A response to an article in the Telegraph newspaper – Monday 10th April 2017
13th April 2017
This article is further to a letter sent by senior researchers at the University of Oxford and Oxford University Innovation to the Editor of the Telegraph newspaper rebutting what we consider a poorly researched and reported article published in the Telegraph on Monday 10th April 2017 and posted online.
The Oxford Hip Score (OHS) and Oxford Knee Score (OKS), designed by researchers at the University of Oxford, were recently the topic of a Telegraph article (found here). We fundamentally disagree with some of the assertions made in the article about OHS/OKS, which has benefitted hundreds of thousands of lives by helping assess the patient view of outcome following total hip or knee replacement.
Fundamentally, we disagree with:
- The OHS and OKS being described as “bogus” despite a mountain of evidence validating their use
- The OHS and OKS being made the target of article when they are clearly being misused by commissioners.
Patient Reported Outcome Measures (PROMs) are a type of health questionnaire used to assess the consequences of disease and/or its treatment (surgical intervention in this case) as reported by the patient. The Oxford Hip and Knee PROM Scores are specifically designed and developed, with proven measurement properties, for the assessment of pain and function for those undergoing total hip or knee replacement surgery. The Oxford PROMs have proven to be reproducible, valid and sensitive to clinically important changes and a significant body of evidence, including peer-reviewed literature, supports this.
The Oxford Hip and Knee scores are widely used, highly regarded and relied upon to assess patients view of outcomes following total hip or knee replacement. Following robust independent review by subject experts (Smith et al 2005), NHS England adopted the Oxford Hip and Knee scores in 2009 as two of the PROMs for the mandatory assessment of outcomes in elective surgery. The OKS and OHS are now used by over 300 organisations worldwide in local, regional, or national health outcome assessment programs or studies. A large body of evidence supports their suitability and reliability as the best PROMs for assessing outcomes of total hip and knee replacement surgery.
The issue the Telegraph is reporting on does not stem from the OHS and OKS, but how they are being used. The OHS and OKS were not designed for the purposes of individual assessment, or as care pathway decision-making tools. They are tools for assessing outcomes of interventions, not tools for clinicians to use for judging whether treatment should be given in the first place.
Using the OHS or OKS for scoring individuals and then applying a threshold to screen patients for referral to elective surgery, as how they are being used according to the Telegraph article, is not supported by anyone involved with the OHS/OKS, including:
- the Clinical Outcomes team at Oxford University Innovation, which manages and supports the OHS/OKS
- The authors / developers of the Oxford orthopaedic PROMs at the University of Oxford and senior Professors of orthopaedic surgery
- The National Institute for Health and Care Excellence (NICE).
Additionally, not only does NICE support the correct use of OKS and OHS, it provides guidance against their misuse, which can be found in Section 1.6 (Referral for consideration of joint surgery) in their clinical guidance [CG177] Osteoarthritis: care and management.
The OKS and OHS can be used by healthcare providers to aid communication and shared decision making between the healthcare professional and the patient, as they provide a simple mechanism for the patient to share their personal experience of pain and function in daily living with their hip or knee problem. Although not designed or validated for this purpose, the Oxford hip and knee scores are considered useful for assisting communication and can provide a record of the patients’ experience of living with their condition. The OHS and OKS results can therefore form a valuable part of the wider evidence gathering used for care pathway decisions, but not as the primary decision making tool, or for screening patients based simply on a single PROM completion.
Dr David Churchman, Business Lead of the Clinical Outcomes team at Oxford University Innovation, said:
“Decisions to refer patients for consideration of joint surgery should not be simply directed by the results of a PROM completion by the patient. Factors considered in such referrals are far more complex and should ideally be the shared decision of the healthcare professional and the patient, based on accumulated evidence. If the Oxford Hip and Knee scores are used as simple information sharing tools to aid that discussion and decision, then all well and good, but they should not be abused as a primary decision-making tool with little further consideration. The decision to refer a patient for surgical intervention is not a tick box exercise (unlike the completion of the PROM), and the simple result from the completion of one of our PROMs should not be used as a blunt tool to dictate a patient’s care pathway.”
About the Clinical Outcomes team at Oxford University Innovation (OUI)
The Clinical Outcomes team at Oxford University Innovation manages a rapidly growing portfolio of high quality Clinical Outcomes Assessments (COA’s), the vast majority being Patient Reported Outcome (PRO) measures or (PROMs). The Oxford Hip and Knee Scores are part of the portfolio of orthopaedic outcome measures that the Clinical Outcomes team have successfully managed for over 12 years. Oxford University Innovation is the technology transfer company for the University of Oxford and copyright owners of the OHS and OKS.
NICE guidance, Osteoarthritis: care and management. Clinical guideline [CG177] Published date: February 2014. https://www.nice.org.uk/guidance/cg177/chapter/1-Recommendations#referral-for-consideration-of-joint-surgery-2
The Oxford Hip and Knee scores are owned and supported by the Clinical Outcomes team at Oxford University Innovation. The Clinical Outcomes team provide over 85% of all licences (permissions) to use their PROMs questionnaires free of copyright use fees to publicly funded healthcare and for academic research use. For further information on the Oxford Hip and Knee scores please visit our website. If you would like to discover more about how Oxford research has contributed to health outcomes assessment in the NHS then please see our video on the subject.
Smith S., Cano S., Lamping D., Staniszewska1 S., Browne J., Lewsey J., van der Meulen J., Cairns J., and Black N. Patient-Reported Outcome Measures (PROMs) for routine use in Treatment Centres: recommendations based on a review of the scientific evidence. Health Services Research Unit, London School of Hygiene & Tropical Medicine, London, UK and Royal College of Nursing Institute, Oxford, UK. Final Report for the Department of Health, December 2005.