Title: Evaluating the clinical and cost effectiveness of total joint replacement
Partners: The University of Melbourne Department Of Surgery and Department of Orthopaedics St Vincent’s Hospital
Supervisors: A/Prof Michelle Dowsey, Prof Peter Choong, Prof Philip Clarke
Background: Annually more than 100,000 joints are replaced in Australia, making it one of the most common elective surgical procedures in this country. Joint replacement numbers are expected to double within the next 30 years and while considered a highly successful procedure, controversies exist regarding best practice in several key areas of surgical practice. These controversies include; patella resurfacing and the use of computer navigation in total knee replacement, surgical approach and cementation techniques in total hip replacement. Despite numerous randomised controlled trials interrogating these issues, there remains little definitive evidence to preference one practice over another and as a consequence, decisions are largely based on surgeon preference.
Although joint replacement has proven to be cost-effective treatments for end-stage osteoarthritis, studies have also shown that the cost of surgery can vary between patient subgroups. Measuring value and understanding the cost of services is imperative in healthcare where providers are challenged to balance between the provision of quality care and cost containment. This study will use a unique dedicated clinical registry that includes high quality patient reported outcome measures for a group of nationally representative joint replacement patients, to interrogate the cost implications of common surgical practices.
The St. Vincent’s Melbourne Arthroplasty Outcomes Registry (SMART) is a registry which collects both clinical and patient reported outcomes in patients who have undergone elective lower limb joint replacement at St. Vincent’s Hospital. The registry has recorded information on patient demographics, surgery details and death for these patients since 1998. From 2006, the collection of patient reported HRQL was initiated and patients are followed-up at regular time intervals. Using techniques such as instrumental variable analysis, propensity score analysis and Markov modelling, the aim of this study will be to evaluate the clinical and cost effectiveness of common surgical practices and in doing so inform the evidence base for surgical decision making in total joint replacement
Preferred prerequisite studies: Orthopaedics/Musculoskeletal Disease, Epidemiology, Health Economics
Title: Optimal Pain Assessment in Joint Replacement Patients
Partners: The University of Melbourne & the University of South Australia
Supervisors: A/Prof Michelle Dowsey, Adjunct A/Prof Maria Inacio
Background: The lifetime risk of an Australian undergoing a knee or hip replacement is 10-12% and annually almost 100,000 joints are replaced in Australia, making it one of the most common elective surgical procedures in this country. Patients have joint replacement surgery because of severe arthritis that causes them debilitating pain and limited function. While this surgery should provide patients with substantial, if not complete, pain relief from their disease, post-surgical pain is common. Thirty eight percent of patients present to their general practitioners within 30 days post-surgery for assistance with pain management.
Up to one third of patients report chronic post-operative pain and 19-42% still take opioids one year after surgery. Opioids are strong pain relief medications associated with significant side effects, including intoxication, dependency, and abuse, with limited evidence of their long term efficacy. Because of the accumulating evidence of the detrimental effects of opioid use and ineffectiveness for long term pain relief, understanding post-surgical use of opioids for pain relief and rehabilitation in joint replacement patients is needed.
To determine the effect of opioids in the post-operative pain relief of joint replacement patients, this study will compare patient reported pain, function, and other patient assessments with their analgesic medication use, with great focus on opioid medication use. We will determine how opioid use is associated with patient reported pain, whether changes in pain are associated with changes in opioid use, and identify patient groups at a high risk for suboptimal opioid use. Our study’s findings will be useful to patients who have joint replacements and their providers, who struggle in balancing the risks and benefits of opioid therapy when recommending pain management treatment.
The study will use a unique dataset, which is a dedicated clinical registry that includes high quality patient reported pain assessments for a group of nationally representative joint replacement patients. Characterising the progression of pain after joint replacement and patients at risk of sub-optimal opioid use will assist and aid clinicians in the identification of patients that will benefit from additional education and support for pain management as well as inform the development of opioid use protocols post-surgery.
Preferred prerequisite studies: Epidemiology, Phamacology or Pharmacoepidemiology, Orthopaedics/Musculoskeletal Disease.
Title: Developing a patient reported outcome measure for joint replacement patients.
Supervisors: A/Prof Michelle Dowsey, Dr Darshini Ayton, Dr Samantha Bunzli, Prof Peter Choong
Partners: St Vincent’s Hospital, University of Melbourne, Monash University
Background: The Australian Commission on Safety and Quality in Health Care recognises that patient reported outcome measures (PROMS) are an emerging method to assess the quality of health care from the patient perspective. A patient-reported outcome (PROs) is a patient’s assessment of their health and well-being without input from a clinician or anyone else. PROs measure the patients’ quality of life, not the clinician’s quality of care. However, insight in patients’ quality of life can indicate where health care system improvement is needed. Joint replacement surgery is one of the most common elective procedures undertaken in Australia with almost 100,000 joints replaced annually. Therefore, exploring PRO for patients undergoing joint replacement surgery will improve understanding of recovery and inform the provision and delivery of health and support services.
The aim of this project is to develop and validate a new PROM for joint replacement patients using patient centred methods. The PROM will be brief to increase clinical utility. A mixed methods approach will be undertaken and will involve focus groups and interviews with patients to identify outcomes, a discrete choice experiment survey to test preferences of outcomes and a Rasch analysis to validate the outcomes.
Preferred prerequisite studies: Epidemiology, Health Economics, Orthopaedics/Musculoskeletal Disease
Title: Predicting outcomes for people with knee osteoarthritis in general practice
Supervisors: A/Prof Michelle Dowsey, Professor Jane Gunn, Dr Jo-Anne Manski-Nankervis
Partners: University of Melbourne
Background: Knee joint replacement (KJR) for people with osteoarthritis offers the potential for improvement of pain and increased function. However, it is estimated that 12%-20% of those who undergo primary KJR do not TKA do not report such benefits. A nomogram has been developed using data from the St Vincent’s Hospital SMART joint replacement registry which can be utilised to predict the probability of non-response to surgery at 12 months. However, this is based on a hospital patient population, not a general practice population.
Osteoarthritis is the fifth most commonly managed chronic condition in general practice, with the aging population and obesity being drivers for both increasing prevalence and referrals for KJR. The majority of referrals from GPs for management of osteoarthritis of the knee are to orthopaedic surgeons – there is a need for the development of a risk prediction tool for use in the general practice setting that can inform appropriate referral to orthopaedic surgeons for consideration of KJR based on the likelihood of response. This PhD project will involve the development of such a tool by linking a large general practice dataset to the SMART joint registry. The candidate will be supported by a multidisciplinary team of researchers as part of the Centre for Research Excellence in Total Joint Replacement (OPUS). Thesis with publication will be supported.
Preferred prerequisite studies: Health Economics, Statistics, Psychology
Title: Using health-related quality of life scores as predictor of outcomes and to advance health economic evaluation methodologies in lower limb arthroplasty patients
Supervisors: A/Prof Michelle Dowsey, Professor Philip Clarke
Partners: University of Melbourne
Patients undergoing lower limb surgeries are generally older patients with considerable co-morbidities hence their competing risk of death and potential surgery-related complications can be high. Although surgeries such as total knee replacements (TKR) have proven to be cost-effective treatments for end-stage osteoarthritis studies have shown that the cost of TKR can vary between patient subgroups; for example, TKR has been found to be more cost-effective in younger patients and those classified as low-risk based on age and co-morbidities. Measuring value and understanding the cost of services is imperative in healthcare where providers are challenged to balance between the provision of quality care and to cost contain.
The St. Vincent’s Melbourne Arthroplasty Outcomes Registry (SMART) is a clinical registry which collects both clinical and patient reported outcomes in patients who have undergone elective lower limb arthroplasty at St. Vincent’s Hospital. The registry has recorded information on patient demographics, arthroplasty details and death for these patients since 1998. From 2006, the collection of patient reported HRQL was initiated and patients were followed-up at regular time intervals. Patients’ hospitalisation and surgery costs will be extracted from routinely collected administrative data at St. Vincent’s Hospital.
This project aims to use the registry data to demonstrate that health-related quality of life (HRQL) scores can be used to independently predict outcomes such as mortality, needed for revisions or surgery-related complications and to develop a risk assessment tool to assess outcomes in patients undergoing lower limb arthroplasty. These findings have the potential to add clinical value in informing the potential effectiveness and cost-effectiveness of the surgery in these patients.
Preferred prerequisite studies: Health Economics, Statistics, Psychology, Quali/Quantitative Analysis
Title: Improving physical activity post hip and knee arthroplasty
Partners: La Trobe University and The University of Melbourne
Background: Hip and knee replacement surgery is an appropriate intervention for severe osteoarthritis unresponsive to conservative management. However, studies have shown that physical activity levels of individuals who undergo hip and knee replacements fail to meet the World Health Organisation’s minimal physical activity recommendations. Consequently, physical activity levels remain reduced despite individuals experiencing a reduction in pain, improved physical functioning and an enhanced ability to mobilise.
Reduced physical activity is associated with higher incidences of health risk factors, ultimately resulting in higher all-cause mortality rates for people with hip and knee replacements, when compared to the average population. As the rates of hip and knee replacement surgery continue to increase, failure to address the issue of reduced physical activity leaves these people at greater risk of early mortality from otherwise preventable health conditions. Evidence from other fields of rehabilitation have shown that patients who participated in an appropriately structured rehabilitation program achieved long-term behavioural change in the area of increased physical activity levels.
This project will comprise of a number of research studies that progressively addresses the question. Firstly, a systematic review of literature identifying physical activity levels and physical function post hip or knee replacement will be conducted. Second, an observational study of physical activity levels and factors associated with those levels. Third, an intervention in the form of a randomised controlled trial. Fourth, a qualitative study on the perceptions of participants in the interventional study. The goal of these studies is to assist rehabilitation clinicians to identify a method of delivering rehabilitation post-lower limb arthroplasty that increases physical activity levels, and to inform post-surgical rehabilitation protocols in this patient population.
Preferred prerequisite studies: Physiotherapy, Rehabilitation, Orthopaedics/Musculoskeletal Disease
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