Evidence base and practice variation in acute care processes for knee and hip arthroplasty surgeries

Abstract

BackgroundLack of evidence contributes to unnecessary variation in treatment costs and outcomes. This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence.MethodsPart 1: Systematic search of electronic library databases for systematic reviews and practice guidelines concerning seven acute-care interventions. Intervention-specific recommendations concerning routine use were extracted by assessors. Part 2: Prospective medical record audit of the acute-care received by 1900 patients involving 120 orthopaedic surgeons. Surgeon use per intervention was summarized using caterpillar plots. Surgeon-specific routine and non-routine use was defined as use in ≥ 90% and ≤ 10% of patients, respectively. Primary analysis included only surgeons contributing ≥ 10 patients.ResultsContinuous passive motion (TKA): Routine use not recommended; 85.7% of surgeons did not use it routinely. Tranexamic Acid: Routine use recommended; 26.9% of surgeons used it routinely. Cryotherapy: Routine use not recommended; 45.7% of surgeons used it routinely for TKA; 31.8% used it routinely for THA. Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 5.7% of surgeons used it routinely for TKA, 0.0% used it routinely for THA. Antibiotic loaded bone cement: Routine use for TKA not supported, recommendations for use for THA are inconsistent; 90.0% of surgeons used it routinely for TKA, 100.0% used it routinely for THA. Patella resurfacing (TKA): No recommendation could be made; 57.1% of surgeons routinely resurfaced the patella. Indwelling urinary catheterisation: Routine use recommended; 59.6% of surgeons used it routinely.ConclusionRecommendations for routine use or not exist for some of the acute-care interventions examined. Surgeon practices vary widely even in the presence of high-level recommendations. It is unclear whether further evidence alone would lessen unwarranted practice variation.

Assessment of periprosthetic joint infection prevention methods amongst Turkish orthopedic surgeons in total joint replacement: A survey

“…Although TXA is recommended for routine use, it is not routinely used for 62% in the UK [24] and 73.1% in Australia. [25] Compared to other countries, TXA usage is higher among orthopedic surgeons in Turkey.…”

Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework

“…From a capacity perspective, variation is unwarranted if it is a result of differences in the level of training, competency, and technical proficiency of providers or of limitations in clinicians' ability to resolve uncertainty . Now, more than ever, the provision of reliable and resilient care to ensure patients' safety is seen as a minimum requirement for health care delivery systems and is not something that can vary according to where patients live or where they are treated.…”

Cement Waste During Primary Total Knee Arthroplasty and its Effect on Cost Savings: An Institutional Analysis

“…Researchers are therefore exploring different avenues for attenuating intraoperative waste accumulation including clinical pathways [6], repurposing of formerly disposable surgical instruments [13, 14], and more recently, reconsidering the amount of bone cement for a standard TKA [15]. As reported [17] by Mayer et al in a combined systematic literature search and prospective audit of 120 surgeons, antibiotic laden bone cement is becoming increasingly utilized for routine TKAs [18, 19]. Cementing is advantageous in versatility and protection, and the combined antibiotic offers resistance against postoperative infection [19].…”