Consensus recommendations for supporting people waiting for total hip and knee arthroplasty in Scotland: A modified Delphi study

Using a three-round modified Delphi study involving both patients and professionals, this paper establishes consensus-based recommendations for supporting individuals in Scotland while they wait for total hip and knee arthroplasty.

The Gist

The "Waiting Room" Problem: A Guide to Staying Strong While You Wait for Surgery

Imagine you are standing in a very long line for a concert. You know the show is going to be amazing, but the line is moving incredibly slowly. Because you’ve been standing there for hours, your legs are getting tired, your back hurts, and you’re starting to feel grumpy and discouraged. If you just stand there doing nothing, you might arrive at the concert feeling too exhausted to even enjoy it.

This paper is about people in Scotland who are in a similar "long line"—but instead of a concert, they are waiting for hip or knee replacement surgery.

Because of various delays (like those caused by the pandemic), many people are waiting months or even over a year for their surgery. The researchers wanted to find out: "While we are waiting for these people to get their surgery, what can we do to make sure they don't 'rust' or lose their strength in the meantime?"

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How did they find the answers? (The "Brainstorming" Method)

The researchers used a method called a Delphi study. Think of this like a giant, organized group chat.

Instead of just asking one doctor, they gathered two different groups:

1. The "Travelers" (Patients): People who have actually been in the long line themselves.
2. The "Tour Guides" (Professionals): Doctors, nurses, and physiotherapists who help people through the process.

They didn't just ask once. They went through three rounds of voting. They would suggest an idea, see if everyone agreed, and if there was a disagreement, they would go back to the drawing board, tweak the idea, and ask again until they reached a "consensus" (a group agreement).

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The "Maintenance Manual": What should happen while waiting?

The study ended up with 108 specific recommendations. You can think of these as a "Maintenance Manual" to keep a person’s body and mind in top shape before the "big repair" (the surgery).

The recommendations fall into four main buckets:

1. The "Instruction Manual" (Preoperative Education)

Before you go into a complex machine, you want to know how it works. Patients need clear, simple information about:

• What the surgery actually feels like.
• How to take care of the wound afterward.
• What to expect when they get home.
• The Twist: Patients specifically asked that this info shouldn't just be a boring pamphlet; they want to hear stories from other people who have been through it.

2. "Tuning the Engine" (Patient Optimisation)

If you are going to take a car for a major engine overhaul, you want to make sure the fuel is good and the battery is charged. For humans, this means:

• Helping people quit smoking or reduce alcohol.
• Managing weight and blood sugar (diabetes).
• Checking for things like anemia (low iron) so the body is ready to heal.

3. "Keeping the Gears Moving" (Other Interventions)

This is about preventing the body from "stiffening up."

• Encouraging gentle exercise (prehabilitation) so the muscles are strong enough to support the new joint.
• Providing mental health support, because waiting for surgery can be scary and lonely.

4. "The Roadmap" (Supporting Long Waits)

When the line is exceptionally long, people feel forgotten. The study suggests:

• Regular Check-ins: Don't leave them in the dark! Send updates every few months.
• Signposting: Pointing people toward community groups or websites where they can find support.

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The Big Takeaway

The researchers found that timing is everything.

If you try to teach someone how to change their diet or quit smoking just one week before surgery, it’s like trying to repaint a house while a storm is hitting. It’s too late and too stressful.

The study argues that support should start the moment someone is put on the waiting list. By "drip-feeding" support and information early on, we can help people stay strong, stay positive, and arrive at their surgery ready to recover quickly, rather than arriving exhausted and worn down.

Technical Summary

Technical Summary: Consensus Recommendations for Supporting People Waiting for Total Hip and Knee Arthroplasty in Scotland

Problem Statement

Osteoarthritis is a leading cause of chronic pain and disability globally, with a projected 50% increase in cases by 2050. In Scotland, the demand for Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA) is rising, but health systems are struggling to meet demand due to surgical backlogs exacerbated by the COVID-19 pandemic. This has resulted in unprecedented waiting lists and a failure to meet the 18-week referral-to-treatment standard. Prolonged waiting times pose significant clinical risks, including physical deconditioning, increased risk of surgical complications, and diminished quality of life. While preoperative education and prehabilitation are established evidence-based interventions, existing models were designed for shorter waiting periods and may not be sufficient for the current extended timelines. Furthermore, support provision across Scottish Health Boards is highly variable, indicating a lack of standardized, consensus-based guidance.

Methodology

The researchers employed a three-round online modified Delphi study to develop evidence-informed recommendations. The study was guided by the CREDES reporting guidelines and overseen by a Project Advisory Group (PAG) comprising patients, professionals, researchers, and policymakers.

• Participants: The expert panel consisted of two subgroups:
  1. Patients: Individuals with lived experience (currently on a waiting list or having undergone surgery within the last 6 months).
  2. Professionals: Healthcare experts (surgeons, physiotherapists, nurses, etc.), service managers, and researchers.
• Process:
  • Round 1 & 2 (Online Surveys): Participants rated statements on a 5-point Likert scale. Consensus was defined as $\ge$70% agreement within a group. Items with $\ge$50% disagreement were removed.
  • Round 3 (Online Workshops): Asynchronous workshops were held via Microsoft Teams to discuss items that failed to reach consensus in previous rounds.
• Input Sources: The initial statement pool (113 items) was derived from an evidence review of >450 sources, a survey of 16 Scottish Health Boards, a desktop review of public information, and previous consensus statements.

Key Contributions

The study provides a comprehensive, multi-dimensional framework for perioperative care during the waiting period. The primary contribution is the development of 108 consensus-based recommendations categorized into four critical domains:

1. Preoperative Education: Detailed guidance on anatomy, surgical preparation, recovery expectations, and lifestyle management.
2. Patient Optimisation: Focused on clinical readiness, including smoking/alcohol cessation, anaemia management, and physiotherapy.
3. Other Supportive Interventions: Addressing weight management and psychologically informed care.
4. Strategies for Long-Term Waiting: Addressing the specific needs of patients facing extended delays, such as regular updates and signposting to third-sector support.

Results

The study successfully reached consensus on the majority of proposed items, though notable divergences occurred between patient and professional perspectives:

• Consensus Achievement: 108 statements reached consensus. The highest level of agreement was found in the "Waiting a long time for surgery" domain (20/20 statements).
• Domain Breakdown: Preoperative education formed the largest portion of recommendations (68 statements).
• Divergent Perspectives:
  • Psychological Interventions: Patients reached consensus on the importance of Cognitive Behavioural Therapy (CBT) and individualised psychological support, whereas professionals expressed concerns regarding service capacity and the feasibility of referrals.
  • Timing of Interventions: A significant point of contention was the "12-week window." Both groups generally agreed that interventions (like smoking cessation or weight management) should be introduced earlier in the pathway rather than just before surgery to allow for meaningful behavioral change.
  • Specific Exercises: Patients favored specific preoperative exercises (e.g., core control, step training), which did not reach consensus among professionals.

Significance

This research represents a vital step toward standardizing best practices for arthroplasty waiting lists in Scotland. By integrating the lived experience of patients with the clinical expertise of professionals, the study moves beyond traditional "pre-surgical" models toward a "continuous support" model.

Clinical and Policy Implications:

• System Efficiency: The findings suggest that a "drip-feed" approach to information and behavioral intervention (starting at the point of being listed) may better optimize patient health and reduce post-operative complications.
• Resource Allocation: The study highlights the need to explore digital health technologies and third-sector partnerships to alleviate the burden on overstretched clinical staff.
• Foundation for Guidance: These recommendations serve as a foundation for developing formal clinical practice guidelines and policy in Scotland, with potential applicability to other healthcare systems facing similar surgical backlogs.