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Transcript of Oahksforum r Osborne
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Origins and validity of the
Osteoarthritis Hip and Knee
Questionnaire
Professor Richard Osborne BSc, PhD
Chair in Public Health
Public Health Innovation@Deakin,Deakin University
Melbourne, Australia
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RMH OWL follow up study:
Quality of life of people waiting for JRS
-0.20 0.00 0.20 0.40 0.60 0.80 1.00
AQoL baseline
0
5
10
15
20
25
Frequency
Mean = 0.3885
Std. Dev. = 0.234
N = 307
Populationnorm
Ackerman IN,
Graves SE, Wicks
IP, Bennell KL,
Osborne RH.
Severely
compromised
quality of life inwomen and those
of lower
socioeconomic
status waiting for
joint replacement
surgery.Arthritis
Rheum
2005;53(5):653-8.
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An evidence-based prioritisationand management system is
required
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RHM OWL Prioritisation Proposal23 12 2003 Final.doc
2. Project OutlineThe aim of the project is to develop a system thatfacilitates the appropriate management of people whomay require JRS. This system will involve clinicalpathways to triage people with hip or knee
osteoarthritis, facilitate fast and slow tracking (ieprioritisation), and ultimately ensure a higherproportion of the most needy people receive timelyJoint Replacement Surgery.
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Sponsor: Victorian
Government, Department
of Human Services
Field Champions
Mr Richard de Steiger (RMH)Mr Stan OLoughlin (DH)
Mr Ian Critchley (GVH)
Mr Chris Haw (WH)
Mr Rob Pianta (WH)
Mr Graeme Brown (Geelong)
Miss Susan Liew (Austin)Mr Roger Westh (Austin)
Investigators
Prof Richard Osborne
Prof Stephen Graves
Prof Ian Wicks
A/Prof Caroline Brand
Consultants
Prof Peter Fayers
Prof Paul Dieppe
Prof Tony Scott
Project staff
RMH: Ms Kerry Haynes
Ms Peta Chubb
Ms Catherine JonesMs Tanja Farmer
Ms Debra RobbinsMs Melanie Hawkins
GVH: Dr Jennifer Critchley
WH: Dr Anjali Haikerwal
DH: Ms Rosie Molloy
Ms Barbara Newell
Phase I:
2.5 years (2004-5)
Development of amanagement andprioritisation system
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Sponsor: VictorianGovernment,Department of HumanServices
Pilot Hospitals
Geelong
Peninsula
Royal Melbourne
St Vincents
Investigators
Prof Richard Osborne
A/Prof Caroline Brand
ConsultantsMr Richard de Steiger
Prof Stephen Graves
Ms Jenni Livingston
Ms Fiona Landgren
Project staffMs Melanie Hawkins
Ms Catherine Jones
Ms Jo Slee
Phase II:
1.5 years (2006-7)
Development ofstatewideimplementation plan
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Development of a
Multi-Attribute Prioritisation Tool (MAPT)
State-of-the-art surgeon/patient/systemconsultation, psychometrics and clinimetrics
Concept Mapping workshops Groups facilitated to identify factors that should be
considered when determining priority for JRS 4 workshops with orthopaedic surgeons
4 workshops with patients
With the grounded consultations we aimed to:
Ensure that the questionnaire was: Clinically relevant, endorsed and owned by clinical groups
Implementable
Embedded into clinical practice
Appropriate across settings
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Prioritisation domains generated from
surgeons and patients
1. Pain1.1. Sleep disturbance1.2. Rest pain1.3. Pain related to movement
2. Limitations to dailyactivities
2.1. Impairment of mobility2.2. Ability to self-care2.3. Level of domestic support2.4. Carer roles
3. Psychosocial health
impact
3.1. Psychological effect of
disability
3.2. Social effect of disability
4. Economic impact
4.1. Interference with ability to
work
4.2. Financial provider for
others
5. Recent deterioration
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MAPT development
Pre-testing draft ~120 questions
Derived from what patients and surgeons saidin
workshops
Consultation with surgeons and other experts
Development of draft questions across 5 domains
Cultural and linguistic audit
Cognitive interviews with patientsField testing
60 draft items
Completed by 600+ patients +/- on OWL
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Questions
Guttman-like scales
Discrete health states in each response
option Verifiable through a clinical interview
Attribution to the hip or knee
Not Likert questions
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WOMAC indexWestern Ontario & McMaster Osteoarthritis Index
24 itemsThink about the difficulty you had in doing the following daily physical activities due to your
arthritis during the last 48 hours. By this we mean your ability to move around and look
after yourself.
QUESTION:What degree of difficulty do you have?
None Mild Moderate Severe Extreme
8. Descending (going down) stairs
9. Ascending (going up) stairs
10. Rising from sitting
11. Standing
12. Bending to the floor
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Weighting items
Some questions (indications for need for joint
replacement) are more important than others
Discrete Choice Experiments
Surgeons asked to apply clinical judgement to
patient vignettes
Helps to appropriately weight clinical red flags
96 Victorian orthopaedic surgeons participated
Simple score
0 (no need for surgery)
100 (highest need for surgery)
Victoria has
~140
arthroplasty
surgeons
Witt J, Scott A, Osborne RH. Designing Choice Experiments with Many Attributes. An Application to
Setting Priorities for Orthopaedic Waiting Lists. Health Economics 18: 681-96, 2009
Orthopaedic Waiting List Project
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Orthopaedic Waiting List ProjectDiscrete Choice Experiments
Please indicate whether you are a consultant or registrar:Consultant Registrar
1 (1.1)
Patient A Patient BI do not look after, or experience nodifficulty looking after, dependents.
It is moderately difficult looking afterdependents.
I have pain that stops me going to
sleep most of the time.
I have pain that stops me going to
sleep all of the time.It does not affect, or causes littleaffect to, my enjoyment of life.
It makes it moderately or verydifficult for me to enjoy my life.
I do not getenough help withlooking after myself.
I do not getenough help with lookingafter myself.
It makes it moderately difficult formy household to manage financially. It does not affect my householdfinances or it makes it slightlydifficult for my household to managefinancially.
Higher priority: Patient A Patient B1% 99%
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The need for surgery assessed
by the MAPT
MAPT WOMAC
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Validation
Administered to 1000+ patients Correlation with international standards
Oxford Hip / Knee
WOMAC
Quality of Life (AQoL)
SF36 EQ-5D
Hospital Anxiety and Depression Scale
Clinical veracity of the questionnaire Face validity
Construct validity Test re-test reliability
Practicality response rate (patient, health professional)
Gaming and stoicism
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Correlation R=0.80
Correlation R=0.84
Correlation between the MAPT and
other questionnaires
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Correlation between the MAPT and
other questionnaires
MAPT MAPT MAPT
Whole Sample Hips Only Knees Only
Oxford Hip - 0.8 -
Oxford Knee - - 0.75WOMAC
Pain 0.75 0.87 0.62
Stiffness 0.66 0.70 0.68
Physical Function 0.75 0.81 0.88
WOMAC Total 0.78 0.84 0.92
MAPT
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MAPTshowed
appropriate
correlationswith other
scales
MAPT
Whole Sample
AQoL
Independent Living -0.57
Social Relationships -0.47
Physical Senses -0.13Psychological Wellbeing -0.75
AQoL Total -0.71
EQ-5D (Euroqol) -0.77
HADS
Depression 0.62
Anxiety 0.58
SF-36
Physical Function -0.57
Role Physical -0.59
Bodily Pain -0.36
General Health -0.32Vitality -0.50
Social Function -0.60
Role Emotional -0.54
Mental Health -0.44
Physical Summary -0.46
Mental Summary -0.51
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Reliability
Internal consistency reliability
Very High
Cronbachs alpha coefficient 0.87 (n=854)
Test-retest reliability
High
Participants on the OWL (n=80).
Two-week interval retest ICC = 0.75
MDD = about 10 units on the 100 unit scale
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MAPT scores x time since surgery
Weeks Since Surgery N Mean SD
Currently on OWL 460 45.5 30.4
1 12 54 21.8 27.5
13 24 32 11.8 22.3
25 -104 118 6.8 15.4
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Coordinator vs patient score(ICC = 0.74)
Coordinator
marks higher
than patient
(stoic?)
Coordinator
marks lower
than patient
(gaming?)
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Key points:
MAPT contains the information a clinician needs for
making sound clinical (holistic) judgments
key information on a platter
Free of bias
Hip/knee, age, education, gender
Transparent
Supports equitable clinical care Developed and validated using state-of-the-art
techniques to prioritise care
The MAPT is a core element of bringing order into
what was a chaotic system
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Thank you
mailto:[email protected]:[email protected]