Virtual clinic for follow up of hip and knee replacement patients

Background to a virtual clinic 

Nearly 200,000 hip and knee total joint replacements were performed in 2016. Because catastrophic failures of joint replacements have poor outcomes for the patient and are difficult to manage for orthopaedic teams, all joint replacement patients are followed up in clinical settings.

National orthopaedic organisations such as the British Orthopaedic Association (which must be envious of the British Hip Society, surely the coolest society in Britain) recommend that outpatient follow-up is one, five or seven years, then every five years for those with implants which have met the Orthopaedic Data Evaluation Panel 10A rating. This places a substantial burden on outpatients, but annual numbers of joint replacements are soaring. If a newly appointed consultant surgeon inherited no patients and started a fresh caseload, by the time he or she had worked for 13 years he or she would see no new patients and would only see 'old' patients in follow up clinics. Yet the failure rate of joint replacements is only 5% and falling. This suggests that a new approach to follow up of joint replacements is called for, one that frees up clinic time but will identify those patients at risk of failure (and needing revision surgery).

A British Journal of Medicine blog highlights beautifully why so many patients need not attend outpatient clinics, and some of the benefits to patients of not having to attend. 

I have been working on the development of a virtual clinic, which is designed to reduce face-to-face outpatient appointments for joint replacement patients by at least 80%. This standardised approach will consist of a patient-reported questionnaire, a standardised radiology report and a clinical algorithm.

Developing the virtual clinic

I developed the virtual clinic using an online Delphi consensus survey. For each of these documents,  anonymised participants with appropriate expertise and experience (joint replacement patients, surgeons, physiotherapists, radiologists and joint replacement practitioners) gave feedback in up to three rounds of the online surveys. With each survey, documents were modified until consensus was achieved.  The patient-reported questionnaire was tested on seven joint replacement patients using a Think Aloud process to capture difficulties with completing the questionnaire, each time undergoing amendments until difficulties appeared to be addressed. 

The final version of the patient-reported questionnaire consists of 13 items, divided into General, Pain, Mobility and Activity sections. There are up to ten items on the radiology report, depending on the element of joint replacement. The algorithm concludes in one of three outcomes: Discharge or standard follow up; See at next available clinic; or Review at surgeon’s discretion (3 – 12 months).

Service evaluation of the virtual clinic

Orthopaedic clinics in five sites across the UK have evaluated use of the virtual clinic in clinical practice. We are still waiting for a large percentage of the data to be returned but 72% of patients reported high satisfaction with the virtual clinic. Almost 80% of patients were given Discharge or standard follow up. 

Findings so far - interim analyses

Out of 317 patients, 120 have returned patient satisfaction questionnaires so far 85% were satisfied with the virtual clinic, with only 2.5% indicating dissatisfaction. Patients were 1.5 times more likely to be satisfied with the virtual clinic if they had mild pain (3/10 or lower).  There was no association between being discharged and patient satisfaction with the virtual clinic.
  
72% of patients said that they preferred the virtual clinic to a face-to-face clinic. Patients were twice as likely to prefer the virtual clinic if they had received a letter or phone call informing them of the virtual clinic outcome, which had not always occurred.

Qualitative feedback from clinicians using the virtual clinic suggests that orthopaedic surgeons save several hours per week of face-to-face clinical appointments. There is a significant administrative burden on other clinical support staff, but this could be relieved with dedicated administrative support (which was organised in some sites). Good support and communication with radiology departments is essential.

Once further data has been received and analysed, I will present more accurate findings from over 500 joint replacement patients. However, it appears that the virtual clinic has great potential and could also be developed and implemented in other clinical areas. 

Expert forum discussion

At the end of October, we are hosting an expert discussion forum in which leading orthopaedic surgeons, radiologists, physiotherapists and arthroplasty practitioners will come together to discuss and vote on the virtual clinic. Joint replacement patients virtual clinic evaluators will be part of the forum, adding their essential contributions. I will update this blog when further feedback and data have been analysed.

Putting the CAT (Critically Appraised Topic) among the pigeons

The Epiphany Club

Research and clinical physiotherapists in Yorkshire have started meeting on a regular basis for mutual support, to share ideas and to improve their capacity for communication and working together.  This is the Epiphany Club, an informal group of physios and other AHPs gathering every few months in a pub near to Leeds Town Centre. 

Click to enlarge

Critically Appraised Topics

One well-received proposal for the Epiphany Club was the development of Critically Appraised Topics (CAT). Keele University School of Health and Rehabilitation has produced a number of very useful musculoskeletal CATs and, over the last fifteen years, their collaboration with clinicians has developed into a hugely beneficial, productive and closely-knit team. A CAT is: 

"a summary of the best available evidence, which answers a clinical question and includes a clinical ‘bottom-line’. A CAT is essentially patient-based, in that it begins with a clinical question generated from a specific patient situation or problem."

This blog will describe the development of the first CAT and its clinical bottom line, generated from the best available evidence. 

Background

No sooner had the CAT idea been put forward than a clinical problem cropped up that was ideal for a CAT. The problem had arisen in a ward-based neuro rehabilitation setting and was causing some anxiety among members of the neuro rehab team. 

After mobilising a patient with an acute partial spinal cord injury, a registrar who had worked at a specialist spinal centre suggested that mobilising patients was inappropriate. He described the current protocol at specialist centres as six weeks' 'bed rest' (or 'Active Bed Based Rehabilitation'). In contrast, the standard procedure on the Leeds Trust rehabilitation unit was early mobilisation when safe to do so (i.e. when medically and surgically stable). But what evidence was there for or against either approach? This then was a clinical question generated by a problem with a specific patient situation, and ideal for a CAT.

Further information: Sir Ludwig Guttmann

There is no doubt that Sir Ludwig Guttmann was a remarkable physican and inspirational human who transformed the quality of care, quality of life and extended the lives of people with spinal cord injuries. The prevailing thought pre-1945 was that rehabilitation was "irrational" and death was inevitable within months, but the principles that he laid down in 1945 were responsible for transforming the outlook and prognosis of people with spinal cord injury. These principles included, for example, the routine turning of patients to prevent skin breakdown. They have remained apparently unchallenged as core practice until at least 1979, but while nobody suggests that turning bedbound patients is not best practice, what is the case for bed rest or against mobilising?

Clinically Appraised Topic (CAT): mobilising acute partial Spinal Cord Injury patients

This Clinically Appraised Topic (Foster et al., 2001) was conducted by Leeds Teaching Hospitals NHS Trust Neurological Rehabilitation team, the Academic Department of Rehabilitation Medicine (University of Leeds) and Leeds Teaching Hospitals Library & Evidence Research Centre, It is described using the the format of the Keele University CATs. 

Acknowledgements

The CAT team would like to thank Kay Stevenson (Consultant Physiotherapist and Clinical Champion, Honorary Lecturer, School of Health and Rehabilitation, Keele University) for her guidance and support leading up to and during the development of this Clinically Appraised Topic.

Specific question 

(click to enlarge)

Clinical bottom line

There was no evidence against mobilising people with partial spinal cord injury (SCI) who are medically and surgically stable less than six weeks after injury. There were no adverse events reported in stable patients with SCI who received early mobilisation.

There was no evidence that bed-based rehabilitation improves outcomes in comparison to early mobilisation in stable patients with partial SCI.

Why is this important?

Once medically and surgically stable, people with acute partial SCI are managed differently in the first six weeks of their rehabilitation depending on the opinion of the professionals caring for them as to best practice. Some centres favour early mobilisation and others support a period (at least six weeks) of active bed-based rehabilitation.

Inclusion criteria

Patients with acute partial Spinal Cord Injury.

Search strategy 

Search terms and databases

(click to enlarge)

Papers found and selection filter

Flow chart 

(click to enlarge)

Summary and assessment of quality of papers

Quality of papers assessed using CASP Systematic review checklist(Critical Appraisal Skills Programme, 2018b) and RCT checklist(Critical Appraisal Skills Programme, 2018a)

Click to enlarge

Click to enlarge

Click to enlarge 

Click to enlarge

Click to enlarge

Summary

There is no evidence that early mobilisation is harmful for acute SCI patients who are medically and surgically stable. Studies are of generally poor quality and do not directly answer the CAT question. 

Evidence from one high quality RCT suggests that overground mobility training is better than body-weight supported treadmill training in acute (2 – 26 weeks) partial SCI patients. There was a positive effect of early exercise on muscle tissue within the first 3–6 months post SCI but these were poor quality studies.

There were weak recommendations in one poor quality paper for early rehabilitation in patients with traumatic SCI when they are medically stable and can tolerate treatment.

There is no evidence supporting six weeks of bed rest.

Suggestions for research

This CAT suggests that properly-conducted research is needed to investigate which approach has better outcomes for people with acute partial spinal cord injury. Given numbers of injuries, this would need to be a large multicentre trial exploring multiple outcomes and long term follow ups. 

References

BAGNALL, A. M., JONES, L., DUFFY, S. & RIEMSMA, R. P. 2008. Spinal fixation surgery foracute traumatic spinal cord injury. Cochrane Database Syst Rev, Cd004725.

CRITICAL APPRAISAL SKILLS PROGRAMME. 2018a. CASP Randomised Control Trial Checklist [Online]. Available: https://casp-uk.net/wp-content/uploads/2018/01/CASP-Systematic-Review-Checklist.pdf [Accessed 01 October 2018].

CRITICAL APPRAISAL SKILLS PROGRAMME. 2018b. CASP Systematic Review Checklist [Online]. Available: https://casp-uk.net/wp-content/uploads/2018/01/CASP-Systematic-Review-Checklist.pdf [Accessed 01 October 2018].

FEHLINGS, et al. 2017. A Clinical Practice Guideline for the Management of Patients WithAcute Spinal Cord Injury: Recommendations on the Type and Timing ofRehabilitation. Global Spine Journal, 7, 231S-238S.

FOSTER, N., BARLAS, P., CHESTERTON, L. & WONG, J. 2001. Critically Appraised Topics (CATs). Physiotherapy, 87, 179-190.

MEHRHOLZ, J., KUGLER, J. & POHL, M. 2012. Locomotor training forwalking after spinal cord injury. Cochrane Database Syst Rev, 11, Cd006676.

PANISSET, M. G., GALEA, M. P. & EL-ANSARY, D. 2016. Does earlyexercise attenuate muscle atrophy or bone loss after spinal cord injury? Spinal Cord, 54, 84-92.

RICE, L. A., SMITH, I., KELLEHER, A. R., GREENWALD, K., HOELMER, C. & BONINGER, M. L. 2013. Impact of the clinical practice guideline forpreservation of upper limb function on transfer skills of persons with acutespinal cord injury. Arch Phys Med Rehabil, 94, 1230-46.

TSE, C. M., CHISHOLM, A. E., LAM, T. & ENG, J. J. 2018. Asystematic review of the effectiveness of task-specific rehabilitationinterventions for improving independent sitting and standing function in spinalcord injury. J Spinal Cord Med, 41, 254-266.

WESSELS, M., LUCAS, C., ERIKS, I. & DE GROOT, S. 2010. Bodyweight-supported gait training for restoration of walking in people with anincomplete spinal cord injury: a systematic review. J Rehabil Med, 42, 513-9.