1. Appropriateness of joint replacement: A multi-stakeholder approach Claudia Sanmartin, Carolyn DeCoster, Gillian Hawker March 28, 2012 Ottawa, Ontario

2. Why Appropriateness? Traditional focus on supply-side management of waiting times Increasing supply increases demand Demand-side management requires definition and management of appropriateness Perspective matters

3. Agenda – WCWL Appropriateness research Program of research oriented toward the development of a multi-stakeholder decision- support tool for appropriateness of total knee and hip replacement –Patient input - focus groups –Surgeon input – interviews –Decision-maker - ???

4. Patient input– Key Findings Consistent with previous studies in physician experts, patients with hip/knee OA identified arthritis severity & motivation as key considerations when evaluating appropriateness for TJR –spoke less about capacity to benefit (risks versus benefits) Patients’ pain experience (impact on quality of life, ability to cope) was seen as the most important determinant –Inadequately evaluated by clinicians –Need to enhance surgeon-patient communication and use of standard tools to measure pain from the patients perspective

5. 5 Surgeon input - Summary Part 1: Criteria used to determine appropriateness –Age – overarching theme used to interpret and assess other criteria which may differ for younger versus older patients –Pain and function (quality of life) –Surgery as a last resort –Patient expectation –Social situation –Mental or psychological health –Comorbidities Part 2: Risks versus Benefits –Immediate risk (comorbidities) versus benefits –Long-term risk (health of joint) versus benefits –Risks versus potential to benefit Part 3: Views on …… –Role of other key stakeholders – decision-makers should not be involved in clincial decision –Usefulness of a decision-making tool – OK to standardize assessment and data – did not want an « absolute » number to identify inappropriate patients

6. PAIN/ FUNCTION JOINT CONDITION Patient Information: Age, gender, joint/side, previous joints COPING (Patients: related to pain, difference by age) SOCIAL CIRCUMSTANCES (support current and post-op PATIENT EXPECTATIONS (rehab and and post-op “READINESS”/ MOTIVATION CO- MORBIDITIES (Include mental health) SURGICAL RISK CAPACITY TO BENEFIT Patient reportedSurgeon/Clincian reported APPROPRIATENESS CRITERIA– CONCEPT MAP PRE-OP MANAGEMENT PATIENT SATISFACTION?

7. Decision-maker input - Literature review –Very little information – focus primarily in terms of economic perspective –TJR found to be cost-effective Decrease pain and improve overall quality of life Decrease long-term costs –Lower costs associated with – Age (younger) (cost of revision?) No comorbidities Earlier stage of disease progression Need input from decision-makers about they view/understand appropriateness and what type of information is required? –Who should

8. Decision-maker input - Proposal Telephone interviews: –One on one interviews – recorded DMs representing various levels –several levels within healthcare –focus on decision-makers who have responsibility for resource allocation decisions Semi-structured questionnaire –To guide but not limit the conversation

9. Questions for you…. How do you, as a decision-maker, define appropriateness? What concepts does that term encompass? What is the role of DMs in determining appropriateness? What type of information would decision-makers like to have in terms of appropriateness to inform their decisions? We’d like to interview decision-makers who need to balance the demand for hip or knee arthroplasty among other competing demands. Does that make sense? What level is that: Ministry of Health? Regional Health Authority?

10. Extra slides

11. Existing tools to measure/estimate appropriateness criteria Identified in appropriateness studies