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Dates: 2013-2020
Funding: NIHR Health Technology Assessment (HTA)
Collaborators: Nuffield Department of Orthopaedics, University of Bristol, University of Exeter
Information: Helen Dakin, Alastair Gray, Peter Eibich

There is currently widespread regional variation in the way that GPs decide which patients with hip or knee pain should be referred to secondary care and in how decisions about whether to conduct hip or knee replacement are made in secondary care. Uncertainty around which patients benefit from knee or hip replacement means that some patients are referred inappropriately for surgery while others who could benefit miss out.

This project developed an evidence-based tool (ACHE) for GPs and/or hospitals to use to identify patients who are highly likely to benefit from hip or knee replacement surgery and guide those unlikely to benefit to other treatment options.

This project reviewed current clinical tools for assessing patients before joint replacement and analysed existing datasets to identify which tool best predicts outcomes and estimate thresholds that identify which patients are candidates for surgery. As part of this project, HERC researchers extended our previous work on knee replacement to assess which tool best predicts incremental costs and QALYs of joint replacement and estimate health economic thresholds for each tool at which joint replacement ceases to be cost-effective.

For more information:



Price A, Kang S, Cook J, Dakin H, Blom A, Arden N, Fitzpatrick R, Beard D, on behalf of the ACHE Study team. The use of patient-reported outcome measures to guide referral for hip and knee replacement: Part 1 – the development of an evidence based model linking pre-operative score to the probability of gaining benefit from surgery. Bone and Joint Journal. 2002:102-B(7):941–949.

Dakin H, Eibich P, Beard D, Gray A, Price A on behalf of the ACHE Study team. The use of patient-reported outcome measures to guide referral for hip and knee replacement: Part 2 – a cost-effectiveness analysis. Bone and Joint Journal. 2020:102-B(7):950–958.

Dakin HA, Eibich P, Gray A, Smith J, Barker KL, Beard D, Price AJ, on behalf of the ACHE Study team. Who gets referred for knee or hip replacement? A theoretical model of the potential impact of evidence-based referral thresholds using data from a retrospective review of clinic records from an English musculoskeletal referral hub. BMJ Open. 2020;10(7):e028915.

Price A, Smith J, Dakin H, Kang S, Eibich P, Cook J, Gray A, Harris K, Middleton R, Gibbons E, Benedetto E, Smith S, Dawson J, Fitzpatrick R, Sayers A, Miller L, Marques E, Gooberman-Hill R, Blom A, Judge A, Arden N, Murray D, Glyn-Jones S, Barker K, Carr A, Beard D. The Arthroplasty Candidacy Help Engine tool to select candidates for hip and knee replacement surgery: development and economic modelling. Health Technol Assess. 2019;23(32):1-216.

Eibich PDakin HA, Price AJ, Beard D, Arden NK, Gray AM. Associations between preoperative Oxford hip and knee scores and costs and quality of life of patients undergoing primary total joint replacement in the NHS England: an observational study. BMJ Open. 2018;8(4):e019477.