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.
The Osteoarthritis Hip and Knee Service (OAHKS) was introduced in 2006 and the aim of this service was to ensure early assessment and monitoring, optimise non-operative and pre-operative management, and ensure equitable access to surgical treatment. Patients were prioritised and monitored for disease deterioration using the Multi-Attribute Arthritis Prioritisation Tool (MAPT). All patients who were referred for assessment by the OAHKS between December 2006 and April 2009 were identified. Data was collected from the OAHKS computer database, hospital patient information computer system and the Department of Health databases. Scores were identified for patients who underwent joint replacement surgery (JRS) following pre-operative MAPT. Demographic and clinical data was collected prospectively and statistically analysed. Demographic data included sex, age and ethnicity. Patient clinical data included referral source and time to initial OAHKS appointment, BMI, co-morbidities, MAPT scores, referrals to other healthcare professionals and outcome of OAHKS appointment. In total, 768 patients (296 males and 472 females) were referred to OAHKS between December 2006 and April 2009. Patients ranged in age from 20 to 94 years with a mean age of 68.22 years at initial review. Patients referred were from 20 different ethnic backgrounds. The median time to initial appointment was 80.5 days (IQR 36.5-99 days). There were 656 (85.4%) patients referred from their GP and 89 referrals were from other sources. Eighty-nine per cent of patients (n=686) were screened for co- morbidities. Of these patients, 58% had hypertension, 20.8% had diabetes mellitus, 19.3% had ischaemic heart disease, and 19.8% had a psychosocial illness. The mean body mass index (BMI) was 32.71 (median 32.01). Only 42.3% patients had some form of conservative management modality prior to attending OAHKS. A total of 1061 referrals to other healthcare professionals were made. Physiotherapy (48.6%), hydrotherapy (40%) and dietician (16.1%) were the most common referrals. Referrals to the orthopaedic surgeon accounted for 15.7% total referrals. MAPT scores increased in 229 patients, decreased in 306 patients and were unchanged in 25 patients. From December 2006–March 2009, 269 patients had MAPT scoring assessment pre-operatively. Of those patients who had surgery 52% had TKR, 40.5% THR, 5.5% UKR and 1.85% hip resurfacing. The OAHKS has enabled patients with osteoarthritis to be rapidly assessed leading to a reduction in outpatient waiting times. Patients suitable for JRS are prioritised according to clinical need and MAPT scores. Thus, patients with greatest clinical need have received surgery much sooner than previously.
