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)