Patient Reported Outcomes in Hip and Knee Replacements: Identifying and prioritising research targets to improve outcomes

For most patients, hip and knee replacements relieve the symptoms of osteoarthritis and provide a significant improvement in their quality of life. However, a significant proportion of patients have persistent pain and are dissatisfied with the outcome after surgery. There remains a need to identify factors that are associated with patient reported outcomes and are suitable targets for intervention.
Several methods have been developed to enhance the efficiency of conducting randomised controlled trials, including Trials Within Cohorts (TWiCs) methodology. The Arthroplasty Research Cohort (ARC) Study is a national cohort study of patients undergoing hip and knee replacements and is designed to support multiple embedded randomised controlled trials of interventions using TWiCs.
To ensure the efficient use of the cohort through delivering future TWiCs that are relevant, impactful and important to patients, a prioritisation process has been conducted to identify and prioritise preoperative patient-related factors as targets for intervention in future trials. This was a multi-stage process, involving key stakeholders throughout, and firstly involved identifying a longlist of preoperative factors. A key component of this stage was an umbrella review, which synthesised a high volume of evidence from systematic reviews for the association between preoperative factors and postoperative patient reported outcomes.
Subsequent stages of the process consisted of formulating a list of factors to be prioritised, interim ranking of these factors and a final group meeting conducted using a modified nominal group technique, to establish the top five priorities to be targeted for intervention in future trials in hip and knee replacements.
A rapid review of trials of interventions targeting the highest prioritised factor was completed, establishing the existing trial evidence and identifying evidence gaps. Finally, the results of this were used to inform considerations for future TWiCs embedded within the ARC Study.