The right people waiting in the right order for joint replacement surgery: Translation of evidence about best care and best assessment A/Prof Richard Osborne 1, A/Prof Caroline Brand 1, Melanie Hawkins 1, Catherine Jones 1, Jenni Monaghan 2, Christine Doerr 2, Prof Stephen Graves 1, 2, Mr Richard de Steiger 1, Prof Ian Wicks 1, Mr Graham Mercer 2. 1 Centre for Rheumatic Diseases Department of Medicine / Department of Orthopaedics, The Royal Melbourne Hospital, The University of Melbourne, Victoria, Australia 2 Department of Orthopaedics Repatriation General Hospital, Adelaide, South Australia, Australia A multi-phase program Outpatients to surgery (Victorian Govt funding) I. Development of a management and prioritisation system 2.5 years II. Development of statewide implementation plan 1.5 years III. Statewide implementation (14 Victorian hospitals) 1.5 years [IV. National diffusion of the innovation] SA (2 years) WA Other GP referral to outpatients (Commonwealth Govt funding) I. Development of guide (referral and prioritisation tool) II. National consultation III. Pilot implementation (SA, Vic) [IV. Incorporation in to statewide electronic referral system, Vic]
Trends in Total Hip and Knee Replacement surgery 350 300 250 200 150 100 50 0 JRS procedures per 100,000 population 1994-1995 1995-1996 1996-1997 1997-1998 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 Source: National Joint Replacement Registry RMH OWL cohort study: Quality of life of people waiting for JRS 25 Frequency 20 15 10 5 Population norm Ackerman IN, Graves SE, Wicks IP, Bennell KL, Osborne RH. Severely compromised quality of life in women and those of lower socioeconomic status waiting for joint replacement surgery. Arthritis Rheum 2005;53(5):653-8. 0-0.20 0.00 0.20 0.40 0.60 0.80 1.00 AQoL baseline Mean = 0.3885 Std. Dev. = 0.2345 N = 307
Trends in Total Hip and Knee Replacement surgery Rudd 350 300 250 200 150 100 50 0 JRS procedures per 100,000 population Government $600 million Elective Surgery Waiting List Reduction Plan 1994-1995 1995-1996 1996-1997 1997-1998 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 Source: National Joint Replacement Registry Currently Referral Orthopaedic Assessment Surgery Waiting: Adversely affects quality of life, Results in de-conditioning, Contributes to compromised patient outcomes, Lost productivity etc
An evidence-based prioritisation and management system is required Development of a Multi-Attribute Prioritisation Tool (MAPT) State-of-the-art patient consultation, psychometrics and clinimetrics Concept Mapping workshops Groups facilitated to identify factors that should be considered when determining priority for JRS 4 workshops with orthopaedic surgeons 4 workshops with patients Aim Ensure that the questionnaire is Clinically relevant, endorsed and owned by clinical groups Appropriate across settings Implementable
MAPT development Pre-testing draft questions Consultation with surgeons and other experts Development of draft questionnaire Cognitive interviews with patients Development of the prioritisation tool 60 draft items Ready for translation (culturally and linguistically generic ) Completed by 600+ patients +/- on OWL Type of questions Guttman-like scales Discrete health states in each response option Verifiable through a clinical interview Attribution to the hip or knee Not Likert questions
WOMAC index Western Ontario & McMaster Osteoarthritis Index 24 items Think about the difficulty you had in doing the following daily physical activities due to your arthritis during the last 48 hours. By this we mean your ability to move around and look after yourself. QUESTION: What degree of difficulty do you have? None Mild Moderate Severe Extreme 8. Descending (going down) stairs 9. Ascending (going up) stairs 10. Rising from sitting 11. Standing 12. Bending to the floor Prioritisation domains generated from surgeons and patients 1. Pain 1.1. Sleep disturbance 1.2. Rest pain 1.3. Pain related to movement 2. Limitations to daily activities 2.1. Impairment of mobility 2.2. Ability to self-care 2.3. Level of domestic support 2.4. Carer roles 3. Psychosocial health impact 3.1. Psychological effect of disability 3.2. Social effect of disability 4. Economic impact 4.1. Interference with ability to work 4.2. Financial provider for others 5. Recent deterioration
Weighting items Some questions (symptoms) are more important than others Discrete Choice Experiments Victoria has ~140 arthroplasty Surgeons asked to apply clinical surgeons judgement to patient vignettes Helps to appropriately weight clinical red flags 96 Victorian orthopaedic surgeons participated Simple score 0 (no need for surgery) 100 (highest need for surgery)
Need for surgery MAPT WOMAC Validation Administered to 1000+ patients Content validity Construct validity Correlation with international standards Test re-test reliability Responsiveness to change Implementability response rate (patient, health professional) gaming and stoicism Clinical veracity
MAPT scores x time since surgery Weeks Since Surgery N Mean SD Currently on OWL 460 45.5 30.4 1 12 54 21.8 27.5 13 24 32 11.8 22.3 25-104 118 6.8 15.4 Who should get surgery next? Lowest priority Middle priority Highest priority Surgery later but not forgotten Surgery now
Hip and Knee Questionnaire Multi-Attribute Prioritisation Tool (MAPT) designed to support a Service Delivery Model (Osteoarthritis Hip and Knee Service) Clear agreed principals
Musculoskeletal Coordinator supports (& is supported by) a multidisciplinary team Rheumatologists GPs Allied health Administrative assistance Musculoskeletal Coordinator Waiting list managers Orthopaedic outpatient managers Surgeons Other specialists eg: rehab, mental health, general medicine The model of care
The OA Hip and Knee Service (usual practice) Referral WAITING Orthopaedic Outpatients WAITING Orthopaedic Surgery Surgeon Surgeon The OA Hip and Knee Service Feedback MSC / Registrar Hip & Knee Questionnaire / MAPT Score Initial assessment / Monitoring / Prioritisation Tool Fast tracked 4 WAITING 2 5 5 1 3 6 OA Hip and Knee Clinic Assessment & Referral MSC WAITING Orthopaedic Outpatients Surgeon Conservative management GP, allied health, rheumatologist, self management WAITING Orthopaedic Surgery Surgeon Six guiding principles: 1. Workforce role redesign (multidisciplinary team) 2. Triage 3. Comprehensive assessment 4. Conservative management and referrals 5. Monitoring 6. Prioritization
Patient outcomes following OA Hip and Knee Service and implications of Orthopaedic Outpatient Clinic and other services Assessment Requires surgery in near future Action Refer for orthopaedic assessment (fast track if urgent) Offer conservative management and monitor Assessment at OA Hip & Knee Service May need surgery eventually but not in near future Defer from surgery Monitor for deterioration Manage conservatively Will not need /want surgery or not suitable for surgery Discharge to GP Advise / refer for conservative management
Impact of OA Hip and Knee Service on outpatient clinic Total patients seen at OA Hip and Knee Service 211 185 114 210 720 Site 1* Site 2 Site 3 Site 4 Total Number (%) fast tracked from OA Hip and Knee Service for early assessment by surgeon Number (%) deferred by OA Hip and Knee Service from surgeon assessment Number (%) not requiring surgery or choosing not to consider surgery in the future (discharged) 0 18 (10%) 24 (44%) 0 3 (1.6%) 13 (11%) 0 87 (76%) 14 (12%) 44 (20%) 75 (13%) 0 111 (20%) 10 (5%) 27 (5%) * Excludes data from community based clinics Includes 2 patients fast tracked directly to the elective surgery waiting list (in consultation with the surgeon) OWL Phase II in Victoria: a system change occurred Strong evidence Triage in outpatients Patients were fast tracked Equivalent information was obtained from several language groups Clinical decisions supported by a common metric Indirect evidence Better use of resources More equitable service Upcoming processes / evidence gathering Publication / distribution of performance indicators across sites Advanced psychometric / clinimetric studies Mandatory use of MAPT for access to elective surgical lists MAPT reporting, population shifts, equity tracking Evidence informed distribution of resources
Planned use of the Hip and Knee MAPT Lowest priority Middle priority Highest priority Surgery later but not forgotten Surgery now Orthopaedic Surgical Waiting List MAPT scores versus length of time waited 100.0 90.0 80.0 1st 1st MAPT Score 70.0 60.0 50.0 40.0 30.0 2 nd 2 nd 20.0 10.0 0.0?? 0 100 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 Days waited N = 382 Category 2 Category 3
The OA Hip and Knee Service Feedback MSC / Registrar Hip & Knee Questionnaire / MAPT Score Initial assessment / Monitoring / Prioritisation Tool Fast tracked 4 WAITING 2 5 5 1 3 6 OA Hip and Knee Clinic Assessment & Referral MSC WAITING Orthopaedic Outpatients Surgeon Conservative management GP, allied health, rheumatologist, self management WAITING Orthopaedic Surgery Surgeon Six guiding principles: 1. Workforce role redesign (multidisciplinary team) 2. Triage 3. Comprehensive assessment 4. Conservative management and referrals 5. Monitoring 6. Prioritization What about GP-land?
A multi-phase program Outpatients to surgery (Victorian Govt funding) I. Development of a management and prioritisation system 2.5 years II. Development of statewide implementation plan 1.5 years III. Statewide implementation (14 Victorian hospitals) 1.5 years [IV. National diffusion of the innovation] SA (2 years) WA Other GP referral to outpatients (Commonwealth Govt funding) I. Development of guide (referral and prioritisation tool) II. National consultation III. Pilot implementation (SA, Vic) [IV. Incorporation in to statewide electronic referral system, Vic]
Pilot Management Flowchart (Part 1) Patient consults GP On arrival as part of pre-consult assessment give patient MAPT and score it on spreadsheet/algorithm. This score becomes part of assessment Score < 20 Initiate Management Plan. Individual MAPT questions inform strategies for conservative management. Administer MAPT 3 monthly or as needed If deterioration occurs (20 units decline) over 3 month period, initiate alternative pathway (see overleaf) ALERT GPs and consultants have discretion for referral / placing on OWL. MAPT score changes are indicators of need for surgery but are not intended to be the only criteria. >20 refer to specialist
Patient s expectation of referral outcome: <<Patient s expectation of referral outcome>> Main site affected: <<Diagnosis?>> Diagnosis: Osteoarthritis Rheumatoid arthritis Other Diagnosis unclear Basis of diagnosis: Clinical only X-ray - date: Report attached (include weight bearing views) Other (Blood results?) MAPT Score: <<MAPT Score>> Urgency of orthopaedic assessment: High Moderate Low Falls: Number in last 12 months: Relevant comorbidities & risks BMI Other surgical risks: History of conservative management (tick only those that are relevant to referral): Simple analgesics Non-selective NSAIDs Cox-2 inhibitors Disease Modifying Anti- Rheumatic Drugs (DMARDs) Intra-articular injections (Corticosteroid) Intra-articular injections (Hyaluronan) Prednisolone Opioid analgaesia Tramadol Physiotherapy Nutritional assessment Occupational therapy (Activity of Daily Living Assessment) Podiatry / Orthotics Formal self-management education program Arthritis SA Home Support Services Other: Additional relevant information (e.g. blood borne viruses, and psychological considerations):
Suggested Management of Patients with Osteoarthritis Suggested stages for initiating GP Management Plan +/- Team Care Arrangements to improve patient access to conservative management and monitor patient progress. PROCESS FEE MBS REBATE TOTAL GP Consultation $52.00 (approx.) $32.10 $32.10 GP refers for X-ray and gives patient MAPT to fill in at home GP consult to review X-ray and calculate MAPT score using Excel spreadsheet S52.00 (approx.) $32.10 S32.10 PN reviews patient three months later to repeat MAPT, GP initiates GPMP +/- TCA with support of PN GPMP 721 $124.95 $93.75 $93.75 TCA 723 $98.95 $74.25 $74.25 PN reviews every three months to repeat MAPT and review GPMP +/- TCA with GP GPMP rev725 (can be reviewed 3 monthly) $62.50 $46.90 x 3 $140.70 TCA rev727 (can be reviewed 3 monthly) $62.50 $46.90 x 3 $140.70 PN Support Item 10997 - PN monitors and supports patients with chronic condition (up to five times per year). Advice to pt re: chronic disease self-management, medication management etc. TOTAL PER ANNUM $10.60 $10.60 x5 $53.00 $566.60 (More if gap charged) Management of patient is guided by MAPT score, however GP has discretion to override score and refer based on his clinical decision. Access to Allied Health Patients with GPMP + TCA can access up to 5 Allied Health + 5 Practice Nurse sessions per 12 month period. Provision of Support / Monitoring for a Person with Chronic Disease by a Practice Nurse Item 10997 - $10.60 per visit RN provides services/support re: clinical progress, medication management, self management advice and can also collect information to support and update GPMP / TCA. GP Management Plan Item 721 $124.95 GP only plan of care, PN can assist Assesses patient / agrees management goals + need for ongoing services Reviewed once every 2 years with a view to re-initiate. Review of TCA Item 727 S62.50 Review of TCA every 6 months or earlier if req. GP collaborates with participating providers re: progress. PN can assist. Chronic Disease Management Medicare Item Fees for GPs managing care of patients with chronic conditions. Review of GPMP Item 725 - $62.50 GP reviews management plan, PN can assist. Review patient once every 6 months or earlier if required. Team Care Arrangements Item 723 - $98.95 GP coordinates TCA, collaborates with participating AH providers. PN can assist. Review every 2 years with view to re-initiate. GP Mental Health Care Plan Item 2710 - $150 For patient with a mental disorder arising from depression, mixed anxiety / depression. Patient eligible to access up to 12 MBS rebates per year for related services. Health Assessment for Patients over 75 Years Item 700 - $167.45 Health Assessment (at GP rooms) of patient s health, physical and social function to determine benefit of preventative health care / education.
GP Management Plan / Team Care Arrangement ARTHRITIS Page 2 1.1. General Patient understanding of arthritis 1.Arthritis Management Patient will have a clear understanding of arthritis and their role in managing the condition Review annually or as condition changes Pain management Optimal pain management Pain management appropriate to patient needs Optimising function/mobility Medication Complementary therapy Specific joint problems Surgical intervention Physical activity Optimal function and mobility Ensure appropriate use of medications and minimise side-effects Identify and review use of complementary medication Minimise specific joint problems Improve mobility and reduce pain Your target: Ideal: Moderate physical activity for 30 mins per day most days of the week Home aids/modification. Review of footwear Review regularly Review regularly Joint specific therapy Assess suitability for surgical intervention including joint replacement therapy MAPT Score: Patient education Exercise regime GP/Practice nurse/arthritis SA/Rheumatologist/ Orthopaedic Surgeon GP/Patient GP/Podiatrist/OT GP/Home Medications review/other specialist GP GP/Rheumatologist/ Orthopaedic surgeon GP/Rheumatologist/ Orthopaedic Surgeon GP/practice nurse to monitor Chronic Disease Self Management Programs/Physio Activity program/ Exercise group Allied Health Professionals Locator Resource for Patients ARTHRITIS SOUTH AUSTRALIA www.arthritissa.org.au Tel: 8379 5711 DIETICIAN www.daa.asn.au Tel: 1800 812 942 PODIATRIST www.findapodiatrist.org Tel: 8363 4144 HOME ACTIVITY MONITORING PROJECT www.hamp.net.au Tel: (08) 8227 0432 EXERCISE PHYSIOLOGIST www.aaess.com.au Tel: (07) 3856 5622 COMMONWEALTH CARELINK SA www.carelinksa.asn.au Tel: 1800 052 222 PHYSIOTHERAPIST www.physiotherapy.asn.au http://apa.advsol.com.au Tel: 8362 1355 OCCUPATIONAL THERAPIST www.otsa.org.au Tel: 8239 1422 DOMICILIARY CARE SA www.domcare.sa.gov.au Tel: 8193 1234 SA HEALTH AND COMMUNITY SERVICES RESOURCE www.infosearchweb.com Tel: 8122 2755 CARERS SA www.carers-sa.asn.au Tel: 8271 6288 HUMAN SERVICES FINDER www.hsfinder.sa.gov.au Allied Health Professionals Locator Resource for GPs ARTHRITIS SOUTH AUSTRALIA www.arthritissa.org.au Tel: 8379 5711 DIETICIAN www.daa.asn.au Tel: 1800 812 942 PODIATRIST www.findapodiatrist.org Tel: 8363 4144 HOME ACTIVITY MONITORING PROJECT www.hamp.net.au Tel: (08) 8227 0432 EXERCISE PHYSIOLOGIST www.aaess.com.au Tel: (07) 3856 5622 COMMONWEALTH CARELINK SA www.carelinksa.asn.au Tel: 1800 052 222 SOUTHERN ADELAIDE HEALTH SERVICE www.southernhealth.sa.gov.au Tel: 8201 7814 PHYSIOTHERAPIST www.physiotherapy.asn.au http://apa.advsol.com.au Tel: 8362 1355 OCCUPATIONAL THERAPIST www.otsa.org.au Tel: 8239 1422 DOMICILIARY CARE SA www.domcare.sa.gov.au Tel: 8193 1234 SA HEALTH AND COMMUNITY SERVICES RESOURCE www.infosearchweb.com Tel: 8122 2755 CARERS SA www.carers-sa.asn.au Tel: 8271 6288 HEALTH PROVIDER REGISTRY www.healthproviders.com.au Tel: 8271 8988 SA DIVISION OF GENERAL PRACTICE www.sadi.org.au SOUTHERN DIVISION OF GENERAL PRACTICE www.sdgp.com.au HUMAN SERVICES FINDER www.hsfinder.sa.gov.au
Concluding comments: Acceptability, uptake and diffusion of innovation The OWL system is more complex than the original but the relative advantage is large and obvious Very well defined core tools (MAPT, model of care) Victoria Clinicians designed and own the MAPT questions Patients generally have no trouble with questions Sites consistently surprised with high return rates (>>80%) MAPT scores are used to organise and prioritise care Clinicians need to develop a relationship with MAPT score MAPT delivers usual/important clinical information on a platter Strong link between capacity to benefit and outcomes measurement Other Australian States SA, WA, etc Federal Government Supportive Thank you Associate Professor Richard Osborne, PhD Centre for Rheumatic Diseases Department of Medicine Royal Melbourne Hospital The University of Melbourne Australia richardo@unimelb.edu.au