The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling
Background: There is no good evidence to support the use of patient-reported outcome measures (PROMs) in setting preoperative thresholds for referral for hip and knee replacement surgery. Despite this, the practice is widespread in the NHS. Objectives/research questions: Can clinical outcome tools b...
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NIHR Journals Library
2019-06-01
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Series: | Health Technology Assessment |
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Online Access: | https://doi.org/10.3310/hta23320 |
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Article |
collection |
DOAJ |
language |
English |
format |
Article |
sources |
DOAJ |
author |
Andrew Price James Smith Helen Dakin Sujin Kang Peter Eibich Jonathan Cook Alastair Gray Kristina Harris Robert Middleton Elizabeth Gibbons Elena Benedetto Stephanie Smith Jill Dawson Raymond Fitzpatrick Adrian Sayers Laura Miller Elsa Marques Rachael Gooberman-Hill Ashley Blom Andrew Judge Nigel Arden David Murray Sion Glyn-Jones Karen Barker Andrew Carr David Beard |
spellingShingle |
Andrew Price James Smith Helen Dakin Sujin Kang Peter Eibich Jonathan Cook Alastair Gray Kristina Harris Robert Middleton Elizabeth Gibbons Elena Benedetto Stephanie Smith Jill Dawson Raymond Fitzpatrick Adrian Sayers Laura Miller Elsa Marques Rachael Gooberman-Hill Ashley Blom Andrew Judge Nigel Arden David Murray Sion Glyn-Jones Karen Barker Andrew Carr David Beard The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling Health Technology Assessment KNEE HIP OSTEOARTHRITIS ARTHROPLASTY REFERRAL OUTCOME SYSTEMATIC REVIEW OUTCOME THRESHOLD COST–UTILITY ANALYSIS |
author_facet |
Andrew Price James Smith Helen Dakin Sujin Kang Peter Eibich Jonathan Cook Alastair Gray Kristina Harris Robert Middleton Elizabeth Gibbons Elena Benedetto Stephanie Smith Jill Dawson Raymond Fitzpatrick Adrian Sayers Laura Miller Elsa Marques Rachael Gooberman-Hill Ashley Blom Andrew Judge Nigel Arden David Murray Sion Glyn-Jones Karen Barker Andrew Carr David Beard |
author_sort |
Andrew Price |
title |
The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling |
title_short |
The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling |
title_full |
The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling |
title_fullStr |
The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling |
title_full_unstemmed |
The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling |
title_sort |
arthroplasty candidacy help engine tool to select candidates for hip and knee replacement surgery: development and economic modelling |
publisher |
NIHR Journals Library |
series |
Health Technology Assessment |
issn |
1366-5278 2046-4924 |
publishDate |
2019-06-01 |
description |
Background: There is no good evidence to support the use of patient-reported outcome measures (PROMs) in setting preoperative thresholds for referral for hip and knee replacement surgery. Despite this, the practice is widespread in the NHS. Objectives/research questions: Can clinical outcome tools be used to set thresholds for hip or knee replacement? What is the relationship between the choice of threshold and the cost-effectiveness of surgery? Methods: A systematic review identified PROMs used to assess patients undergoing hip/knee replacement. Their measurement properties were compared and supplemented by analysis of existing data sets. For each candidate score, we calculated the absolute threshold (a preoperative level above which there is no potential for improvement) and relative thresholds (preoperative levels above which individuals are less likely to improve than others). Owing to their measurement properties and the availability of data from their current widespread use in the NHS, the Oxford Knee Score (OKS) and Oxford Hip Score (OHS) were selected as the most appropriate scores to use in developing the Arthroplasty Candidacy Help Engine (ACHE) tool. The change in score and the probability of an improvement were then calculated and modelled using preoperative and postoperative OKS/OHSs and PROM scores, thereby creating the ACHE tool. Markov models were used to assess the cost-effectiveness of total hip/knee arthroplasty in the NHS for different preoperative values of OKS/OHSs over a 10-year period. The threshold values were used to model how the ACHE tool may change the number of referrals in a single UK musculoskeletal hub. A user group was established that included patients, members of the public and health-care representatives, to provide stakeholder feedback throughout the research process. Results: From a shortlist of four scores, the OHS and OKS were selected for the ACHE tool based on their measurement properties, calculated preoperative thresholds and cost-effectiveness data. The absolute threshold was 40 for the OHS and 41 for the OKS using the preferred improvement criterion. A range of relative thresholds were calculated based on the relationship between a patient’s preoperative score and their probability of improving after surgery. For example, a preoperative OHS of 35 or an OKS of 30 translates to a 75% probability of achieving a good outcome from surgical intervention. The economic evaluation demonstrated that hip and knee arthroplasty cost of < £20,000 per quality-adjusted life-year for patients with any preoperative score below the absolute thresholds (40 for the OHS and 41 for the OKS). Arthroplasty was most cost-effective for patients with lower preoperative scores. Limitations: The ACHE tool supports but does not replace the shared decision-making process required before an individual decides whether or not to undergo surgery. Conclusion: The OHS and OKS can be used in the ACHE tool to assess an individual patient’s suitability for hip/knee replacement surgery. The system enables evidence-based and informed threshold setting in accordance with local resources and policies. At a population level, both hip and knee arthroplasty are highly cost-effective right up to the absolute threshold for intervention. Our stakeholder user group felt that the ACHE tool was a useful evidence-based clinical tool to aid referrals and that it should be trialled in NHS clinical practice to establish its feasibility. Future work: Future work could include (1) a real-world study of the ACHE tool to determine its acceptability to patients and general practitioners and (2) a study of the role of the ACHE tool in supporting referral decisions. Funding: The National Institute for Health Research Health Technology Assessment programme. |
topic |
KNEE HIP OSTEOARTHRITIS ARTHROPLASTY REFERRAL OUTCOME SYSTEMATIC REVIEW OUTCOME THRESHOLD COST–UTILITY ANALYSIS |
url |
https://doi.org/10.3310/hta23320 |
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doaj-d9341cdc9b084acd979eda8c9c6638ce2020-11-25T00:17:27ZengNIHR Journals LibraryHealth Technology Assessment1366-52782046-49242019-06-01233210.3310/hta2332011/63/01The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modellingAndrew Price0James Smith1Helen Dakin2Sujin Kang3Peter Eibich4Jonathan Cook5Alastair Gray6Kristina Harris7Robert Middleton8Elizabeth Gibbons9Elena Benedetto10Stephanie Smith11Jill Dawson12Raymond Fitzpatrick13Adrian Sayers14Laura Miller15Elsa Marques16Rachael Gooberman-Hill17Ashley Blom18Andrew Judge19Nigel Arden20David Murray21Sion Glyn-Jones22Karen Barker23Andrew Carr24David Beard25Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKHealth Economics Research Centre, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKHealth Economics Research Centre, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKHealth Economics Research Centre, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Population Health, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Population Health, University of Oxford, Oxford, UKNuffield Department of Population Health, University of Oxford, Oxford, UKMusculoskeletal Research Unit, University of Bristol, Bristol, UKMusculoskeletal Research Unit, University of Bristol, Bristol, UKMusculoskeletal Research Unit, University of Bristol, Bristol, UKMusculoskeletal Research Unit, University of Bristol, Bristol, UKMusculoskeletal Research Unit, University of Bristol, Bristol, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UKBackground: There is no good evidence to support the use of patient-reported outcome measures (PROMs) in setting preoperative thresholds for referral for hip and knee replacement surgery. Despite this, the practice is widespread in the NHS. Objectives/research questions: Can clinical outcome tools be used to set thresholds for hip or knee replacement? What is the relationship between the choice of threshold and the cost-effectiveness of surgery? Methods: A systematic review identified PROMs used to assess patients undergoing hip/knee replacement. Their measurement properties were compared and supplemented by analysis of existing data sets. For each candidate score, we calculated the absolute threshold (a preoperative level above which there is no potential for improvement) and relative thresholds (preoperative levels above which individuals are less likely to improve than others). Owing to their measurement properties and the availability of data from their current widespread use in the NHS, the Oxford Knee Score (OKS) and Oxford Hip Score (OHS) were selected as the most appropriate scores to use in developing the Arthroplasty Candidacy Help Engine (ACHE) tool. The change in score and the probability of an improvement were then calculated and modelled using preoperative and postoperative OKS/OHSs and PROM scores, thereby creating the ACHE tool. Markov models were used to assess the cost-effectiveness of total hip/knee arthroplasty in the NHS for different preoperative values of OKS/OHSs over a 10-year period. The threshold values were used to model how the ACHE tool may change the number of referrals in a single UK musculoskeletal hub. A user group was established that included patients, members of the public and health-care representatives, to provide stakeholder feedback throughout the research process. Results: From a shortlist of four scores, the OHS and OKS were selected for the ACHE tool based on their measurement properties, calculated preoperative thresholds and cost-effectiveness data. The absolute threshold was 40 for the OHS and 41 for the OKS using the preferred improvement criterion. A range of relative thresholds were calculated based on the relationship between a patient’s preoperative score and their probability of improving after surgery. For example, a preoperative OHS of 35 or an OKS of 30 translates to a 75% probability of achieving a good outcome from surgical intervention. The economic evaluation demonstrated that hip and knee arthroplasty cost of < £20,000 per quality-adjusted life-year for patients with any preoperative score below the absolute thresholds (40 for the OHS and 41 for the OKS). Arthroplasty was most cost-effective for patients with lower preoperative scores. Limitations: The ACHE tool supports but does not replace the shared decision-making process required before an individual decides whether or not to undergo surgery. Conclusion: The OHS and OKS can be used in the ACHE tool to assess an individual patient’s suitability for hip/knee replacement surgery. The system enables evidence-based and informed threshold setting in accordance with local resources and policies. At a population level, both hip and knee arthroplasty are highly cost-effective right up to the absolute threshold for intervention. Our stakeholder user group felt that the ACHE tool was a useful evidence-based clinical tool to aid referrals and that it should be trialled in NHS clinical practice to establish its feasibility. Future work: Future work could include (1) a real-world study of the ACHE tool to determine its acceptability to patients and general practitioners and (2) a study of the role of the ACHE tool in supporting referral decisions. Funding: The National Institute for Health Research Health Technology Assessment programme.https://doi.org/10.3310/hta23320KNEEHIPOSTEOARTHRITISARTHROPLASTYREFERRALOUTCOMESYSTEMATIC REVIEWOUTCOMETHRESHOLDCOST–UTILITY ANALYSIS |