Quality standard
Quality statement 8: Referral for consideration of joint surgery
Quality statement 8: Referral for consideration of joint surgery
Quality statement
Healthcare professionals do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.
Rationale
Evidence for the Oxford Hip and Knee scores, Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip disability and Osteoarthritis Outcome Score (HOOS) showed that these numerical scales alone were unlikely to determine whether someone should have surgery, and are not recommended for making decisions on eligibility for joint surgery. The adult with osteoarthritis should be given support and advice by their healthcare professional to reach a shared decision on whether surgery is likely to be beneficial, based on the severity of their symptoms, their general health, their expectations of lifestyle and activity, and the effectiveness of any non‑surgical treatments. Ensuring that inappropriate scoring tools are not used will improve equality of access to surgery.
Quality measures
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
Structure
Evidence of local arrangements to ensure that healthcare professionals do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.
Data source: Evidence can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from service specifications and local commissioning agreements for joint replacement surgery.
Process
Proportion of adults with osteoarthritis referred for consideration of joint surgery whose referral is based on a scoring tool.
Numerator – the number in the denominator for whom the referral decision is based on a scoring tool.
Denominator – the number of adults with osteoarthritis referred for consideration of joint surgery.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records or referral records.
What the quality statement means for different audiences
Service providers (GPs, community healthcare providers and hospitals) ensure that scoring tools are not used to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery. Decisions on referral thresholds should instead be based on discussions between patient representatives, referring clinicians and surgeons.
Healthcare professionals ensure that they do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery.
Commissioners ensure that they commission services that do not use scoring tools to identify which adults with osteoarthritis are eligible for referral for consideration of joint surgery. Commissioners should not restrict referral pathways on the basis of arbitrary referral thresholds, but should ensure that thresholds are agreed with patient representatives, referring clinicians and surgeons.
Adults with osteoarthritis who are considering joint surgery discuss this with their healthcare professional to decide if it is right for them, and are not denied a referral because they have not met particular requirements.
Source guidance
Osteoarthritis in over 16s: diagnosis and management. NICE guideline NG226 (2022), recommendations 1.6.2 and 1.6.3
Definitions of terms used in this quality statement
Scoring tools
The use of orthopaedic scores and questionnaire‑based assessments to identify people who are eligible for referral for consideration of joint surgery has become widespread. These usually assess pain, functional impairment and sometimes radiographic damage. Evidence for the Oxford Hip and Knee scores, Knee injury and Osteoarthritis Outcome Score (KOOS), and Hip disability and Osteoarthritis Outcome Score (HOOS) showed that these numerical scales alone were unlikely to determine whether someone should have surgery, so they were not recommended for use. [Adapted from NICE's guideline on osteoarthritis in over 16s, rationale and impact section]
Equality and diversity considerations
Age, sex or gender, overweight, obesity, smoking, disability (including learning disabilities) and comorbidities should not be barriers to referral for consideration of joint surgery [NICE's guideline on osteoarthritis in over 16s, recommendation 1.6.3].