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Knee replacement and the STAR care pathway

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View the STAR: Support and Treatment After Replacement programme

Over 110,000 total knee replacements were performed in the UK in 2019. The aim of surgery is to reduce pain and improve function, usually due to osteoarthritis. The STAR care pathway is a clinically important and cost-effective treatment for patients with chronic pain three months after total knee replacement for osteoarthritis. Rachael Gooberman-Hill discusses knee replacement and the Support and Treatment After Replacement (STAR) care intervention.

Image courtesy of interviewee. July 18, 2024

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This video discusses the need for knee replacements, primarily driven by pain and functional impairment often due to osteoarthritis. In the UK, approximately 100,000 knee replacements are performed annually, but about 20% of patients experience long-term pain after surgery, defined as pain persisting three months post-operation.

To address this issue, the STAR Care Pathway (Support and Treatment after Replacement) was developed to provide tailored support for patients experiencing pain after knee replacements. The intervention involves a clinic appointment for patients with long-term pain, where they engage with trained practitioners to receive assessments, recommendations, and potential referrals for further treatment.

The STAR program, a decade-long initiative supported by the UK’s National Institute for Health Research, included a randomized controlled trial with 363 participants. Those receiving the STAR intervention showed improved pain management and reduced costs to the NHS compared to those receiving usual care.

The STAR Care Pathway is now available as a training package for NHS clinicians, aiming to ensure effective patient care. Future research areas include preventing long-term pain and improving communications about surgical risks to enhance patient decision-making before knee replacement surgery. The program emphasizes the importance of a collaborative, interdisciplinary approach to effectively address the complexities of post-operative pain management.

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Here are some key quotes from the video regarding knee replacement surgeries, pain management, and the STAR Care Pathway:

1. **Purpose of Knee Replacement**:
- "The reason why someone might have a knee replacement is in order to address the pain that they're having and the functional impairment that they're having, largely often in relation to having osteoarthritis."

2. **Prevalence of Long-term Pain**:
- "About one in five of those people find that they have long-term pain after their knee replacement."

3. **Definition of Long-term Pain**:
- "When we are thinking in research about what we mean by long-term pain after an operation, we're really thinking about pain that happens three and more months after the surgery itself."

4. **STAR Care Pathway**:
- "So altogether in total, we call that the STAR Care Pathway. STAR stands for Support and Treatment after replacement."

5. **Individualized Care**:
- "STAR is all about trying to tailor care to an individual's needs rather than a one size fits all."

6. **Evaluation of the STAR Intervention**:
- "We invited people with long-term pain to take part in the research... The median age of people taking part in the trial was 67 years old."
- "At 12 months after surgery, we found that people who had received the STAR care pathway had better scores on the brief pain inventory pain and interference scores."

7. **Economic Impact**:
- "We found that people who had received the STAR care pathway were not costing as much to the NHS care services as those who had not received the care pathway."

8. **Future Research Directions**:
- "We think there's a really important future research question about how to prevent people having long-term pain in the first place."
- "We know that the risk of long-term pain after knee replacement is about one in five, roughly."

These quotes encapsulate the key points about why knee replacement surgeries are performed, the issue of long-term pain, the STAR Care Pathway initiative aimed at improving outcomes for patients, and the importance of future research in this area.

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The reason why someone might have a knee replacement is in

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order to address the pain that they're having

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and the functional impairment that they're having,

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largely often in relation to having osteoarthritis, but also

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because of other conditions as well.

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So a knee replacement happens in order to relieve someone of

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that pain and to help improve their function.

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So improve, improve how much they can get about,

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and how much they can do in their daily lives.

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So in the UK at the moment,

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about 100,000 people a year have a knee replacement.

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And that knee replacement usually happens to relieve pain

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and improve function, improve mobility.

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But about one in five of those people find

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that they have long-term pain after their knee replacement.

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And when we are thinking in research about what we mean

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by long-term pain after an operation,

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we're really thinking about pain that happens three

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and more months after the surgery itself.

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So some pain is to be expected

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after a knee replacement operation in the same way

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that you might expect some pain after any kind of surgery.

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But when that pain carries on

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and persists, then we think of that as long-term pain.

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We also call it chronic pain.

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That's the same word for diff,

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different word for the same things.

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But what pain that happens at three months

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and afterwards is something

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that we think is really important to understand

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and try to help with.

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And working together in a kind

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of transdisciplinary partnership, we were able to design,

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a care pathway, an intervention, which was designed

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to try to help people who found that they have pain

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after knee replacement surgery.

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And just in brief, what

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that care pathway involves is inviting people who have pain

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after knee replacement surgery at two or three months

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after surgery to come to a clinic appointment.

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And at the clinic appointment, the patient with pain,

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the person with pain will get the chance

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to have a one hour conversation

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and examination with a specially trained practitioner.

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And the specially trained practitioner is someone

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that we'd call a extended, scope practitioner

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who would be trained in physiotherapy

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and would be specifically trained in delivering an

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intervention focused on long-term pain

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after knee replacement.

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So in that clinic appointment, there'd be a conversation,

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there'd be an examination of the knee,

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there'd be a discussion

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and completion of some validated outcome measures

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relating to knee replacement.

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And then based on that conversation

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and examination, the, the person

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with pain would receive a recommendation about follow-up.

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And that follow-up could be any number

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of a whole range of options.

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The follow-up could be a re-referral, back

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to the surgeon who carried out the operation.

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The follow-up could be a referral onto the gp.

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The the follow-up could be a referral onto a pain clinic.

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Uh, it, it could be that the person

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with pain receives a referral to several of those options

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and then the patient is offered those options

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and then also offered the opportunity have

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to have follow up phone calls

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with the extended scope practitioner

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and the follow up phone calls can track,

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the person's progress over the next few months to see

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how they're getting on to see if there's any further support

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That's needed.

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So altogether in total, we call that the STAR Care Pathway.

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STAR stands for Support and Treatment after replacement.

03:08.025 --> 03:11.405
And STAR is all about trying to tailor, care

03:11.465 --> 03:14.045
to an individual's needs rather than a one size fits all.

03:14.065 --> 03:16.325
So that's star and that's the piece of work

03:16.395 --> 03:18.365
that we've done over the past few years.

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And we've done a really thorough piece of development work

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and a really thorough evaluation of the Star Care pathway.

03:25.205 --> 03:27.605
I think that if we come together from different disciplines,

03:27.665 --> 03:29.485
we do a better job of the research

03:29.985 --> 03:32.405
and actually coming together across disciplines also

03:32.405 --> 03:34.165
involves coming together with practitioners

03:34.185 --> 03:36.565
and also, people living with pain.

03:37.025 --> 03:39.245
And we have to hear all those voices to make the research

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as good as it can be, as relevant as it can be,

03:41.285 --> 03:44.085
it actually is kind of efficient and effective as it can be.

03:44.105 --> 03:46.765
So in the STAR program of research,

03:46.765 --> 03:49.165
we were Multim method and transdisciplinary,

03:49.665 --> 03:51.365
and that means that we involve people

03:51.365 --> 03:53.765
with backgrounds in qualitative research,

03:54.605 --> 03:57.965
evidence synthesis, health, economic statistics,

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clinical trials, behavioral science, health

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and experts in all sorts of fields,

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especially including people with pain

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and especially including, clinicians

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and the kind of health professionals that were included

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involved orthopedic surgeons, physiotherapists,

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and a whole range of other colleagues

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who were involved in provision of care.

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Um, I'm not a clinician, but I had the pleasure

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and privilege of, of leading this program of work

04:23.365 --> 04:25.725
that was all about bringing those different experts

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together, including experts by experience.

04:28.345 --> 04:31.165
So I'd, I'd call that team research in its broadest sense,

04:31.225 --> 04:33.725
and I think that that's a really effective mechanism

04:33.785 --> 04:36.725
and process for getting research done that's as good

04:36.725 --> 04:37.725
as it possibly can be.

04:38.105 --> 04:40.765
So the STAR Program of research, which was supported

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by the UK's National Institute

04:42.365 --> 04:44.085
for Health Research, lasted for about 10 years.

04:44.105 --> 04:46.565
And we started the program by speaking with people

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who were living with pain and

04:47.725 --> 04:48.845
finding out what mattered to them.

04:49.185 --> 04:51.725
We also started the program by thinking about

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what outcomes could be assessed after knee replacement.

04:55.185 --> 04:58.765
We also looked at the existing evidence-based drawing on all

04:58.765 --> 05:00.565
of that, we developed the STAR intervention.

05:00.945 --> 05:03.125
And then it was really important

05:03.125 --> 05:05.685
that we carry out a really robust evaluation of

05:05.685 --> 05:08.405
that intervention to see, to see if it's helpful

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or not, to see if there are any unintended negative

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consequences or not,

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and also to see if there's any economic benefit

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to individuals and to the NHS of this kind of intervention.

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And the NHS really matters to us in the UK

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because the National Health Service is the

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main provider of healthcare.

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So ensuring that what we were doing made sense within the

05:27.445 --> 05:30.005
context of the NHS really mattered to us as a team.

05:31.025 --> 05:34.285
So we ran what's called a randomized controlled trial

05:34.435 --> 05:37.325
that took place across eight centers in the uk,

05:37.345 --> 05:40.125
so eight centers that carry out knee replacement surgery.

05:40.865 --> 05:44.005
And what we did in the trial, was invited people

05:44.075 --> 05:47.725
with long-term pain to take part in the research.

05:48.705 --> 05:53.125
The randomized trial included 363 people

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who found that they had long-term pain

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after knee replacement. And

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The, the median age of people taking part in the trial was

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67 years old.

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And what we did in the trial was we randomly allocated

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people to either receive the STAR care pathway

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plus their usual care or to simply receive usual care.

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So people were randomly allocated to either one

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of those streams within the trial.

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We then invited people to agree to take part,

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and people very kindly said that they would,

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and this was not without some time on, on their part.

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So anyone who took part was asked to fill in questionnaires

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and those who were randomly allocated

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to receive the Stark Care pathway were invited to come in

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and have a, a clinic appointment

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and follow up, processes.

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From there, we were really interested in whether the STAR

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intervention was going to make a longer term difference

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to people who had pain.

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So, what we did was we used something called the Brief

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Pain Inventory to assess whether STAR made a difference.

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And the brief pain inventory very briefly is a validated

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existing well-regarded,

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well-known assessment measure for pain.

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The reason why we used it, because it's

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because not only did it assess severity of pain,

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but it also assessed the impact

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of pain on someone's daily life.

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And these two things are both equally important

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to people living with pain.

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So everyone who was allocated

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to receive the STA STAR care pathway was invited in.

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Everyone who was taking part in the trial

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filled in questionnaires.

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And the headline finding from the STAR trial is

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that at 12 months

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after surgery, we found that people who had

07:37.615 --> 07:41.615
received the STAR care pathway, had better

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scores on the brief pain and inventory pain

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and interference scores.

07:47.115 --> 07:50.055
So they did better if they had the intervention.

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The other headline message from the trial is that we found

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that people who had,

07:57.535 --> 08:01.095
received the STAR care pathway, were,

08:02.165 --> 08:05.895
were not costing as much to the NHS Care services as those

08:05.895 --> 08:07.975
who had not received the care pathway.

08:08.885 --> 08:11.855
Obviously what we're interested in is individuals health

08:11.875 --> 08:13.415
and wellbeing and their outcomes.

08:13.955 --> 08:16.895
But part of the picture here for us as health researchers is

08:16.895 --> 08:20.335
to understand economic financial impact on the NHS.

08:20.395 --> 08:22.655
And we found that there was a real benefit,

08:22.655 --> 08:24.935
to the NHS at the STAR Care pathway.

08:25.595 --> 08:29.975
The Star Care Pathway has been developed now into a training

08:29.975 --> 08:33.135
package for NHS National Health Service clinicians.

08:33.155 --> 08:36.135
So anyone working in the NHS who provides care for people

08:36.195 --> 08:38.895
who have pain after knee replacement can access a training

08:38.895 --> 08:41.135
package to find out about the STAR care pathway

08:41.155 --> 08:42.175
and how to deliver it.

08:43.105 --> 08:45.615
There are also some really important research questions

08:45.615 --> 08:47.815
that we think, warrant, answers.

08:48.035 --> 08:50.415
And they would include thinking about how

08:50.415 --> 08:53.175
to prevent people having long-term pain in the first place.

08:53.235 --> 08:54.615
So people who go for knee

08:54.615 --> 08:55.685
Replacement do so

08:55.685 --> 08:58.765
because they want to, have less pain.

08:58.995 --> 09:01.725
They want to be able to get about in their daily lives a lot

09:01.725 --> 09:03.325
better, and they don't want to be living

09:03.325 --> 09:04.965
with pain on a daily basis anymore.

09:05.385 --> 09:07.645
So for those people, if they have this,

09:07.645 --> 09:09.165
they have pain after the knee replacement.

09:09.165 --> 09:10.325
It's mentally disappointing.

09:11.065 --> 09:14.045
So anything that we can do to work out how we can prevent

09:14.045 --> 09:16.405
that pain happening in the first place would be a really

09:16.405 --> 09:18.885
good thing for people going through knee replacement.

09:19.145 --> 09:21.125
And we think that's a really important,

09:21.305 --> 09:22.565
future research question.

09:23.315 --> 09:26.565
Another thing that we're interested in is how people

09:26.595 --> 09:28.645
with pain who are thinking about surgery

09:29.585 --> 09:31.485
are informed about the risks of surgery.

09:31.625 --> 09:33.685
So we know that the risk of long-term pain

09:33.685 --> 09:36.325
after knee replacement is about one in five, roughly.

09:36.385 --> 09:38.365
It depends on which evidence base you look at.

09:38.825 --> 09:41.765
And we think there's a piece of work to do to think about

09:41.765 --> 09:43.845
how those risks, risks are communicated,

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how those risks are understood

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before surgery so that people can make the best

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possible decision about going forward into

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the, the surgical pathway.

09:51.505 --> 09:53.965
So there's a few questions there that I think we need

09:53.965 --> 09:56.365
to look at into the future, and all of those are going

09:56.365 --> 09:58.325
to require a, an integrated approach.

09:58.325 --> 10:00.565
They're all going to require transdisciplinarity.

10:00.565 --> 10:03.245
They're all going to really require involvement

10:03.245 --> 10:05.485
of people living with pain as well as, surgeons,

10:05.775 --> 10:08.165
other healthcare professions and methodologists.

00:00 - The reason why someone might have a knee replacement is in order to address the pain that they're having and the functional impairment that they're having, largely often in relation to having osteoarthritis, but also because of other conditions as well. So a knee replacement happens in order to relieve someone of

00:16 - that pain and to help improve their function. So improve, improve how much they can get about, and how much they can do in their daily lives. So in the UK at the moment, about 100,000 people a year have a knee replacement. And that knee replacement usually happens to relieve pain and improve function, improve mobility. But about one in five of those people find that they have long-term pain after their knee replacement. And when we are thinking in research about what we mean

00:42 - by long-term pain after an operation, we're really thinking about pain that happens three and more months after the surgery itself. So some pain is to be expected after a knee replacement operation in the same way that you might expect some pain after any kind of surgery. But when that pain carries on and persists, then we think of that as long-term pain. We also call it chronic pain. That's the same word for diff,

01:06 - different word for the same things. But what pain that happens at three months and afterwards is something that we think is really important to understand and try to help with. And working together in a kind of transdisciplinary partnership, we were able to design, a care pathway, an intervention, which was designed to try to help people who found that they have pain after knee replacement surgery.

01:29 - And just in brief, what that care pathway involves is inviting people who have pain after knee replacement surgery at two or three months after surgery to come to a clinic appointment. And at the clinic appointment, the patient with pain, the person with pain will get the chance to have a one hour conversation and examination with a specially trained practitioner. And the specially trained practitioner is someone that we'd call a extended, scope practitioner

01:56 - who would be trained in physiotherapy and would be specifically trained in delivering an intervention focused on long-term pain after knee replacement. So in that clinic appointment, there'd be a conversation, there'd be an examination of the knee, there'd be a discussion and completion of some validated outcome measures relating to knee replacement. And then based on that conversation

02:17 - and examination, the, the person with pain would receive a recommendation about follow-up. And that follow-up could be any number of a whole range of options. The follow-up could be a re-referral, back to the surgeon who carried out the operation. The follow-up could be a referral onto the gp. The the follow-up could be a referral onto a pain clinic. it, it could be that the person with pain receives a referral to several of those options

02:43 - and then the patient is offered those options and then also offered the opportunity have to have follow up phone calls with the extended scope practitioner and the follow up phone calls can track, the person's progress over the next few months to see how they're getting on to see if there's any further support That's needed. So altogether in total, we call that the STAR Care Pathway. STAR stands for Support and Treatment after replacement.

03:08 - And STAR is all about trying to tailor, care to an individual's needs rather than a one size fits all. So that's star and that's the piece of work that we've done over the past few years. And we've done a really thorough piece of development work and a really thorough evaluation of the Star Care pathway. I think that if we come together from different disciplines, we do a better job of the research and actually coming together across disciplines also involves coming together with practitioners

03:34 - and also, people living with pain. And we have to hear all those voices to make the research as good as it can be, as relevant as it can be, it actually is kind of efficient and effective as it can be. So in the STAR program of research, we were Multim method and transdisciplinary, and that means that we involve people with backgrounds in qualitative research, evidence synthesis, health, economic statistics, clinical trials, behavioral science, health

04:02 - and experts in all sorts of fields, especially including people with pain and especially including, clinicians and the kind of health professionals that were included involved orthopedic surgeons, physiotherapists, and a whole range of other colleagues who were involved in provision of care. I'm not a clinician, but I had the pleasure and privilege of, of leading this program of work that was all about bringing those different experts

04:25 - together, including experts by experience. So I'd, I'd call that team research in its broadest sense, and I think that that's a really effective mechanism and process for getting research done that's as good as it possibly can be. So the STAR Program of research, which was supported by the UK's National Institute for Health Research, lasted for about 10 years. And we started the program by speaking with people who were living with pain and

04:47 - finding out what mattered to them. We also started the program by thinking about what outcomes could be assessed after knee replacement. We also looked at the existing evidence-based drawing on all of that, we developed the STAR intervention. And then it was really important that we carry out a really robust evaluation of that intervention to see, to see if it's helpful or not, to see if there are any unintended negative consequences or not,

05:13 - and also to see if there's any economic benefit to individuals and to the NHS of this kind of intervention. And the NHS really matters to us in the UK because the National Health Service is the main provider of healthcare. So ensuring that what we were doing made sense within the context of the NHS really mattered to us as a team. So we ran what's called a randomized controlled trial that took place across eight centers in the uk, so eight centers that carry out knee replacement surgery.

05:40 - And what we did in the trial, was invited people with long-term pain to take part in the research. The randomized trial included 363 people who found that they had long-term pain after knee replacement. And The, the median age of people taking part in the trial was 67 years old. And what we did in the trial was we randomly allocated people to either receive the STAR care pathway plus their usual care or to simply receive usual care.

06:12 - So people were randomly allocated to either one of those streams within the trial. We then invited people to agree to take part, and people very kindly said that they would, and this was not without some time on, on their part. So anyone who took part was asked to fill in questionnaires and those who were randomly allocated to receive the Stark Care pathway were invited to come in and have a, a clinic appointment and follow up, processes.

06:37 - From there, we were really interested in whether the STAR intervention was going to make a longer term difference to people who had pain. So, what we did was we used something called the Brief Pain Inventory to assess whether STAR made a difference. And the brief pain inventory very briefly is a validated existing well-regarded, well-known assessment measure for pain. The reason why we used it, because it's because not only did it assess severity of pain,

07:05 - but it also assessed the impact of pain on someone's daily life. And these two things are both equally important to people living with pain. So everyone who was allocated to receive the STA STAR care pathway was invited in. Everyone who was taking part in the trial filled in questionnaires. And the headline finding from the STAR trial is that at 12 months

07:32 - after surgery, we found that people who had received the STAR care pathway, had better scores on the brief pain and inventory pain and interference scores. So they did better if they had the intervention. The other headline message from the trial is that we found that people who had, received the STAR care pathway, were, were not costing as much to the NHS Care services as those who had not received the care pathway.

08:08 - Obviously what we're interested in is individuals health and wellbeing and their outcomes. But part of the picture here for us as health researchers is to understand economic financial impact on the NHS. And we found that there was a real benefit, to the NHS at the STAR Care pathway. The Star Care Pathway has been developed now into a training package for NHS National Health Service clinicians. So anyone working in the NHS who provides care for people who have pain after knee replacement can access a training

08:38 - package to find out about the STAR care pathway and how to deliver it. There are also some really important research questions that we think, warrant, answers. And they would include thinking about how to prevent people having long-term pain in the first place. So people who go for knee Replacement do so because they want to, have less pain. They want to be able to get about in their daily lives a lot

09:01 - better, and they don't want to be living with pain on a daily basis anymore. So for those people, if they have this, they have pain after the knee replacement. It's mentally disappointing. So anything that we can do to work out how we can prevent that pain happening in the first place would be a really good thing for people going through knee replacement. And we think that's a really important, future research question.

09:23 - Another thing that we're interested in is how people with pain who are thinking about surgery are informed about the risks of surgery. So we know that the risk of long-term pain after knee replacement is about one in five, roughly. It depends on which evidence base you look at. And we think there's a piece of work to do to think about how those risks, risks are communicated, how those risks are understood before surgery so that people can make the best

09:48 - possible decision about going forward into the, the surgical pathway. So there's a few questions there that I think we need to look at into the future, and all of those are going to require a, an integrated approach. They're all going to require transdisciplinarity. They're all going to really require involvement of people living with pain as well as, surgeons, other healthcare professions and methodologists.

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