Clinical care patterns in the 10-years prior to primary total hip replacement: a matched population-based case-control analysis in England.

backgroundThe quality of evidence supporting recommendations for conservative hip osteoarthritis management limits the treatment options available to patients prior to surgery. The care individuals receive prior to their eventual total hip replacement (THR) is likely to be variable and complex. These long-term care patterns remain undefined.

methodsA population-based retrospective case-control study using linked primary and secondary care data (CPRD Aurum/HES APC) in England was conducted to identify the longitudinal prevalence of surgical, pharmacological and non-pharmacological care strategies in the 10 years preceding THR between 2007 and 2021. 480,598 individuals (240,299 THR recipients matched 1:1 to non-recipients) were identified. Prevalence rate ratios (PRRs) modelled chronological changes in care, referencing the 6-month period immediately prior to surgery (or index date for controls). Conditional logistic regression estimated odds ratios (ORs) for THR adjusted for confounders.

resultsThe prevalence of all pharmacological prescriptions increased over the 10-year observation period prior to THR, with an escalation in rates for opioids, oral NSAIDs and paracetamol starting at 24 months before surgery. All medication prescriptions were consistently higher in females across all time periods. The prevalence of sick leave and referrals for physiotherapy, hip imaging and pain clinic (non-pharmacological care) also increased. Hip injection prevalence increased from 0.03% at 12 months (6 to 12 month period) to 15.1% at 6 months (0 to 6 month period) pre-THR. Prescriptions for all analgesic sub-types, antidepressants, sick leave, and referrals for physiotherapy, pain clinic and hip imaging had increased odds of THR throughout the observation period. Strong opioid use in the final 6-month period represented the strongest association with surgery (OR 5.0 [95% CI 4.7, 5.2]). Younger patients consistently demonstrated a lower prevalence of medication prescriptions, and higher prevalence of sick leave issuance, relative to older groups.

conclusionsEscalating care is observed from 24 months prior to surgery among individuals who progress to THR. Prevalence of paracetamol and opioid prescriptions are high. Important age-related differences in care provision prior to THR relating to medication prescriptions and non-pharmacological interventions are present. This is accompanied by long-term elevated rates of sick leave in the working population.