The value of hip replacement

210,000 hip and knee replacements took place in the UK last year. Lucinda Gabriel, Clinical Fellow at King’s Health Partners [pictured below], blogs about a new study on best practices in outcomes and cost measurement.

Lucinda gabrielOur Value Based Healthcare pilot project in orthopaedics has recently been published in the journal BMJ Open Quality, where we highlighted best practices in outcomes and cost measurement in the elective hip replacement pathway at King’s College Hospital NHS Foundation Trust.

The King’s Health Partners Value Based Healthcare (VBHC) agenda sets out to re-orientate our healthcare delivery system. Value in healthcare is defined as outcomes that matter to patients and carers relative to the costs of delivering those outcomes and is measured over the complete care pathway.

Our study aimed to gauge if pathway redesign based on the principles of VBHC could increase value. The aim was to calculate the value of treatment for primary hip osteoarthritis through measuring outcomes that matter to patients as well as the costs of delivering them.

Additionally, our work aimed to compare two care pathways to identify which elements may better promote the delivery of high-value clinical care.

Hip osteoarthritis is a particularly high-volume condition with significant clinical need and population-level costs. In the UK alone more than 210,000 hip and knee replacements were undertaken in the last year according to the National Joint Registry.

There remains much variation in patient outcomes and care delivery costs for this condition. Tackling this condition is a high value proposition; the demand is increasing at every point of clinical contact, contributing significantly to the already overburdened health service.

To measure value, we initially looked at outcomes for our two models. The first being a traditional model with multiple entry points and without pathway standardisation, and the second an intentionally designed standardised multidisciplinary pathway. Mandated NHS patient-reported outcomes (PROMS) were attained but were restructured to assess the impact on pain, function and psychological outcomes in a more meaningful way to patients.

We found no significant differences in clinical outcomes between our two models. Patient-level pathway economic evaluation was also performed. Using these data, outcomes were mapped against cost to calculate value. The intentionally designed model delivered better value care, having lower pathway costs. This pathway maximised the benefits of having an integrated practice team. Physiotherapists and orthopaedic surgeons worked together side by side. This pathway model produced a small but inconsistent positive financial margin.

Intentionally designed, integrated elective services offer an opportunity to develop and evaluate VBHC models. Our work has shown that value calculation can be performed but we have learned that it requires considerable resource and access to NHS PROMs and costing information.

There is value in communicating these outcomes back to clinicians, and patients alike. If data capture, and specifically outcomes collection, becomes more relevant to financial remuneration, it may improve and allow outcomes to be better understood. This will better align stakeholders. This can be challenging and relies on good clinical leadership and secure relationships across clinical and costing departments.

Developing and measuring patient-orientated outcomes and performing accurate economic evaluation are key to understanding and achieving better value care. Implementing a VBHC approach has the potential to change the way healthcare is incentivised, and ultimately has the potential to reinvent the funding structure while delivering sustainable, equitable and effective healthcare services for all.

This work is a valuable addition to the VBHC literature and will be critical in progressing our work in VBHC at King’s Health Partners.

Read the full journal article on the BMJ Open website.

Read more about the Vital 5 and Value Based Healthcare on the King's Health Partners website.