Patient-centred care

Since the early work of Archie Cochrane and the drive from Oxford, much has been made of evidence based medicine. As orthopaedic surgeons we have historically been the poor relations of other areas of medicine; averting our gaze in embarrassment as physician colleagues discuss the latest results of a tablet x versus tablet y trial which is a relatively easy to perform outcome to study. Surgery is different, the majority of treatments we offer are ‘complex interventions’ with many factors comprising the treatment and potentially determining the outcome (surgery, anaesthesia, implant choice, physiotherapy, planning, prophylactic antibiotics to name just a few) making studying surgery in a randomised manner extremely difficult, let alone blinding patients and assessors to their treatment allocation. However, times have most definitely changed in recent years and orthopaedics has been in the vanguard of surgical research. Problems of rarity of diagnosis have been overcome with large multicentre studies and pragmatic trial designs have helped to ‘iron out the wrinkles’ from the difficulties of study design. These great strides we have made as a scientific and surgical community have been brought clearly into focus for me with this issue of 360. We have been able to include no less than 22 randomised controlled trials in these pages. Adding to knowledge in almost every aspect of orthopaedics from sham surgery studies,¹ to the use of topical antibiotic prophylaxis in spinal surgery.². The world has changed and we are now living in the age of evidence based orthopaedics.

One of the revolutions, rather than evolutions, that has had to occur during the drive towards improved evidence for our treatments, is the development of appropriate outcome measures. Although on the face of it, assessing how patients have actually done and expressing that as an easy to understand number sounds straightforward, it is fraught with difficulty. Perhaps one of the most important changes is the move towards patient centred outcome measures. After all success is best measured from a patient’s perspective. In a superb article this month James Rickert examines the next step, not just assessment of outcomes from the patient’s perspective, but makes a powerful case for patient-centred care models.

Patient-centred care should also encompass patient safety, and in a decade when the World Health Organization has introduced its patient safety checklist and made surgical safety a priority it is a delight to share a review of surgical safety from Philip Stahel in Denver. His article beautifully traces the evolution of patient safety and particularly the ten year outcomes of the Universal Protocol introduced in the USA a decade ago. Sharing insights from the evolution of patient safety peri-operatively makes this an essential read for all surgeons. I still find it amazing that despite widespread adoption of improved safety algorithms worldwide, there were 57 events of wrong site surgery in the UK during 2009/2010.³

This month sees the birth of the 360 medico-legal section, edited by Mike Foy, which will set new and emerging research and outcomes into the medico-legal context. Covering perhaps two the most important medico-legal issues this month, the emerging minefield of metal-on-metal hip replacement and the old favourite of whiplash injuries.

My very best wishes to you all.

Ben Ollivere

Editor-in-Chief