ayton), the Centre’s framework for implementation will be informed by PRISM (Practical, Robust Implementation and Sustainability Model). This approach recognises the complexity of working across multidisciplinary groups and will facilitate more effective implementation and the use of knowledge translation strategies through systematic testing and shared learning.
Synergies achieved by a Centre wide approach to implementation activity
Each Workplan aims to implement new knowledge while maintaining clinical relevance and focus by ensuring shared participation between expert clinicians and specialist researchers. Our strategy of early development of translation plans, including clarity and agreement over the desired impact will help to overcome the difficulties with amalgamation of knowledge that may arise from different disciplines and stakeholder groups.
Health economics and modelling
A key component of centre is the integration of health economics into medical decision-making. This economic method will be incorporated into all stages from assisting in the design of RCTs to the evaluation and translation research findings. The centre will benefit from having access to patient level data and will use health economic modelling to extrapolate our findings to the wider Australian population so that gains in cost-effectiveness can be spread across the sector. Our health economic team is strong with a proven policy translation record supported by experienced outcomes modellers, their networks, and the experience within our Stake Holder Advisory Council. The health economic program will aim to build capacity in the health economic evaluation of TJR in Australia and to strengthen ongoing international links such as with Health Economics Research Centre at University of Oxford.
Plans for promoting the Centre’s activities to the wider community
We shall capitalise on our team’s extensive experience in networking to build a strongly connected translation community to ensure high impact interventions. This will be supported by a Stakeholder Advisory Council (SAC) who will foster a two-way exchange of information between end-users and researchers. The Centre will also engage with other CREs (TRIUMPH, MABEL, NCAS) through direct CI involvement (as CIs/AIs on these CREs) to share in translational expertise, learn from others’ experiences and to extend the reach of this Centre.
Involvement of end-users and the wider community
Practice change in TJR must be led by orthopaedic surgeons. The Centre will leverage it’s networks with various internal and external critical players and associated existing stakeholder programs to reach surgeons and trainees.
As past-President, Professor Jane Gunn will facilitate the transfer of knowledge from this Centre to the primary care community through Australian Association for Academic Primary Care. Using her role as foundation Chair of Victorian Primary Care Research Network, Professor Gunn will engage general practitioners in a broad spectrum of clinical settings to test the useability of the nomogram from Workplan#1.
Community Advocacy Groups: Among others, the CEO of Arthritis & Osteoporosis Victoria (AOV) is on the Centre’s Stakeholder Advisory Council and has had considerable experience driving funding and policy changes that impact those with chronic diseases including OA.
Private Health Sector
With over 50% of TJRs performed in the private sector, it is critical to include the input of private sector funders. Dr. Linda Swan is the Chief Medical Officer of Medibank Private LTD (MPL), Australia’s largest private health fund and sits on this Centre’s Stakeholder Advisory Council. This Centre will work closely with MPL to develop methods to access, analyse and interpret private hospital data that will inform our research and evaluate the impact of interventions in that sector.
The Victorian Department of Health and Human Services (DHHS) has auspiced a strategic advisory group, the Musculoskeletal Clinician Leadership Group: a multidisciplinary group of medical, nursing and allied health leaders whose mandate is to identify problems and solutions to assist DHHS focus its strategic efforts when dealing with MSK issues. Professor Peter Choong through his position as inaugural chair of this group and Chair of the OA Model of Care group, is in an ideal position to engage a broad range of stakeholders at the highest levels to evaluate needs, garner support and to drive change.
Broader research world through journal editorships
All Researchers will leverage their positions on the editorial boards of 17 top ranked international journals in the fields of orthopaedics and surgery (3), physiotherapy and rehabilitation (6), speciality medicine (3) primary care (3) and health economics (2) to profile the Centre’s work and also to promote further research and dialogue in this arena.
Development of the Health and Medical Research Workforce
We are strongly committed to capacity building both for the benefit of the program itself and to that of Australian medical research now and in future generations. Future leaders in the musculoskeletal field will require strong research translational capabilities and this centre with its multidisciplinary approach is ideally placed to provide the platform and networks which will help facilitate training and advancement opportunities to new researchers, particularly those with a capacity for independent research and future leadership roles
This centre will target a broad-range of key professional groups with a specific focus on orthopaedic surgeons and early/mid-career researchers from a variety of backgrounds including universities, hospitals and community clinics. Our key trans-disciplinary hub in Melbourne interacts strongly with collaborators interstate and internationally, offering graduate students, post-doctoral early/mid-career researchers unique opportunities to extend their research experiences.
We will generate a strategy for new researcher capability, mentoring and encouragement of further career development, targeting and supporting new researchers and provide mentoring strategies to integrating new researchers into the teams. We will also help facilitate collaboration with other groups in the field of research by building smart collaborations and team cohesion.
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