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Appropriateness of joint replacement:
A multi-stakeholder approach
Claudia Sanmartin, Carolyn DeCoster, Gillian Hawker March 28, 2012Ottawa, Ontario
Why Appropriateness?
• Traditional focus on supply-side management of waiting times
• Increasing supply increases demand
• Demand-side management requires definition and management of appropriateness
• Perspective matters
Agenda – WCWL Appropriateness research
• Program of research oriented toward the development of a multi-stakeholder decision-support tool for appropriateness of total knee and hip replacement
– Patient input - focus groups– Surgeon input – interviews– Decision-maker - ???
Patient input– Key Findings
• Consistent with previous studies in physician experts, patients with hip/knee OA identified arthritis severity & motivation as key considerations when evaluating appropriateness for TJR
– spoke less about capacity to benefit (risks versus benefits)
• Patients’ pain experience (impact on quality of life, ability to cope) was seen as the most important determinant
– Inadequately evaluated by clinicians
– Need to enhance surgeon-patient communication and use of standard tools to measure pain from the
patients perspective
5
Surgeon input - Summary
• Part 1: Criteria used to determine appropriateness– Age – overarching theme used to interpret and assess other criteria which
may differ for younger versus older patients– Pain and function (quality of life)– Surgery as a last resort– Patient expectation– Social situation– Mental or psychological health– Comorbidities
• Part 2: Risks versus Benefits– Immediate risk (comorbidities) versus benefits– Long-term risk (health of joint) versus benefits– Risks versus potential to benefit
• Part 3: Views on ……– Role of other key stakeholders – decision-makers should not be involved
in clincial decision– Usefulness of a decision-making tool – OK to standardize assessment and
data – did not want an « absolute » number to identify inappropriate patients
PAIN/FUNCTION
JOINT CONDITION
Patient Information: Age, gender, joint/side, previous joints
COPING(Patients: related to pain,
difference by age)
SOCIALCIRCUMSTANCES
(support current and post-op
PATIENT EXPECTATIONS
(rehab and and post-op
“READINESS”/MOTIVATION
CO-MORBIDITIES
(Include mental health)
SURGICAL RISK
CAPACITY TO BENEFIT
Patient reported Surgeon/Clincian reported
APPROPRIATENESS CRITERIA– CONCEPT MAP
PRE-OPMANAGEMENT
PATIENT SATISFACTION?
Decision-maker input -
• Literature review– Very little information – focus primarily in terms of economic perspective– TJR found to be cost-effective
• Decrease pain and improve overall quality of life• Decrease long-term costs
– Lower costs associated with –• Age (younger) (cost of revision?)• No comorbidities• Earlier stage of disease progression
• Need input from decision-makers about they view/understand appropriateness and what type of information is required?
– Who should
Decision-maker input - Proposal
• Telephone interviews:– One on one interviews – recorded
• DMs representing various levels– several levels within healthcare– focus on decision-makers who have responsibility for
resource allocation decisions
• Semi-structured questionnaire– To guide but not limit the conversation
Questions for you….
• How do you, as a decision-maker, define appropriateness? What concepts does that term encompass?
• What is the role of DMs in determining appropriateness?
• What type of information would decision-makers like to have in terms of appropriateness to inform their decisions?
• We’d like to interview decision-makers who need to balance the demand for hip or knee arthroplasty among other competing demands. Does that make sense? What level is that: Ministry of Health? Regional Health Authority?
Extra slides
Existing tools to measure/estimate appropriateness criteria
Pain/Function/Quality of Life VAS score PCS (?) WOMAC (hip and knee) Oxford Knee/Hip OARSI/OMERACT Lequense Am. Coll of Rheumatology WCWL priority and referral tools Knee-Patient Specific Indix (KSPI)
Knee Injury and Osteo Outcome Score (KOOS) KOOS - Short-form SF-36/12 (Q of L) HUI (Q of L) EQ-5D Coping Pain catastrophizing (?)Co-morbidities (1) Charlson Index Index of Coexistent Disease Functional Comorbidity Index ASA score Charnley classification BMISocial Circumstances WCWL priority tool Availability of post-op support???Patient Expectations
Hospital for Special Surgery Hip/Knee Replacement Expectation Survey (2)
Expectation WOMAC (?) Reasons for and against surgery - OHRI tool
Goal attainment - (Rehab)"Readiness" (Measure??)
Identified in appropriateness studies
Joint condition/Structure X-ray (space) Ahlback Radographic score (Chang et al) Physical assessment (Mike's measures)Adequacy of Pre-op treatment
Aequacy assessment (Quintana et al (2009) WCWL Primary care tool Manitoba referral tool Halifax - HipBooklet
Joint Longevity Age (?)
Surgical Risk Co-morbidity measures ASA scoreCapacity to Benefit (definition?) Change in pain/function
Minimally important clinical difference (MICD) (3) BLISS (WOMAC Meet Patient expectations Goal attainment - (Rehab)