P056 Clinical pathways in the 10 years before knee replacement: sequence analysis of multi-linked electronic health records in England

Background/Aims Total knee replacement (TKR) represents the definitive treatment for advanced knee osteoarthritis (KOA). UK NICE guidelines outline a staged management pathway beginning with self-care, and core non-surgical treatments followed by adjunctive non-pharmacological and pharmacological interventions, and when appropriate, surgical referral. However, real-world patient journeys leading to TKR are not well described and often diverge from recommended practice. To fill this gap, we analysed large-scale linked UK electronic health records covering both primary and secondary care using sequence analysis (SA) to map 10-year pathways preceding TKR. The objectives were to identify typical care trajectories and examine how these vary according to patient characteristics, thereby informing improvements in OA management before surgery. Methods Population-based retrospective cohort study, using data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) datasets. Adults aged ≥45 years with an OPCS code for primary TKR between January 1, 2007 and December 31, 2021 were included. The care strategies considered for defining patient care sequences included primary care consultations for knee pain, prescriptions for analgesics, referrals for imaging, referrals for physiotherapy, referrals to specialist care, corticosteroid intra-articular injections, and knee surgeries. SA, using optimal matching with transition rate cost-setting, was employed to identify clusters of patients who followed similar care pathways prior to TKR. The association between patients’ characteristics and cluster membership were investigated using a multinomial logistic regression model. Subgroup analyses were conducted by sex, age group, and calendar period. Results Among 129,470 adults undergoing primary TKR, we identified five distinct care pathway typologies: “low healthcare use” (37.8%), “moderate healthcare use” (23.9%), “opioids predominant” (20.1%), “gabapentinoids and antidepressants predominant” (4.6%), and “NSAIDs predominant” (13.7%). The distribution of clusters differed significantly across sociodemographic and clinical factors, including age, sex, BMI, comorbidities, smoking status, ethnicity, region, neighbourhood deprivation, and year of surgery. Patients living in the most deprived areas were disproportionately represented in the “opioids predominant” and “gabapentinoids and antidepressants predominant” clusters. Conclusion This study demonstrates marked heterogeneity in pre-TKR care, with many patients following pathways that diverge from NICE-recommended non-pharmacological management. The observed socioeconomic variation highlights inequities in access to guideline-based conservative treatment and underscores the need for targeted policy and service interventions to promote equitable, evidence-informed OA care across patient groups. Disclosure S. Mathew: None. E. Parry: None. G. Peat: None. D. Yu: None.