Implementation of Day-case Hip and Knee Arthroplasty ensuring Optimal Patient Experience and Outcomes.(IDAPO)

Background: Hip and knee arthroplasty is highly successful at improving pain and function in advanced osteoarthritis, with over 200,000 procedures performed annually in the UK. Current provision remains inadequate. Over 7.6 million patients are awaiting elective surgery in the UK. Those awaiting hip or knee arthroplasty represent the greatest proportion and wait the longest, frequently more than a year. National guidelines recommend that hip and knee arthroplasty is performed as a day-case whenever possible. In some hospitals, up to 50% of hip and knee arthroplasty is day-case. However, nationally fewer than 1% of patients go home on the day of surgery, and fewer than half of hospitals discharge any patients on the same day as hip or knee arthroplasty. Average length of stay remains more than two nights. Aim: Develop and implement an inclusive day-case arthroplasty pathway that ensures optimal clinical outcomes and patient experience, with improved efficiency and reduced costs. Objectives and Methods: Workpackage (WP)1: Understand current practice (and inequalities), clinical outcomes, and cost-effectiveness of day-case hip and knee arthroplasty. Analysis of National Joint Registry, Hospital Episode Statistics, Patient Reported Outcomes Measures. WP2: Explore beliefs and experiences of patients, care-givers, clinical teams, and commissioners to understand barriers and facilitators of day-case arthroplasty. Sequential mixed methods consisting of surveys and qualitative interviews. Emphasis on recruiting ethnic minorities and lower socioeconomic groups. WP3: Establish current evidence for interventions that improve feasibility and outcomes of day-case arthroplasty. Evidence synthesis to identify interventions for successful day-case arthroplasty including guidelines and health economic studies. WP4: Co-design day-case pathway with training packages and patient/care-giver resources. Mixed methods to synthesise findings from preceding WPs. Workshops with key stakeholders (including PPI) to finalise day-case pathway, patient information and training package. Undertake feasibility assessment. WP5: Evaluate outcomes of implementing day-case hip and knee arthroplasty. Randomised controlled trial of 1406 patients from 20 sites comparing day-case pathway with standard care. Primary outcome Forgotten Joint Score at six months. Secondary outcome Picker Patient Experience Questionnaire. Process and health economic analysis. WP6: Disseminate findings, implement change through engagement events with patients, care-givers, clinical teams, commissioners, and professional bodies. Update patient and care-giver resources (different languages). Update GIRFT and NICE guidance. PPI and EDI: We worked with three groups of patients and care-givers. There was feedback of fear and anxiety of going home on the day of surgery. Families from ethnic minorities and lower socioeconomic groups felt they were disadvantaged during their admission and abandoned following discharge, highlighting language barriers and racial bias. We will continue to work with PPI groups and our PPI co-applicant, and will undertake community outreach activities. Impact: Protocoled evidence-based day-case hip and knee arthroplasty pathway feasible in the NHS ensuring good clinical outcomes, patient experience, and cost-effectiveness. Updated patient and care-giver information resources and national guidelines for hip and knee replacement. Increase the number of hospitals providing day-case surgery and proportion of patients discharged home on day of surgery. Potential annual NHS savings exceed £40 million. Translation of findings and adaptation of pathway to other surgical specialities.