OPUS CRE Research Streams

Project Details

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. Postdoctoral Fellow: Aves Middleton


What are the knowledge gaps? 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.

Current work: We applied the recently validated OMERACT-OARSI criteria for response in 615 consecutive cases prior to and at 12 months after knee TJR. Based on these criteria we identified that 15% of these individuals were non-responders to surgery. 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 (BMI > 40kg/m2, Kellgren-Lawrence Grade ≤3, Pre-op WOMAC, and SF12 MCS Disability) from which we developed a nomogram (Figure 2 below) 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.

Workplan 2

Planned research:

Phase 1: External validation of the knee nomogram


We will externally test the predictive probabilities of the nomogram across centres representative of the broader knee TJR population. Professor Peter Choong, will lead a multicentre prospective cohort study, collecting the WOMAC as well as candidate predictors in order to externally test the predictive probabilities of the nomogram across centres representative of the broader knee TJR population. Coordination of this has commenced. We will also collaborate with Prof Alistair Gray and Senior Researcher Helen Dakin from the Health Economics Research Centre at Oxford Unuiversity who have a strong history of collaboration with Professor Philip Clarke, including over 10 co-authored publications. Gray and Dakin are co-investigators on a National Institute for Health Research (NIHR) funded project (HTA-11/63/01) to develop an ‘arthroplasty candidacy help tool’ for the UK. Specifically, this collaboration will assist with international external validation of the patient selection nomogram.

Phase 2: Testing acceptability/useability of the nomogram amongst patients and clinicians


Dr Darshini Ayton will assess i) the views of patients and clinicians of the usability and acceptability of the nomogram and ii) establish cut points at which the probability of non-response to knee TJR is perceived by patients and clinicians to outweigh the potential benefit of surgery. This will involve i) 15-20 interviews in patients with end-stage Osteoarthritis (OA) representing each of the explanatory factors of the nomogram, followed by ii) 3-4 patients and clinicians focus groups to test and confirm themes in a broader group and to explore the group interactions for agreement and disagreement around cut points. Directed content analysis methods will be applied using deductive coding to validate the nomogram. Inductive codes (emerging concepts) will be analysed to determine if they represent new categories or whether they expand on the existing deductive codes. 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.

Phase 3: Implementation of the nomogram

We will assess the acceptability of the nomogram amongst user groups. Professor Peter Choong will engage orthopaedic surgeons through the Australian Orthopaedic Association, and allied health professionals through the Musculoskeletal Clinician Leadership Group, and Professor Jane Gunn will engage primary care physicians through VicRen, the Victorian General Practice Research Network. Professor Jasvinder Singh, University of Birmingham, co-chairs the outcomes measures special interest group of OMERACT with Professor Peter Choong, will use this forum to assess the useability of the nomogram w 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: concurrent work is underway (Dowsey/Spelman/Inacio) on a hip TJR nomogram with model development informed by current work arising from the knee cohort.

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.

Translation

A web-based and ‘smart phone app’ enabled version of the nomogram will be developed with automated scoring for ready use by clinicians and patients and will be freely available, promoting the uptake and use of this tool. We have established a collaboration with Prof Michael Kattan, Cleveland Clinic, and the world-leading expert in prognostic nomogram development, validation, translation and use. Professor Kattan will provide expert guidance in developing the web- and application-enabled versions of our nomogram as he has done for numerous other health conditions (see website ‘The Kattan nomograms and how to use them’), including linking such tools to the registry data sources to permit ongoing updating of the nomogram as registry data accumulates. We have engaged an early career researcher, Aves Middleton, who has research interests and expertise in the use of technologies in health promotion and health services research. Aves will lead testing and translation of the nomogram under the mentorship of Professors Choong, Gunn and Kattan. This will include undertaking a 3-month visiting fellowship made possible through this CRE’s capacity building program outlined in Section 3.

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. Postdoctoral Fellow: Elizabeth Nelson.


What are the knowledge Gaps? Patients’ and surgeons’ assessments of the risks and benefits of TJR surgery; how this might influence expectation and; why surgeons offer surgery to inappropriate candidates have not been subjected to rigorous evaluation. Research in other domains indicate complex influences on clinicians’ decisions. 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 Cochrane 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.

Current research: We are conducting a first of its kind NHMRC funded study (APP1058438 - MARKA) that examines and compares benefit and risk preferences of patients with end-stage OA undergoing knee TJR with surgeon preferences. The study uses discrete choice experiments (DCEs) to i) explore how patients balance risks and benefits, ii) determine the extent these align with surgeons’ expectations, and iii) explores whether guiding patients through a decision making process prior to surgery improves patient expectations, health outcomes and satisfaction. MARKA aims 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 finalized with patient input, pre-tested for understanding and piloted in patients and surgeons. 

Results of the pilot data is startling. 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 ii) alter behavioural biases in surgeons who may be overconfident and believe that these outcomes would not occur for ‘their’ patients.

Planned research 

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.

Intervention design 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.

Phase 1: The DCEs of surgeons’ preferences for knee TJR

This will reveal the extent to which they focus on surgical risks or post-operative patient outcomes, and the extent to which these influence their decision to recommend surgery. It will inform the content of the feedback required to influence their decision to recommend surgery. In addition, the research will reveal the extent to which surgeons’ preferences are different to patients’ for the same risks and outcomes, again informing the content of the feedback intervention. The research 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. This will help inform the specific nature of the feedback and assist to tailor feedback according to surgeon profiles, to maximise the likely impact of the intervention.

Phase 2: Mixed methods research 

Utilising surveys and focus groups will explore surgeons’ beliefs about abilities, outcomes and risks and the context and process by which surgeons (and registrars) consent patients for surgery. This will help inform the timing, frequency and context of delivery of the feedback intervention through alignment with the decision-making context. The role of technology and data visualisation will also be explored in designing the feedback intervention.

Phase 3: Phase 1 and 2 will inform the design of the intervention and feedback 

The intervention will be sought through participatory workshops with surgeons and registrars prior to implementation. In addition to the MARKA study, we have recently been awarded a U of Melbourne Faculty of Business & Economics and Medicine, Dentistry & Health Sciences Collaboration Grant to undertake phase 2 and 3 of this research program, which will be critical for our proposed cluster RCT below.

Phase 4: We will conduct a cluster RCT 

The unit of analysis will be the surgeon or registrar/consultant dyad to evaluate the effect of a feedback intervention on patient pain and function. An economic evaluation will be conducted alongside the cluster RCT (Professor Philip Clarke).

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.

Translation: 

This research is of international importance because it is estimated that up to one third of TJR’s are performed in inappropriate candidates. Outcomes of this research have the potential to inform the teaching and training curriculum of relevant professional and educational bodies. Dr Ian Incoll, Chair of Education and Training, Australian Orthopaedic Association will assimilate the knowledge and principles of the feedback intervention into the teaching curriculum of Surgeons.

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. Postdoctoral Fellow: Samantha Bunzli, Alison Dale


What are the knowledge gaps? There is an imperative to find alternative care pathways/ interventions for the 15% of people who are unlikely to benefit from TJR. While multidisciplinary 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.

Current research: 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. The findings were far superior to current therapy interventions. CFT comprehensively operationalises and integrates a self-management program, targeting psychological (cognitive and emotional factors), physical (e.g. movement and avoidance) and lifestyle factors (e.g. obesity). The intervention addresses these targets using a tailored behavioural self-management 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 different phenotypes for the pain experience may be present which are differentiated by varying contributions from genetic, structural, psychological, physical and lifestyle domains, which in turn influence inflammatory processes and neurophysiological profiles. Our NHMRC (APP1035810 - Prof Gunn) has supported the identification of subgroups of patients undergoing TJR that are differentiated by their illness beliefs, arthritis self-efficacy, anxiety, depression and catastrophising.

Planned research

Workplan #3 will develop and test a personalised therapy approach for those at risk of poor outcome after knee TJR in a multi-centre randomised controlled trial. We have adapted a personalised CFT approach from CLBP for the management of end-stage OA. However, research establishing the effectiveness of this approach is needed. This approach offers 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:

  • Specific targeting of the factors that are likely to be operational in those at risk, namely psychological, physical and lifestyle factors;
  • Integration of targeting of relevant factors from different domains within single treatment sessions by a single specialised Healthcare Professional, who integrates with further expertise from a medical practitioner and psychologist as needed. This is in the case of morbid obesity or uncontrolled mental health problems presenting significant barriers to behavioural change.
  • Specific focus on self-management strategies, utilising motivational techniques known to be effective for behaviour change such as reflective listening and experiential behavioural learning. This is targeted towards providing pain control through behavioural and cognitive strategies, physical activation and weight loss.

Draws 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.

Workplan #3 will be led by Professor Peter O’Sullivan and Associate Professor Anne Smith, who along with Dr Kieran O’Sullivan have developed and tested the CFT intervention in CLBP with Professor Smith having previous NHMRC supported track record in the field of TJR and knee OA. Associate Professor Peter Kent will provide experience in prognostic and subgrouping methodology. A post-doctoral fellow, Dr Bunzli, will apply her experience in mixed methods and models of health behaviour in CLBP to play a key role in understanding the application of CFT from both the Healthcare Professional and patient perspective to inform the development of personalized CFT care in this group. The development and testing of CFT in this population has two phases:

Phase 1: Development of an understanding of factors driving pain and disability in this group of patients at risk of poor outcome after knee TJR. 

Qualitative explorations of both pre-surgery patients at risk of non-response, and patients identified as non-responders to surgery 1-2 years post-operatively. This will inform development of the treatment protocol and training model for phase 2.

Phase 2: A CFT intervention is currently being developed 

Will be trialled in two case series of knee TJR candidates with two or more of risk factors identified from current research in Workplan#1, which is supported by University of Melbourne Research Grant Support Scheme (2015). Case-series will be conducted in Perth, Australia (private orthopaedic setting) and in Limerick, Ireland (secondary care orthopaedic hospital clinic setting). A comprehensive quantitative and qualitative evaluation will be conducted. The specific level of risk used as the criterion for inclusion in both these phases will be further informed by findings of Workplans#1 and #2.

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.

Translation

As this research will be embedded in existing hospital and private orthopaedic settings, it will be immediately translatable to clinical practice e.g. incorporated in to clinical practice guidelines. Prof Peter O’Sullivan and Dr Keiran O’Sullivan have extensive national and international experience in delivery of a training model already established for management of CLBP, which will be adapted for knee OA.

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. Postdoctoral Fellow: Sina Babazadeh


What is the knowledge gap? 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. Workplan#4 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 in the Australian healthcare setting and internationally.

Current research: A pilot cohort study to inform Workplan#4 undertaken at SVHM examined the impact of day of mobilisation on length of stay and complications. Overall, 37% who mobilised within the first 24 hours following TJR had a shorter mean length of stay compared to patients mobilised after 24 hours (4.4 days [SD 1.3] v 5.1 days [SD 1.8]; p=0.0004). 23% experienced one or more post-operative complications. There were fewer post-operative complications in the early mobilisation group (16% v 26%; log rank test p=0.03). Early mobilisation was associated with a 45% reduction in post-operative complications. Our NHMRC (APP1057736 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.

Planned research

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 has five major interlinked avenues of investigation:


Phase 1: To develop a multimodal enhanced recovery program through engagement of the key TJR care-providers.
Phase 2: To investigate the clinical and economic impact of the enhanced recovery program in a single-centre pragmatic, assessor blinded, parallel design, randomised controlled trial.
Phase 3: To tailor implementation of the enhanced recovery program through Action Research Cycle with feedback from key stakeholders including care-providers and consumers.
Phase 4: To undertake a modelled health economic analysis comparing post-operative complications with the refined enhanced recovery program compared to standard post-operative care in a multi-centre, pragmatic, assessor blinded, parallel design, RCT.
Phase 5: To tailor implementation of the enhanced recovery program through feedback from key stakeholders including care-providers and consumers to develop strategies for the results to inform clinical practice guidelines.


We have received funding through the BUPA Health Foundation to undertake phases 1-3. In addition to examining the impact on length of stay and cost-effectiveness, phase 1-3 of this research program is critical in informing phases 4-5. Phases 4–5 will examine the impact of the enhanced recovery program on post-operative complications and will be addressed in a larger, multicentre trial forming part of an NHMRC project grant application. The implementation of phase 4-5 will draw on networks established by the research team and will be enriched by data from phases 1-3. This research will be conducted in the ‘real-world’ comparing the clinical and cost-effectiveness of an enhanced recovery program. All analysis will be in accordance with the Medical Research Council Framework. Professor's Nicolas Taylor, Peter Choong and Dr Trisha Peel have successful NHRMC track records in RCTs including multicentre, complex interventions, (APP1019866, 1057736, 541958, 602535, 387421, 509129). Associate Professor Michael Barrington, an academic anaesthetist with an interest in regional anaesthesia in TJR, will have a key role in developing an evidence-based anaesthesia approach. The post-doctoral fellow, Dr Babazadeh is a trainee orthopaedic surgeon who completed his PhD (2013) on TJR and will graduate as a surgeon in 2017. He will assist in the conduct of the trial using this experience to pursue a career in academic orthopaedics.

Expected Outcomes and significance: 

Workplan#4 will provide new knowledge about the clinical and health economic benefits of this multimodal enhanced recovery program 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.

Translation

This research, which is of national and international relevance, is embedded in ‘real-life’ hospital settings, including a mix of metropolitan and rural, public and private hospital, and is therefore immediately translatable to clinical practice through incorporation into clinical practice guidelines. The combined expertise of the research team including surgery, medicine, pain control and rehabilitation and their established links with key organisations will ensure a strong foundation for the multidisciplinary approach this Centre is pursuing. The Stakeholder Advisory Group representing the varied interests of the community, patients, regulator, funder, provider, institution and health professionals will have a critical role in ensuring that the focus of efficiency, safety and cost-effectiveness balances the imperatives of demand and supply.

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). Specifically, we will tailor our approach on (i) the views of end-users (clinicians, administrators and policy makers), (ii) the needs of intervention target groups to achieve maximal reach; and (iii) the range of settings in which the intervention can be applied. This approach recognizes 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 that specifically includes both outcomes and cost data. We 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: (Prof Clarke and Graves) supported by experienced outcomes modellers (Dr Spelman and Prof Kattan) and their exhaustive networks, and the experience (Duckett, Pike, Swan) 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, including where appropriate, for commercial gain

We shall capitalize on our team’s extensive experience in networking to build a strongly connected translation community to ensure high impact interventions (best evidence, broad reach, cost effective). 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 skills-based SAC will include key leaders with experience in Government (Bronwyn Pike –past State Health Minister with current interests in health benchmarking), Health policy advice (Stephen Duckett –architect of casemix funding and current Health Program Director of Grattan Institute), Guideline development and promulgation (Andrew Briggs, co-developer of OA management guidelines WA and VIC), Private health funder (Dr. Linda Swan, Medical Director, Medibank Private LTD), Consumer advocacy (Linda Martin, CEO Arthritis & Osteoporosis Victoria), Australian Orthopaedic Association National Joint Replacement Registry (Prof. Richard de Steiger, Deputy Director), Regulatory authority (A/Prof Bruce Love, Member, Prosthesis Listing Advisory Committee), Training (Dr. Ian Incoll, Australian Orthopaedic Association), Hospital administration (A/Prof. Patricia O’Rourke, CEO, St. Vincent’s Health (Public) Australia), Department of Health (Dr. Judith Abbott, Section Director, DHS Victoria). This 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 in the planning, implementation and uptake of the research program
Orthopaedic Surgeons

Practice change in TJR, must be led by orthopaedic surgeons. The Centre will leverage CI Choong’s position as the Chair of the Australian Orthopaedic Association (AOA) Research Committee and member of the Arthroplasty Society of Australia (ASA) to reach surgeons and trainees. This will be through AOA’s and ASA’s annual scientific meetings, continuing professional development program, continuing orthopaedic education committee seminars, regular e-bulletins and newsletters. AI Incoll current Vice President AOA leads the AOA curriculum review and implementation initiative (AOA21), which will be integral to embedding this Centre’s findings into the new orthopaedic training curriculum. Prof. De Steiger is the deputy director of the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) and member of the Stakeholder Advisory Council. A major strength of the AOANJRR is its ability to track changes in TJR practice, which it regularly reports publically. The Centre will leverage its relationship with the AOANJRR to develop methods to evaluate the effectiveness of implementation activities. The Centre’s relationship with the Swedish knee registry, the Scottish joint registry and the Kaiser-Permanente (USA) joint registry will inform a better understanding of the drivers of surgeon decisions, and practises. For example, we are comparing mortality data with Kaiser-Permanente and we have conducted a preliminary external validation of the Nomogram with the Swedish Knee Registry.This Centre will leverage the network of the AOA National Orthopaedic Academic Departments (NOADS) to create opportunities to harness clinical resources and expertise of leading orthopaedic research programs and to pool institutional datasets to create for the first time a national data resource of considerable size and depth.

Primary Care

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 and Medicare Locals of which Prof Gunn is past-President and Chair, respectively. Using her role as foundation Chair of Victorian Primary Care Research Network (VicReN) CI-Gunn will engage general practitioners in a broad spectrum of clinical settings to test the useability of the nomogram (Workplan#1).

The Community

Community Advocacy Groups 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. Specifically, AOV will be built into this Centre’s activities through membership of key Centre committee.

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.

Health authorities

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

The CI’s 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.

Read more about our staff.

Chief Investigators

Associate Investigators

Advisory Committee

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References

Cobos R, et al. Variability of indication criteria in knee and hip replacement: an observational study. BMC Musculoskelet Disord. 2010;11.

Dowsey MM, et al. Associations between pre-operative radiographic changes and outcomes after total knee joint replacement for osteoarthritis. Osteoarthritis Cartilage. 2012;20.

Baker PN, et al. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Joint Surg Br. 2007;89.

Hoffmann TC, et al. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175.

Wylde V, et al. Patient-reported outcomes after total hip and knee arthroplasty: comparison of midterm results. J Arthroplasty. 2009;24.

Wylde V, et al. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain. 2011;152.

Riddle DL, et al. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. 2014;66.

Strategic Review of Health and Medical Research in Australia. Consultation Paper Summary. Canberra: Department of health and Ageing, Australian Government, 2012.

Escobar A, et al. Patient acceptable symptom state and OMERACT-OARSI set of responder criteria in joint replacement. Identification of cut-off values. Osteoarthritis Cartilage. 2012;20.

Dowsey MM, et al. Associations between pre-operative radiographic osteoarthritis severity and pain and function after total hip replacement : Radiographic OA severity predicts function after THR. Clin Rheumatol. 2014.

Choong PF, et al. Obesity in total hip replacement. J Bone Joint Surg Br. 2009;91.

Dowsey MM, et al. The impact of obesity on weight change and outcomes at 12 months in patients undergoing total hip arthroplasty. Med J Aust. 2010;193.

Dowsey MM, et al. The impact of pre-operative obesity on weight change and outcome in total knee replacement: a prospective study of 529 consecutive patients. J Bone Joint Surg Br. 2010;92.

Paulsen MG, et al. Preoperative psychological distress and functional outcome after knee replacement. ANZ J Surg. 2011;81.

Escobar A, et al. Patient acceptable symptom state and OMERACT-OARSI set of responder criteria in joint replacement. Identification of cut-off values. Osteoarthritis Cartilage. 2012;20.

Dowsey MM, et al. Latent Class Growth Analysis predicts long term pain and function trajectories in total knee arthroplasty: a study of 689 patients. Osteoarthritis Cartilage. 2015.

Davies P, et al. A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations. Implement Sci. 2010;5.

Ivers N, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6.

John OP, Donahue, E.M., Kentle, R.L. The Big Five Inventory-Versions 4a and 54. University of California, Berkeley, Institute of Peronality and Social Research. 1991;Berkeley, CA.

Pearlin LI, et al. The structure of coping. J Health Soc Behav. 1978;19.

Scheier MF, et al. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the Life Orientation Test. J Pers Soc Psychol. 1994;67.

Scott IA, et al. Foregoing low-value care: how much evidence is needed to change beliefs? Intern Med J. 2013;43.

Hill JC, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378.

CI Vibe Fersum K, et al. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: a randomized controlled trial. Eur J Pain. 2013;17.

Kittelson AJ, et al. Future directions in painful knee osteoarthritis: harnessing complexity in a heterogeneous population. Phys Ther. 2014;94.

Dimitroulas T, et al. Neuropathic pain in osteoarthritis: a review of pathophysiological mechanisms and implications for treatment. Semin Arthritis Rheum. 2014;44.

Holla JF, et al. Predictors and outcome of pain-related avoidance of activities in persons with early symptomatic knee osteoarthritis: a five-year followup study. Arthritis Care Res (Hoboken). 2015;67.

Lluch Girbes E, et al. Pain treatment for patients with osteoarthritis and central sensitization. Phys Ther. 2013;93.

Riddle DL, et al. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res. 2010;468.

Skou ST, et al. Knee Confidence as It Relates to Self-reported and Objective Correlates of Knee Osteoarthritis: A Cross-sectional Study of 220 Patients. J Orthop Sports Phys Ther. 2015;45.

Caneiro JP, et al. Cognitive functional therapy for the management of low back pain in an adolescent male rower: a case report. J Orthop Sports Phys Ther. 2013;43

O'Sullivan K, et al. Cognitive Functional Therapy for Disabling Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study. Phys Ther. 2015;95.

Smith AJ, et al. Pre-surgery knee joint loading patterns during walking predict the presence and severity of anterior knee pain after total knee arthroplasty. J Orthop Res. 2004;22.

Smith AJ, et al. A kinematic and kinetic analysis of walking after total knee arthroplasty with and without patellar resurfacing. Clin Biomech (Bristol, Avon). 2006;21.

Smith AJ, et al. Total knee replacement with and without patellar resurfacing: a prospective, randomised trial using the profix total knee system. J Bone Joint Surg Br. 2008;90.

unzli S, et al. Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear. BMJ Open. 2015;5.

Bunzli S, et al. Lives on hold: a qualitative synthesis exploring the experience of chronic low-back pain. Clin J Pain. 2013;29.

Feldstein AC, et al. A practical, robust implementation and sustainability model (PRISM) for integrating research findings into practice. Jt Comm J Qual Patient Saf. 2008;34.

Research Group

CRE in Total Joint Replacement - OPUS


School Research Themes



Key Contact

For further information about this research, please contact the research group leader.

Department / Centre

Surgery Research

Unit / Centre

CRE in Total Joint Replacement - OPUS