An engagement tool called PRO-MAPP is providing intelligent decision support to optimise the preoperative assessment (POA) process in the pre-assessment clinic triage (PACT) pathway for high volume, low complexity (HVLC) orthopaedic cases. This digital transformation allowed a more personalised approach to the individual needs of patients on the hip and knee surgical waiting list. Patients are triaged for either a face-to-face or telephone assessment. Previously all patients had an in-person appointment prior to surgery. Now more than 70% can be assessed effectively on the phone instead. In-person outpatient appointments remain available to those who still need them, with PRO-MAPP identifying medically complex patients or those needing specialist investigation. As a result, fewer pre-op assessment appointments have been cancelled or missed (down from 8% in 2021 to fewer than 1% in 2022). With potential issues identified and dealt with at an early stage, the number of operations cancelled further down the line is also reduced.
With more patients assessed remotely instead of in person, the NHS saves money and can reallocate resources and facilities to other services.
This new approach is being used prior to planned hip and knee replacement surgery at the Nuffield Orthopaedic Centre (NOC), part of Oxford University Hospitals. The potential to apply this model in other specialties is being explored.
The Oxford AHSN carried out a real world evaluation of PRO-MAPP at the NOC, working with key stakeholders to determine the potential impact of the technology and suitability for spread and adoption. The evaluation found that PRO-MAPP reduced cancellation rates for surgery and preoperative appointments, leading to better use of resources. An independent health economic analysis found significant potential cost savings and further analysis identified positive environmental impacts too.
What is the challenge?
After the onset of Covid-19 pandemic many non-urgent elective activities were postponed to free up inpatient and critical care capacity. The NOC faced a challenge in increasing its elective capacity and reducing the backlog which built up during the pandemic. In addition, insufficient patients were ‘fit for surgery’. Without the option of a personalized pre-op assessment service, many patients needed multiple face-to-face appointments to prepare them for surgery. Another limitation was the lack of differentiation between high and low complexity cases. All POA appointments were conducted face-to-face approximately 4-6 weeks before anticipated surgery.
The NOC’s health professionals and management team identified an unmet need for digital collection of health screening data completed by patients when listed for surgery. They also identified the need for early identification of patients requiring investigation or treatment before surgery to prevent subsequent surgery postponement.
What did we do?
The NHS Transformation Directorate Adoption Fund supports elective recovery through innovations that help people stay well or get well at home. The Oxford AHSN led a successful bid for funding with the Buckinghamshire, Oxfordshire and Berkshire West (BOB) Integrated Care System (ICS), receiving £424,000 for four projects including PRO-MAPP.
The Oxford AHSN contribution supported the development of a business case for implementing PRO-MAPP. It also conducted a service evaluation to gather real world evidence relating to initial implementation of the technology at Oxford University Hospitals. And the AHSN worked with key stakeholders to help design the new clinical pathway, gathering feedback on the innovation from patients and healthcare professionals. In addition, the AHSN worked with York Health Economics Consortium (YHEC) to create a health economics model for further potential adoption, and the AHSN’s Environmental Sustainability Lead established the carbon footprint reduction related to this innovation.
What has been achieved?
The evaluation found that PRO-MAPP reduced surgery cancellation rates and preoperative appointment cancellations, leading to better resource utilisation and cost savings. All patients surveyed during the evaluation were either satisfied or very satisfied with their visit, indicating that there are few barriers to adoption from a patient perspective.
The new pathway also reduced outpatient attendances and unnecessary travel to OUH. A sustainability and social value review found that implementing PRO-MAPP could lead to a significant decrease in carbon emissions due to reduced patient travel with 70% of patients assessed as being suitable for a telephone consultation after their first outpatient clinic visit. During the real world evaluation, PRO-MAPP saved 51,382km (more than 32,000 miles) of travel. In the UK, average CO2 emissions per car equate to 171 grams per km, according to the latest data from the Department of Transport. Therefore, this distance equates to 8.8 tonnes of CO2 saved. For comparison, one tonne of CO2 is the equivalent of a return flight from Paris to New York, meaning that during the evaluation period (April 2022-January 2023) use of PRO-MAPP saved almost nine return flights from Paris to New York. Read more in the sustainability and social value review.
This approach proved particularly useful for tertiary and quaternary referrals, allowing patients from outside the region to easily access specialised services.
The results of the YHEC health economics analysis indicated that implementing PRO-MAPP into the clinical pathway for those on the hip and knee surgical waiting list brought significant cost savings. The health economics model saved £152 per patient, rising to £769 per patient when length of stay was considered. Length of stay can be influenced by a multitude of factors, and it was thought that the introduction of PRO-MAPP might not directly influence this, even though a reduced length of stay was noted in the evaluation.
The utilisation of PRO-MAPP has been recognised as a national exemplar of best practice in the NHS and has been included in the NHS Digital Playbook for Perioperative Care.  A case study has also been included on NHS England’s website as a guide for providers and integrated care boards on earlier screening, risk assessment and health optimisation in perioperative pathways.
The Oxford AHSN is creating an implementation support pack to help roll out this innovation across the NHS.
What people said
“Thank you for inviting us to see the innovative work you are doing for your patients, providing person-centred pre-operative care with digital technology.” – Rachel Brown, NHS England Transformation Directorate
“Our new clinical pathway has enabled us to increase preoperative assessment capacity and commence patient optimisation as soon as individuals are listed for surgery. It has also allowed us to digitise the pathway, reduce hospital visits, and improve carbon footprint.” – Antony Palmer, Consultant Orthopaedic Surgeon Clinical Lead for NOC Preoperative Assessment
“This project has transformed the way we provide pre-assessment care for patients. It’s a fantastic example of digital enhancement of a clinical pathway improving patient experience.” – Professor Andrew Price, Trauma and Orthopaedic Surgery Clinical Director
“Triaging patients earlier in their surgical pathway has improved the optimisation and management of their complex long-term conditions. This allows follow up of patients to be arranged in a timely manner and to reduce unnecessary visits to the hospital.” – Natasha Brand, Specialist Nurse Practitioner at the pre-assessment clinic
“The benefit of PACT is to work in a different and effective way to enable us to have a pool of patients fit for surgery, so if we do have any last-minute cancellations we have patients to fill the gaps rather than wasting precious theatre time.” – Lucy Barrett, Deputy Matron for Orthopaedics
Following the encouraging results from the real world evaluation, OUH is developing a business case for implementing PRO-MAPP throughout the orthopaedics department as well as in other specialties. The independent health economic analysis is supporting this work.
Flora Gleave, Project Manager, Health Innovation Oxford and Thames Valley firstname.lastname@example.org