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.