Exploring patient perspectives on EQ-5D-5L data visualization within an individualized decision aid for total knee arthroplasty (TKA) in Alberta, Canada

BACKGROUND

Decision aids can help patients set realistic expectations. In this study, we explored alternative presentations to visualise patient-reported outcomes (EQ-5D-5L) data within an online, individualized patient decision aid for total knee arthroplasty (TKA) that, in part, generates individualized comparisons based on age, sex and body mass index, to enhance usability prior to implementation into routine clinical practice.

METHODS

We used data visualization techniques to modify the presentation of EQ-5D-5L outcomes data within the decision aid. The EQ-5D-5L data was divided into two parts allowing patients to compare themselves to similar individuals (1) pre-surgery and (2) 1-year post-surgery. We created 2 versions for each part and sought patient feedback on comprehension, usefulness, and visual appeal. Patients from an urban orthopedic clinic were recruited and their ratings and comments were recorded using a researcher-administered checklist. Data were managed using Microsoft Excel, R version 3.6.1 and ATLAS.ti V8 and analyzed using descriptive statistics and directed content analysis.

RESULTS

A total of 24 and 25 patients participated in Parts 1 and 2, respectively. Overall, there was a slight preference for Version 1 in Part 1 (58.3%) and Version 2 in Part 2 (64%). Most participants demonstrated adequate comprehension for all versions (range 50-72%) and commented that the instructions were clear. While 50-60% of participants rated the content as useful, including knowing the possible outcomes of surgery, some participants found the information interesting only, were unsure how to use the information, or did not find it useful because they had already decided on a treatment. Participants rated visual appeal for all versions favorably but suggested improvements for readability, mainly larger font and image sizes and enhanced contrast between elements.

CONCLUSIONS

Based on the results, we will produce an enhanced presentation of EQ-5D-5L data within the decision aid. These improvements, along with further usability testing of the entire decision aid, will be made before implementation of the decision aid in routine clinical practice. Our results on patients' perspectives on the presentation of EQ-5D-5L data to support decision making for TKA treatments contributes to the knowledge on EQ-5D-5L applications within healthcare systems for clinical care.

Electronic Patient-Reported Outcome Monitoring to Improve Quality of Life After Joint Replacement: Secondary Analysis of a Randomized Clinical Trial

Importance

Although remote patient-reported outcome measure (PROM) monitoring has shown promising results in cancer care, there is a lack of research on PROM monitoring in orthopedics.

Objective

To determine whether PROM monitoring can improve health outcomes for patients with joint replacement compared with the standard of care.

Design, Setting, and Participants

A 2-group, patient-level randomized clinical trial (PROMoting Quality) across 9 German hospitals recruited patients aged 18 years or older with primary hip or knee replacement from October 1, 2019, to December 31, 2020, with follow-up until March 31, 2022.

Interventions

Intervention and control groups received the standard of care and PROMs at hospital admission, discharge, and 12 months after surgery. In addition, the intervention group received PROMs at 1, 3, and 6 months after surgery. Based on prespecified PROM score thresholds, at these times, an automated alert signaled critical recovery paths to hospital study nurses. On notification, study nurses contacted patients and referred them to their physicians if necessary.

Main Outcomes and Measures

The prespecified outcomes were the mean change in PROM scores (European Quality of Life 5-Dimension 5-Level version [EQ-5D-5L; range, -0.661 to 1.0, with higher values indicating higher levels of health-related quality of life (HRQOL)], European Quality of Life Visual Analogue Scale [EQ-VAS; range, 0-100, with higher values indicating higher levels of HRQOL], Hip Disability and Osteoarthritis Outcome Score-Physical Function Shortform [HOOS-PS; range, 0-100, with lower values indicating lower physical impairment] or Knee Injury and Osteoarthritis Outcome Score-Physical Function Shortform [KOOS-PS; range, 0-100, with lower values indicating lower physical impairment], Patient-Reported Outcomes Measurement Information System [PROMIS]-fatigue [range, 33.7-75.8, with lower values indicating lower levels of fatigue], and PROMIS-depression [range, 41-79.4, with lower values indicating lower levels of depression]) from baseline to 12 months after surgery. Analysis was on an intention-to-treat basis.

Results

The study included 3697 patients with hip replacement (mean [SD] age, 65.8 [10.6] years; 2065 women [55.9%]) and 3110 patients with knee replacement (mean [SD] age, 66.0 [9.2] years; 1669 women [53.7%]). Exploratory analyses showed significantly better health outcomes in the intervention group on all PROMs except the EQ-5D-5L among patients with hip replacement, with a 2.10-point increase on the EQ-VAS in the intervention group compared with the control group (HOOS-PS, -1.86 points; PROMIS-fatigue, -0.69 points; PROMIS-depression, -0.57 points). Patients in the intervention group with knee replacement had a 1.24-point increase on the EQ-VAS, as well as significantly better scores on the KOOS-PS (-0.99 points) and PROMIS-fatigue (-0.84 points) compared with the control group. Mixed-effect models showed a significant difference in improvement on the EQ-VAS (hip replacement: effect estimate [EE], 1.66 [95% CI, 0.58-2.74]; knee replacement: EE, 1.71 [95% CI, 0.53-2.90]) and PROMIS-fatigue (hip replacement: EE, -0.65 [95% CI, -1.12 to -0.18]; knee replacement: EE, -0.71 [95% CI, -1.23 to -0.20]). The PROMIS-depression score was significantly reduced in the hip replacement group (EE, -0.60 [95% CI, -1.01 to -0.18]).

Conclusions and Relevance

In this randomized clinical trial, the PROM-based monitoring intervention led to a small improvement in HRQOL and fatigue among patients with hip or knee replacement, as well as in depression among patients with hip replacement.

Trial registration

Deutsches Register Klinischer Studien ID: DRKS00019916.

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

OBJECTIVE

To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).

DESIGN

Cluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients.

SETTING

20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands.

PARTICIPANTS

32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care).

INTERVENTION

The intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken.

MAIN OUTCOME MEASURES

The primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS). The individual indicators were analysed as secondary outcomes. Changes in outcomes from pre-intervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII.

RESULTS

16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 4.32% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95%CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95%CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95%CI 0.67-1.30).

CONCLUSION

The multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes.

TRIAL REGISTRATION NUMBER

NCT04055103.

Orthopaedic trauma on the weekend: Longer surgical wait times, and increased after-hours surgery

INTRODUCTION

Orthopaedic trauma does not present in a linear fashion. Fluctuations in trauma volumes, after-hours surgery and surgical wait times impact orthopaedic surgeons and patients. There is little research focussing on how surgical trauma volumes change throughout the week. This study investigated the relationship between day of the week and surgical orthopaedic trauma volumes, after-hours surgery, and wait times for orthopaedic trauma patients.

METHODS

All unscheduled surgical orthopaedic trauma cases presenting to one level I and three level IV urban adult trauma centers between 2008 and 2018 were retrospectively reviewed. Fluctuations in orthopaedic trauma volumes and amount of after-hours surgeries completed were investigated using Multivariable Poisson regression. Fluctuations in patient wait times were investigated using linear regression.

RESULTS

Weekends were associated with increased surgical wait times (8.9%, p<0.001) despite decreased surgical trauma volumes (9.1%, p<0.001). Surgical orthopaedic trauma volumes were elevated on weekdays and decreased on weekends. More after-hours surgeries were performed from Thursday to Saturday with most performed on Friday night (26.6%, p<0.001). Surgical wait times increased midweek and remained high until Saturday.

CONCLUSION

With a lack of dedicated trauma resources on the weekend, a significant increase in after-hours surgery and surgical wait times was identified following surgical volumes peaking on Thursday and Friday. We suggest adapting resource allocation to reflect surgical volumes. Dedicated weekend orthopaedic trauma resources or an adaptable schedule during increased orthopaedic trauma have the potential to ease this bottleneck, improve patient care, and decrease hospital costs.

The use of patient-reported outcome measures in hip and knee arthroplasty in Alberta

PROMs are part of routine measurement for hip and knee replacement in Alberta, Canada. We provide an overview of how PROMs are implemented in routine care, and how we use PROMs data for decision-making at different levels within the health system. The Alberta Bone and Joint Health Institute (ABJHI) ran a randomized controlled trial to determine the effectiveness and cost-effectiveness of an evidence-based care pathway for hip and knee arthroplasty in 2004. The study included several PROMs questionnaires: Western Ontario and McMaster Universities Osteoarthritis Index, Health Utility Index, Short Form 36 and the EQ-5D-3L. Subsequently, the focus shifted to spread and scale of the care pathway provincially. WOMAC and EQ-5D-3L and a patient experience survey were selected for provincial adoption – captured before surgery, three-months post-surgery, and 12-months post-surgery. These PROMs data were integrated into research and routine clinical practice at the micro, meso and macro levels. At the micro level, PROMs data are used at the individual patient and provider level for patients to provide input on their care and as a tool to communicate with their healthcare providers. We examined the relationship of appropriateness and patient reported outcomes in a prospective cohort study. We evaluated whether routinely collected PROMs could be integrated into a patient decision aid to better inform shared decision making. At the meso level, continuous quality improvement reports are provided routinely to individual health care providers, hospitals and clinics on their performance against the measurement framework and standard key performance indicators. At the macro level, PROMs data are used to evaluate system performance by comparing outcomes across different jurisdictions or over time and support health policy decision making. Combined with administrative databases, we have used simulation models to reflect transition through the continuum of care from disease onset through end-stage care regarding the burden of disease, healthcare resource requirements and associated healthcare costs. The addition of PROMs data in clinical repositories and analyses enables the system to identify and address issues of continuous quality improvement against a measurement framework of performance indicators and to explicitly recognize the trade-offs that are inherent in any resource-constrained system.

Strategies for developing and implementing a rheumatoid arthritis healthcare quality framework: a thematic analysis of perspectives from arthritis stakeholders

OBJECTIVES

To obtain stakeholder perspectives to inform the development and implementation of a rheumatoid arthritis (RA) healthcare quality measurement framework.

DESIGN

Qualitative study using thematic analysis of focus groups and interviews.

SETTING

Arthritis stakeholders from across Canada including healthcare providers, persons living with RA, clinic managers and policy leaders were recruited for the focus groups and interviews.

PARTICIPANTS

Fifty-four stakeholders from nine provinces.

INTERVENTIONS

Qualitative researchers led each focus group/interview using a semistructured guide; the digitally recorded data were transcribed verbatim. Two teams of two coders independently analysed the transcripts using thematic analysis.

RESULTS

Perspectives on the use of different types of measurement frameworks in healthcare were obtained. In particular, stakeholders advocated for the use of existing healthcare frameworks over frameworks developed in the business world and adapted for healthcare. Persons living with RA were less familiar with specific measurement frameworks, however, they had used existing online public forums for rating their experience and quality of healthcare provided. They viewed a standardised framework as potentially useful for assisting with monitoring the care provided to them individually. Nine guiding principles for framework development and 13 measurement themes were identified. Perceived barriers identified included access to data and concerns about how measures in the framework were developed and used. Effective approaches to framework implementation included having sound knowledge translation strategies and involving stakeholders throughout the measurement development and reporting process. Clinical models of care and health policies conducive to outcome measurement were highlighted as drivers of successful measurement initiatives.

CONCLUSION

These important perspectives will be used to inform a healthcare quality measurement framework for RA.

Surgical Approaches in Total Hip Arthroplasty Cost Per Case Analysis: A Retrospective, Matched, Micro-costing Analysis in a Socialised Healthcare System

BACKGROUND

Total hip arthroplasty (THA) offers an effective method of pain relief and restoration of function for patients with end-stage arthritis. The anterior approach (AA) claims to benefit patients with decreased pain, increased mobilisation and decreasing length of hospital stay (LOS). In a socialised healthcare platform we questioned whether the AA, compared to posterior (PA) and lateral (LA) approaches, can decrease the cost burden.

METHODS

Using a retrospective matched cohort study, we matched 69 AA patients to 69 LA and 69 PA patients for age (p = 0.99), gender (p = 0.99) and number of pre-surgical risk factors (p = 0.99). First, we used the Resource Intensity Weights (RIW) using the Health Services agreed on method of calculating cost. Secondly, micro-costing analysis was performed using the financial services data for each patient's hospital stay.

RESULTS

Using the RIW based cost analysis and 2-day reduction (95% CI 1.8-2.4) in LOS, the AA offers an estimated savings per case of $4099 (p < 0.001) compared to the LA and PA. Using micro-costing analysis, we found a total saving of $1858.00 per case (95% CI 1391-2324) when comparing the AA to the PA and LA. There was a statistically significant cost savings using every category: Net Direct Salary ($901.00, p < 0.001), Net Drug ($8.00, p = 0.003), Patient Supply ($454.00, p = 0.001), Patient Drug ($15.00, p = 0.008), Indirect Cost ($385.00, p < 0.001), Patient Care Administration ($106.00, p < 0.001). Furthermore, the AA saved 142 minutes of in-hospital rehabilitation time.

CONCLUSION

The AA THA provides statistically significant reductions in cost compared to PA and LA while releasing rehabilitation resources.

Do preoperative patient-reported outcomes predict hospital length of stay for surgically-treated end-stage ankle osteoarthritis patients?

BACKGROUND

End-stage ankle arthritis is often debilitating, associated with diminished mobility, pain, and reduced health related quality of life. Direct hospital costs of AA and TAA differ, with hospital length of stay being a major contributor. The objective of this study is to test the association between four patient-reported outcome measures with hospital length of stay, potentially important for preoperative planning and care.

METHODS

This study is based on a prospective cohort of patients scheduled for AA or TAA for end-stage ankle arthritis in the Vancouver Coastal Health authority, Canada. Participants completed a condition-specific instrument, the AOS, and three generic instruments, the PHQ-9, PEG and EQ-5D(3L) shortly after being scheduled for surgery. Multivariate mixed-effects Poisson regression models were used to measure the association between preoperative patient-reported outcome measures and length of stay.

RESULTS

Among the 183 patients eligible to participate, the participation rate was 48.5%. There were 89 participants. Participants reported a high level of preoperative ankle impairment and pain. The adjusted results found no relationship between the AOS, EQ-5D(3L) VAS or PHQ-9 values and participants' LOS. Participants with at least one chronic health condition and lowest SES category had longer LOS.

CONCLUSIONS

This study found no evidence of an association between four PROs collected prior to AA or TAA with hospital LOS. This finding suggests collecting these PROs preoperatively may not help with discharge planning.

Quality improvement in hospitals' surgery-related processes: A systematic review

Background: There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The fundamentals of QI begin with an understanding of the underlying theoretical framework. This study aims to provide an overview of the existing QI models and frameworks for general surgery. Methods: In this systematic review, published literature from January 2007 until September 2018 were retrieved from PubMed, Scopus, Web of Science and Embase databases, and Google Scholar using the MeSH terms related to QI and surgery. In total, 25 fulltext articles were finally included, and data extraction was based on research objectives. Results: Nine models were identified for QI in general surgery. These models were categorized into two main groups: (i) conceptual models or frameworks designed for QI in industry and applied in surgery, and (ii) those designed specifically for QI in surgery. Identified QI models were more used for improving postoperative processes and pre-hospital trauma care, identifying causes of prolonged periods of stay and lowering LOS index, improving surgical antimicrobial prophylaxis and antibiotics administrating during surgery process, reducing and controlling infections, reducing complications, reducing mortality and morbidity, reducing waiting times and start time delays, reducing variability and improving surgical clinic experience, reducing costs, improving operating room efficiency by removing processes that add no value, and lowering per-capita costs. Conclusion: According to the findings of this study, there are different models and frameworks with different aspects and dimensions for QI in surgery, which is recommended to use either of these models alone or with each other for specific circumstances. The use of these models in surgery is increasing, and it is recommended that these models could be used according to their functions in cases such as reducing the unnecessary use of resources, increasing the satisfaction of patients and their families with health care and improving the efficiency, safety and quality of healthcare in the surgical departments.

A multifaceted intervention to improve the quality of care for patients undergoing total joint arthroplasty

Knee and hip arthroplasties vary in cost, quality and outcomes. We developed a Lean quality improvement intervention for knee and hip arthroplasty patients encompassing the recognition, readiness, restoration and recovery phases of care. The intervention included standardised, evidence-based pathways, shared decision making, patient and family member engagement, and transdisciplinary rounding, implemented successively through a series of rapid process improvement workshops. We evaluated the intervention through run charts and time series analysis for 2005-2014. Outcomes included length of stay (LOS), 30-day readmission, discharge disposition, postsurgical complications and patient satisfaction. Included were 4253 total joint arthroplasty procedures, 1659 hip and 2594 knee. LOS decreased from 3.2 to 2.4 days postintervention for both hip and knee patients (p<0.001). The 30-day hospital readmission rate for hip patients decreased from 3.1% (18/576) to 1.1% (5/446, p=0.032) with knee patients unchanged. Discharge to home (vs rehabilitation facility or skilled nursing facility) increased from 72% (415/576) to 91% (405/446) (p<0.001) for hip patients, and from 70% (599/860) to 87% (578/663) for knee patients (p<0.001). Our standardised multifaceted Lean quality improvement programme was associated with reduced LOS, decreased readmission rates and improved discharge disposition in total knee and hip arthroplasty patients.

The EQ-5D-5L Is Superior to the -3L Version in Measuring Health-related Quality of Life in Patients Awaiting THA or TKA

BACKGROUND

As a generic measure of health-related quality of life among patients awaiting THA or TKA, the three-level version of the EQ-5D (EQ-5D-3L), which has three response levels of severity (no problems, some problems, and extreme problems/unable) to five questions, is widely used. Previous studies indicated that the ceiling effect of the EQ-5D-3L limits its application. The five-level version of the EQ-5D (EQ-5D-5L) was developed to enhance the measurement properties of the tool by adding two levels: slight problems and severe problems. However, only a few small studies have compared the EQ-5D-3L and EQ-5D-5L in patients awaiting THA and TKA.

QUESTIONS/PURPOSES

The purpose of this study was to examine the performance of the EQ-5D-3L and EQ-5D-5L among patients awaiting THA or TKA in terms of (1) response patterns, (2) convergent construct validity, (3) known-group validity, and (4) informativity and discriminatory power.

METHODS

This is a retrospective analysis of the Alberta Bone and Joint Health Data Repository, which recorded information on all patients receiving hip or knee arthroplasties between April 2010 and March 2017 in Alberta, Canada (n = 37,377). Patients receiving THA or TKA and who completed the EQ-5D and WOMAC at baseline (presurgery) were included in this study (n = 24,766). The EQ-5D-3L was administered to all patients in 2010, and was gradually replaced by the EQ-5D-5L between 2013 and 2016; the EQ-5D-5L reached full application in all clinics by 2017.A propensity score was used to match patients 1:1 who completed either the EQ-5D-3L or EQ-5D-5L before surgery. Response patterns have been explored using ceiling and floor effects and distribution across severity levels of each dimension. Convergent construct validity was examined using Spearman's correlation (rho) against the WOMAC. Known-group validity was examined by gender, preoperative risk factors, mental health, obesity, and WOMAC physical function score. Informativity and discriminatory power were examined using the Shannon (H') and Shannon evenness (J') indices. A total of 3446 pairs of patients awaiting THA (55% women; mean age, 66 years) and 5428 pairs of patients awaiting TKA (59% women; mean age 67 years) were included in this analysis; the study group included all patients who were kept in the propensity score matching.

RESULTS

Ceiling and floor effects were comparable and small (less than 0.5%) for both versions; the responses across severity levels for each dimension were more evenly distributed for the EQ-5D-5L. Convergent construct validity was stronger for the EQ-5D-5L as it consistently had stronger correlations with the WOMAC overall and domain scores than the EQ-5D-3L (rho(3L-THA), -0.77 to -0.31; rho(3L-TKA), -0.71 to -0.24; rho(5L-THA), -0.71 to -0.17; rho(5L-TKA), -0.64 to -0.17; all p values < 0.001). The hypotheses of known-group analyses were confirmed for both versions. The EQ-5D-5L demonstrated stronger informativity and discriminatory power than the EQ-5D-3L, particularly for the mobility dimension (THA, H'(5L/3L)=1.66/0.37, J'(5L/3L)=0.72/0.23; TKA, H'(5L/3L)=1.66/0.41, J'(5L/3L)=0.71/0.26).

CONCLUSIONS

This study demonstrates the superior construct validity, and informativity and discriminatory power of the EQ-5D-5L compared with the EQ-5D-3L among patients awaiting THA or TKA.

CLINICAL RELEVANCE

Compared with the three-level version, the five-level version of the EQ-5D differentiates between patients awaiting THA and TKA much better based on their mobility, which is a key health aspect or outcome in these patients. Our findings suggest that the EQ-5D-5L is more appropriate for this population.

Validation of a tool to assess patient satisfaction, waiting times, healthcare utilization, and cost

AIM

Patients' experience of the quality of care received throughout their continuum of care can be used to direct quality improvement efforts in areas where they are most needed. This study aims to establish validity and reliability of the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) - a tool that collects patients' experience that quantifies aspect of care used to make judgments about quality from the perspective of the Alberta Quality Matrix for Health (AQMH).

BACKGROUND

The AQMH is a framework that can be used to assess and compare the quality of care in different healthcare settings. The AQMH provides a common language, understanding, and approach to assessing quality. The HAPSQ is one tool that is able to assess quality of care according to five of six AQMH's dimensions.

METHODS

This was a prospective methodologic study. Between March and October 2015, a convenience sample of patients presenting with chronic full-thickness rotator cuff tears was recruited prospectively from the University of Calgary Sport Medicine Centre in Calgary, Alberta, Canada. Reliability of the HAPSQ was assessed using test-retest reliability [interclass correlation coefficient (ICC)>0.70]. Validity was assessed through content validity (patient interviews, floor and ceiling effects), criterion validity (percent agreement >70%), and construct validity (hypothesis testing).

FINDINGS

Reliability testing was completed on 70 patients; validity testing occurred on 96 patients. The mean duration of symptoms was three years (SD: 5.0, range: 0.1-29). Only out-of-pocket utilization possessed an ICC<0.70. Patients reported that items were relevant and appropriate to measuring quality of care. No floor or ceiling effects were present. Criterion validity was reached for all items assessed. A priori hypotheses were confirmed. The HAPSQ represents an inexpensive, reliable, and valid approach toward collecting clinical information across a patient's continuum of care.

Responsiveness of the EQ-5D-3L and EQ-5D-5L in patients following total hip or knee replacement

PURPOSE

To examine the responsiveness of the EQ-5D-3L and EQ-5D-5L among total hip/knee replacement (THR/TKR) patients.

METHODS

The EQ-5D (3L or 5L) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) have been routinely administered to all THR/TKR patients before and at 3 months after surgery in Alberta, Canada, since 2010. Patients were included in this analysis if they completed the WOMAC and the same version of EQ-5D at baseline and 3-month follow-up. The WOMAC was used as an anchor to categorize patients into 9 subgroups according to the relative change from baseline, i.e., no change, and 4 categories each for the amount of deterioration or improvement: large (≥ 70%), moderate (50% ≤ change < 70%), small but important (20% ≤ change < 50%), and very mild (0 < change ≤ 20%). The responsiveness of the EQ-5D-3L and EQ-5D-5L for each subgroup was assessed using effect size, standardized response mean, and Guyatt's Responsiveness Index.

RESULTS

A total of 1594 patients completed the EQ-5D-3L and WOMAC (60% females, mean age 66 years, N = 646 [41%] THR), and 3180 completed the EQ-5D-5L and WOMAC (60% females, mean age 66 years, N = 1352 [43.2%] THR) at baseline and 3-month follow-up. For both THR and TKR patients with "small but important" improvement, the EQ-5D-5L was consistently more responsive than the EQ-5D-3L.

CONCLUSION

Our study demonstrated that the EQ-5D-5L is more responsive than the EQ-5D-3L in identifying health-related quality of life changes in THR/TKR patients. We recommend using the EQ-5D-5L in longitudinal studies in this patient population.

Association between Allogeneic Blood Transfusion and Wound Infection after Total Hip or Knee Arthroplasty: A Retrospective Case-Control Study

Background: To assess using a retrospective case control study, whether patients undergoing primary, elective total hip or knee arthroplasty who receive blood transfusion have a higher rate of post-operative infection compared to those who do not.

Materials and Methods: Data on elective primary total hip or knee arthroplasty patients, including patient characteristics, co-morbidities, type and duration of surgery, blood transfusion, deep and superficial infection was extracted from the Alberta Bone and Joint Health Institute (ABJHI). Logistic regression analysis was used to compare deep infection and superficial infection in blood-transfused and non-transfused cohorts.

Results: Of the 27892 patients identified, 3098 (11.1%) received blood transfusion (TKA 9.7%; THA 13.1%). Overall, the rate of superficial infection (SI) was 0.5% and deep infection (DI) was 1.1%. The infection rates in the transfused cohort were SI 1.0% and DI 1.6%, and in the non-transfused cohort were SI 0.5% and DI 1.0%. The transfused cohort had an increased risk of superficial infection (adjusted odds ratio (OR) 1.9 [95% CI 1.2-2.9, p-value 0.005]) as well as deep infection (adjusted OR 1.6 [95% CI 1.1-2.2, p-value 0.008]).

Conclusion: The odds of superficial and deep wound infection are significantly increased in primary, elective total hip and knee arthroplasty patients who receive blood transfusion compared to those who did not. This study can potentially help in reducing periprosthetic hip or knee infections.

Evaluating quality of care for patients with rotator cuff disorders

Background

Measuring quality in healthcare is vital in evaluating patient outcomes and system performance. The availability of reliable and valid information about the quality of care for patients presenting with rotator cuff disorders (RCD) in Alberta, Canada is scarce. The objective of this study is to measure quality of care for patients with RCD in order to identify areas of improvement.

Methods

This study employs descriptive survey research design. Between March 2015 and November 2016, a convenience sample of patients presenting with chronic, full-thickness rotator cuff tears to two sport medicine centres in Calgary and Edmonton, Alberta completed two questionnaires: the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ) and the Rotator Cuff Quality-of-Life Index (RC-QOL). Data collected using both questionnaires were used to make judgments about quality of care. Quality of care was evaluated using six dimensions of quality defined by the Alberta Quality Matrix for Health: accessibility, acceptability, efficiency, effectiveness, appropriateness, and safety. Data was also used to compare current patient clinical pathways to ideal clinical pathway algorithms and used to make judgments about the appropriateness and safety of healthcare practices.

Results

One hundred seventy-one patients participated in the study. The longest mean waiting times for medical services in Alberta were for magnetic resonance imaging (MRI) received in the public sector (103 days) and consultation by orthopaedic surgeon (172 days). Patient satisfaction with respect to quality of care was lowest for emergency room physician and highest for orthopaedic surgeon visits. Patients were treated by a mean of 2.5 physicians (SD: 0.77, range: 2–7). The total aggregate average cost per patient was $4541.19. The mean RC-QOL score for all patients was 42 (SD: 22). Only 54 patients (64%) requiring surgery were able to consult with a surgeon within benchmark timeframes. A comparison of current to ideal clinical pathway algorithms found that 38 patients (22%) experienced indirect clinical pathways, whereby care was fragmented and patients received care from multiple and often, redundant healthcare professionals.

Conclusion

There is a discrepancy between current and ideal clinical pathways whereby some patients are experiencing quality of care that is inefficient, disjointed, and less than ideal.

Complications and Mortality Following Total Hip Arthroplasty in the Octogenarians: An Analysis of a National Database

BACKGROUND

As advances in medicine have increased life expectancy, more octogenarians are undergoing total hip arthroplasty (THA) than ever before. Concerns exist, however, about the safety of performing this elective procedure in this age group. The purpose of this study is to determine the 30-day complications associated with THA patients over 80 years of age and to identify high-risk patients.

METHODS

We queried the American College of Surgeons-National Surgical Quality Improvement Program database for all patients who underwent primary THA from 2011 to 2014. Demographic variables, medical comorbidities, and 30-day complication, readmission, and reoperation rates were compared between patients under vs over 80 years of age. A multivariate logistic regression analysis was then performed to identify independent risk factors of poor short-term outcomes.

RESULTS

Of the total 66,839 patients who underwent THA, 7198 (11%) patients were 80 years of age or older. Octogenarians had a higher overall complication rate (29% vs 15%, P < .001) and a higher mortality rate (0.9% vs 0.1%, P < .001). When controlling for other comorbidities, age over 80 years is an independent risk factor for mortality (odds ratio 2.02, 95% confidence interval 1.25-3.26, P = .004) and complications (odds ratio 1.41, 95% confidence interval 1.30-1.525, P < .001) following THA. Malnutrition and chronic kidney disease are also independent risk factors for readmission, complications, and mortality (all P < .05).

CONCLUSION

THA in patients older than 80 years old are at an increased risk of complications and mortality. Octogenarian patients should be counseled on their risk profile, particularly those with malnutrition and chronic kidney disease.