Evaluating a pre-surgical health optimisation programme: a feasibility study

Feasibility of data collection

Mapping the patient pathway from initial general practice referral to discharge identified seven services with potential patient contact and therefore sources of data pertinent to the evaluation; primary care, the Referral Support Service, physiotherapy team, Healthy Lifestyle Service, community-based smoking cessation services, community-based weight management services and secondary care at the acute trust (see Additional file 1). General practice data were only indirectly available by accessing the information provided to the Referral Support Service. This provided the main source of demographic data. Data from each source were not routinely integrated, for example, general practice did not receive information on the patient’s interaction with the Healthy Lifestyles Service. Information technology systems within the organisations did not allow automatic data collation, as many data sources consisted of manually populated spreadsheets. It took 12 months to agree on the data collation, information governance arrangements and provision to the research team. Honorary NHS Clinical Support Unit contracts for the research team were instrumental in allowing data provision.

Data completeness

Age and sex were available for all patients. Ethnicity was poorly recorded in general practice and was often mixed up with nationality, so is not reported here. Baseline BMI and Oxford scores were well completed (96% and 99%, respectively), and for patients who completed the referral pathway, Oxford scores were also well recorded at the end of the pathway (95%). In contrast, BMI was poorly recorded at the end of the pathway for these patients (52%), though was better recorded for health optimisation patients than non-health optimisation patients (68% and 45%, respectively). Smoking at baseline appeared to be under-reported compared to population figures (5% in our study compared to 11.7% of adults in the CCG region in 2018 (Public Health England, 2019)) and was not collected at follow-up for any patients who completed the pathway, so changes to smoking status could not be assessed.

Patient population and baseline characteristics

During the 6-month study period, 502 patients were referred to the NHS elective hip/knee surgery pathway from general practice. Of these, 37% (184) were referred for health optimisation: 91% (168) were obese, 11% (29) were smokers, 7% (13) were both and 5% (9) did not appear to meet either criterion.

The health optimisation group compared to the non-health optimisation group were similar in age and sex but were more socioeconomically deprived (Table 1). The health optimisation group also included a larger proportion of knee patients (compared to hip patients) than the non-health optimisation group (73.4% vs. 58.2%). Patients had worse average baseline Oxford scores in the health optimisation group than the non-health optimisation group (median 16 vs. 19). As expected, there were more smokers in the health optimisation group than the non-health optimisation group (11% vs. 2%), and the health optimisation group had a higher median BMI (33 vs. 26). Within the health optimisation group, patients who accepted referral to the Healthy Lifestyles Service were more likely to be female and deprived than those who did not accept referral. They also had slightly higher average BMI, were more likely to smoke and had worse Oxford scores (Table 1).

Table 1 Baseline information by patient group (health optimisation and non-health optimisation)Movement through pathway

Patient engagement with the hip and knee pathway was variable. Only 68% of patients in the health optimisation group and 78% of other patients completed the pathway (Table 2). In part, this was because fewer patients in the health optimisation group attended the 6-week physiotherapy component (76% vs. 81%) that was viewed as forming an integral part of the pathway for all patients (see Fig. 1), and more patients in the health optimisation group dropped out of the pathway (8% vs. 3%) (Table 2). In addition, fewer patients in the health optimisation group were referred to self-management compared to other patients (26% vs. 32%) (Table 2).

Table 2 Patient outcomes by group for all patients referred into the Hip and Knee pathway: surgery or self-management

Only 28% (51/184) of the health optimisation group accepted referral to the Healthy Lifestyles Service. Nearly all (49/51) of these referrals were to weight management services (such as Weightwatchers/Slimming World) and 4% (2/51) were to smoking cessation services. While the proportion of patients referred for surgery was similar for health optimisation group patients and other patients, fewer health optimisation group patients who accepted referral to the Healthy Lifestyles Service were referred for surgery (49%) compared to those (61%) who did not (Table 2). The comparatively high proportion of health optimisation group patients who did not accept a referral for support and were referred to surgery was matched by a comparatively low proportion of these patients referred to self-management (23%) compared to those referred to the Healthy Lifestyles Service (33%) or other patients (32%) (Table 2). Table 2 records the reasons for no onward referral.

For patients who completed physiotherapy, the duration of physiotherapy treatment was longer for health optimisation patients compared to non-health optimisation patients, and there is no difference in length of stay for these patients who went on to be admitted for surgery during the follow-up period (Table 2).

Outcomes

Repeat measures of BMI, smoking status and Oxford score were not recorded unless patients completed physiotherapy and attended a final assessment appointment. For these patients, 31% (39/125) of the health optimisation group reduced their BMI by at least 2 kg/m2 compared to 4% (10/249) of the non-health optimisation group. Changes in median BMI are shown in Table 3. Thirteen per cent (16/125) of the health optimisation group and 24% (60/249) of the non-health optimisation group moved from ‘severe/moderate’ to ‘mild/normal’ Oxford score categories. Health optimisation patients who accepted referral to the Healthy Lifestyles Service had a larger median reduction in BMI than those who did not accept referral (− 1.8 vs. − 0.5) (Table 3). There was no difference between these groups in median change in Oxford score (Table 3).

Table 3 Patient outcomes by group for those who completed the physiotherapy pathway: BMI and Oxford scoresCostings

National reference cost data indicate that the mean cost for the standard surgery pathway, from initial general practitioner (GP) appointment to rehabilitation, was £6883 for knee patients and £7110 for hip patients (see Additional file 2). This included the estimated cost of £105 for the physiotherapy-led element of care (hip and knee team) for patients who fully engaged with it. For health optimisation patients who accepted a weight management referral, literature-based data suggested a mean cost of £57 (across a range of £40 to £75), and local NHS smoking cessation support cost of £505 per participant (see Additional file 2).

留言 (0)

沒有登入
gif