Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from “The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man”

Garriga, César; Murphy, Jacqueline; Leal, José; Price, Andrew; Prieto-Alhambra, Daniel; Carr, Andrew; Arden, N K; Rangan, Amar; Cooper, Cyrus; Peat, George; Fitzpatrick, Ray; Barker, Karen; Judge, Andrew

doi:10.1016/j.joca.2019.05.001

Cited by 26 publications

(44 citation statements)

References 29 publications

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“…Furthermore, other practices in the included studies are now outdated. For example, patients in the control group of Brunenberg and colleagues’ trial had had an in-patient stay of 9.4 days,37 whereas by 2015 the mean length of stay in England was 4.9 days for TKA and 5.4 days for THA8 and has further decreased since 67. Also, practices such as blood transfusion rates have changed greatly: the two studies included in this review assumed transfusion rates of 89%44 to 100%,42 whereas rates in 2014 were 22% for THA and 18% for TKA patients,68 and rates of infection from blood transfusion are now lower than those used in the models 69…”

Section: Discussionmentioning

confidence: 99%

Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

et al. 2020

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ObjectivesTo assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work.DesignSystematic review of cost–utility analyses.Data sourcesOvid MEDLINE, Embase, the National Health Service Economic Evaluations Database and EconLit, January 2000 to August 2019.Eligibility criteriaEnglish-language peer-reviewed cost–utility analyses of enhanced recovery pathways, or components of one, compared with usual care, in patients having total hip or knee arthroplasties for osteoarthritis.Data extraction and synthesisData extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria list, the International Society for Pharmacoeconomics and Outcomes Research and Assessment of the Validation Status of Health-Economic decision models tools; for trial-based studies the Cochrane Collaboration’s tool to assess risk of bias. No quantitative synthesis was undertaken.ResultsWe identified 17 studies: five trial-based and 12 model-based studies. Two analyses evaluated entire enhanced recovery pathways and reported them to be cost-effective compared with usual care. Ten pathway components were more effective and cost-saving compared with usual care, three were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation.ConclusionsConsistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies.PROSPERO registration numberCRD42017059473.

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Section: Discussionmentioning

confidence: 99%

Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

et al. 2020

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“…16 However, LOS literature is mostly in the context of enhanced recovery interventions, 17 where our previous work showed that older age and comorbidity were associated with longer LOS. 15 Regarding patient case-mix variables, it has been shown that lower baseline levels of pain and functional disease severity, 3,18,19 age, 20 sex, 18 obesity, 18,20 comorbidities, 18,19 and socioceconomic deprivation 21,22 are all associated with patient-reported outcomes of postoperative pain and function. Less is known about factors associated with rarer outcomes, such as complications of surgery, but we have previously shown 23 that such complications are rare and that obesity was associated with small but clinically insignificant effects.…”

Section: Discussionmentioning

confidence: 99%

Geographical Variation in Outcomes of Primary Hip and Knee Replacement

et al. 2019

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Key PointsQuestionAre hospital organizational factors, surgical factors, and patient factors associated with patient outcomes and National Health Service costs for total hip and knee replacement?FindingsThis cohort study of more than 383 000 patients in 207 health areas in England identified significant health area–level variation in patient outcomes for total hip and knee replacement surgery. Geographical variation was associated with better outcomes for surgical procedures in private and high-volume hospitals as well as for operations performed by more experienced surgeons with a higher volume of operations per year.MeaningFindings are informative for commissioners in monitoring variations in surgical outcomes and for patients deciding where to undergo surgery.

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“…Despite this apparent success, other large series have shown problems with implementation of most recent evidence-based care principles. In this context, a recent UK analysis in more than 400,000 TKA’s investigating the association of national ERAS implementation while adjusting for time trends in LOS found no benefits of ERAS implementation, but without details on the ERAS protocols 8 . .…”

Section: Introductionmentioning

confidence: 99%

Improvement in fast-track hip and knee arthroplasty: a prospective multicentre study of 36,935 procedures from 2010 to 2017

Petersen

Kehlet

Jørgensen

2020

Sci Rep

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Abstract“Fast-track” protocols has improved surgical care with a reduction in length of hospital stay (LOS) in total hip (THA) and knee arthroplasty (TKA). However, the effects of continuous refinement of perioperative care lack detailed assessment. We studied time-related changes in LOS and morbidity after THA and TKA within a collaboration with continuous scientific refinement of perioperative care. Prospective multicentre consecutive cohort study between 2010 and 2017 from nine high-volume orthopaedic centres with established fast-track THA and TKA protocols. Prospective collection of comorbidities and complete 90-day follow-up from the Danish National Patient Registry and medical records. Of 36,935 procedures median age was 69 [62 to 75] years and 58% women. LOS declined from three [two to three] days in 2010 to one [one to two] day in 2017. LOS > 4 days due to “medical” or “surgical” complications, and “with no recorded morbidity” declined from 4.4 to 2.7%, 1.5 to 0.6%, and 3.8 to 1.3%, respectively. 90-days readmission rate declined from 8.6 to 7.7%. Our multicentre study in a socialized healthcare setting was associated with a continuous reduction in LOS and morbidity after THA and TKA.

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Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from “The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man”

Cited by 26 publications

References 29 publications

Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

Enhanced recovery following hip and knee arthroplasty: a systematic review of cost-effectiveness evidence

Geographical Variation in Outcomes of Primary Hip and Knee Replacement

Improvement in fast-track hip and knee arthroplasty: a prospective multicentre study of 36,935 procedures from 2010 to 2017

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