Discussion
chronic pain, neuropathic pain, pain
CHRONIC PAIN, COMPLICATIONS
We evaluated implementation of the STAR care pathway for chronic pain after knee replacement. The study elicited and explored views of the healthcare professionals involved in delivery of the care pathway in a randomised controlled trial. Allen and colleagues have emphasised the importance of incorporating conceptual frameworks to guide implementation in trials to enhance the translation of findings [Our findings indicate that healthcare professionals quickly became familiar with the STAR care pathway and felt it had potential to become a normal part of their practice. ESPs were already familiar with many elements of the pathway in their current clinical roles. However, the pathway differed from normal practice in many respects: that the duration of the clinic provided patients with more opportunity to reflect on their experience of surgery and recovery; the pathway gave increased focus on identification of potential complications including neuropathic pain; and the pathway provided regular telephone follow-up. Healthcare professionals felt that decisions by healthcare providers about future implementation would depend on trial results. The results of the trial have now been published and indicate that the STAR care pathway is both clinically beneficial and cost-effective over a 1-year period for patients with chronic pain at 3 months after total knee replacement [Our evaluation of the implementation potential of the STAR care pathway indicates that healthcare professionals valued the patient-centredness of the intervention. Training during the trial enabled and empowered ESPs to identify and provide support for patients at-risk of developing chronic post-surgical pain. During the trial, those with problematic knee replacements, were referred on to appropriate services. ESPs also valued the additional focus on neuropathic pain, which some had previously suspected was a cause of chronic post-surgical pain. This is supported by the baseline information about trial participants, which show that more than half reported neuropathic pain characteristics [Potential challenges to implementation include the extra resources needed for the clinic and telephone follow-up, which required more time to deliver. Healthcare professionals felt there may be need for further funding and support from management. Some ESPs also felt that the telephone follow-ups may save time and costs compared with face-to-face consultations. In a separate interview study with patients who took part in the STAR trial, we found that patients derived reassurance and encouragement from the clinic and telephone calls [A key aspect of implementation is the need for a collective understanding and awareness of the intervention. We found that in some centres, surgeons who were not directly involved in the trial did not know why patients whom they had treated were receiving assessment in a STAR clinic and who were sometimes referred back to them. Some were surprised or disappointed to see their patients in STAR having thought they were recovering well at the six-week post operative clinic appointment. We suggest that when implementing the STAR care pathway, all clinicians who provide support for patients with knee replacements should be made aware of and be engaged with the pathway and any changes in referral processes.Our main theoretical contribution has been to extend the use of NPT to the implementation of a clinical care pathway for chronic post-surgical pain after knee replacement. Our findings complement those of a previous UK study, which shows that when successfully implemented, care pathways encourage a systematic approach that can improve referral and access to appropriate care, promoting person-centred care, better multidisciplinary communication, and management of at-risk patients [