Clinical Thresholds

Condition or Treatment / Hip and knee arthroplasty for osteoarthritis (only)
Commissioning Threshold / Hip and knee arthroplasty for osteoarthritis will be commissioned when all the following criteria have been met:
•Patient is experiencing moderate-to-severe persistent pain not adequately relieved by an extended course of non-surgical management. Pain is at a level at which it interferes with activities of daily living – washing, dressing, lifestyle and sleep;
•Is troubled by clinically significant functional limitation resulting in diminished quality of life;
•The patient is eligible for a referral in-line with the CCG’s Health Optimisation policy (please see for exclusions)
•The patient has radiological features of disease.
•A simple x-ray to confirm diagnosis has been carried out within the past 6 months;
The GP referral letter contains evidence that:
•the recommended hierarchy of management has been followed (or reasons why a treatment is not appropriate): non-pharmacological treatments first including referral to the OA education class and then if required a referral to physiotherapy, drugs, and then if necessary, surgery;
•a confirmation that patients have been made aware of the options available as an alternative to surgery and the risks associated with surgery (this includes patients being advised to access the local OA information website, where appropriate, via the following link:
•An option has been selected in-line with the CCGs Health Optimisation policy (please see referral guidance below)
•Oxford hip or knee pain scoring has taken place and the score is recorded (the patient’s Oxford Hip score is ≤24 or Knee score ≤23 on the 0 to 48 system).
Referral guidance / When referral to surgical speciality is appropriate, all referrals to secondary care should include the following information regarding a patient’s BMI and smoking status:
Option 1:Non-Smoker & BMI under 30
Option 2:Active Smoker or BMI 30 or above with applicable exclusions (see list of exclusions) or has been approved by the IFR panel
Option 3:6 month health optimisation period complete
Option 4:Active Smoker or BMI 30 or above (not eligible for referral)
Referrals received by RSS which identifies a patient underOption 4 -BMI 30 or above or does not include Options 1-3 will be returned to the referring GP in order that the patient can be offered health optimisation prior to referral.
Referrals for exceptional circumstances are to be submitted by way of an IFR referral form for decision by the IFR panel. The referral form is available through the following link:

Effective from / November 2016
Summary of evidence /
Rationale / The referral criteria were inherited from the former North Yorkshire and York PCT and were adopted by HaRD CCG.
The Clinical Knowledge Summaries give recommendations for treatment based on the National Institute for Health and Care Excellence (NICE) Guideline for care and management of osteoarthritis in adults. NICE reviewed a large number of studies and concluded that there is very little evidence on which to base decisions about referral for hip joint replacement.
Date / November 2016
Review Date / November 2017
Contact for this policy / Dr Bruce Willoughby
GP/Governing Member

References:

1. National Patient Safety Agency (NPSA). Rapid Response Report NPSA/2009/RRR001: Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur. London: NPSA; 2009.

2. HESonline. Hospital Episodes Statistics [Internet]. London: Health and Social Care Information Centre [accessed 18 October 2010].

3. National Institute for Health and Clinical Excellence (NICE). Osteoarthritis: the care and management of osteoarthritis in adults. Clinical guideline 59. London: NICE; 2008. Now replaced by

4. American College of Radiology (ACR).ACR Appropriateness criteria.Imaging after total hip arthroplasty. Reston, VA: ACR; 2005.

5. British Orthopaedic Association (BOA). Primary total hip replacement: a guide to best practice. London: BOA; 2011.

6. National Institute for Health and Clinical Excellence (NICE). Guidance on the use of metal on metal hip resurfacing arthroplasty.Technology appraisal guidance 44. London: NICE; 2002.

7. Clinical Knowledge Summaries, Knee Pain Assessment, March 2011.