Healthcare professionals’ views on implementing the STAR care pathway for people with chronic pain after total knee replacement: A qualitative study

Andrew J Moore*, Vikki Wylde, Wendy A Bertram, Andrew D Beswick, Nicholas R Howells, Rachael Gooberman-Hill

*Corresponding author for this work

Research output: Contribution to journalArticle (Academic Journal)peer-review

1 Citation (Scopus)


For many people with advanced osteoarthritis, total knee replacement is an effective treatment to relieve pain and improve function. However, 10-34% of people experience chronic postsurgical pain in the months and years after total knee replacement. The Support and Treatment After Replacement (STAR) randomised controlled trial (ISCRTN92545361) evaluated the clinical- and cost-effectiveness of a new multifaceted and personalised care pathway, compared with usual care, for people with pain at three months after total knee replacement. Our objective was to identify factors promoting or inhibiting its implementation, and to inform future training and wider implementation of the pathway. We conducted a prospective process evaluation using qualitative interviews with eight Extended Scope Practitioners and six Principal Investigators from seven trial sites who were involved in delivering the STAR care pathway during the trial. We used Normalization Process Theory as a theoretical framework for qualitative data collection and content analysis. We identified that factors promoting the implementation of the pathway were quick familiarisation with the pathway, valuing patient-centredness, formalising referral processes, and increasing confidence to address neuropathic pain. Challenges to implementation were availability of time and resources, sensitivity in referral process, and ensuring collective understanding of the pathway. These findings have enabled us to make recommendations about the future implementation of the STAR care pathway and will inform the development of a training package, and updated manual for successful delivery in usual care. Furthermore, this model of care has potential value in diverse elective surgeries and pain conditions.
Original languageEnglish
Article numbere0284406
Number of pages12
JournalPLoS ONE
Issue number4
Publication statusPublished - 28 Apr 2023

Bibliographical note

Funding Information:
We thank all participants in the study for their time and expertise. We are also grateful to Mrs Gemma Munkenbeck, Research Administrator for her support throughout the study. The authors would like to acknowledge the following for their help and input into the STAR research programme: Andrew D Beswick, Tim J Peters, Emily Sanderson, Sian Noble, Ashley W. Blom, David A Walsh, Shaun Harris, Kirsty Garfield, Simon White, Andrew Toms, Andrew Judge, Athene Lane, Fiona MacKichan, Nicolas Ambler, Susan Bridgewater, Leigh Morrison, Gemma Munkenbeck, Candida McCabe, Rowenna Stroud, Kate Button, Nigel Arden, Andrew Price, Rafael Pinedo-Villaneuva, Anushka Soni, Stewart Long, Joanne Adams, and the public and patient representatives from the PEP-R group.

Publisher Copyright:
© 2023 Moore et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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