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Research - 16.10.2024 - 09:00 

Better treatment and lower costs: Health monitoring after hip and knee joint replacement

The systematic questioning of patients after an operation improves healing and reduces treatment costs. This is shown by the results of the “PROMoting Quality” project from the Department of Healthcare Management at the Technical University of Berlin and the Chair of Health Economics, Policy and Management at the School of Medicine (Med-HSG), which have now been published in the renowned journal “PLoS Medicine”.

The replacement of hip and knee joints is one of the most frequently performed operations in most Western countries, including Germany and Switzerland. They are regarded as a key driver of national healthcare expenditure. Costs are incurred not only during the initial stay and operation, but also during the patient's follow-up care. In addition, poor treatment results lead to increased costs incurred by expensive revisions and repeat operations. 

Treatment experiences from the patient's perspective

The use of patient-reported outcome measures (PROMs) serves, among other things, to monitor patients’ state of health after an operation. PROMs are standardized surveys. For example, they measure the patient’s health-related quality of life, the functionality of the hip or knee, as well as the level of pain or mental health. The information should help to better manage the patient’s follow-up care. Studies with cancer patients have already shown that PROMs improve treatment outcomes (survival, emergency admissions) and reduce healthcare costs (Basch et al. 2016, Lizée et al. 2019). 

The use of PROMs is particularly suitable for “remote health monitoring” of patients following hip or knee replacement surgery. This is because there is usually a break in care between the surgeon and the doctor providing follow-up treatment. PROM-based monitoring makes it possible to intervene at an early stage in the event of undesirable treatment results and to make individualized therapy adjustments. 

 

“PROMs not only have the potential to improve the health of patients, but also to actively improve the healthcare system through early interventions and more targeted therapies in the long term.”
Lukas Schöner, Technical University of Berlin

Cost-effectiveness and improved treatment outcomes

Various questionnaires were used for the Patient-Reported Outcome Measures (PROMs) to assess the following criteria:

  1. Health-related quality of life (see “EQ-5D-5L” and “EQ-VAS” questionnaires),
  2. Functionality of the hip or knee (see “HOOS-PS” and “KOOS-PS” questionnaires),
  3. Symptoms of fatigue (see “PROMIS-Fatigue” questionnaire),
  4. Symptoms of depression (see “PROMIS-Depression” questionnaire). 

The data was collected using the “Heartbeat ONE” software from Heartbeat Medical and processed in the participating clinics. The main results at a glance 


Cost-effectiveness of the intervention 12 months after the operation:

  • Overall, the PROM-based digital health monitoring and alert system proved to be cost-effective for both knee and hip procedures.
  • For patients with a hip replacement, the probability that the intervention would both improve the treatment outcome and save costs was 97.5% (including intervention costs). In patients with knee replacements, the probability was 73.3%. 

Improvement in treatment results 12 months after surgery in almost all health dimensions:

  • The greatest improvements in the physical health dimensions of functionality and pain were observed in patients with hip replacements.
  • Significantly higher improvements in health-related quality of life and depression symptoms were observed in patients with knee replacements.

Reduction in costs 12 months after the operation compared to standard care:

  • The cost reduction amounts to −9.4% (EUR 376.43) for patients with hip replacements and −7.1% (EUR 375.50) for patients with knee replacements.
  • Reasons for the cost savings of hip replacement patients: significantly fewer outpatient consultations, fewer remedies such as physiotherapy and fewer drug prescriptions.  
  • Reasons for the cost savings of knee replacement patients: fewer prescriptions for medicines and additional treatment such as physiotherapy.
“Patients who receive regular feedback throughout the monitoring process about their recovery require fewer outpatient consultations, especially GP consultations. This can drastically reduce the burden on the healthcare system.”
Dr. David Ehlig (né Kuklinski), University of St.Gallen

Patient-centred monitoring: implications and next steps

The project came to the conclusion that by anchoring the patient perspective more firmly within the process, more individualized treatment paths can be designed and resources can be used more efficiently. Practical implications for Switzerland can also be derived from the results in the German clinics: 

  • A critical recovery that is not recognized after a surgical procedure leads to both undesirable health consequences and increased expenditure in the healthcare system. Patient-centred health monitoring is therefore recommended for implementation. 
  • The use of a post-operative PROM monitoring and alert system helps to improve the health outcomes of knee and hip replacement patients and reduce healthcare expenditure. Medical professionals and political decision-makers should be informed about this and the measure implemented at system level. 
  • The study can stimulate discussion about the ongoing digitalization of healthcare and advance research into the use of PROMs as a monitoring and warning system for other diseases, e.g. chronic diseases. Another research project “Enhancing T2D Care” under the scientific leadership of the HSG team is currently investigating the use of PROMs to improve the care of diabetes patients in Switzerland.

Research project “PROMoting Quality”

The research project “PROMoting Quality” was awarded EUR 3.5. million from the German G-BA Innovation Fund. The authors of the study evaluated whether digital “remote health monitoring” using PROMs is cost-effective – i.e. improves treatment and reduces costs and visits to the doctor. The patients in the intervention group completed the surveys in months 1, 3 and 6 following the operation. They were contacted by their hospital in the event of any abnormalities in the recovery process.    

The study, which was conducted in collaboration with the Chair of Health Economics, Policy and Management at the School of Medicine (Med-HSG) and the project consortium led by the Technical University of Berlin (TU Berlin), included information from 2,697 hip and 3,110 knee replacement patients from nine German hospitals between 2019 and 2020. In addition, the billing data from one year before to one year after the operation was added at patient level for around 20% of patients (insured by the BARMER and BKKen health insurance funds).

“The potential for PROMs in the treatment of chronic illnesses is currently the subject of various research projects.”
Prof. Dr. Alexander Geissler, University of St.Gallen

Project partners from various sectors

The project involves the School of Medicine (Med-HSG) at the University of St.Gallen and the consortium leader, the Technical University of Berlin (TU Berlin), the software manufacturer Heartbeat Medical, the health insurance companies BARMER and BKK Dachverband, the aQua Institute and the clinics Charité – Universitätsmedizin Berlin, Diakovere Annastift, Helios ENDO-Klinik Hamburg, Schoen Klinik Neustadt, Schoen Klinik Hamburg Eilbek, Sana Kliniken Berlin-Brandenburg, RoMed Kliniken Prien am Chiemsee, VAMED Ostseeklinik Damp and Waldkliniken Eisenberg.

Successful completion of the project in Berlin: the participants from the University of St.Gallen and the TU Berlin

The results of the project in the journal PLoS Medicine:
https://doi.org/10.1371/journal.pmed.1004459

Further studies as part of the project:

  • «Electronic Patient-Reported Outcome Monitoring to Improve Quality of Life After Joint Replacement» (jamanetwork.com)
  • «Exploring treatment effect heterogeneity of a PROMs alert intervention in knee and hip arthroplasty patients: A causal forest application» (sciencedirect.com)
  • «The use of digitally collected patient-reported outcome measures for newly operated patients with total knee and hip replacements to improve post-treatment recovery» (trialsjournal.biomedcentral.com)


Main image: Adobe Stock / Toowongsa

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