Effects of a Total Knee Arthroplasty Care Pathway on Cost, Quality, and Patient Experience: Toward Measuring the Triple Aim

Featherall, Joseph; Brigati, David P.; Arney, Andrea; Faour, Mhamad; Bokar, Daniel; Murray, Trevor G.; Molloy, Robert; Rueda, Carlos A. Higuera

doi:10.1016/j.arth.2019.06.011

Cited by 23 publications

(52 citation statements)

References 58 publications

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“…The evidence that standardization works to reduce variation in costs and outcomes was adopted from manufacturing concepts popularized by Shewhart and Deming, 40 , 41 but have been have been successful in other surgical EBCP such as knee arthroplasty. 42 - 44 To implement bundled payment systems, EBCP are essential to reducing cost variability and generating data for smaller, less experienced institutions to use in the care of spinal surgery patients.…”

Section: Strategies For Implementationmentioning

confidence: 99%

Bundled Payment Models in Spine Surgery

Hines

Mouchtouris

Getz

et al. 2021

Global Spine Journal

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Study Design: The following is a narrative discussion of bundled payments in spine surgery. Objective: The cost of healthcare in the United States has continued to increase. To lower the cost of healthcare, reimbursement models are being investigated as potential cost saving interventions by driving incentives and quality improvement in fields such a spine surgery. Methods: Narrative overview of literature pertaining to bundled payments in spine surgery synthesizing findings from computerized databases and authoritative texts. Results: Spine surgery is challenging to define payment modes because of high cost variability and surgical decision-making nuances. While implementing bundled care payments in spine surgery, it is important to understand concepts such as value-based purchasing, episodes of care, prospective versus retrospective payment models, one versus two-sided risk, risk adjustment, and outlier protection. Strategies for implementation underscore the importance of risk stratification and modeling, adoption of evidence based clinical pathways, and data collection and dissemination. While bundled care models have been successfully implemented, challenges facing institutions adopting bundled care payment models include financial stressors during adoption of the model, distribution of risks, incentivization of treating only low risk patients, and nuanced variation in procedures leading to variation in costs. Conclusion: An alternative for fee for service payments, bundled care payments may lead to higher cost savings and surgeon accountability in a patient’s care.

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Section: Strategies For Implementationmentioning

confidence: 99%

Bundled Payment Models in Spine Surgery

Hines

Mouchtouris

Getz

et al. 2021

Global Spine Journal

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“…On review of published research regarding early mobilisation, the studied interventions varied markedly [3,[5][6][7][8][9][10][11][12][13][14][15][16][17][18][19]. Much of the research was arguably outdated, as there were multiple concurrent changes were made to existing protocols, and there were mixed definitions of early mobilisation.…”

Section: Identification and Management Of The Problemmentioning

confidence: 99%

“…Earlier discharge home from hospital following arthroplasty and other major surgeries decreases care costs [3][4][5] and increases capacity in a stretched public health environment. Early mobilisationvariably defined as mobilisation or getting out of bed on the day of surgery or within 24 h of surgery [6] has been incorporated into models of care as a strategy to decrease acute-care length of stay (LOS) [3,[6][7][8][9][10][11][12][13][14][15][16][17][18][19].…”

Section: Introductionmentioning

confidence: 99%

“…It is unclear why this evidence -practice gap exists and there may be several factors contributing to or explaining the divide. Trials where LOS has been successfully reduced have included early mobilisation as one part of multiple changes to the pathway [3,5,[14][15][16][17], included only those undergoing unicompartmental knee arthroplasty [7,8], excluded patients with complications or co-morbidities [7,21], or mandated discharge at 24 h post-operatively regardless of the level of mobility [7]. Thus, it is unclear if early mobilisation in isolation is effective, and if so, if it can be attempted in all patients or only a subset.…”

Section: Introductionmentioning

confidence: 99%

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Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

Chua

Brady

Farrugia

et al. 2020

BMC Musculoskelet Disord

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Background Models of care for managing total knee or hip arthroplasty (TKA, THA) incorporating early mobilisation are associated with shorter acute length-of-stay (LOS). Few studies have examined the effect of implementing early mobilisation in isolation, however. This study aimed to determine if an accelerated mobilisation protocol implemented in isolation is associated with a reduced LOS without undermining care. Method A Before-After (quasi-experimental) study was used. Standard practice pre-implementation of the new protocol was physiotherapist-led mobilisation once per day commencing on post-operative Day 1 (Before phase). The new protocol (After phase) aimed to mobilise patients four times by end of Day 2 including an attempt to commence on Day 0; physiotherapy weekend coverage was necessarily increased. Poisson regression modelling was used to determine associations between study period and LOS. Additional outcomes to 12 weeks post-surgery were monitored to identify unintended consequences of the new protocol. Time to first mobilisation (hours) and proportion mobilising Day 0 were monitored to assess protocol compliance. An embedded qualitative component captured staff perspectives of the new protocol. Results Five hundred twenty consecutive patients (n = 278, Before; n = 242, After) were included. The new protocol was associated with no change in unadjusted LOS, a small reduction in adjusted LOS (8.1%, p = 0.046), a reduction in time to first mobilisation (28.5 (10.8) vs 22.6 (8.1) hrs, p < 0.001), and an increase in the proportion mobilising Day 0 (0 vs 7%, p < 0.001). Greater improvements were curtailed by an unexpected decrease in physiotherapy staffing (After phase). There were no significant changes to the rates of complications or readmissions, joint-specific pain and function scores or health-related quality of life to 12 weeks post-surgery. Qualitative findings of 11 multidisciplinary team members highlighted the importance of morning surgery, staffing, and well-defined roles. Conclusion Small reductions in LOS are possible utilising an early mobilisation protocol in isolation after TKA or THA although staff burden is increased likely undermining both sustainability and the magnitude of the change. Simultaneous incorporation of other changes within the pathway would likely secure larger reductions in LOS.

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“…Another way via which care can be optimized is by use of a transmural care pathway, which includes a short stay (1–2 days) and acute (secondary care) and post-acute care (primary care). In TKA and THA these transmural pathways are known to result in less postoperative complications, shorter length of hospital stay and lower costs during hospital stay when compared to standard care (3–4 nights inpatient) [ 21 – 23 ]. Hence, a transmural pathway for PPT after TKA and THA linking all organizational aspects related to the continuum of TKA/THA care might also improve PPT.…”

Section: Introductionmentioning

confidence: 99%

Rationale and design of the PaTIO study: PhysiotherApeutic Treat-to-target Intervention after Orthopaedic surgery

Groot

Gademan

Peter

et al. 2020

BMC Musculoskelet Disord

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Background: Physiotherapy is a proven effective treatment strategy after total knee and hip arthroplasty (TKA/THA), however there is considerable practice variation regarding its timing, content and duration. This study aims to compare the (cost-) effectiveness of a standardized, treat-to-target postoperative physiotherapy strategy with usual postoperative care. Methods: Using a cluster randomized study design, consecutive patients scheduled for a primary TKA/THA in 18 hospitals in the Netherlands will be assigned to the treat-to-target physio therapy strategy or usual postoperative care. With the treat-to-target strategy a standardized, individually tailored, exercise program is aimed at the attainment of specific functional milestones. Assessments are done at baseline, 6 weeks and 3, 6, 9 and 12 months follow up. The primary outcome will be the Knee injury / Hip disability and Osteoarthritis Outcome Score-Physical Function Short Form (KOOS-PS / HOOS-PS) at 3 months follow up. Secondary outcomes are the numeric rating scale for pain, the Oxford Knee and Hip Scores, performance-based test and the EuroQol 5D-5L for quality of life. Healthcare use, productivity and satisfaction with postoperative care are measured by means of questionnaires. In total, 624 patients will be needed of which 312 TKA and 312 THA patients. Discussion: The study will provide evidence concerning the (cost-) effectiveness of the treat-to-target postoperative physiotherapy treatment compared to usual postoperative care. The results of this study will address an important evidence gap and will have a significant impact in daily practice of the physio therapist.

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Effects of a Total Knee Arthroplasty Care Pathway on Cost, Quality, and Patient Experience: Toward Measuring the Triple Aim

Cited by 23 publications

References 58 publications

Bundled Payment Models in Spine Surgery

Bundled Payment Models in Spine Surgery

Implementing early mobilisation after knee or hip arthroplasty to reduce length of stay: a quality improvement study with embedded qualitative component

Rationale and design of the PaTIO study: PhysiotherApeutic Treat-to-target Intervention after Orthopaedic surgery

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