Revision knee replacement outcomes and implications for the organisation of care in the NHS: Can regional networks improve outcomes?

Introduction Revision knee replacement (RevKR) is a complex and costly procedure with high rates of reoperations. Identifying better models of care delivery is a top research priority in RevKR. Regional networks were introduced in England to improve outcomes through multidisciplinary decision making and complex cases being done by fewer more experienced surgeons and hospitals. While higher procedure volumes are associated with improved outcomes in surgery, RevKR is still often performed by low volume surgeons and hospitals. The literature shows an inconsistent relationship between volume and outcomes in RevKR, highlighting the need to better understand this relationship, particularly as the National Health Service (NHS) considers reconfiguring care for low volume, high complexity orthopaedic procedures. Methods This work aimed to explore the association between procedural volume and outcomes following RevKR using data from the UK National Joint Registry (NJR), Hospital Episode Statistics (HES), and the Department of Health’s Patient Reported Outcome Measures (PROMs). Semi-structured interviews were also conducted with patients and carers who had experience or knowledge of RevKR. Results Multivariable fixed effects models with restricted cubic splines revealed that for first-time RevKR for non-infected causes, higher surgeon volume was associated with lower re-revision rates. For revisions due to prosthetic joint infection, the relationship between volume and outcome was more complex. Surgical units with the highest annual volumes (52) were associated with lower re-revision rates compared with the lowest volume units (<12), whereas no surgeon-level volume-outcome relationship was observed. Increased travel distance from specialist hospitals did not worsen emergency readmission or mortality rates. Patients and carers supported travelling further for specialist surgery, although many expressed concerns about the burden of travel for hospital visits before and after surgery. Conclusion This work supports the setting of minimum activity levels for surgeons and units. It also advocates for early warning systems for outlier detection and emphasises the importance of incorporating patient perspectives in service redesign. While volume outcome relationships in RevKR may be complex, regional coordination is generally supported by patients. Local services and pathways should be examined to address the impact of travel on an older, less mobile patient group.<p></p>

Author dc:creator

• Alex Matthews (21052865)

• orthopaedics
• knee replacement
• outcomes
• surgical volumes
• networks

Statement dc:rights

• All rights reserved

Identifier

10779/exe.31188514.v1

OAI identifier oai:identifier

oai:figshare.com:article/31188514