Abstract
Background
Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed.
Questions/purposes
The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA.
Methods
We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9).
Results
The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level.
Conclusions
We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation.
Level of Evidence
Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
References
American Academy of Orthopaedic Surgeons (AAOS). Clinical Practice Guidelines. Rosemont, IL: AAOS. Available at: http://www.aaos.org/research/guidelines/guide.asp. Accessed October 28, 2013.
American Academy of Orthopaedic Surgeons (AAOS). Guideline on the Diagnosis of Periprosthetic Joint Infections of the Hip and Knee. Rosemont, IL: AAOS. Available at: http://www.aaos.org/Research/guidelines/PJIguideline.asp. Accessed October 28, 2013.
American Academy of Orthopaedic Surgeons (AAOS). Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. Rosemont, IL: AAOS. Available at: http://www.aaos.org/Research/guidelines/VTE/VTE_full_guideline.pdf. Accessed October 28, 2013.
Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in the joint replacement: a meta-analysis. BMC Med. 2009;7:32.
Bone and Joint Canada. Hip and Knee Replacement Toolkit: A Living Document. In: Waddell JP, Frank C, eds. Toronto,Canada: Bone and Joint Canada. Available at: http://www.boneandjointcanada.com. Accessed October 28, 2013.
Bozic KJ. Value-based healthcare and orthopaedic surgery. Clin Orthop Relat Res. 2012;470:1004–1005.
Bozic KJ, Maselli J, Pekow PS, Lindenauer PK, Vail TP, Auerbach AD. The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am. 2010;92:2643–2652.
Cima RR, Brown MJ, Hebl JR, Moore R, Rogers JC, Kollengode A, Amstutz GJ, Weisbrod CA, Narr BJ, Deschamps C; Surgical Process Improvement Team Mayo Clinic, Rochester. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg. 2011;213:83–92; discussion 93–94.
Cram P, Lu X, Kaboli PJ, Vaughan-Sarrazin MS, Cai X, Wolf BR, Li Y. Clinical characteristics and outcomes of Medicare patients undergoing total hip arthroplasty, 1991–2008. JAMA. 2011;305:1560–1567.
Curry LA, Nembhard IM, Bradley EH. Qualitative and mixed methods provide unique contributions to outcomes research. Circulation. 2009;119:1442–1452.
Dartmouth-Hitchcock Medical Center. Dartmouth-Hitchcock “Green Care”. Available at: http://lebanon.dhortho.org/dartmouth-hitchcock-green-care/. Accessed October 28, 2013.
DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. Natl Health Stat Report. 2008;5:1–20.
DiGioia AM 3rd, Greenhouse PK. Care experience-based methodologies: performance improvement roadmap to value-driven health care. Clin Orthop Relat Res. 2012;470:1038–1045.
DiGioia AM 3rd, Greenhouse PK, Levison TJ. Patient and family-centered collaborative care: an orthopaedic model. Clin Orthop Relat Res. 2007;463:13–19.
Friedman RJ, Gallus AS, Cushner FD, Fitzgerald G, Anderson FA Jr; Global Orthopaedic Registry Investigators. Physician compliance with guidelines for deep-vein thrombosis prevention in total hip and knee arthroplasty. Curr Med Res Opin. 2008;24:87–97.
Harders M, Malangoni MA, Weight S, Sidhu T. Improving operating room efficiency through process redesign. Surgery. 2006;140:509–514; discussion 514–516.
Institute for Healthcare Improvement. Welcome to Project JOINTS. Available at: http://www.ihi.org/ProjectJOINTS. Accessed October 28, 2013.
Institute of Medicine of the National Academies. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy of Sciences; 2001.
Januel JM, Chen G, Ruffieux C, Quan H, Douketis JD, Crowther MA, Colin C, Ghali WA, Burnand B, IMECCHI Group. Symptomatic in-hospital deep vein thrombosis and pulmonary embolism following hip and knee arthroplasty among patients receiving recommended prophylaxis: a systematic review. JAMA. 2012;307:294–303.
Kim S. Changes in surgical loads and economic burden of hip and knee replacements in the US: 1997–2004. Arthritis Rheum. 2008;59:481–488.
Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.
Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey-Bass Publishers; 2009.
Map of Medicine. Elective knee surgery. Available at: http://healthguides.mapofmedicine.com/choices/map-open/elective_knee_surgery1.html. Accessed October 28, 2013.
Pour AE, Parvizi J, Sharkey PF, Hozack WJ, Rothman RH. Minimally invasive hip arthroplasty: what role does patient preconditioning play? J Bone Joint Surg Am. 2007;89:1920–1927.
Premier Inc, Institute for Healthcare Improvement. Integrated Care Pathway for Total Joint Arthroplasty. Charlotte, NC: Premier, Inc. and Cambridge, MA: Institute for Healthcare Improvement; 2013. Available at: www.premierinc.com and www.ihi.org. Accessed October 28, 2013.
Rosenthal JA, Lu X, Cram P. Availability of consumer prices from US hospitals for a common surgical procedure. JAMA Intern Med. 2013;173:427–432.
Shaller D, Shaller Consulting. Patient-Centered Care: What Does it Take? The Commonwealth Fund. Available at: http://www.commonwealthfund.org/usr_doc/Shaller_patient-centeredcarewhatdoesittake_1067.pdf. Accessed November 7, 2013.
Sood N, Huckfeldt PJ, Escarce JJ, Grabowski DC, Newhouse JP. Medicare’s bundled payment pilot for acute and postacute care: analysis and recommendations on where to begin. Health Aff (Millwood). 2011;30:1708–1717.
SooHoo NF, Lieberman JR, Farng E, Park S, Jain S, Ko CY. Development of quality of care indicators for patients undergoing total hip or total knee replacement. BMJ Qual Saf. 2011;20:153–157.
Soohoo NF, Tang EY, Krenek L, Eagan M, McGlynn E. Variations in the quality of care delivered to patients undergoing total knee replacement at 3 affiliated hospitals. Orthopedics. 2011;34:356.
Tomek IM, Sabel AL, Froimson MI, Muschler G, Jevsevar DS, Koenig KM, Lewallen DG, Naessens JM, Savitz LA, Westrich JL, Weeks WB, Weinstein JN. A collaborative of leading health systems finds wide variations in total knee replacement delivery and takes steps to improve value. Health Aff (Millwood). 2012;31:1329–1338.
Van Herck P, Vanhaecht K, Deneckere S, Bellemans J, Panella M, Barbieri A, Sermeus W. Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review. J Eval Clin Pract. 2010;16:39–49.
Vanhaecht K, Bellemans J, De Witte K, Diya L, Lesaffre E, Sermeus W. Does the organization of care processes affect outcomes in patients undergoing total joint replacement? J Eval Clin Pract. 2010;16:121–128.
Vanhaecht K, Panella M, van Zelm R, Sermeus W. An overview on the history and concept of care pathways as complex interventions. Int J Care Pathways. 2010;14:117–123.
Womack JP, Jones DT. Lean consumption. Harvard Business Review. 2005;83:58–68, 148.
Acknowledgments
We thank Julia Rowe Taylor for assistance with project oversight; Jane Roessner and Val Weber for editorial assistance; Vanessa Chan for help with manuscript preparation; members of the 16 interdisciplinary care teams and two patients for their participation in semistructured interviews; and the 32 members of our multistakeholder panel for their work to refine and improve the care pathway. We also acknowledge that this work arose from efforts by the Dartmouth population health team and individuals at Dartmouth-Hitchcock Medical Center (ECN, KMK) to incorporate the Institute of Medicine’s quality aims into their care pathway development efforts. Dartmouth-Hitchcock’s GreenCare approach uses a similar conceptual framework, process flow diagrams to illustrate roles and tasks over the entire episode, integration of tasks into team roles and into the electronic medical record, and use of patient-reported outcomes. The current project offered the opportunity to adopt and extend Dartmouth’s approach to pathway development and to engage a diverse cross section of clinicians and health systems in developing a potentially generalizable care pathway.
Author information
Authors and Affiliations
Corresponding author
Additional information
The institution of the authors (ADVC, DAG, ECN, BO, FAF) has received funding from Premier Healthcare Alliance, Inc, Washington, DC, USA, through a research partnership with the Institute for Healthcare Improvement.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
The primary work for this project was performed at the Institute for Healthcare Improvement main office (Cambridge, MA, USA) and in Washington DC, Hanover, NH, and Lebanon, NH, USA.
Appendix 1. Suggestions (n = 132) included in the care pathway
Appendix 1. Suggestions (n = 132) included in the care pathway
About this article
Cite this article
Van Citters, A.D., Fahlman, C., Goldmann, D.A. et al. Developing a Pathway for High-value, Patient-centered Total Joint Arthroplasty. Clin Orthop Relat Res 472, 1619–1635 (2014). https://doi.org/10.1007/s11999-013-3398-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11999-013-3398-4