Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial

Regional variation in low-value musculoskeletal surgery: a nationwide study from the Finnish Care Register

BACKGROUND AND PURPOSE

 Healthcare systems globally are grappling with resource constraints and rising costs. Concerns have been raised about "low-value" care, which consumes healthcare resources without benefiting patients. We aimed to examine regional differences in common low-value musculoskeletal surgeries in Finland and explore explanatory factors behind the variation.

METHODS

 Using data from the Finnish Care Register for Health Care, surgeries conducted from 2006-2007 compared with 2020-2021 were analyzed across 20 hospital districts. Selected surgeries (acromioplasty, rotator cuff repair, partial meniscectomy, wrist arthroscopy, ankle arthroscopy, and distal radius fracture fixation) were categorized based on NOMESCO procedure codes, and incidence rates in older populations were calculated based on population size derived from Statistics Finland.

RESULTS

 We found substantial regional disparities in low-value surgeries. The incidence rates were higher in hospitals with high historical incidence rates and smaller population sizes, suggesting that the uptake of evidence is slower in small non-academic hospitals.

CONCLUSION

 The incidence of low-value surgery is declining but regional differences remain large. It is unlikely that regional variation in disease incidence explains such large variation in low-value surgery. Instead, local treatment culture seems to be the driving force behind low-value surgery, and the practices seem to be more entrenched in small hospitals.

Comparative long-term outcomes of unicompartmental and total knee arthroplasty in knee osteoarthritis patients: a systematic review and meta-analysis

Background

Long-term outcomes for knee osteoarthritis patients undergoing unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) remain inconclusive.

Objectives

This study aims to evaluate the long-term outcomes over five years, including Knee Society Pain Scores (KSPS), Knee Society Scores (KSS), Knee Society Function Scores (KSFS), range of motion (ROM), and survival rates-of UKA vs. TKA in knee osteoarthritis patients.

Design

Systematic review using data from randomized controlled and cohort trials, and world databases.

Data sources

Researchers searched Medline, Embase, Cochrane Controlled Register of Trials, and ClinicalTrials.gov from January 1990 to March 2024.

Eligibility criteria for selecting studies

The researchers selected studies based on adult participants with knee osteoarthritis. Eligible studies compare UKA and TKA reports on clinical or surgical outcomes, including KSPS, KSS, KSFS, ROM and survival rates, over 5 years. The researchers excluded the studies fewer than five years, or if English text was unavailable.

Results

Researchers categorized twenty-nine eligible studies into three groups: five randomized controlled trials, 11 registries and database studies, and 13 cohort studies. The analysis revealed that neither TKA nor UKA definitively outperformed the other in terms of pain (SMD (95% CI): -0.06 [-0.41, 0.28], I 2 = 90%) and KSS scores (SMD (95% CI): -0.07 [-0.23, 0.008], I 2 = 81%) over a period of five years. However, KSFS (SMD (95% CI): -0.30 [-0.43, -0.17], I 2 = 74%) and ROM (SMD (95% CI): -0.78 [-1.11, -0.46], I 2 = 92%) tended to favor UKA, and survival rate favor TKA at 5 or over 5-year follow-up periods.

Conclusions

UKA shows a trend towards better outcomes in KSFS and ROM, alongside a more favorable survival rate in TKA at the five-year and beyond follow-up periods.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=517835, PROSPERO (CRD42024517835).

Linking Patient-Reported Outcome Measure Scores to Adverse Event Data to Gain Insight into Overestimation of Postoperative Patient-Reported Outcome Measure Improvement After Total Hip Arthroplasty and Total Knee Arthroplasty Due to Selective Nonresponse

BACKGROUND

The purpose of the study was to gain insight into how clinically relevant improvement in patient-reported outcome measure scores after total hip arthroplasty (THA) and total knee arthroplasty (TKA) may be underestimated or overestimated, we compared patient-reported outcome measure respondents and nonrespondents on their adverse event rates and assessed whether adverse event occurrence was associated with clinically relevant patient-reported outcome measure improvement from those without adverse events.

METHODS

All primary THAs and TKAs performed in 19 Dutch hospitals between January 2017 and December 2019 were included. The hip disability and osteoarthritis outcome score-physical function short form (HOOS-PS) and knee injury and osteoarthritis outcome score-physical function short form (KOOS-PS) were used to assess the physical function after THA and TKA, respectively. Adverse events included 1-year revision, 30-day readmission, 30-day complications, and long (ie, >75th percentile) length of stay. A clinically relevant improvement was defined as at least a 10-point decrease in HOOS-PS and 9 points in KOOS-PS scores. Associations between adverse events and clinically relevant HOOS-PS and KOOS-PS improvement were assessed using binary logistic regression models adjusted for patient characteristics and clustering of patients within hospitals.

RESULTS

There were 20,338 THA and 18,082 TKA procedures included. Adverse events occurred more frequently in HOOS-PS and KOOS-PS nonrespondents than in respondents. The THA patients experiencing revision, complications, or long length of stay were less likely to experience clinically relevant HOOS-PS improvements (odds ratios of 0.11 [0.06 to 0.20], 0.44 [0.30 to 0.63], and 0.66 [0.50 to 0.88], respectively). The TKA patients experiencing revision or long length of stay were less likely to experience clinically relevant KOOS-PS improvements (odds ratios of 0.26 [0.12 to 0.55] and 0.63 [0.50 to 0.80], respectively).

CONCLUSIONS

Clinically relevant HOOS-PS and KOOS-PS improvements are likely overestimated, as nonrespondents had higher adverse event rates which were associated with lower likelihood to achieve clinically relevant HOOS-PS and KOOS-PS improvements.

A Systematic Review on the Impact of Quality Assurance Programs on Outcomes after Radical Prostatectomy

BACKGROUND AND OBJECTIVE

The implementation of quality assurance programs (QAPs) within urological practice has gained prominence; yet, their impact on outcomes after radical prostatectomy (RP) remains uncertain. This paper aims to systematically review the current literature regarding the implementation of QAPs and their impact on outcomes after robot-assisted RP, laparoscopic RP, and open prostatectomy, collectively referred to as RP.

METHODS

A systematic Embase, Medline (OvidSP), and Scopus search was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) process, on January 12, 2024. Studies were identified and included if these covered implementation of QAPs and their impact on outcomes after RP. QAPs were defined as any intervention seeking quality improvement through critically reviewing, analyzing, and discussing outcomes. Included studies were assessed critically using the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool, with results summarized narratively.

KEY FINDINGS AND LIMITATIONS

Ten included studies revealed two methodological strategies: periodic performance feedback and surgical video assessments. Despite conceptual variability, QAPs improved outcomes consistently (ie, surgical margins, urine continence, erectile function, and hospital readmissions). Of the two strategies, video assessments better identified suboptimal surgical practice and technical errors. Although the extent of quality improvements did not appear to correlate with the frequency of QAPs, there was an apparent correlation with whether or not outcomes were evaluated collectively.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Current findings suggest that QAPs have a positive impact on outcomes after RP. Caution in interpretation due to limited data is advised. More extensive research is required to explore how conceptual differences impact the extent of quality improvements.

PATIENT SUMMARY

In this paper, we review the available scientific literature regarding the implementation of quality assurance programs and their impact on outcomes after radical prostatectomy. The included studies offered substantial support for the implementation of quality assurance programs as an incentive to improve the quality of care continuously.

Grand rounds in methodology: four critical decision points in statistical process control evaluations of quality improvement initiatives

Quality improvement (QI) projects often employ statistical process control (SPC) charts to monitor process or outcome measures as part of ongoing feedback, to inform successive Plan-Do-Study-Act cycles and refine the intervention (formative evaluation). SPC charts can also be used to draw inferences on effectiveness and generalisability of improvement efforts (summative evaluation), but only if appropriately designed and meeting specific methodological requirements for generalisability. Inadequate design decreases the validity of results, which not only reduces the chance of publication but could also result in patient harm and wasted resources if incorrect conclusions are drawn. This paper aims to bring together much of what has been written in various tutorials, to suggest a process for using SPC in QI projects. We highlight four critical decision points that are often missed, how these are inter-related and how they affect the inferences that can be drawn regarding effectiveness of the intervention: (1) the need for a stable baseline to enable drawing inferences on effectiveness; (2) choice of outcome measures to assess effectiveness, safety and intervention fidelity; (3) design features to improve the quality of QI projects; (4) choice of SPC analysis aligned with the type of outcome, and reporting on the potential influence of other interventions or secular trends.These decision points should be explicitly reported for readers to interpret and judge the results, and can be seen as supplementing the Standards for Quality Improvement Reporting Excellence guidelines. Thinking in advance about both formative and summative evaluation will inform more deliberate choices and strengthen the evidence produced by QI projects.