key: cord-0883939-h3m7lxpt
authors: El Ashmawy, Abd-Allah; Dowson, Kathleen; El-Bakoury, Ahmed; Hosny, Hazem A.H.; Yarlagadda, Rathan; Keenan, Jonathan
title: Effectiveness, Patient Satisfaction and Cost Reduction of Virtual Joint Replacement Clinic (VJRC) Follow-Up of Hip and Knee Replacement.
date: 2020-08-15
journal: The Journal of Arthroplasty
DOI: 10.1016/j.arth.2020.08.019
sha: 7704ce78df76a537e47a06649dd8a9b7d56d7f3a
doc_id: 883939
cord_uid: h3m7lxpt

Abstract Background Total hip (THR) and knee (TKR) replacements are increasingly performed operations and routine follow-up places huge demands on orthopedic services. This study investigates the effectiveness, patients’ satisfaction and cost reduction of Virtual Joint Replacement Clinic (VJRC) follow-up of THR and TKR patients in a university hospital. VJRC are especially valuable when in-person appointments are not advised or feasible such as during the COVID-19 pandemic. Methods 1749 patients who were invited for VJRC follow up for knee or hip arthroplasty from January 2017 to December 2018 were included in this retrospective study. Patients were referred to VJRC after their 6-week post-operative review. Routine VJRC postoperative review was undertaken at 1, 7 years and then 3 yearly thereafter. We evaluated the VJRC patient response rate, acceptability and outcome. Patient satisfaction was measured in a subgroup of patients using a satisfaction survey. VJRC costs were calculated compared to face-to-face follow up. Results The VJRC had a 92.05 % overall response rate. Only 7.22 % required further in-person appointments with only 3% being reviewed by an orthopedic consultant. VJRC resulted in an estimated saving of £43,644 per year at our institution. The patients’ satisfaction survey showed that 89.29% of the patients were either satisfied or very satisfied with VJRC follow-up. Conclusions VJRC follow-up for hip and knee arthroplasty patients is an effective alternative to in-person clinic assessment which is accepted by patients, has high patient satisfaction and can reduce the cost to both health services and patients.

With an ever increasing ageing population, improved life expectancy and quality of life 32 expectations, the demand for hip and knee arthroplasty is on the rise [1] . The required follow-up 33 for these operations has placed huge demands on orthopaedic services in terms of limited 34 outpatient resources and clinical staff [2] . 35

Randomised trials in other specialties have shown general practitioner [3] , telephone [4] , paper 36

[5], and nurse led [6] follow-up as valuable alternatives to surgeon led follow-up clinics. These 37 options can increase patient's convenience and satisfaction while reducing cost to the national 38 health services [7] . Virtual fracture clinics, whereby patient information is collected remotely 39 and then reviewed by a specialist have shown to be cost-effective [8, 9] . National guidelines in 40 the United Kingdom recognise that virtual clinic follow-up maybe useful to monitor outcome of 41 hip and knee arthroplasty [2, 10, 11]. 42 43 After a successful pilot in our university hospital with encouraging results, we further developed 44 a Virtual Joint Replacement Clinic (VJRC) [12] , The aim of this study was to investigate the 45 reliability, patient's satisfaction and cost effectiveness of the VJRC. were discharged from follow up and not included in VJRC. VJRC follow-up was not only offered 64 to new patients who recently had hip or knee replacements (one-year follow-up) but also to 65 patients who were due to have their year seven or later long-term follow-up for their joint 66 replacement (legacy patients). Routine VJRC postoperative review following national 67 guidelines[2, 10] was undertaken at 1, 7 years and then 3 yearly thereafter. 68 J o u r n a l P r e -p r o o f Response rate and acceptability: 120

The VJRC had a 92.05 % overall response rate from invited patients (1610 out of 1749), 139 121 (7.95%) did not return forms and/or attend x-ray) ( Figure 2 ). Eighty-seven patients (4.97%) were 122 discharged post invite for reasons listed in Table 1 The average VJRC process appointment was found to cost £79 while an average face-to-face 144 process orthopaedic outpatient follow-up appointment costed £135, resulting in an estimated 145 saving of £43,644 per year at our institution as shown in Table 2 . 146 147 148

Increasing demand for THR and TKR with associated follow-up has placed huge demands on 150 orthopaedic services [7] and a more efficient and acceptable method to monitor arthroplasty 151 patients is required. Previous studies have shown that patients completing questionnaires in 152 their own time are less likely to omit information than during a perceived rushed consultation 153 [18] and that questions asked by an interviewer can lead to a preferred rather than a factual 154 answer owing to the patient's embarrassment [19] . The concept of virtual clinics has been 155 established for some time, although often related to trauma or fracture clinics [8] . Kingsbury et 156 al [7] found that a questionnaire and radiograph-based remote review, of 599 patients, 157 identified all patients in need of increased surveillance, with good agreement for on-going 158 patient management and may represent a feasible total joint arthroplasty follow-up mechanism. 159 160

The VJRC response rate of 92% is higher than in other studies, with reported rates ranging from 161 76 to 83% [20, 21]. A web-based follow-up study showed that 24% of their eligible patients 162 declined to participate in the virtual follow up due to lack of internet access. They suggested 163 that computer access may present a technological barrier for older people as the mean age of 164 the patients who declined participation was 74 years old [21] . We used paper PROMs 165 questionnaires, that were sent to the patients by post rather than electronically, which were 166 acceptable to our patient population (mean age = 71 years) and may be a reason for the high 167 VJRC response rate. Only 8 % of patients surveyed stated a preference for web-based follow up. 168

One of the concerns about reviewing arthroplasty patients remotely is the failure to identify 169 patients who might require revision or subsequent surgical intervention. Marsh et al [22] stated 170 that the causes for subsequent revision were not missed in their study using a web-based 171 follow-up and Kingsbury identified all patients in need of increased surveillance [7] . We also 172 believe that meticulous assessment of PROMS, plain radiographs reviewed by a surgeon 173 together with providing the option to have further in-person appointments to the patients can 174 make this issue to be very unlikely to occur. We had three patients who were identified and 175 Table 1 and we do not believe there has been selection bias in this study. Table 1 If you have any comments on how we could improve the service, please tell us (please continue on the back page if you like)

What would be your preferred method of future routine joint replacement review (normally at 1, 7, and 10 years following surgery, then every 3 years) Virtual Clinic (as the previous review, with option of formal appointment if concerns) Web-based follow up (email and electronic questionnaires to complete on a computer, tablet, or suitable phone, with the option of formal appointment if concerns) Formal outpatient clinic appointment at Derriford Hospital None, I would rather be discharged to the care of my GP

Two and a half years on: data and experiences 255 establishing a 'Virtual Clinic' for joint replacement follow up

British Orthopaedic Association. Primary total hip replacement: A guide to good practice

Routine follow up of breast cancer in primary care: randomised trial

Telephone follow-up following office 261 anorectal surgery

Paper Clinics'-a model for improving delivery of outpatient colorectal 263 services

Nurse-led follow-up on demand or by a 265 physician after breast cancer surgery: a randomised study

Is a questionnaire and 267 radiograph-based follow-up model for patients with primary hip and knee arthroplasty a viable 268 alternative to traditional regular outpatient follow-up clinic?

Fracture clinic redesign 270 reduces the cost of outpatient orthopaedic trauma care

Virtual fracture clinic delivers British Orthopaedic Association 272 compliance

British Association of knee Surgery, British Orthopaedic Association, Royal College of 276 Surgeons of England. Commissioning guide: Painful osteoarthritis of the knee

Developing and implementing a virtual clinic for follow-up of 278 major joint arthroplasty in the NHS

The use of the 281 Oxford hip and knee scores

Comparative responsiveness of the PROMIS-10 Global Health and EQ-283 5D questionnaires in patients undergoing total knee arthroplasty

Meaningful changes for 288 the Oxford hip and knee scores after joint replacement surgery

Telephone follow-up after treatment for breast cancer: 290 views and experiences of patients and specialist breast care nurses

An electronic clinic for arthroplasty 293 follow-up: a pilot study

J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f

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