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Dubin J, Bains S, Ihekweazu UN, Mont MA, Delanois R. Social Determinants of Health in Total Joint Arthroplasty: Education. J Arthroplasty 2024; 39:1897-1899. [PMID: 38490570 DOI: 10.1016/j.arth.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/07/2024] [Indexed: 03/17/2024] Open
Affiliation(s)
- Jeremy Dubin
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep Bains
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald Delanois
- Rubin Institute for Advanced Orthopedics, LifeBridge Health, Sinai Hospital of Baltimore, Baltimore, Maryland
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Depp S, Brown L, Quatman-Yates C, Foraker R, Patterson ES, Vasileff WK, Di Stasi S. Feasibility of interdisciplinary evaluation in non-arthritic hip pain: A randomized trial. Musculoskelet Sci Pract 2024; 73:103154. [PMID: 39116761 DOI: 10.1016/j.msksp.2024.103154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 07/25/2024] [Accepted: 07/27/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Physical therapy and orthopaedic surgery are two common treatments for non-arthritic hip pain. Interdisciplinary evaluation across these disciplines may produce a more supportive treatment-planning process; however, the feasibility of such an evaluation remains unknown. HYPOTHESIS OBJECTIVE To assess the feasibility of an interdisciplinary evaluation with an orthopaedic surgeon and physical therapist for non-arthritic hip pain. STUDY DESIGN Observational feasibility study of a randomized controlled trial. METHODS Participants were randomized to an interdisciplinary (surgeon + physical therapist) or standard (surgeon) evaluation in a hip preservation clinic. Recruitment rate was recorded. Retention rate was calculated for all variables of interest. Enrollment and refusal reasons were recorded as patient quotes and categorized by a single grader. Time spent in clinic was compared across groups using Mann Whitney U tests (P ≤ 0.05). Study clinicians were interviewed, and responses were categorized based on pre-determined themes. RESULTS Eighty-one percent of eligible patients enrolled over a 15-month recruitment period. Willingness(n = 16), urgency to resolve pain(n = 10), financial compensation(n = 1), interest in research(n = 42), physical therapy(n = 6), or multiple-provider care(n = 15) were participants' enrollment reasons; reason was not recorded for 22 participants. Time(n = 11), preference for single-provider care(n = 6), current physical therapy treatment(n = 1), and disinterest in physical therapy(n = 7) or research(n = 2) were refusal reasons of patients who did not enroll. Retention for primary variables of interest was 100% in both groups. Participants spent, on average, 23.5 min more time in clinic for the interdisciplinary evaluation compared to the standard (P < 0.001). CONCLUSIONS An interdisciplinary evaluation for patients with non-arthritic hip pain that included a physical therapist and orthopaedic surgeon in a hip preservation clinic was feasible and may better inform the treatment planning process.
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Affiliation(s)
- Sarah Depp
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Lindsey Brown
- Feasibility Informatics, Medpace, Inc., Cincinnati, OH, USA
| | - Catherine Quatman-Yates
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA; Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Randi Foraker
- Institute for Informatics, Washington University School of Medicine, St. Louis, MO, USA
| | - Emily S Patterson
- Division of Health Information Management and Systems, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA
| | - W Kelton Vasileff
- Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA; Department of Orthopaedics, The Ohio State University, Columbus, OH, USA
| | - Stephanie Di Stasi
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH, USA; Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Pilares Ortega E, Colomina Morales J, Gómez Arbonés J, Drudis Morrell R, Torra Riera M. [Translated article] Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00119-X. [PMID: 38971560 DOI: 10.1016/j.recot.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 12/05/2023] [Accepted: 12/23/2023] [Indexed: 07/08/2024] Open
Abstract
INTRODUCTION There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure. OBJECTIVE To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS). METHODS A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed. RESULTS Average age of 71.7±8.2years, 62.4% were women and the 77.3% were classified as ASA II. The significantly associated factors to an increased length of stay are: age (p=.001), ASA scale (p=.04), day of surgery (p<.001), blood transfusion (p<.001), postoperative haemoglobin level at 48-72h (p<.001), the time of first postoperative mobilisation to ambulate and climb stairs (p<.001), the need for analgesic rescues (p=.003), and the presence of postoperative nausea and vomiting (p=.008). CONCLUSIONS There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimise the quality of care and available health resources.
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Affiliation(s)
- E Pilares Ortega
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Santa María, Lleida, Spain.
| | - J Colomina Morales
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Santa María, Lleida, Spain; Grupo Multidisciplinar de Investigación Clínica en Patología Musculoesquelética, Fragilidad y Tratamiento del Dolor, Instituto de Investigación Biomédica de Lleida, Lleida, Spain
| | | | - R Drudis Morrell
- Departamento de Anestesiología y Reanimación, Hospital Universitario Santa María, Lleida, Spain
| | - M Torra Riera
- Departamento de Anestesiología y Reanimación, Hospital Universitario Santa María, Lleida, Spain
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4
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Pilares Ortega E, Colomina Morales J, Gómez Arbonés J, Drudis Morrell R, Torra Riera M. Determining factors on length of stay in primary total knee arthroplasty patients using enhanced recovery protocol after surgery (ERAS) pathway. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024:S1888-4415(24)00001-8. [PMID: 38184294 DOI: 10.1016/j.recot.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 12/05/2023] [Accepted: 12/23/2023] [Indexed: 01/08/2024] Open
Abstract
INTRODUCTION There is an increase in degenerative arthropathies because of the increase in the longevity of world's population, making primary knee arthroplasties a procedure to recover quality of life without pain. There are factors associated with the length of hospital stay after this procedure. OBJECTIVE To determine the risk factors influencing the hospital stay during the postoperative period of patients undergoing primary total knee arthroplasty with an enhanced recovery after surgery protocol (ERAS). METHODS A retrospective study is carried out on patients undergoing primary total knee arthroplasty at an University Hospital in the period 2017-2020 using the ERAS protocol, during which 957 surgeries were performed. RESULTS Average age of 71.7±8.2years, 62.4% were women and the 77.3% were classified as ASAII. The significantly associated factors to an increased length of stay are: age (P=.001), ASA scale (P=.04), day of surgery (P<.001), blood transfusion (P<.001), postoperative hemoglobin level at 48-72h (P<.001), the time of first postoperative mobilization to ambulate and climb stairs (P<.001), the need for analgesic rescues (P=.003), and the presence of postoperative nausea and vomiting (P=.008). CONCLUSIONS There are statistically significant and clinically relevant factors associated with hospital stay. Determining these factors constitutes an advantage in hospital management, in the development of strategies to improve and optimize the quality of care and available health resources.
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Affiliation(s)
- E Pilares Ortega
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Santa María, Lleida, España.
| | - J Colomina Morales
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Santa María, Lleida, España; Grupo Multidisciplinar de Investigación Clínica en Patología Musculoesquelética, Fragilidad y Tratamiento del Dolor, Instituto de Investigación Biomédica de Lleida, Lleida, España
| | | | - R Drudis Morrell
- Departamento de Anestesiología y Reanimación, Hospital Universitario Santa María, Lleida, España
| | - M Torra Riera
- Departamento de Anestesiología y Reanimación, Hospital Universitario Santa María, Lleida, España
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Xie J, Luo C, Du Q, Zou W, Li X, Ma Z, Wu X, Zhang M. Factors associated with early mobilization among colorectal cancer patients after surgery: A cross-sectional study. Eur J Oncol Nurs 2023; 64:102317. [PMID: 37187102 DOI: 10.1016/j.ejon.2023.102317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/17/2023] [Accepted: 03/10/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Jingyue Xie
- School of Nursing, Sun Yat-sen University, No.74, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Chuqing Luo
- Health Management Center, General Practice Medical Center, West China Hospital, Sichuan University / West China School of Nursing, Sichuan University, No.37, Guoxue Road, Chengdu, 610041, Sichuan Province, China
| | - Qianqian Du
- School of Nursing, Sun Yat-sen University, No.74, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Wenjie Zou
- School of Nursing, Sun Yat-sen University, No.74, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Xinxin Li
- School of Nursing, Sun Yat-sen University, No.74, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Ziyan Ma
- School of Nursing, Sun Yat-sen University, No.74, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China
| | - Xiaodan Wu
- Sun Yat-sen University Cancer Center, No.651, Dongfeng East Road, Guangzhou, 510080, Guangdong Province, China; Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, China.
| | - Meifen Zhang
- School of Nursing, Sun Yat-sen University, No.74, Zhongshan Rd.2, Guangzhou, 510080, Guangdong Province, China.
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Yi JA, Hakimi A, Vavra AK. Application of dissemination and implementation science frameworks to surgical research. Semin Vasc Surg 2022; 35:456-463. [DOI: 10.1053/j.semvascsurg.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/27/2022] [Accepted: 10/04/2022] [Indexed: 11/17/2022]
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Anderson AM, Drew BT, Antcliff D, Redmond AC, Comer C, Smith TO, McHugh GA. Content and delivery of pre-operative interventions for patients undergoing total knee replacement: a rapid review. Syst Rev 2022; 11:184. [PMID: 36050795 PMCID: PMC9436722 DOI: 10.1186/s13643-022-02019-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/07/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Total knee replacement (TKR) is a common operation typically performed for end-stage knee osteoarthritis. Patients awaiting TKR often have poor health-related quality of life. Approximately 20% of patients experience persistent pain post-TKR. Pre-operative TKR interventions could improve pre- and post-operative outcomes, but future research is required to inform their design. This review aimed to identify and synthesize recent literature on the content and delivery of pre-operative TKR interventions to help guide future research and clinical practice. METHODS This rapid review included randomized trials of pre-operative TKR interventions ("outcomes studies") and primary studies exploring patients' and/or health professionals' views of pre-operative TKR interventions ("views studies"). Medline, Embase, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials were searched for English language studies published between January 2009 and December 2020. Eligible studies' reference lists were screened. Studies were appraised using the Mixed Methods Appraisal Tool. The findings were narratively synthesized using a convergent segregated approach. RESULTS From 3263 records identified, 52 studies were included (29 outcomes studies, 21 views studies, two outcomes/views studies). The studies' methodological quality varied but was generally highest in qualitative studies. The outcomes studies investigated education (n=5), exercise (n=20), psychological (n=2), lifestyle (n=1), and/or other interventions (n=5). The views studies addressed education (n=20), exercise (n=3), psychological (n=1), lifestyle (n=4), and/or other interventions (n=1). Only three outcomes studies (two randomized controlled trials (RCTs) and a pilot study) compared the effectiveness of intervention components/delivery approaches. The two RCTs' results suggest that pre-operative TKR exercise interventions are equally effective regardless of whether they include strength or strength plus balance training and whether they are hospital- or home-based. Personal tailoring and using more than one delivery format were associated with improved outcomes and/or perceived as beneficial for multiple intervention types. CONCLUSIONS Definitive evidence on the optimal design of pre-operative TKR interventions is lacking. Personal tailoring and employing multiple delivery formats appear to be valuable design elements. Preliminary evidence suggests that including balance training and hospital versus home delivery may not be critical design elements for pre-operative TKR exercise interventions. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42019143248 FUNDER: National Institute for Health and Care Research (ICA-CDRF-2018-04-ST2-006).
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Affiliation(s)
- Anna M Anderson
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK. .,NIHR Leeds Biomedical Research Centre, Leeds, UK.
| | - Benjamin T Drew
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Deborah Antcliff
- School of Healthcare, University of Leeds, Leeds, UK.,Physiotherapy Department, Bury Care Organisation, Northern Care Alliance NHS Group, Bury, UK.,School of Medicine, Keele University, Keele, UK
| | - Anthony C Redmond
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Christine Comer
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Community Healthcare NHS Trust Musculoskeletal and Rehabilitation Services, Leeds, UK
| | - Toby O Smith
- School of Health Sciences, University of East Anglia, Norwich, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Abstract
Variation in care is associated with variation in outcomes after total joint arthroplasty (TJA). Accordingly, much research into enhanced recovery efficacy for TJA has been devoted to linking standardization with better outcomes. This article focuses on recent advances suggesting that variation within a set of core protocol elements may be less important than providing the core elements within enhanced recovery pathways for TJA. Provided the core elements are associated with benefits for patients and health care system outcomes, variation in the details of their provision may contribute to a pathway's success. This article provides an updated review of the literature.
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Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth University, 89 Holdenhurst Road, Bournemouth, Dorset BH8 8FT, UK
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9
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Choi YS, Kim TW, Chang MJ, Kang SB, Chang CB. Enhanced recovery after surgery for major orthopedic surgery: a narrative review. Knee Surg Relat Res 2022; 34:8. [PMID: 35193701 PMCID: PMC8864772 DOI: 10.1186/s43019-022-00137-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/08/2022] [Indexed: 12/17/2022] Open
Abstract
Background With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully. Main body Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary. Conclusion The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.
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Affiliation(s)
- Yun Seong Choi
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea
| | - Tae Woo Kim
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea
| | - Moon Jong Chang
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea
| | - Seung-Baik Kang
- Department of Orthopedic Surgery, SMG-SNU Boramae Medical Center, Seoul, South Korea.,Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea
| | - Chong Bum Chang
- Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, South Korea. .,Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, South Korea.
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Koto S, Ikeda T, Inoue S, Inoue H, Watanabe M. Differences in preoperative function and outcome of patients with versus without sarcopenia after total hip arthroplasty. J Phys Ther Sci 2022; 34:60-64. [PMID: 35035081 PMCID: PMC8752275 DOI: 10.1589/jpts.34.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/25/2021] [Indexed: 11/24/2022] Open
Abstract
[Purpose] Public attention regarding sarcopenia has increased in recent years. Patients
with sarcopenia reportedly show worse return home rates and activities of daily living at
discharge. However, no reports have described the function and outcomes of hip
osteoarthrosis patients with sarcopenia after total hip arthroplasty. This study aimed to
clarify differences in preoperative physical function and outcomes of hip osteoarthrosis
patients with versus without sarcopenia after total hip arthroplasty. [Participants and
Methods] Twenty-five patients with hip osteoarthrosis who underwent total hip arthroplasty
were included. Evaluation items were preoperative skeletal muscle mass of the extremities,
isometric strength of the lower extremities (hip abduction and knee extension), grip
strength, and the 10-m timed gait test results. [Results] The prevalence of sarcopenia was
8% (2/25 patients). The sarcopenic group displayed lower skeletal muscle mass index, grip
strength, and 10-m timed gait test values. The sarcopenic group showed lower muscle mass
in the upper and lower limbs and trunk and lower hip abductor strength than the
non-sarcopenic group. [Conclusion] Eight percent of patients developed sarcopenia after
total hip arthroplasty. Due to the low average age (66.0 ± 9.5 years), the prevalence was
lower than that of other orthopedic diseases.
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Affiliation(s)
- Satoshi Koto
- Department of Physical Therapy, School of Nursing and Rehabilitation, Showa University: 1865 Tokaichiba-cho, Yokohama, Kanagawa 226-8555, Japan.,Department of Rehabilitation, Fujigaoka Hospital, Showa University, Japan.,Research Institute for Sport and Exercise Sciences, Showa University, Japan
| | - Takashi Ikeda
- Department of Physical Therapy, School of Nursing and Rehabilitation, Showa University: 1865 Tokaichiba-cho, Yokohama, Kanagawa 226-8555, Japan.,Research Institute for Sport and Exercise Sciences, Showa University, Japan.,Department of Rehabilitation, Fujigaoka Rehabilitation Hospital, Showa University, Japan
| | - Shunya Inoue
- Department of Rehabilitation, Fujigaoka Rehabilitation Hospital, Showa University, Japan
| | - Hiroyasu Inoue
- Department of Physical Therapy, School of Nursing and Rehabilitation, Showa University: 1865 Tokaichiba-cho, Yokohama, Kanagawa 226-8555, Japan.,Department of Rehabilitation, Fujigaoka Hospital, Showa University, Japan
| | - Minoru Watanabe
- Department of Orthopedic Surgery, Fujigaoka Hospital, Showa University, Japan
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Anderson AM, Comer C, Smith TO, Drew BT, Pandit H, Antcliff D, Redmond AC, McHugh GA. Consensus on pre-operative total knee replacement education and prehabilitation recommendations: a UK-based modified Delphi study. BMC Musculoskelet Disord 2021; 22:352. [PMID: 33853564 PMCID: PMC8044503 DOI: 10.1186/s12891-021-04160-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 03/09/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Over 90,000 total knee replacement (TKR) procedures are performed annually in the United Kingdom (UK). Patients awaiting TKR face long delays whilst enduring severe pain and functional limitations. Almost 20% of patients who undergo TKR are not satisfied post-operatively. Optimising pre-operative TKR education and prehabilitation could help improve patient outcomes pre- and post-operatively; however, current pre-operative TKR care varies widely. Definitive evidence on the optimal content and delivery of pre-operative TKR care is lacking. This study aimed to develop evidence- and consensus-based recommendations on pre-operative TKR education and prehabilitation. METHODS A UK-based, three-round, online modified Delphi study was conducted with a 60-member expert panel. All panellists had experience of TKR services as patients (n = 30) or professionals (n = 30). Round 1 included initial recommendations developed from a mixed methods rapid review. Panellists rated the importance of each item on a five-point Likert scale. Panellists could also suggest additional items in Round 1. Rounds 2 and 3 included all items from Round 1, new items suggested in Round 1 and charts summarising panellists' importance ratings from the preceding round. Free-text responses were analysed using content analysis. Quantitative data were analysed descriptively. All items rated as 'Important' or 'Very important' by at least 70% of all respondents in Round 3 were included in the final set of recommendations. RESULTS Fifty-five panellists (92%) (patients n = 26; professionals n = 29) completed Round 3. Eighty-six recommendation items were included in Round 1. Fifteen new items were added in Round 2. Rounds 2 and 3 therefore included 101 items. Seventy-seven of these reached consensus in Round 3. Six items reached consensus amongst patient or professional panellists only in Round 3. The final set of recommendations comprises 34 education topics, 18 education delivery approaches, 10 exercise types, 13 exercise delivery approaches and two other treatments. CONCLUSIONS This modified Delphi study developed a comprehensive set of recommendations that represent a useful resource for guiding decision-making on the content and delivery of pre-operative TKR education and prehabilitation. The recommendations will need to be interpreted and reviewed periodically in light of emerging evidence.
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Affiliation(s)
- Anna M Anderson
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK.
- NIHR Leeds Biomedical Research Centre, Leeds, UK.
| | - Christine Comer
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Leeds Community Healthcare NHS Trust Musculoskeletal and Rehabilitation Services, Leeds, UK
| | - Toby O Smith
- School of Health Sciences, University of East Anglia, Norwich, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Benjamin T Drew
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Hemant Pandit
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Deborah Antcliff
- School of Healthcare, University of Leeds, Leeds, UK
- Physiotherapy Department, Bury Care Organisation, Northern Care Alliance NHS Group, Bury, England, UK
| | - Anthony C Redmond
- Leeds Institute of Rheumatic & Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Biomedical Research Centre, Leeds, UK
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Gertner AK, Franklin J, Roth I, Cruden GH, Haley AD, Finley EP, Hamilton AB, Palinkas LA, Powell BJ. A scoping review of the use of ethnographic approaches in implementation research and recommendations for reporting. IMPLEMENTATION RESEARCH AND PRACTICE 2021; 2. [PMID: 34056611 PMCID: PMC8153409 DOI: 10.1177/2633489521992743] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Researchers have argued for the value of ethnographic approaches to implementation science (IS). The contested meanings of ethnography pose challenges and possibilities to its use in IS. The goal of this study was to identify sources of commonality and variation, and to distill a set of recommendations for reporting ethnographic approaches in IS. Methods: We included in our scoping review English-language academic journal articles meeting two criteria: (1) IS articles in the healthcare field and (2) articles that described their approach as ethnographic. In March 2019, we implemented our search criteria in four academic databases and one academic journal. Abstracts were screened for inclusion by at least two authors. We iteratively develop a codebook for full-text analysis and double-coded included articles. We summarized the findings and developed reporting recommendations through discussion. Results: Of the 210 articles whose abstracts were screened, 73 were included in full-text analysis. The number of articles increased in recent years. Ethnographic approaches were used within a wide variety of theoretical approaches and research designs. Articles primarily described using interviews and observational methods as part of their ethnographic approaches, though numerous other methods were also employed. The most cited rationales for using ethnographic approaches were to capture context-specific phenomena, understand insiders’ perspective, and study complex interactions. In reporting on ethnographic approaches, we recommend that researchers provide information on researcher training and position, reflect on researchers’ positionality, describe observational methods in detail, and report results from all the methods used. Conclusion: The number of IS studies using ethnography has increased in recent years. Ethnography holds great potential for contributing further to IS, particularly to studying implementation strategy mechanisms and understanding complex adaptive systems. Researchers have proposed that ethnographic methods may be valuable to implementation research and practice. Ethnographic approaches have their roots in the field of anthropology, but they are now used in many fields. These approaches often involve a researcher spending time in “real-world” settings, conducting interviews and observation to understand a group of people. That said, researchers disagree on the meaning of ethnography, which presents a challenge to its use in implementation science (IS). We searched for articles in the field of IS that described their methods as ethnographic. We then reviewed the articles, looking for similarities and differences in how and why ethnographic approaches were used. Many of these articles said they used ethnographic methods because they were interested in issues like context, research participants’ views, and complex interactions. We found a large amount of variation in how ethnographic methods were used. We developed recommendations for describing ethnographic methods in a way that readers can clearly understand. We also made several observations of the value ethnographic approaches can bring to IS. Ethnographic methods may be especially useful to studying unplanned and unexpected changes that take place during implementation. These recommendations and observations could be helpful to implementation researchers wishing to use ethnographic methods.
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Affiliation(s)
- Alex K Gertner
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joshua Franklin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Isabel Roth
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | | | - Amber D Haley
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Erin P Finley
- VA Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Alison B Hamilton
- VA Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lawrence A Palinkas
- Department of Children, Youth and Families, University of Southern California, Los Angeles, CA, USA
| | - Byron J Powell
- Brown School and School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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13
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Julien-Marsollier F, Michelet D, Assaker R, Doval A, Louisy S, Madre C, Simon AL, Ilharreborde B, Brasher C, Dahmani S. Enhanced recovery after surgical correction of adolescent idiopathic scoliosis. Paediatr Anaesth 2020; 30:1068-1076. [PMID: 32750176 DOI: 10.1111/pan.13988] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/08/2020] [Accepted: 07/19/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Few publications in the literature examine enhanced recovery after scoliosis surgery (ERAS) in children, despite significant scientific interest in adults. The objective of the current study was to describe an ERAS protocol for surgical correction of adolescent idiopathic scoliosis (AIS) and its results. METHODS ERAS outcomes were measured in two patient cohorts. Historical controls and ERAS groups were selected from patients managed for scoliosis surgery in 2015 and 2018, respectively. The ERAS protocol included fasting minimization, carbohydrate loading, the avoidance of background morphine infusions, perioperative opioid-sparing protocols, the use of a cooling brace, early physiotherapy, feeding and oral medications, and the early removal of urinary catheters and surgical drains. The main outcome of the study was hospital length of stay. RESULTS Overall, 82 controls and 81 ERAS patients were recruited. ERAS protocols were observed in over 80% of patients for almost items. Median length of hospital stay was significantly lower in the ERAS group (- 3 [95% confidence interval: -2; -4] days). Median morphine consumption was reduced by 25% and 35% on days 2 and 3, respectively. The incidence of PONV did not differ between the two groups, and the incidence of constipation decreased slightly but significantly in the ERAS group on day 2. Pain intensity at rest and movement were lower in the ERAS group at day 2 and 3. CONCLUSIONS The current study suggests an ERAS protocol after adolescent idiopathic scoliosis surgery is associated with reduced hospital length of stay and improved postoperative care.
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Affiliation(s)
- Florence Julien-Marsollier
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | - Daphné Michelet
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | - Rita Assaker
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | - Antoine Doval
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | - Simon Louisy
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
| | | | - Anne-Laure Simon
- Department of Orthopaedic Surgery, Robert Debré Hospital, Paris, France
| | | | - Christopher Brasher
- Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Vic., Australia.,Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Vic., Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Vic., Australia
| | - Souhayl Dahmani
- Department of Anesthesia and Intensive Care, Robert Debré Hospital, Paris, France.,Université de Paris, Paris, France.,DHU PROTECT, Robert Debré Hospital, Paris, France
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14
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Charipova K, Gress KL, Urits I, Viswanath O, Kaye AD. Maximization of Non-Opioid Multimodal Analgesia in Ambulatory Surgery Centers. Cureus 2020; 12:e10407. [PMID: 33062524 PMCID: PMC7550222 DOI: 10.7759/cureus.10407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Ambulatory surgery centers aid the healthcare system by not only providing a cost-effective option for delivery of care but also by helping to reduce overwhelming case volumes at inpatient facilities. While outpatient protocols have been designed for an increasing number of surgical procedures, the inpatient to outpatient transition of surgery remains limited by both procedure type and patient comorbidities. This limitation stems in part from the heavy emphasis on accelerated discharge following outpatient procedures, given that prolonged recovery time is associated with delayed turnover and increased nursing care demands. Since its inception, enhanced recovery after surgery (ERAS) has aimed to primarily reduce the disruption of physiologic homeostasis that occurs secondary to surgery. More recently, the aim of ERAS has evolved to help transition inpatient procedures to outpatient settings and may even be useful in more emergent cases. It should be noted, however, that outpatient surgery even in combination with ERAS is not the best option for all patients, and the use of ERAS protocols should be complemented with predictive assessments of patient risk. Beyond augmenting the efficiency of outpatient surgery, ERAS protocols, when used in eligible patients and especially when combined with regional anesthetic techniques, are effective in delivering opioid-sparing pain management while increasing overall outcomes and patient satisfaction rates.
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Affiliation(s)
- Karina Charipova
- Medicine, MedStar Georgetown University Hospital, Georgetown University School of Medicine, Washington D.C., USA
| | - Kyle L Gress
- Medicine, MedStar Georgetown University Hospital, Georgetown University School of Medicine, Washington D.C., USA
| | - Ivan Urits
- Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Omar Viswanath
- Anesthesiology, University of Arizona College of Medicine, Phoenix, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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15
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Pulkkinen M, Jousela I, Engblom J, Salanterä S, Junttila K. The effect of a new perioperative practice model on length of hospital stay and on the surgical care process in patients undergoing hip and knee arthroplasty under spinal anesthesia: a randomized clinical trial. BMC Nurs 2020; 19:73. [PMID: 32765189 PMCID: PMC7395411 DOI: 10.1186/s12912-020-00465-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 07/24/2020] [Indexed: 11/24/2022] Open
Abstract
Background The shortened length of hospital stays (LOS) requires efficient and patient-participatory perioperative nursing approaches to enable early and safe discharge from hospitals for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). The primary aim of this study was to explore the effect comparative to standard perioperative care of a new perioperative practice model (NPPM) on the LOS and the time points of the surgical care process in patients undergoing THA and TKA under spinal anesthesia. The secondary aim was to find out if any subgroups with different response could be found. Methods Patients scheduled for elective, primary THA and TKA were assessed for eligibility. A two-group parallel randomized clinical trial was conducted with an intervention group (n = 230) and control group (n = 220), totaling 450 patients. The patients in the intervention group were each designated with one named anesthesia nurse, who took care of the patient during the entire perioperative process and visited the patient postoperatively. The patients in the control group received standard perioperative care from different nurses during their perioperative processes and without postoperative visits. The surgical care process time points for each study patient were gathered from the operating room management software and hospital information system until hospital discharge. Results We did not find any statistically significant differences between the intervention and control groups regarding to LOS. Only slight differences in the time points of the surgical care process could be detected. The subgroup examination revealed that higher age, type of arthroplasty and ASA score 3–4 all separately caused prolonged LOS. Conclusion We did not find the new perioperative practice model to shorten either length of hospital stays or the surgical care process in patients undergoing THA and TKA. Further studies at the subgroup level (gender, old age, and ASA score 3 and 4) are needed to recognize the patients who might benefit most from the NPPM. Trial registration This study was registered in NIH Clinical.Trials.gov under registration number NCT02906033, retrospectively registered September 19, 2016.
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Affiliation(s)
- Maria Pulkkinen
- University of Helsinki, Helsinki University Hospital, Perioperative, Intensive Care and Pain Medicine, PO. Box. 900, Vantaa, FI00029 Helsinki, HUS Finland.,Department of Nursing Science, University of Turku, Joukahaisenkatu 3-5, 20520 Turku, Finland
| | - Irma Jousela
- University of Helsinki, Helsinki University Hospital, Perioperative, Intensive Care and Pain Medicine, PO. Box. 900, Vantaa, FI00029 Helsinki, HUS Finland.,University of Eastern Finland, Kuopio, Finland
| | - Janne Engblom
- Department of Mathematics and Statistics, University of Turku, Turku, Finland.,School of Economics, University of Turku, Rehtorinpellonkatu 3, 20500 Turku, Finland
| | - Sanna Salanterä
- Department of Nursing Science, University of Turku, Joukahaisenkatu 3-5, 20520 Turku, Finland.,Turku University Hospital, Kiinanmyllynkatu 4-8, 20500 Turku, Finland
| | - Kristiina Junttila
- Department of Nursing Science, University of Turku, Joukahaisenkatu 3-5, 20520 Turku, Finland.,University of Helsinki and Helsinki University Hospital, Nursing Research Center, Tukholmankatu 8F, PO.Box. 442, FI00029 Helsinki, HUS Finland
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16
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Shibuya M, Nanri Y, Kamiya K, Fukushima K, Uchiyama K, Takahira N, Takaso M, Fukuda M, Matsunaga A. The maximal gait speed is a simple and useful prognostic indicator for functional recovery after total hip arthroplasty. BMC Musculoskelet Disord 2020; 21:84. [PMID: 32033550 PMCID: PMC7007664 DOI: 10.1186/s12891-020-3093-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 01/24/2020] [Indexed: 01/14/2023] Open
Abstract
PURPOSE The present study aimed to compare the capabilities of preoperative usual and maximal gait speeds in predicting functional recovery in patients who have undergone total hip arthroplasty (THA). METHODS Primary and unilateral THAs were performed in 317 patients, and the proportion of patients who achieved unassisted walking (functional recovery) 5 days postoperatively was recorded as an outcome measure. Preoperative functional assessment included hip pain, leg muscle strength, range of motion (ROM), and gait speed evaluations. The capabilities of preoperative usual and maximal gait speeds in predicting functional recovery were compared based on the areas under the curves (AUCs) of receiver operating characteristic (ROC) curves. Further, ROC curves were constructed using two models: 1. a model of gait speed only and 2. a clinical model including age, sex, leg muscle strength, and ROM. RESULTS On the AUCs for predictive ability of functional recovery, maximal gait speed was greater than usual gait speed (0.66 and 0.70, respectively). The AUC for maximal gait speed was as large as that of the clinical model (0.70 and 0.70, respectively). CONCLUSION Our results suggest that maximal gait speed is a simple and useful prognostic indicator of functional recovery in patients who have undergone THA.
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Affiliation(s)
- Manaka Shibuya
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan.,Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
| | - Yuta Nanri
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan
| | - Kentaro Kamiya
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan. .,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.
| | - Kensuke Fukushima
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Katsufumi Uchiyama
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Naonobu Takahira
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Michinari Fukuda
- Department of Rehabilitation, Kitasato University Hospital, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0375, Japan.,Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
| | - Atsuhiko Matsunaga
- Department of Rehabilitation Sciences, Kitasato University Graduate School of Medical Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan.,Department of Rehabilitation, School of Allied Health Sciences, Kitasato University, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan
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17
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Judge A, Carr A, Price A, Garriga C, Cooper C, Prieto-Alhambra D, Old F, Peat G, Murphy J, Leal J, Barker K, Underdown L, Arden N, Gooberman-Hill R, Fitzpatrick R, Drew S, Pritchard MG. The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system.
Objectives
To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement.
Design
(1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness.
Setting
Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England.
Participants
Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement.
Interventions
Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation).
Main outcome measures
Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years.
Results
Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole.
Limitations
Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors.
Conclusion
No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts.
Future work
There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals.
Study registration
This study is registered as PROSPERO CRD42017059473.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew Judge
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- National Institute for Health Research Bristol Biomedical Research Centre, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Andrew Carr
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew Price
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cesar Garriga
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Cyrus Cooper
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Daniel Prieto-Alhambra
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
- GREMPAL Research Group, Musculoskeletal Research Unit, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - George Peat
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Jacqueline Murphy
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Karen Barker
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Lydia Underdown
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nigel Arden
- National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Rachael Gooberman-Hill
- National Institute for Health Research Bristol Biomedical Research Centre, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Sarah Drew
- National Institute for Health Research Bristol Biomedical Research Centre, Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark G Pritchard
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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