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We examined relationships between measures of total knee arthroplasty (TKA) “appropriateness” constructs and surgeon TKA recommendations in people with knee osteoarthritis (OA). Although TKA is highly effective, fifteen to thirty percent of recipients report dissatisfaction and/or little or no symptom improvement. More appropriate selection of surgical candidates may improve both patient outcomes and healthcare resource use, but no validated appropriateness criteria exist currently in Canada.
Patients 30 years of age or older with knee OA referred for surgical consultation at two large joint arthroplasty centres in Alberta, Canada were invited to participate. Participants completed a standardized pre-consult questionnaire, which included the following sociodemographics and validated measures of appropriateness constructs for TKA: knee symptoms; non-surgical management; patient readiness for and expectations of TKA; and net patient benefit. Post-consultation, surgeons were asked to confirm knee OA and their recommendation. We used multivariable logistic regression to examine the relationship between measures of appropriateness constructs and receipt of surgeon TKA recommendation.
Of 3,009 patients approached, 2,360 completed the questionnaire and 2,064 (sixty-nine percent) were eligible at surgical consultation (mean age 65.7 years, standard deviation 9.1; fifty-nine percent were women); 1,495 (seventy-two percent) were recommended for TKA. The likelihood of receiving a TKA recommendation was independently associated with: knee symptoms (odds ratio [OR] per unit increase in pain intensity, 1.19 (95% confidence interval [CI]: 1.11–1.27)); prior non-surgical OA management (OR for prior knee injection, 1.53 (95% CI: 1.21–1.94)); readiness for surgery (OR if definitely/probably willing to undergo TKA, 3.03 (95% CI: 1.99–4.59)); and TKA expectations (OR outcome “very important”: ability to perform daily activities, 1.40 (95% CI: 1.04–1.88); straighten the knee/leg 1.42 (95% CI: 1.13–1.80); participate in exercise/sports 0.75 (95% CI: 0.58–0.98)).
In our cohort of patients with confirmed knee OA who consulted a surgeon for TKA, appropriateness constructs were significantly associated with receipt of a TKA recommendation. Research is ongoing to evaluate the predictive validity of these measures for patient-reported outcomes associated with TKA.
The high prevalence, disability, and work absenteeism associated with back pain make it the single most costly musculoskeletal health condition in developed countries. However, the majority of back pain has no identifiable pathological cause and resolves without surgery or imaging. This paradox suggests that we need to change how back pain is managed to reduce unnecessary burden to individuals and the healthcare system. This study evaluated the cost of a new model of early triage-based, interprofessional care for patients with back pain.
We evaluated the outcomes and cost of implementing a provincial care pathway for early assessment of patients with back pain at three sites: (i) adjacent to an emergency department in a community hospital; (ii) co-located with an orthopedic surgeon's clinic in a hospital; and (iii) in a primary care network (PCN) with private practice physiotherapists and chiropractors. Time-driven activity-based costing (TDABC), in combination with discrete event simulation, was used to estimate costs.
Costs were significantly lower in the models that used hospital-based physiotherapists and in the PCN model that used private practice physiotherapists and chiropractors to triage patients. These costs ranged from CAD 20 (USD 16) to manage patients identified with low severity back pain to CAD 175 to 200 (USD 137 to 156) for those with moderate to severe back pain. Models that implemented the care pathway using family physicians and surgeons to review non-surgical patients were more expensive at CAD 339 (USD 265) and CAD 514 (USD 402), respectively.
New models of care that use the skills of physiotherapists and chiropractors to assess and triage patients with back pain adjacent to emergency departments and in the primary care sector are cost effective, compared with traditional physician-led models. The overarching intent is to use these data to enable evidence-informed policy and practice changes, so that more appropriate and cost-effective care is provided to patients with back pain.
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