Shift Follow-up Slots to New Patients (But Color In the Lines)

What’s the Claim?

You probably missed this well-hidden paper, but if you currently see patients back for annual follow-up (or even every few years) as a matter of routine, you’ll be glad you’re reading CORRelations today. The findings of this paper support the conversion of follow-up slots in the office to new-patient visits, which is always nice, and you can do this knowing that the best-available evidence supports your choice. This whale of a study — nearly 200 pages long — concludes that after recovery from routine hip or knee replacement, “it is safe to disinvest” in follow-up visits in asymptomatic patients in the first decade, provided that you’ve used an implant rated “ODEP-10A* minimum,” which are those implants found to have a >90% survivorship at 10 years (you can see whether your favorite implant makes the list here). This recommendation depends on two important conditions: (1) That the patient has access to rapid follow-up with a surgeon should problems arise, and (2) that you make sure to bring the patient in for clinical and radiographic follow-up at 10 years, whether or not the patient is symptomatic. Follow-up beyond 10 years depends upon what you find at the 10-year visit, and the free pass for the first decade does not apply to complex reconstructions, or to straightforward reconstructions that used implants not on the “ODEP-10A* minimum” list.

How’s It Stack Up?

There is nothing out there like this. It’s comprehensive, based on an expert panel’s review of three “work packages,” which really are three separate sets of methods: (1) A comprehensive and beautifully done systematic review; (2) two analyses of five linked, national electronic health record data sets to understand which patients present for revision surgery (particularly between 5 and 10 years after surgery) and when, and how they are currently identified; and (3) a complex mathematical (Markov) model to simulate what would happen to implant survivorship, health-related quality of life, and care costs if patients’ health states changed over time in myriad ways. Wow.

What’s Our Take?

Provided that you color within the lines — use implants on the list, apply this approach only to straightforward primary arthroplasty (not complex cases), find a way to have a reminder to contact patients at 10 years (and create a pathway for them to have an easy way back in to see you before then if they need to) — it seems reasonable to use this comprehensive guideline in practice. The full text of the guideline is available below. We’re excited about these evidence-based recommendations, which — in this case — happen also to support the running of efficient, effective joint replacement practices. You can use them to accommodate many more new patients seeking arthroplasty care. Win-win.

Source

Kingsbury SR, Smith LK, Czoski Murray CJ, et al. Safety of Disinvestment in Mid- to Late-term Follow-up Post Primary Hip and Knee Replacement: The UK SAFE Evidence Synthesis and Recommendations. Health and Social Care Delivery Research. No. 10.16. Jun 2022. PMID: 35767667. DOI: 10.3310/KODQ0769.

Further Commentary

Saul H, Cassidy S, Deeney B, Kwint J, Conaghan P. Routine Follow-up May Not Be Needed for People Undergoing Joint Replacement Surgery. BMJ. 2023;380:222.