The Centre for Research Excellence for OPtimising oUtcomes, equity, cost effectiveness and patient Selection (OPUS) in Total Joint Replacement will transform the research and practice landscape of joint replacement surgery, and promote critically needed stewardship to optimise management for better outcomes and reduced costs for this high volume and expensive procedure.
OPUS draws together Australian and international experts in clinical care, health economics, outcomes modelling, and implementation research to address unprecedented demand for the procedure (100,000/yr and rising), burgeoning costs ($4.5 billion/yr) and unresolved dissatisfaction (up to 1 in 3 patients).
Scope of the Problem
Osteoarthritis – A leading contributor to the Global Burden of Disease.
Half of all Australians over 65 years are affected by osteoarthritis (OA) of the knee and hip. OA, which is the largest contributor to the global burden of musculoskeletal (MSK) disorders, has the sharpest upward trajectory across the MSK conditions (58% increase in the next 2 decades). With musculoskeletal (21%) rivaling mental and behavioural (23%) disorders for the greatest proportion of years lost through disability, the Global Burden of Disease Study has identified the former as one of the top three priorities that require urgent policy responses.
Use of Total Joint Replacement as a Treatment to Osteoarthritis
Current guidelines recommend non-surgical interventions for the majority of people with OA. In a proportion, however, OA progresses to a point where these interventions are considered ineffective and total joint replacement (TJR) becomes the only option to improve their quality of life.
Key Issues Involving Total Joint Replacements
Although TJR has revolutionized the treatment of patients crippled by end-stage OA and has been referred to as the operation of the century there is growing concern related to cost, demand and dissatisfaction that compels a reassessment of how TJR should be best deployed.
TJR is a highly cost-effective procedure for treating end-stage OA. Alarming increases in incremental and total costs of this procedure as well as projected rises in disease burden have raised considerable concern about the sustainability of current practices in the Australian private sector alone. In 2013, the direct cost of total knee and hip TJR was $414 million and $522 million respectively. These represent a rise in cost of 20% and 25%, respectively from the previous year.
It is also estimated that one quarter of TJRs are performed in inappropriate candidates at an average cost of $21k per procedure, suggesting that up to $284 million of healthcare expenditure may be attributed to overuse of TJR each year in Australia. Moreover, post-operative complications add a further 18% of direct hospital costs ($210 million) in the first 30 days following TJR. The total direct cost of joint replacement surgery (public and private) in Australia in 2013 approximated $1.5 billion dollars. If indirect costs are estimated to be twice the direct costs, then the combined cost (direct and indirect) of treating end-stage OA with TJR is almost $4.5 billion. This represents almost 10% of all hospital costs ($55.9 billion) in Australia for the same period.
In 2014, almost 100,000 Australians received TJRs, representing an increase of 45% in hip and 77% in knee procedures since the first year of complete national TJR data collection in 2003. The annual number of TJRs is expected to double by 2030. This is consistent with overseas trends where TJR is projected to rise between 300-600% in the United States by 2030.
This may reflect lack of alignment of patient perception and operator expectations. The costs are high and can be reduced. Approximately 15-30% of patients remain dissatisfied following TJR, even in the absence of acute complications such as infection. Recent research indicates that the majority of patients undergoing surgical interventions overestimate the expected benefit and underestimate the harm and it is this imbalance that leads to dissatisfaction levels as high as 49% in TJR recipients compared to 6% in those whose expectations have been met. Patients regard this as a ‘poor outcome’, which leads many to seek ongoing care including implant revision of the implant or non-surgical therapies. This dissatisfaction is estimated to cost Australia $405 million from non-beneficial surgery in 2014.
We will cover clinical processes (Professors Peter Choong, Jane Gunn, Peter O’Sullivan, Nicolas Taylor, Peter Kent, Associate Professor Anne Smith and Dr Trisha Peel), decision making (Professor Anthony Scott and Associate Professor Michelle Dowsey), mixed outcomes (Professor Michael Kattan and Dr Tim Spelman), economic modelling (Professors Philip Clarke and Nicolas Graves) and implementation science (Professor Jane Gunn and Associate Professor Anne Smith) for interpretation and generalisation of our findings. These specialty areas of the patient journey are further defined through four research streams and related objectives:
Prognostic factors and outcomes modelling: We will Validate our risk prediction tool (nomogram) to identify preoperatively those patients likely to benefit and not benefit from total joint replacement.
Shared decision making: We will develop a framework that facilitates informed consent by clarifying, quantifying and aligning patients’ and surgeons’ aversion/acceptance of risk.
Non-surgical therapies: We will explore the barriers, develop and optimise conditions for a novel evidence-based multi-dimensional non-surgical intervention as an alternative to total joint replacement.
Hospital services coordinated care: We will develop a framework for a safe, efficient, cost-effective, enhanced recovery program after total joint replacement that leverages coordinated multidisciplinary care.
An overarching transfer theme across all four work plans will also promote effective transfer of research outcomes into health policy and/or practice
These streams will focus on appropriate patient selection, informed consent, multidimensional cognitive therapies, and enhanced recovery care programs, respectively. Patient-centric safety and quality data, augmented by robust economic analysis, will underpin policy decisions, drive practice change and improve cost-effective, efficient and safe joint replacement surgery. Drawing on the experience and expertise of this multidisciplinary Research Team, dissemination, translation and implementation will be achieved through engagement of a scientific advisory council, annual stakeholder workshops, practical tools to aid community and specialist practitioners, and health professional training.
Capacity building will be realized through funding PhD scholarships and post-doctoral fellowships in this priority area, developing mentorship pathways for the future leaders, informing and influencing surgeon training, and developing and delivering training materials for professional capacity building Australia-wide. OPUS will engage a national team of research collaborators by providing a coordination and integration hub that will target and leverage all levels of NHMRC, ARC and NGO investment in musculoskeletal research. Through its unique and highly innovative approaches, OPUS will have a significant global impact by informing iterations of existing and future models of osteoarthritis care.
The Work of this Centre will lead to:
Investigators Critical Mass
A critical mass of investigators from various disciplines at the leading edge of world research with the skills to develop tools, respond to changes in practice or unexpected consequences of orthopaedic care identified through our large databases and to ensure that novel global changes in practice are rapidly tested for their place in the Australian system.
Initially a tool to identify likely responders from non-responders of TJR will be developed and translated to practice, assessing its performance in high and low volume practices in rural and city locations. Translated and validated, this tool will inform appropriate patient selection. This will lead to significant cost savings by avoiding unnecessary and inappropriate surgery.
A patient and surgeon “risk inventory” to help patients and surgeons understand their aversion/acceptance of risk and through this to highlight miss-alignments of expectations thereby enhancing the informed consent process. A translated and validated feedback intervention for surgeons will inform evidence-based decision-making and has the potential to minimise inappropriate surgery.
Ongoing Review Structures
Ongoing review of new evidence-based treatment alternatives developed and assessed by our team or others for those patients unlikely to benefit from TJR. This will provide an alternative to the primary surgical procedure for this cohort of patients and will lead to significant reductions in healthcare costs.
Heath Economic Advantages
New knowledge about the clinical and health economic benefits of a multimodal pathway of care, leading to the development of evidence-based guidelines for patient care following TJR. In addition, accelerated pathways may lead to significant reductions in healthcare costs through decreased length of stay and reduced post-operative complications.
New Osteoarthritis National Researchers
Expansion in the cadre of multidisciplinary OA researchers through the Centre with PhD, Master’s and post-doctoral scientists immersed in this leading Australian centre at the cutting edge of research in orthopaedics . This will create a wide network of future leaders to equip our health professionals and health systems with evidence-based solutions in this global health priority area.
New knowledge will form the curriculum development for the Australian Orthopaedic Association (AOA) surgical training program. This Centre will also integrate with the National Orthopaedic Academic Departments to establish expert research sites for the AOA Surgeon-Scientist program. This will ensure that orthopaedic surgeons of the future practice TJR in a multidisciplinary environment, cognisant of and guided by the evidence for and against surgery.
Revolutionary studies and tools created by our team prior to the inception of OPUS
St. Vincent’s Melbourne Arthroplasty Outcomes (SMART) Registry which is a unique Australian resource developed by Professor Peter Choong and Associate Professor Michelle Dowsey. It holds data pertaining to over 11,000 total joint replacement procedures undertaken in over 8,500 consecutive patients, growing by 800 procedures/year, and yielding an extensive range and depth of demographic, surgical, functional outcomes and quality of life data.
There are very few publications on costs of total joint replacement in Australia; Our group has published 3 and counting! This research has highlighted the important influence of patient, surgical, non-surgical interventions and health services factors on patient outcomes and health economics
SMART in Action
First to show that radiologic osteoarthritis severity correlated with pain after total joint replacement surgery, a study that the International Society of Osteoarthritis Research considered as one of the most important pieces of work in 2013.
Computer assisted (CAS) knee total joint replacement study
First RCT ever to show the correlation between accuracy of surgery and sustained patient outcomes and satisfaction, setting the scene for the adoption of CAS in Australia that has now translated into longer survival of prosthesis
with this technique.
Mindfulness based cognitive therapy Approach
An international first trial and multidisciplinary collaboration between orthopaedic surgeons and psychiatrists that examines mindfulness in patients undergoing total joint replacement. This major piece of work has led to the development
and use of the common sense model to examine the interrelationships between quality of life and clinical symptom severity in patients with end-stage osteoarthritis.
Clinical pathways in total joint replacement study
First RCT ever to demonstrate the efficacy of clinical pathways for shortening LOS, and has been cited in a Cochrane Review on clinical pathways and translated into practice pathways for total joint replacement across Australia and
Direct hospital costs study
Only publication using Australian data to examine cost determinants of total joint replacement, informing our successful BUPA Foundation Grant, which underpins Workplan#4.
The following metrics highlights the experience and expertise of our team to date (June 2016).
|Cumulative Research Funding||$100,000,000+|
OPUS has been made possible thanks to the generosity of the National Health and Medical Research Council and their commitment to funding projects of national importance. All OPUS outputs are acknowledged in recognition of this generosity as below:
This study/work/research is supported through the NHMRC Centre for Research Excellence in Total Joint Replacement (APP1116235), awarded to the University of Melbourne, Department of Surgery, St. Vincent’s Hospital
Researcher X receives funding support from the NHMRC Centre for Research Excellence in Total Joint Replacement (APP1116235), awarded to the University of Melbourne, Department of Surgery, St. Vincent’s Hospital
Researcher X is the recipient of a NHMRC Centre for Research Excellence in Total Joint Replacement (APP1116235) Scholarship, awarded to the University of Melbourne, Department of Surgery, St. Vincent’s Hospital