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.