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Quality indicators in primary elective total hip and knee arthroplasty

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Abstract

Purpose

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent a significant portion of healthcare spending and are high-priority for quality improvement initiatives. This study aims to develop quality indicators (QIs) in the care of primary elective THA and TKA patients. These QIs serve a number of purposes including documentation of the quality of care, objective comparisons of institutions/providers, facilitating pay-for-performance initiatives, and supporting accountability, regulation, and accreditation.

Methods

A guideline-based approach, initially described by Kötter et al., was utilized. Eight clinical practice guidelines (CPGs) were evaluated for candidate indicators (CIs). CIs with high-quality evidence and consensus statements were extracted. Eighteen additional CIs were included from previous work that evaluated quality improvement databases. Each CI and supporting evidence was submitted for independent review by an expert panel. The RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology was utilized and items were rated based on validity, reliability, and feasibility of measurement. After two rounds of ratings and ranking, a final ranked list of QIs was obtained.

Results

Fifty-six CIs were identified from the literature and CPGs or proposed by the expert panel. Two rounds of voting resulted in 12 total QIs that were deemed appropriate measures of high-quality care. The final 12 QIs were ranked by order of importance: use of peri-operative tranexamic acid, infusion of prophylactic antibiotics prior to inflation of tourniquet, appropriate post-operative venous thromboembolic prophylaxis, complication rate, rate of secondary procedure, readmission rate, early mobilization, average change of pre- to one year post-operative functional status, use of multimodal analgesia, use of neuraxial anesthesia, use of peri-articular injection in TKA, and use of pre-operative PO analgesia.

Conclusion

This study is an expert opinion based on parameters observed in modern and high-quality academic settings. Twelve QIs are proposed to assess the quality of care in the peri-operative management of primary elective THA and TKA patients.

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References

  1. Hip and knee replacements in Canada: CJRR annual statistics summary, 2018–2019. https://www.cihi.ca/sites/default/files/document/cjrr-annual-statistics-hip-knee-2018-2019-report-en.pdf, (2020) Accessed March 1, 2021.

  2. Kozma CM, Slaton T, Paris A, Edgell ET (2013) Cost and utilization of healthcare services for hip and knee replacement. J Med Econ 16(7):888–896

    Article  PubMed  Google Scholar 

  3. Robinson JC, Pozen A, Tseng S, Bozic KJ (2012) Variability in costs associated with total hip and knee replacement implants. J Bone Joint Surg Am 94(18):1693–1698

    Article  PubMed  Google Scholar 

  4. Healthcare cost and utilization project (HCUP). Agency Healthc Res Qual. https://www.hcup-us.ahrq.gov/, (2007) Accessed June 10, 2021.

  5. A study of cost variations for knee and hip replacement surgeries in the U.S. Blue Health Intelligence. https://www.bcbs.com/sites/default/files/file-attachments/health-of-america-report/BCBSHealthOfAmericaReport-KneeHipReplacementSurgeries.pdf, (2015) Accessed June 10, 2021.

  6. Cram P, Lu X, Kaboli PJ et al (2011) Clinical characteristics and outcomes of Medicare patients undergoing total hip arthroplasty, 1991–2008. JAMA 305(15):1560–1567

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Mahomed NN, Barrett JA, Katz JN et al (2003) Rates and outcomes of primary and revision total hip replacement in the United States medicare population. J Bone Joint Surg Am 85(1):27–32

    Article  PubMed  Google Scholar 

  8. Aynardi M, Post Z, Ong A, Orozco F, Sukin DC (2014) Outpatient surgery as a means of cost reduction in total hip arthroplasty: a case-control study. HSS J 10(3):252–255

    Article  PubMed  PubMed Central  Google Scholar 

  9. Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M (2005) Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am 87(7):1487–1497

    PubMed  Google Scholar 

  10. Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR (2012) Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA 308(12):1227–1236

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4):780–785

    Article  PubMed  Google Scholar 

  12. Sloan M, Premkumar A, Sheth NP (2018) Projected volume of primary total joint arthroplasty in the US.,2014 to 2030. J Bone Joint Surg Am 100(17):1455–1460

    Article  PubMed  Google Scholar 

  13. Jubelt LE, Goldfeld KS, Blecker SB et al (2017) Early lessons on bundled payment at an academic medical center. J Am Acad Orthop Surg 25(9):654–663

    Article  PubMed  PubMed Central  Google Scholar 

  14. Feng JE, Padilla JA, Gabor JA et al (2019) Alternative payment models in total joint arthroplasty: an orthopaedic surgeon’s perspective on performance and logistics. JBJS Rev 7(6):e5

    Article  PubMed  Google Scholar 

  15. Krueger CA, Yayac M, Vannello C, Wilsman J, Austin MS, Courtney PM (2021) From winners to losers: the methodology of bundled payments for care improvement advanced disincentivizes participation in bundled payment programs. J Arthroplasty 36(4):1204–1211

    Article  PubMed  Google Scholar 

  16. The Affordable Care Act. Healthcare.gov. http://housedocs.house.gov/energycommerce/ppacacon.pdf, Accessed March 1, 2021.

  17. Centers for Medicare and Medicaid services: value based payment modifier. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/2016-QRUR.html, (2016) Accessed March 1, 2021.

  18. Liao JM, Navathe AS, Werner RM (2020) The impact of Medicare’s alternative payment models on the value of care. Annu Rev Public Health 41:551–565

    Article  PubMed  Google Scholar 

  19. In: Crossing the quality chasm: a new health system for the 21st century. Washington (DC)2001.

  20. Stelfox HT, Straus SE (2013) Measuring quality of care: considering measurement frameworks and needs assessment to guide quality indicator development. J Clin Epidemiol 66(12):1320–1327

    Article  PubMed  Google Scholar 

  21. Mainz J (2003) Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 15(6):523–530

    Article  PubMed  Google Scholar 

  22. Cottrell J, Yip J, Chan Y et al (2018) Quality indicators for the diagnosis and management of chronic rhinosinusitis. Int Forum Allergy Rhinol 8(12):1369–1379

    Article  PubMed  Google Scholar 

  23. Kötter T, Blozik E, Scherer M (2012) Methods for the guideline-based development of quality indicators–a systematic review. Implement Sci 7:21

    Article  PubMed  PubMed Central  Google Scholar 

  24. Fillingham YA, Ramkumar DB, Jevsevar DS et al (2019) Tranexamic acid in total joint arthroplasty: the endorsed clinical practice guides of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. Reg Anesth Pain Med 44(1):7–11

    Article  PubMed  Google Scholar 

  25. American Academy of Orthopaedic Surgeons Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline. https://www.aaos.org/globalassets/quality-and-practiceresources/osteoarthritis-of-the-hip/oa-hip-cpg_6-11-19.pdf, (2017) Accessed March 1, 2021.

  26. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee – 2nd Edition Evidence-Based Clinical Practice Guideline. https://www.aaos.org/globalassets/quality-and-practiceresources/osteoarthritis-of-the-knee/osteoarthritis-of-the-knee-2nd-editiion-clinical-practice-guideline.pdf, (2013) Accessed March 1, 2021.

  27. American Academy of Orthopaedic Surgeons. Surgical management of osteoarthritis of the knee – evidence-based clinical practice guideline. https://www.aaos.org/globalassets/quality-and-practice-resources/surgical-management-knee/smoak-cpg_4.22.2016.pdf, (2015) Accessed March 1, 2021.

  28. American Academy of Orthopaedic Surgeons. Diagnosis and prevention of periprosthetic joint infections clinical practice guideline. https://www.aaos.org/pjiguideline, (2019) Accessed March 1, 2021

  29. American Academy of Orthopaedic Surgeons. Clinical practice guideline on preventing thromboembolic disease in patients undergoing elective hip and knee arthroplasty. https://www.aaos.org/globalassets/quality-and-practiceresources/vte/vte_full_guideline_10.31.16.pdf, (2012) Accessed March 1, 2021

  30. Falck-Ytter Y, Francis CW, Johanson NA et al (2012) Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2 Suppl):e278S-e325S

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Korean Knee S (2012) Guidelines for the management of postoperative pain after total knee arthroplasty. Knee Surg Relat Res 24(4):201–207

    Article  Google Scholar 

  32. Amanatullah DF, McQuillan T, Kamal RN (2019) Quality measures in total hip and total knee arthroplasty. J Am Acad Orthop Surg 27(6):219–226

    Article  PubMed  Google Scholar 

  33. Cottrell J, Yip J, Chan Y et al (2020) Quality indicators for the diagnosis and management of acute bacterial rhinosinusitis. Am J Rhinol Allergy 34(4):519–531

    Article  PubMed  Google Scholar 

  34. Center for Health Policy/Center for Primary Care and Outcomes Research & Battelle Memorial Institute (2011) Quality Indicator Measure Development, Implementation, Maintenance, and Retirement (Prepared by Battelle, under Contract No. 290-04-0020). Agency for Healthcare Research and Quality, Rockville

  35. Donabedian A (1966) Evaluating the quality of medical care. Milbank Mem Fund Q 44(3):166–206

    Article  Google Scholar 

  36. Fitch K.B.S. and M.D. Aguila, (2011) The RAND/UCLA appropriateness method user’s manual. https://www.rand.org/pubs/monograph_reports/MR1269.html

  37. Comprehensive Care for Joint Replacement Model. https://innovation.cms.gov/innovation-models/cjr. Accessed March 1, 2021

  38. (AOANJRR) AOANJRR, (2020) Hip, knee & shoulder arthroplasty: 2020 Annual Report

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Author information

Author notes

  1. Scott Kim

    Present address: , Toronto, Canada

Authors and Affiliations

  1. University of Toronto Division of Orthopaedics, 149 College St Room 508-A, Toronto, ON, M5T 1P5, Canada

    Scott Kim, James Waddell, Sarah Ward, Earl Bogoch, David Backstein, Michael Zywiel & Jesse Isaac Wolfstadt

  2. Department of Otolaryngology, University of Toronto, 600 University Ave #401, Toronto, ON, M5G 1X5, Canada

    Justin Cottrell, Sarah Ward & Eric Monteiro

  3. St. Michael’s Hospital, 55 Queen St East #800, Toronto, ON, M5C 1RC, Canada

    James Waddell & Earl Bogoch

  4. University of Manitoba, 1155 Concorida Ave #301, Winnipeg, MB, R2K 4L5, Canada

    Eric Bohm

  5. St. George and Sutherland Clinical School, University of New South Wales, Clinical Sciences Building, Short Street St George Hospital, Kogarah, NSW, 2217, Australia

    Sam Adie

  6. Institute for Health Policy, Management, and Evaluation, University of Toronto, 155 College St 4th floor, Toronto, ON, M5T 3M6, Canada

    Sarah Ward, Michael Zywiel & Jesse Isaac Wolfstadt

  7. Dalhousie University, QEII Health Sciences Centre, Halifax Infirmary, 1796 Summer St, 4th Floor, Halifax, NS, B3H 3A6, Canada

    Jennifer Leighton & Michael Dunbar

  8. Sinai Health System, 600 University Ave, Toronto, ON, M5G 1X5, Canada

    David Backstein, Eric Monteiro & Jesse Isaac Wolfstadt

  9. University of British Columbia, 2775 Laurel St, Vancouver, BC, V5Z 1M9, Canada

    Bassam Masri

  10. Vancouver Coastal Health, UBC Hospital 2211 Westbrook Mall, Vancouver, BC, V6T 2B5, Canada

    Bassam Masri

  11. Schroeder Arthritis Institute, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada

    Michael Zywiel

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  1. Scott Kim
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Scott Kim and Jesse Wolfstadt. The first draft of the manuscript was written by Scott Kim, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Scott Kim.

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Kim, S., Cottrell, J., Waddell, J. et al. Quality indicators in primary elective total hip and knee arthroplasty. International Orthopaedics (SICOT) 47, 647–658 (2023). https://doi.org/10.1007/s00264-022-05665-x

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