Is virtual clinic follow-up of hip and knee joint replacement acceptable to patients and clinicians? A sequential mixed methods evaluation.

Objective: To evaluate the acceptability to key stake holders of a newly introduced virtual clinic follow-up pathway for hip and knee joint replacement. Design: A service evaluation comprising a questionnaire sent electronically to 115 patients and interviews with 10 individuals. Setting: A newly introduced virtual clinic follow-up pathway for hip and knee replacement patients in a district general hospital. Participants: The electronic questionnaire was distributed to all patients treated under the virtual clinic service over a 5-month period (n=115). Purposive sampling from volunteers among respondents, leading to semi-structured interviews with eight patients. Two orthopaedic consultants were also interviewed. Intervention: Consultant review of web-based patient reported outcome measures and digital radiographs, with feedback to patients via letter, replacing face-to-face outpatient appointments for the follow-up of hip and knee joint replacement. Results: The response rate to the questionnaire was 40%. 44% indicated they would prefer a virtual appointment over a face-to-face consultation in future. The most common word in the free text comments was 'good' (n=107).Seven main themes were identified from the patient interviews: patient understanding and expectations, patient confidence, patient voice, managing deterioration of condition, patient benefit, patient satisfaction using technology and navigating the website.Two main themes were identified from the staff interviews: the adapting patient pathway and project management.Combined analysis elucidated that patients who were doing well liked the 'click and go' approach but those with problems were concerned about how to report these and were therefore less satisfied. Conclusion: The virtual clinic process appears to be well accepted by both patients and clinicians. However, appropriate patient selection and clear pathways of communication to address patient concerns are pivotal to success.

Non-operative management, supported by self-monitoring using web-based patient reported outcome measures (PROMs), in knee osteoarthritis.

Despite being straightforward to collect and key to providing patient-centred, individualised care, the routine use of patient reported outcome measures (PROMs) remains limited in the National Health Service. Herein is described the case of a 69-year-old woman who presented to secondary care with osteoarthritis. Web-based PROMs were used to track the patient's symptoms and function. Lifestyle changes were recommended to manage the osteoarthritis. Monitoring enabled the patient to take control of her disease management. Two years later, she continues to manage her knee symptoms conservatively, recording progress by using a web-based system. This case illustrates how web-based PROMs can be used to support conservative management of knee osteoarthritis by both empowering patients and minimising the burden on secondary care outpatient services.

Tracking a painful episode after a joint replacement using patient-reported outcome measures (PROMs).

Patient-reported outcome measures (PROMs) are an important tool in measuring the benefit of a surgery for patients and for clinicians. The results of such assessment tools can be used to monitor patient progress or initiate intervention. The scores also provide a reproducible evaluation of functional recovery and well-being after surgery. We report the case of a 68-year-old woman who underwent left unicondylar knee replacement in November 2011 followed by right unicondylar knee replacement in April 2012. Prospective, web-based electronic PROMs were used preoperatively and every 6-12 months postoperatively to monitor the improvement in pain and function symptoms. These outcome measures were beneficial in helping to monitor an episode of new pain in her left knee, without requiring invasive or extensive investigation.

Patient-reported outcome measures (PROMs): enhancing decision making and follow-up.

A case presentation of patient undergoing elective total knee replacement. Patient-reported outcome measures prospectively collected electronically pre and postoperatively allowed real-time review, aiding follow-up and reducing the need for clinical, face-to-face follow-up.

Performance of EQ-5D, howRu and Oxford hip & knee scores in assessing the outcome of hip and knee replacements.

BACKGROUND: We aimed to compare the performance of EQ-5D-3 L and howRu, which are short generic patient-reported outcome measures (PROMs), in assessing the outcome of hip and knee replacements, using the Oxford Hip Score (OHS) and the Oxford Knee Scores (OKS) for comparison. METHODS: Outcome was assessed as the difference between pre-surgery and 6-month post-surgery scores. We used a large sample from the NHS PROMs database, which used EQ-5D-3 L, and a small cohort of patients having the same operations collected by MyClinicalOutcomes (MCO), which used howRu. Both cohorts completed the OHS (hips) or the OKS (knees). RESULTS: The change (outcome) between pre-op and post-op scores as measured by howRu was greater than that measured by EQ-5D, relative to that measured by OHS or OKS. For hip replacements, the correlation for change measured by howRu and OHS was r = 0.77 (0.66-0.85). The corresponding correlation for change measured by EQ-5D Index and OHS was r = 0.64 (0.63-0.64). For knee replacements the correlation between change in howRu and OKS was r = 0.86 (0.75-0.92); between EQ-5D Index and OKS r = 0.59 (0.58-0.60). CONCLUSIONS: For hip and knee replacement, the outcome measured by howRu was more highly correlated with that measured by the condition-specific Oxford Hip and Knee Scores than were EQ-5D Index or EQ-VAS. The magnitude of change before and after surgery was also greater.

Long-term survival after "drop metastases" of renal cell carcinoma to the bladder.

Renal cell carcinoma can metastasize to virtually any organ, yet isolated bladder metastases are exceedingly rare, and most of these patients die within 1 year of diagnosis. Proposed mechanisms of renal cell carcinoma metastases to the bladder include hematogenous spread, lymphatic dissemination, and "drop metastases" by way of the urinary tract. We present the longest reported survival after isolated "drop metastases" of renal cell carcinoma to the bladder.