Awareness of performance on outcomes after total hip and knee arthroplasty among Dutch orthopedic surgeons: how to improve feedback from arthroplasty registries

Abstract

Background and purpose — The Netherlands Registry of Orthopedic Implants (LROI) uses audit and feedback (A&F) as the strategy to improve performance outcomes after total hip and knee arthroplasty (THA/TKA). Effectiveness of A&F depends on awareness of below-average performance to initiate improvement activities. We explored the awareness of Dutch orthopedic surgeons regarding their performance on outcomes after THA/TKA and factors associated with this awareness. Methods — An anonymous questionnaire was sent to all 445 eligible Dutch orthopedic surgeons performing THA/TKA. To assess awareness on own surgeon-group performance, they were asked whether their 1-year THA/TKA revision rates over the past 2 years were below average (negative outlier), average (non-outlier), above average (positive outlier) in the funnel plot on the LROI dashboard, or did not know. Associations were determined with (1) dashboard login at least once a year (yes/no); (2) correct funnel-plot interpretation (yes/no) and; (3) recall of their 1-year THA/TKA revision rate (yes/no). Results — 44% of respondents started the questionnaire, 158 THA and 156 TKA surgeons. 55% of THA surgeons and 55% of TKA surgeons were aware of their performance. Surgeons aware of their performance more often logged in on the LROI dashboard, more often interpreted funnel plots correctly, and more often recalled their revision rate. 38% of THA and 26% of TKA surgeons scored “good” on all 3 outcomes. Interpretation — Only half of the orthopedic surgeons were aware of their performance status regarding outcomes after THA/TKA. This suggests that to increase awareness, orthopedic surgeons need to be actively motivated to look at the dashboard more frequently and educated on interpretation of funnel plots for audit and feedback to be effective.

Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial

“…The intervention was designed based on evidence regarding effective feedback19 21–23 for orthopaedic surgeons20 and included the following components:…”

“…Worldwide, arthroplasty registries include different performance indicators in their feedback, with revision most commonly used 7 11–18. A recent study showed that Dutch orthopaedic surgeons would like to receive feedback not just on revisions but also on readmission, complications and LOS 20. For arthroplasty surgery, even a relatively small absolute improvement will have huge impact considering the large annual number of THA and TKA performed worldwide.…”

more comprehensive evaluation of quality of care after total hip and knee arthroplasty: combining 4 indicators in an ordered composite outcome

“…Reminders were sent 1 and 2 weeks after the first invitation, resulting in a response rate of 39%. The final ordering was based on the mean number of points assigned per indicator across respondents: ( 1 ) long LOS (1.1 points); ( 2 ) complications (2.5 points); ( 3 ) readmission (2.6 points) and ( 4 ) revision (3.9 points). This ordering seems to be supported by previous studies, showing that complications during admission (resulting in long LOS) did not affect patient quality of care evaluation, while complications after discharge (resulting in readmission) did, suggesting that patients consider readmissions to be worse than long LOS ( 11 , 17 , 18 ).…”

“…As quality of care covers different domains such as effectiveness, safety, and efficiency, these are measured with additional indicators ( 2 ). This is acknowledged in a recent Dutch study showing that orthopedic surgeons would like to receive feedback not only on revision, but also regarding readmission, complications, and length of stay (LOS) for hospital comparisons and to monitor the quality of care delivered ( 3 ). The rationale is that benchmarking and feedback may spur quality improvement initiatives in case of suboptimal performance.…”

International comparison of variation in performance between hospitals for THA and TKA: Is it even possible? A systematic review including 33 studies and 8 arthroplasty register reports

“…In addition, scientific articles are published for quality improvement purposes; for example, hospitals are benchmarked, ranked, or (statistical) methods are compared to monitor the quality of care delivered (9,10,11,12,13). The most commonly used quality indicators in this context are implant revision, readmission, and complications, as these indicators are considered reliable, actionable, and fit for purpose (14,15,16,17,18,19). However, the reliability of hospital rankings has been shown to be affected by for example, minor registration incompleteness in the outcome and low event rates, with particularly low volume providers being less likely to become an outlier in funnel plots (11,13).…”