Purpose/Background

More than 20 million UK citizens have MSK conditions, and post-pandemic the backlog awaiting access to MSK services has increased. The most prevalent MSK condition is low back pain (LBP), and getUBetter has been recommended by NICE as one of five digital health technologies for helping manage LBP. Purpose: Evaluate impact of getUBetter on a community MSK waiting list.

Aims

The primary aim was to assess change in health-related quality of life (HRQoL) of patients as they waited from six to 12 months for a total hip (THA) or total or partial knee arthroplasty (KA). Secondary aims were to assess change in joint-specific function, mental health, quality of sleep, number living in a state worse than death (WTD), wellbeing, and patient satisfaction with their healthcare.

Aims

The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD).

Aims. This study aimed to investigate the estimated change in primary and revision arthroplasty rate in the Netherlands and Denmark for hips, knees, and shoulders during the COVID-19 pandemic in 2020 (COVID-period). Additional points of focus included the comparison of patient characteristics and hospital type (2019 vs COVID-period), and the estimated loss of quality-adjusted life years (QALYs) and impact on waiting lists. Methods. All hip, knee, and shoulder arthroplasties (2014 to 2020) from the Dutch Arthroplasty Register, and hip and knee arthroplasties from the Danish Hip and Knee Arthroplasty Registries, were included. The expected number of arthroplasties per month in 2020 was estimated using Poisson regression, taking into account changes in age and sex distribution of the general Dutch/Danish population over time, calculating observed/expected (O/E) ratios. Country-specific proportions of patient characteristics and hospital type were calculated per indication category (osteoarthritis/other elective/acute). Waiting list outcomes including QALYs were estimated by modelling virtual waiting lists including 0%, 5% and 10% extra capacity. Results. During COVID-period, fewer arthroplasties were performed than expected (Netherlands: 20%; Denmark: 5%), with the lowest O/E in April. In the Netherlands, more acute indications were prioritized, resulting in more American Society of Anesthesiologists grade III to IV patients receiving surgery. In both countries, no other patient prioritization was present. Relatively more arthroplasties were performed in private hospitals. There were no clinically relevant differences in revision arthroplasties between pre-COVID and COVID-period. Estimated total health loss depending on extra capacity ranged from: 19,800 to 29,400 QALYs (Netherlands): 1,700 to 2,400 QALYs (Denmark). With no extra capacity it will take > 30 years to deplete the waiting lists. Conclusion. The COVID-19 pandemic had an enormous negative effect on arthroplasty rates, but more in the Netherlands than Denmark. In the Netherlands, hip and shoulder patients with acute indications were prioritized. Private hospitals filled in part of the capacity gap. QALY loss due to postponed arthroplasty surgeries is considerable. Cite this article: Bone Jt Open 2022;3(12):977–990

Aims

The primary aim of this study was to assess whether patients waiting six months or more for a total hip (THA) or knee (KA) arthroplasty had a deterioration in their health-related quality of life (HRQoL). Secondary aims were to assess changes in frailty and the number of patients living in a state considered to be worse than death (WTD), and factors associated with changes in HRQoL and frailty.

Aims

Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care.

Background. Scoliosis is described as a lateral spinal curvature exceeding ten degrees on radiograph with vertebral rotation. Approximately 80% of scoliosis presentations are adolescent idiopathic scoliosis (AIS). Current management for AIS in the UK occurs in Surgeon or Paediatrician-led clinics and can be conservative or surgical. The musculoskeletal assessment and triage of AIS appears well-suited to an advanced physiotherapist practitioner (APP) skill set. The aim of this service evaluation was to scope, develop, implement and evaluate a four-month pilot of an APP-led AIS triage pathway. Method and Results. Spinal Consultant deformity and scoliosis clinics were scoped and observed. Clinic inclusion criteria and a patient assessment form was developed. An APP AIS clinic was set up beside a consultant led clinic. All patients assessed were discussed with a spinal surgeon. Consultant and APP agreement (% of total), waiting times, surgical conversion, and patient satisfaction were reviewed. A clinical competency package was developed for training and development of APPs. A total of 49 patients were seen (20 sessions). Waiting list reduced from 10 weeks to 6 weeks. 45%(n=22) of new patients seen were diagnosed with AIS, 27% (n=6) were directly listed for surgery. Consultant/ APP percentage agreement was high for Cobb angle measurement (82%), management plans (90%), and further diagnostic requests (94%). There were no adverse events and high patient satisfaction levels (n=20), (100% Very satisfied or satisfied) were reported. Conclusion. APP-led AIS clinics can provide similar levels of management and assessment as Spinal Consultants with improved waiting times and high levels of satisfaction. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Aims

Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the NHS, which have been further lengthened by the onset of the COVID-19 global pandemic in March 2020. The Department of Health in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to total hip arthroplasty (THA) and total knee arthroplasty (TKA).

Waiting times for arthroplasty surgery in Northern Ireland are among the longest in the National Health Service, which have been further lengthened by the onset of the SARS-CoV-19 global pandemic in March 2020. The Department of Health (DoH) in Northern Ireland has announced a new Elective Care Framework (ECF), with the framework proposing that by March 2026 no patient will wait more than 52 weeks for inpatient/day case treatment. We aimed to assess the feasibility of achieving this with reference to Total Hip Arthroplasty (THA). Waiting list information was obtained via a Freedom of Information request to the DoH (May 2021) and National Joint Registry data was used to determine baseline operative numbers. Mathematical modelling was undertaken to calculate the time taken to meet the ECF target and also to determine the time to clear the waiting lists for THA using the number of patients currently on the waiting list and percentage operating capacity relative to pre-Covid-19 capacity to determine future projections. As of May 2021, there were 3,757 patients awaiting primary THA in Northern Ireland. Prior to April 2020, there were a mean 2,346 patients/annum added to the waiting list for primary THA and there were a mean 1,624 primary THAs performed per annum. The ECF targets for THA will only be achieved in 2026 if operating capacity is 200% of pre COVID-19 pandemic capacity and will be achieved in 2030 if capacity is 170%. Surgical capacity must exceed pre-Covid capacity by at least 30% to meet ongoing demand. THA capacity was significantly reduced following resumption of elective orthopaedics post-COVID-19 (22% of pre-COVID-19 capacity – 355 THAs/annum post-COVID-19 versus 1,624/annum pre-COVID-19). This modelling demonstrates that, in the absence of major funding and reorganisation of elective orthopaedic care, the targets set out in the ECF will not be achieved with regards to hip arthroplasty. Waiting times for THA surgery in the NHS in Northern Ireland are likely to remain greater than 52 weeks for most of this decade

Aims

COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms.

Aims

The aim of this study was to assess the quality of life of patients on the waiting list for a total hip (THA) or knee arthroplasty (KA) during the COVID-19 pandemic. Secondary aims were to assess whether length of time on the waiting list influenced quality of life and rate of deferral of surgery.

Aims

The primary aim is to estimate the current and potential number of patients on NHS England orthopaedic elective waiting lists by November 2020. The secondary aims are to model recovery strategies; review the deficit of hip and knee arthroplasty from National Joint Registry (NJR) data; and assess the cost of returning to pre-COVID-19 waiting list numbers.

The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of “failure to warn”, i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on “failure to warn” and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA.

Cite this article: Bone Joint J 2020;102-B(5):550–555.

Aims

The EuroQol five-dimension (EQ-5D) questionnaire is a widely used multiattribute general health questionnaire where an EQ-5D < 0 defines a state ‘worse than death’ (WTD). The aim of this study was to determine the proportion of patients awaiting total hip arthroplasty (THA) or total knee arthroplasty (TKA) in a health state WTD and to identify associations with this state. Secondary aims were to examine the effect of WTD status on one-year outcomes.

Introduction. Idiopathic scoliosis is a lateral curvature of the spine >10° as measured on a frontal plane radiograph by the Cobb angle. Important variables in assessing the risk of curve progression include a young age at presentation, female sex, a large amount of growth remaining, the rate of growth, the curve magnitude, and the curve location. Curves >20° have an inherently low risk of progression. Surgery is indicated for curves >50° or rapidly progressing curves. The timing of surgery is paramount in order to intervene in cases where rapid progression is evident to prevent further deterioration. There is a greater likelihood for more complex surgery to be required in major curves. At present, there are severe restrictions on resources to cater for patients with scoliosis. As a result, patients spend excessive periods on waiting lists prior to having their procedure. The aim of this study is to analyse the progression of curves of patients while on the waiting list and assess the cost implications of curve deterioration. Methods. A retrospective analysis of 40 cases of adolescent idiopathic scoliosis performed from between 2007-2010 was carried out. All radiographs at the time of being placed on the waiting list and the time of admission were reviewed to assess the Cobb angle. The radiographs were analysed independently by three spinal surgeons to determine what level of surgical intervention they would recommend at each time point. The final procedure performed was also recorded. A cost analysis was carried out of all of the expenses that are incurred as part of scoliosis surgery, including length of hospital stay, intensive care admission, spinal monitoring, implant cost, and the requirement for multiple procedures. Results. The average time on the waiting list was 12 months (range 6 – 16 months). Comparison of radiographs at the time of listing and time of admission revealed a deterioration of the Cobb angle by an average of 12°. The average Cobb angle at time of surgery was 78° (range 55° - 96°). Analysis of cost implications revealed an increase in cost based on implant requirements, length of stay and intensive care admission estimated at 25%. Conclusion. The results of this study demonstrate that there is a significant deterioration of scoliosis curvature in patients while on the waiting list. The consequence of this progression results in longer operative time, increased requirement for intensive care beds, an increase in requirements for additional levels of pedicle instrument, and a prolonged length of stay. The implications of the deterioration in curvature result in an increase in overall cost estimated at 25%. Waiting list initiatives established over the past 6 months have reduced the waiting list to 6-9 months. Further efforts to continue this initiative are likely to give rise to further cost reductions and result in more manageable curvatures being dealt with in a timely fashion

Long waiting times and a growing demand on services for joint replacement surgery (JRS) prompted the Victorian Department of Human Services to fund a University of Melbourne/Melbourne Health partnership to develop and implement an osteoarthritis (OA) hip and knee service delivery and prioritisation system for those who may require JRS.

The service delivery model consists of a multidisciplinary team providing, comprehensive early assessment, evidence-based interventions, including support for patient self-management, continuity of care processes, and prioritisation for both surgical assessment and JRS. Prioritisation occurs via clinical assessment and the Hip and Knee Multi-Attribute Prioritisation Tool (MAPT), a patient, clinician, or proxy-administered 11-item questionnaire, resulting in a 100-point scale ranking of need for surgery. The Hip and Knee MAPT was developed using intensive consultation with surgeons, state-of-the-art clinimetrics and with input from patients, hospital management groups. Ninety-six surgeons contributed to the developing the final scoring system.

Over 4000 patients per year are entering the system across 14 hospitals in Victoria. Under the supervision of the orthopaedics unit, musculoskeletal coordinator (MSC), typically an experienced physiotherapist or nurse, as part of the multidisciplinary team, undertakes early comprehensive assessment, referral and prioritisation of patients with hip or knee OA referred to orthopaedic outpatient clinics. In addition, the MSC coordinates the monitoring and management of patients on the orthopaedic surgery waiting list. The processes enable patients who are most needy (via higher MAPT score and clinical assessment) to be fast-tracked to orthopaedic surgery; conversely those patients with lower scores receive prompt conservative management.

Time to first assessment and waiting times to see a surgeon for many patients have reduced from 12+ months to weeks. Patients seen by surgeons are more likely to be ready for surgery and have had more comprehensive non-operative optimisation. Patients placed on the surgical waiting list receive quarterly reassessments and evidence of deterioration is used as a basis for fast-tracking to surgery.

The OWL system is a whole of system(tm) approach informed by patients needs and surgeons needs. Clinicians have developed confidence in the clinical relevance of the MAPT scores. Uptake of the OWL model of care has been very high because it facilitates better care and better patient outcomes.

Introduction

Elective Orthopaedics has been targeted by the UK Department of Health as a maximum six-month waiting time for operations could not be met. The National Orthopaedic Project was initiated as a consequence and Independent Sector Treatment Centres (ISTCs) and well established private hospitals were utilised to treat NHS long wait patients.

Background. Exercise can be effective in treating Chronic Low Back Pain (CLBP) (Hayden et al 2005). Pilates-based group exercise programmes may be useful in the treatment of CLBP. Aim. To carry out a feasibility study of group Pilates exercise course compared to individual physiotherapeutic intervention and a waiting list control, in the treatment of CLBP. Methods. 52 Patients with CLBP: referred for physiotherapy were randomly assigned to: (1) Conventional physiotherapy for 6 weeks; (2) 6-week course of Pilates group exercise; (3) Waiting list control. Outcome measures were; RMDQ, VAS for pain and SF-36 quality of life questionnaire; completed at baseline, seven weeks and three months. Results. Although the study was successful in recruiting patients, loss to follow up (25% at 7 weeks; 40% at 3 months) and patient adherence with treatment was a problem. Conclusion. Stricter inclusion criteria may be required in studies of this type defining, duration of symptoms, number of episodes of pain and upper age limit. A change in RMDQ score was used to calculate the power for a main RCT. 334 patients per group would allow for a 40% loss at follow-up

Background: Our Trust consists of two separate hospitals with duplicated Orthopaedic services at both sites. Sterile Services were centralised to one site in February 2006. Various problems were encountered leading to cancelled cases. What have been the financial implications of these cancellations?. It is difficult to estimate the true cost to the Trust for a cancelled case. Each cancelled case is a ‘slot’ on an operating list that has not been filled. There are regular Waiting List Initiative (WLI) Lists – the number of these have increased. Could an empty slot on a regular list have been filled by a WLI case? Would the cost of the WLI case theoretically performed in the empty slot be the cost of the cancelled case? The model is basic and has many assumptions. Patients are allocated a slot on a WLI list for a variety of reasons, however with enough numbers and across enough time, the true cost must be somewhere near these figures. Method: Every cancelled case coded as “Surgical Equipment: checking/malfunction/unavailable” between April 2006 and Mar 2008 (2 financial years). The total number of WLI cases in the same period and the total cost of those cases. Results: There were 239 cancelled cases for Sterile Services reasons across Trust April 2006 – March 2008. During the same period, there were 1,566 Waiting List Initiative. Cases Cost: £3,234,000 (£2,065 per case). Conclusions: If all of the cancelled slots had been filled by WLI cases this would have avoided a total cost to the Trust of £493,535

Waitemata DHB serves a population of approximately 500,000. There are 396 general practitioners who refer to the services. Approximately 400 patients are referred per month. Budget constraints mean not all patients referred can be seen and various Ministry of Health guidelines and Health and Disability Commission rulings help to determine which patients will be seen.

All referrals to the service are assessed by one surgeon. There are specific requirements for referral of patients with certain complaints.

Assistance is given to the general practitioner in organising the more specialist investigations. Help is given to GPs by telephone for patient management particularly of the simpler conditions.

Approximately a quarter of patients referred are referred back to the GP. MRI and CT scans are arranged of which half are returned.

Time must be allocated within the department to allow this specialist liaison with GPs to occur.