Stakeholders’ Perspectives on the Development of the Early Pain Intervention After Knee Replacement Model of Care: A Qualitative Study

Abstract

Objective

Persistent pain affects around 20% of Australians after total knee replacement (TKR), yet no dedicated Australian model of care exists to address this unmet need. The Early Pain Intervention after Knee replacement (EPIK) model is being developed, informed by the effective and cost‐effective UK Support and Treatment After Replacement care pathway and extensive multistakeholder engagement. Before evaluating the EPIK model of care in a randomized controlled trial, it must be adapted for the Australian context. This qualitative study aimed to explore stakeholders’ perspectives to inform this adaptation.

Methods

This qualitative descriptive study, guided by a subtle realist ontologic stance and a pragmatic epistemology, used semistructured interviews with key stakeholders across Australia. A preinterview screening questionnaire captured demographic, clinical, and professional characteristics which informed purposive sampling to ensure diverse views. Interviews were audio‐recorded, transcribed verbatim, and analyzed using inductive analysis.

Results

Sixty‐one participants were interviewed (9 patients, 20 physiotherapists, 15 orthopedic surgeons, 14 general practitioners, 1 nurse, and 2 health fund managers) across all six states and the Australian Capital Territory, with 75% residing in metropolitan areas. We identified four key themes: (1) living with pain after TKR, (2) acceptability and value of EPIK, (3) defining the scope of the EPIK care coordinator, and (4) infrastructure and system‐level challenges.

Conclusion

The EPIK model was well accepted by stakeholders as the first approach designed to improve care coordination for Australians with persistent pain after TKR, with potential to support a more efficient and patient‐centered health care system. These insights will inform the EPIK model, which will be tested in a registry‐nested randomized controlled trial.

INTRODUCTION

Total knee replacement (TKR) is an effective and cost‐effective intervention for end‐stage knee osteoarthritis. ¹ , ² However, approximately 20% of patients undergoing TKR experience persistent pain after surgery. ³ Many patients do not seek care, believing nothing can be done for their persistent pain. ⁴ Those who do seek care are sometimes referred back to their orthopedic surgeon, though evidence suggests surgical follow‐ups beyond the postoperative period (eg, 1–10 years after TKR) are not needed and do not always improve outcomes. ⁵ Australian data suggest pain management remains inadequate for many who undergo TKR, as about 40% of people are still using opioids to some degree one year after surgery. ⁶ These findings highlight the need to identify safer and more effective strategies for managing pain after surgery.

SIGNIFICANCE & INNOVATIONS.

• This qualitative study found that patients with persistent pain after total knee replacement have complex, often unmet needs, underscoring the need for personalized, patient‐centered care.

• The Early Pain Intervention after Knee replacement (EPIK) model of care is designed to address a critical gap in the management of persistent pain after total knee replacement for Australians, with the potential to improve patient outcomes.

• The EPIK model of care will be tested in a registry‐nested randomized controlled trial to assess its effectiveness, cost‐effectiveness, and potential for national implementation.

Poor mental health and psychologic factors contribute to suboptimal outcomes following TKR, yet uptake of psychologically informed pain management remains limited. ⁷ , ⁸ This reflects a critical gap in perioperative care. Recent meta‐analyses show that interventions such as cognitive behavioral therapy reduce pain catastrophizing and kinesiophobia in the early postoperative window. ⁹ , ¹⁰ By addressing these maladaptive responses, patients are better able to engage in rehabilitation. Remotely delivered psychologic therapies offer a scalable solution to the logistical barriers limiting intervention uptake. Given their proven efficacy across chronic pain populations, ¹¹ adapting these remote models for perioperative TKR could bridge this critical gap in care.

There are currently no formal models of care specifically designed to address the needs of people with persistent pain after TKR in Australia. Routine care for this population lacks a standardized framework and is often fragmented. ¹² Patients typically navigate a combination of ad hoc general practitioner (GP) visits, physiotherapy, and pharmacologic management alongside specialist surgical reviews that primarily focus on excluding mechanical failure or infection. ⁸ For that reason, we are adapting a model of care that has been shown to be effective and cost‐effective in the United Kingdom, the Support and Treatment After Replacement (STAR) care pathway, to the Australian context. ¹³ , ¹⁴ In STAR, people who had TKR were assessed three months after surgery. Those with persistent pain were given a comprehensive assessment by an allied health professional, who then coordinated their care and referred them to appropriate services as needed. The care coordinator also followed up with patients up to six times over the following year.

We refer to the Australian adaptation of STAR as the Early Pain Intervention after Knee replacement (EPIK) model of care. ¹⁴ A comprehensive adaptation process is required because of fundamental differences between the Australian and UK health systems. For example, unlike the United Kingdom's publicly funded NHS, Australia operates a hybrid public–private model. ¹⁵ EPIK is also being designed to ensure patients in rural and regional areas benefit from the model of care, with telehealth as the core mechanism for delivering this support.

Qualitative research in TKR has largely focused on patients’ lived experiences of recovery and persistent postoperative pain. ¹⁶ , ¹⁷ Some studies have examined the perspectives of individual clinicians, ¹⁸ , ¹⁹ but few integrate the views of multiple system‐level stakeholders in long‐term postoperative care.

Adaptation of the preliminary EPIK model of care required a comprehensive exploration of contextual barriers and facilitators from the perspective of key stakeholders, such as patients and clinicians. The initial phase, reported here, comprised a qualitative study involving consultation with patients, multidisciplinary clinicians, and health fund managers, collectively termed stakeholders. This approach was selected over structured surveys or focus groups, which may constrain the emergence of unanticipated themes and limit the depth of individual perspectives. Employing a flexible methodology enabled in‐depth exploration of the underlying reasons shaping stakeholders’ views, ensuring that subsequent adaptations to the EPIK model are grounded in their lived experiences and operational contexts.

MATERIALS AND METHODS

Design

We used a qualitative description methodology, employing in‐depth, semistructured interviews to explore stakeholders’ views of the preliminary EPIK model of care, underpinned by a subtle realist ontologic stance and a pragmatic epistemology. ²⁰ This approach was chosen to generate rich accounts of participants’ experiences, ensuring that findings remain closely grounded in the data and inform EPIK program adaptation. ²¹ This study is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) reporting guidelines ²² (Supplementary File 1). Before this qualitative study, we held extensive consultations with the multidisciplinary EPIK steering committee, including consumer partners, clinicians, and members of the UK STAR team. This collaboration shaped the preliminary EPIK model of care (Figure 1). EPIK will be led by experienced orthopedic physiotherapists known as EPIK care coordinators, who will assess biopsychosocial pain factors via telehealth and refer patients to existing health services. Each patient will receive a one‐hour initial telehealth assessment, followed by coordinated care as needed. Similar to UK STAR, patients will have four to six follow‐up consultations with their EPIK care coordinator over 12 months. A key distinction is the use of telehealth throughout the EPIK model. Ethics approval was granted by the University of Sydney Human Research Ethics Committee (2024/HE000870), and all participants provided informed consent.

Figure 1.

EPIK model of care. CRPS, complex regional pain syndrome; EPIK, Early Pain Intervention after Knee replacement; GP, general practitioner; TKR, total knee replacement; PFJ, patellofemoral joint.

Participants

We recruited adults living in Australia who had undergone TKR, clinicians registered to practice in Australia who manage TKR patients (eg, orthopedic surgeons, physiotherapists, and GPs), and health fund managers. We excluded people unable to provide informed consent or lacking English proficiency.

We recruited clinicians through emails from the EPIK steering committee and passive snowball sampling. Patients were recruited through social media and Arthritis Australia.

Potential participants completed a REDCap screening questionnaire (Supplementary File 2) capturing demographic (eg, age, gender, and ethnicity), clinical (ie, knee‐specific function with the Oxford Knee Score ²³ [OKS]), and professional characteristics (eg, years of clinical experience and location of clinical practice). Participants were purposively sampled for diverse demographics, clinical backgrounds, and perspectives.

Data collection

We invited eligible participants to participate in a single semistructured, one‐on‐one interview between October 2024 and January 2025 with one of the three researchers (NC, AO, or HR) via Zoom. Recruitment within each stakeholder group ceased when either informational saturation was reached (no new insights emerged) or the pool of available and interested participants within the study timeframe was exhausted.

An interview guide (Supplementary File 3) was developed and included open‐ended questions and probes to explore stakeholders’ perspectives of the preliminary EPIK model of care, ²⁴ focusing on postoperative pain management, care coordination, and implementation challenges. Two pilot interviews (one patient and one clinician) were initially conducted to refine the guide; and as no substantive changes were required, these interviews were included in the final analysis.

All participants provided written informed consent before the interview. Interviews were audio‐recorded, transcribed using Microsoft Word transcription feature, and checked for accuracy by one of the three researchers (NC, AO, or HR) before analysis. To enhance transparency, participants received their transcripts within 24 hours of the interview and were invited to review and refine their responses. This approach aimed to ensure accurate representation of their perspectives and alignment with their lived experiences before analysis. Interviews continued until inductive descriptive saturation was reached, as determined by ongoing transcript and codebook review. ²⁵ , ²⁶

Data analysis

We used an inductive approach, developing concise codes to capture key points. ²⁷ Transcripts were coded line by line, with a preliminary codebook developed and refined iteratively in Microsoft Excel. Coding was performed in duplicate by NC and either AO or HR, with 10 transcripts independently coded by a fourth researcher (GF). Any discrepancies in initial coding between paired researchers were resolved through discussion and comparison with the raw data to reach mutual agreement. Where consensus could not be achieved, disputed excerpts were escalated to the wider research team for adjudication and final code assignment. Participants were analyzed as a single group to explore commonalities and differences across stakeholder types. Data collection and analysis were conducted concurrently, with interviews across all stakeholder groups continuing until saturation was achieved, defined as the point where new interviews yielded no new insights, and no new descriptive categories were identified. ²¹ Codes were refined and grouped into themes and subthemes, with illustrative quotations supporting interpretation. After double coding all transcripts, the EPIK steering committee reached consensus on final themes and subthemes (Supplementary File 4). Reflexivity was supported through duplicate coding and regular team discussions. Following preliminary analysis, we held an online meeting with four consumers with lived experience of persistent post‐TKR pain to critically review and refine the findings. This approach, also known as “critical friends,” was adopted to fostered dialogue between researchers and consumers, encouraging the exploration of differing perspectives and challenging assumptions. ²⁸

Researchers’ positionality

NC, a female physiotherapist with over seven years’ experience managing persistent knee pain post‐TKR, led interviews and analysis, supported by BB, a female qualitative expert and physiotherapist. AO (female) and HR (male), third‐year postgraduate medical students, were trained in qualitative interviewing by NC. Preliminary analysis was conducted by NC, JZ, and GF, with JZ and GF being male researchers with physiotherapy backgrounds. Although individual reflective journals were not maintained, the team ensured reflexivity through regular collaborative discussions that informed data collection and interpretation. ²⁹

Furthermore, a detailed audit trail was maintained throughout the project to document methodologic changes and coding decisions.

RESULTS

Characteristics of the included participants are described in Tables 1 and 2. Eighty‐five potential participants were invited, of whom 61 responded and were included. The remaining 24 individuals either did not respond to the initial invitation or declined participation citing time constraints. Participants consisted of 9 patients, 20 physiotherapists, 15 orthopedic surgeons, 14 GPs, 1 nurse, and 2 health fund managers. The median duration of the interviews was 34 (range 20–52) minutes. We included 9 patients, mean age of 66 (SD 8.5) years, most of whom were women (78%). Patients’ mean OKS was 25 (SD 10.7) (Table 1 and Supplementary File 5). We included 50 clinicians and 2 health fund managers (Table 2).

Table 1.

Participant demographics: patients^*

Participant identification	Sex	Age, y	Self‐reported ethnicity	OKS pain a	OKS function a
ID1	Male	68	Aboriginal and Torres Strait Islander	6	5
ID3	Female	57	Aboriginal and Torres Strait Islander, English	13	11
ID4	Female	67	Australian	28	14
ID5	Female	50	English, Scottish	20	15
ID6	Female	70	English	14	10
ID7	Female	67	English, Scottish	17	13
ID8	Female	72	German, Polish	20	14
ID10	Male	81	Australian	9	7
ID11	Female	60	Dutch	4	5

^*OKS, Oxford Knee Score.

^a The OKS is divided into two subscales: pain subscale with a score out of 28 and function subscale with a score out of 20; lower scores on these subscales indicate more severe pain and reduced function, reflecting poorer knee‐related outcomes.

Table 2.

Participant demographics: clinicians and health fund managers

Variable	(n = 52)
Profession, n (%)
Orthopedic surgeons	15 (29)
Physiotherapists	20 (38)
General practitioners	14 (27)
Nurse	1 (2)
Health fund managers	2 (4)
Age, mean (SD), y	46 (12.0)
Sex, n (%)
Male	35 (67)
Female	17 (33)
Years practicing, mean (SD)
Orthopedic surgeons	15 (9.2)
Physiotherapists	17 (12.0)
General practitioners	18 (10.5)
Nurse	24 (0)
Health fund managers	19 (11.0)
Location of practice, n (%)
Metropolitan	40 (77)
Rural	12 (23)
Occupation setting, n (%)
Private practice	32 (62)
Public hospital	16 (31)
Private hospital	2 (4)
Private health fund	2 (4)
Able to provide high quality patient care for patients who have undergone total knee replacement for knee osteoarthritis as a clinician, n (%)
Strongly agree	22 (44)
Agree	22 (44)
Somewhat agree	6 (12)
Able to provide care aligned with the currently accepted best practice for knee osteoarthritis as a clinician, n (%)
Strongly agree	21 (42)
Agree	23 (46)
Somewhat agree	6 (12)

We identified four key themes: living with pain after TKR, acceptability and value of EPIK, defining the scope of the EPIK care coordinator, and infrastructure and system‐level challenges. Illustrative quotations are presented in Tables 3 and 4.

Table 3.

Themes 1 and 2: subthemes and illustrative quotes from participant interviews^*

Theme	Illustrative quotes
Theme 1: living with pain after TKR
Emotional and physical challenges	“Too many people talk to too many other people, and everybody's journey is different” (ID4‐patient)
	“I now have a permanent limp because of the pain …, so I'm limited in what I can do” (ID10‐patient)
	“Persisting pain … is a multifactorial issue for the person and I think of the clinician for me, I look at that biopsychosocial aspect of it” (ID33‐physiotherapist)
Empowering patient engagement	“As I said, every individual has, you know, no one outcome is going to be the same. So, if people can have things tailored to their, you know, specific needs, I think it's a great idea” (ID5‐patient)
	“I mean, it's always good to talk to someone else and get an opinion on what you're doing and whether you could be doing something better or something different” (ID6‐patient)
	“If anything, … you know, empowers them” (ID79‐GP)
Theme 2: acceptability and value of EPIK
Perceived benefits	“Personally, that sounds really good to me. I find that easy. If something is sent to me that automated, it it's quite easy for me to go” (ID5‐patient)
	“People would appreciate being reached out to …, someone who's going to help and listen” (ID4‐physiotherapist)
	“If they feel they're being looked after, even if it makes no difference at all, … but it makes the patient feel comfortable, I think it's a great idea” (ID10‐surgeon)
	“I think that it's great and it might be a stepping stone, you know, while they're waiting for pain management physician” (ID63‐surgeon)
	“I think that EPIK model is absolutely would be wonderful. A lot of patients and a lot of consumers … would benefit from that” (ID74‐nurse)
	“I think it's a great idea … I would really like that to become more of accessible to people” (ID82‐GP)
Anticipated barriers	“So, everyone's diverse, so everybody's going to need some sort of specialised care plan to suit their, you know, how it's affected them” (ID5‐patient)
	“I'll probably wouldn't just have it as a substitute for proper review by pain specialist, that's all” (ID60‐surgeon)
	“I think it would depend on cost and if it's tailored to what the individual is requiring, and if there's any travel out” (ID74‐nurse)
	“I think telehealth has worked better for follow‐up. But, you know, I think there's no substitution for face‐to‐face medicine” (ID87‐GP)
	“The barriers are just not getting the full picture of the patient, particularly if you're concerned about a complication that is difficult to identify via telehealth” (ID55‐surgeon)

^*EPIK, Early Pain Intervention after Knee replacement; GP, general practitioner; TKR, total knee replacement.

Table 4.

Themes 3 and 4: subthemes and illustrative quotes from participant interviews^*

Theme	Illustrative quotes
Theme 3: defining the scope of the EPIK care coordinator
Lifestyle interventions	“I'm very open to any suggestion to combat the pain in my knees. Personally, I'm open to anything that can alleviate the pain and willing to try anything basically” (ID1‐patient)
	“Helping the patient understand that even though it's still sore in most cases it will get better over time” (ID41‐surgeon)
	“If you don't educate patients … then you will probably get patients who are more vocal and more concerned and have a heightened sense of their pain because they have no understanding of what to expect” (ID48‐surgeon)
Multidisciplinary care coordination	“Successful were the ones where all the team members were on board with how it how the model of care is run, and everyone was aware of the boundaries of their role and what we needed to do” (ID11‐physiotherapist)
	“We're one part of the whole team that they're seeing … we just have to make sure we're all working together and communicating all together” (ID32‐physiotherapist)
	“Using a multi‐modal approach is definitely helpful” (ID86‐GP)
Theme 4: infrastructure and system‐level challenges
Telehealth considerations	“Look, I can tell you that our members prefer face to face. Given a choice, most of our members will choose face to face over telehealth, that's our experience” (ID19‐health‐fund‐manager)
	“Our jobs as clinicians … identify those contributors to pain … thorough biopsychosocial assessment … I don't think [it] is done well” (ID26‐physiotherapist)
	“Imagine there be a sort of thought to be a barrage of measures that would give you a better insight into whether you know people's function and post op suffering” (ID27‐physiotherapist)
System‐level inconsistencies	“I would like it not to undermine the doctor patient relationship, or the communication is outside, or that interventions are not evidence based, and I would like to see a clearer algorithm of treatment before participating in the study” (ID15‐surgeon)
	“Some patients … [are] more motivated than others to seek care, … and access to care is quite variable between public and private system” (ID16‐surgeon)
	“Whenever I find a good psychologist within roughly six months, they don't have any spots available. They're not taking new patients … it seems to be very hard to find a reliable psychologist that is good with chronic pain and that doesn't fill up very quickly … you're forever trying to find someone's in a private setting. That's a big hurdle for us” (ID2‐physiotherapist)
Interprofessional dynamics	“I mean clear communication is the only thing that always helps” (ID17‐surgeon)
	“I think having a consistent message from all the treatment providers is really important … good communication between the various treatment providers is also important so we're working on common goals with the client… the client will also need to be obviously included in those in that goal setting so that the patient is having good access to care” (ID27‐physiotherapist)
	“That's one of my sort of big parts of my role as opioid stewardship … not just increasing opioids, but looking at the problem and looking at … what the problem is and if there's other ways to use a nonpharmacologic approach to managing pain” (ID74‐nurse)

^*EPIK, Early Pain Intervention after Knee replacement; GP, general practitioner.

Theme 1: Living with pain after TKR

Patients reported experiencing emotional and physical challenges after surgery, a view that was echoed by clinicians. Some patients described not receiving sufficient support after hospital discharge as “there was no … follow‐up, very limited” (ID1‐patient), leading to gaps in care that hindered their recovery and quality of life. Many expressed a need for clarity on what to expect after surgery with emphasis on “not a one size fits all” (ID11‐patient) with the likelihood of causing “mismatch in expectations … around their ability to function” and “big barriers to improvement” (ID27‐physiotherapist). Most patients represented pain after surgery as a major turning point expressing that “the pain brought me to tears” (ID3‐patient) (Table 3).

Patients and clinicians thought a model of care would allow their voices to be heard, understood, and foster a sense of partnership in decision‐making because “people would appreciate being reached out to …, someone who's going to help and listen” (ID4‐physiotherapist), supporting the purpose of EPIK. They perceived that EPIK would offer a more personalized approach to current standards of care and “identification of their true goals” (ID26‐physiotherapist) at a time when patients often feel overlooked, still in need of support.

Theme 2: Acceptability and value of EPIK

Patients and clinicians generally found EPIK to be acceptable, especially for its potential to offer more individualized support later in recovery. They identified both perceived benefits and anticipated barriers. Clinicians, especially GPs, appreciated that EPIK could “free up resources in general practice” workload and “specialist time” (ID80‐GP). EPIK was thought to have the potential to “simplify” and “optimise patient care” allowing streamlined referrals to appropriate services, which can ultimately “help patients navigate their care a lot easier” (ID11‐physiotherapist) (Table 3).

Patients valued that EPIK recognized recovery is not linear and supported care beyond the standard rehabilitation period. The inclusion of psychologic support was seen as a strength by many. However, concerns were raised about potential out‐of‐pocket costs, particularly for services like psychology or pain clinics as “public patients … don't have many finances” and would be “less likely to continue with services” (ID4‐physiotherapist). Some patients and clinicians were hesitant about referring patients to psychologic care and unsure about the benefits of seeing a clinical psychologist as “there's a pushback to go out of their way to attend a psychologist to deal with a pain issue for the knee” (ID45‐surgeon). These findings highlight the need for ongoing, flexible support that includes psychologic care, while also addressing cost barriers, reducing stigma, and improving understanding of its benefits among both patients and clinicians.

Theme 3: Defining the scope of the EPIK care coordinator

Clinicians emphasized recommending lifestyle interventions and empowering patients to take ownership of their health. These discussions prompted reflection on how such strategies could be implemented within EPIK, particularly through “lifestyle management and education” that “would really be useful” for “measuring lifestyle factors” (ID39‐physiotherapist). A suggested approach was integrating patient‐reported outcomes and educational support to monitor and encourage changes in physical activity, diet, sleep, and psychosocial well‐being (Table 4).

Several patients and clinicians recommended expanding the care coordinator's role to include patient education and behavior change support, as this could improve recovery. However, clinicians raised concerns about unclear role definitions within EPIK, including responsibility for delivering lifestyle interventions. These were viewed as “a huge educational component,” requiring time to be done correctly, as “time needs to go into behaviour change” (ID27‐physiotherapist). Given the complex needs of this population, some patients and clinicians recommended broadening the EPIK model to incorporate additional services, such as social work and dietetics. This implies a more comprehensive role for the care coordinator, underscoring the importance of clearly defining the capabilities needed to implement the model effectively.

Clinicians emphasized that effective, “clear communication” (ID53‐GP) across the multidisciplinary team is essential to delivering cohesive care. They also stressed that consistently prioritizing the patient's needs by “putting the patient at first” (ID53‐GP) relies heavily on mutual understanding of each team member's role and responsibilities.

Theme 4: Infrastructure and system‐level challenges

Some clinicians were hesitant with the care coordination being delivered via telehealth due to limited examination quality and potential challenges in detecting early signs of serious post‐TKR conditions that can manifest as persistent pain after TKR such as prosthetic joint infection, knee stiffness, and instability because “if you can't touch the patient, you can only perform a very limited clinical exam” (ID40‐surgeon). However, GPs and some surgeons were “big on using telehealth” and “all for it” (ID91‐GP) to be integrated into a care coordination model because it is a flexible way to improve regional and rural care access, and support follow‐up and clinician communication. Many recognized the ubiquitous use of telehealth “because of the regional work and distances” (ID28‐surgeon), which in the context of EPIK would facilitate timely and efficient assessment and service delivery (Table 4).

Clinicians raised system‐level inconsistencies in care and interprofessional dynamics. Access depends on insurance status, with public patients often waiting “months to sometimes over a year” to see specialists (ID49‐GP), whereas private patients face higher out‐of‐pocket costs. Balancing public and private care were seen as a likely challenge for EPIK. Power dynamics were also highlighted, with some noting that care is “very much driven by what the surgeon thinks, what they want to happen to that patient” (ID19‐health‐fund‐manager). This could increase specialist visits and costs as some surgeons preferred to remain closely involved in their patients’ care, potentially increasing costs. Imbalances in interprofessional relationships were frequently noted: “our reputation is made on what the patients say about their reputations, made or lost” (ID10‐surgeon). Clinicians perceived that this can be mitigated by adopting a patient‐centered approach where “ultimately, it's the patient's decision what treatment they want” (ID84‐GP).

Consumer review meeting feedback

We held an online Zoom meeting with four additional consumers acting as “critical friends” to review and refine the qualitative findings. They highlighted that recovery after surgery is not uniform, and that care pathways need to reflect different recovery trajectories. They emphasized the need to include health coaching and individualized support as part of standard care, to account for changes in patient motivation and readiness to engage. They also suggested expanding the role of the care coordinator beyond logistics to include patient education, coaching, and coordination between clinicians. Finally, they supported a more holistic approach that goes beyond pain outcomes to include routine assessment of psychosocial factors affecting patient well‐being.

DISCUSSION

We identified four key themes that will inform adaptations to the EPIK model of care. Patients described ongoing physical and emotional challenges, unmet expectations, and limited support after discharge, whereas clinicians recognized the multifactorial nature of persistent pain and the value of a model of care where patients are monitored. EPIK was generally seen as acceptable, with potential to streamline care, free up clinical resources (particularly in general practice), and extend support beyond standard rehabilitation, though concerns about costs were raised. Clinicians and patients emphasized the importance of expanding the role of the EPIK care coordinator to encompass education interventions, and support to promote behavior change. Variations in insurance coverage, power dynamics between patients’ usual clinicians and the EPIK care coordinator, and infrastructure issues such as limited internet access to allow for telehealth consultations with the EPIK care coordinator were viewed as barriers by some. However, telehealth was seen as a practical tool with the potential to enhance rural care access, improve follow‐up, and strengthen communication between patients and clinicians.

Compared to the UK STAR model of care, EPIK will include additional pathways for people experiencing mental health issues that might be impairing their recovery. In STAR, those with signs of depression and anxiety were referred to a GP for treatment at their discretion. In EPIK, in addition to this pathway, patients will have access to the Pain Course—an evidence‐based online program designed to reduce disability, anxiety, and depression in patients with persistent pain. ³⁰ Our findings however suggest that referring patients with persistent pain after TKR to psychologic care such as the Pain Course may not be acceptable for some. Both patients and clinicians expressed some hesitation, with some questioning the value of seeing a psychologist for what was perceived as a knee‐specific problem.

This resistance underscores an ingrained biomedical paradigm that limits the uptake of psychologic services. For patients, psychologic referrals can be perceived as invalidating, evoking fears that their physical pain is being dismissed as psychogenic. Conversely, clinicians with predominantly biomedical training may inadvertently deprioritize psychosocial interventions. EPIK has been adapted to actively reframe this support. Furthermore, the model will adopt adapted terminology and encourage EPIK care coordinators to frame interventions as “pain coping strategies” rather than “psychologic care” to mitigate any potential stigma around the use of Pain Course. ³¹ , ³²

Delivering EPIK via telehealth is intended to ensure equitable access for patients in rural and regional areas. Telehealth is ubiquitous in Australian health care, accounting for one in six general practice consultations. ³³ Although most stakeholders supported telehealth use, resistance emerged from a subset of surgeons who expressed apprehension regarding the remote detection of physical complications, such as infection or joint stiffness. To address clinicians’ concerns, EPIK will include strict assessment protocols, including escalation pathways for in‐person clinical review. ³⁴ , ³⁵ , ³⁶

Our qualitative study findings prompted three primary structural shifts in the final EPIK model of care to ensure clinical utility and stakeholder buy‐in. First, the model shifted from a passive referral system to an active engagement strategy. This prompted us to redefine the role of the EPIK care coordinator to include advice and education, as well as to incorporate principles of pain management into the role. Second, the EPIK care coordinator will ask patients a few questions to check for common complications. Finally, we expanded the role of the EPIK care coordinator beyond managing clinical referrals to include behavioral education, directly addressing the postdischarge support gap reported by patients.

Our study has several limitations. First, excluding non‐English speakers limits equity and reduces the inclusiveness of our findings, particularly given EPIK's focus on underserved populations. We acknowledge that not including caregiver perspectives is a limitation, especially as this was originally planned. However, this may be less critical in the context of EPIK, which focuses on people more than three months after surgery. At this stage, patients are typically more independent and less reliant on caregiver support than in the immediate postdischarge period, when caregiver input is likely to be more influential. ³⁷

Clinicians who manage people with persistent pain post‐TKR such as specialist pain medicine physicians, rehabilitation physicians, and clinical psychologists were also not directly interviewed. Although represented on the EPIK steering committee, proxy representatives may not fully reflect the unfiltered, day‐to‐day realities of clinicians in these fields. Additionally, although the sample of nursing and funding participants was small, their data were rich and consistent, adequately representing their perspectives.

Finally, participants’ awareness that our team was developing the EPIK model may have introduced social desirability bias, ³⁸ leading them to unconsciously frame responses positively. Although our sampling captured diverse perspectives, we acknowledge potential nonresponse bias. The 24 individuals who did not participate may hold differing views or face barriers such as time constraints or lower engagement with the EPIK model, which are underrepresented in these findings.

Despite its limitations, a major strength of our study was the inclusion of 61 participants from six states, representing diverse stakeholder groups and experiences. This diversity, along with a transparent and descriptive analytic approach, enriched the findings. Input from the multidisciplinary EPIK steering committee added depth and credibility to the data interpretation. Another key strength was the involvement of consumers with lived experience of persistent pain post‐TKR in data interpretation. Using a “critical friends” approach ensured that the proposed model of care was grounded in real‐world patient needs. ²⁸ Their input was instrumental in refining referral pathways, particularly in identifying the need for flexible, holistic support structures, such as health coaching and an expanded care coordinator role, to accommodate the varied patient experience post‐TKR.

This study highlights the complex and often unmet needs of patients living with persistent pain after TKR and the shared recognition among patients and clinicians of the importance of more personalized, patient‐centered care. EPIK was viewed as an acceptable model with potential to address current gaps in TKR management by aiming to streamline care and foster patient engagement through shared decision‐making. We identified barriers to the potential success of EPIK, such as the acceptability of psychologic interventions, which will need to be addressed. Taken together, findings from this study will inform the refinement of the EPIK model of care before it undergoes evaluation in a future randomized controlled trial.

AUTHOR CONTRIBUTIONS

All authors contributed to at least one of the following manuscript preparation roles: conceptualization AND/OR methodology, software, investigation, formal analysis, data curation, visualization, and validation AND drafting or reviewing/editing the final draft. As corresponding author, Navneet Chadha confirms that all authors have provided the final approval of the version to be published and takes responsibility for the affirmations regarding article submission (eg, not under consideration by another journal), the integrity of the data presented, and the statements regarding compliance with institutional review board/Declaration of Helsinki requirements.

Supporting information

Disclosure Form:

Supplementary File 1. COREQ Checklist.

Supplementary File 2. Pre‐Interview Questionnaire.

Supplementary File 3. Interview Guide.

Supplementary File 4. Coding Tree.

Supplementary File 5. PCCCT Questionnaire.