Overcoming resistance to implementation of integrated care pathways in orthopaedics

Artificial neural network prediction of same-day discharge following primary total knee arthroplasty based on preoperative and intraoperative variables

AIMS

This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA).

METHODS

Data for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital length of stay.

RESULTS

The predictability of the ANN model, area under the curve (AUC) = 0.801, was similar to the logistic regression model (AUC = 0.796) and identified certain variables as important factors to predict same-day discharge. The ten most important factors favouring same-day discharge in the ANN model include preoperative sodium, preoperative international normalized ratio, BMI, age, anaesthesia type, operating time, dyspnoea status, functional status, race, anaemia status, and chronic obstructive pulmonary disease (COPD). Six of these variables were also found to be significant on logistic regression analysis.

CONCLUSION

Both ANN modelling and logistic regression analysis revealed clinically important factors in predicting patients who can undergo safely undergo same-day discharge from an outpatient TKA. The ANN model provides a beneficial approach to help determine which perioperative factors can predict same-day discharge as of 2018 perioperative recovery protocols. Cite this article: Bone Joint J 2021;103-B(8):1358-1366.

Hospital Discharge Within a Day After Total Knee Arthroplasty Does Not Affect 1-Year Complications Compared With Rapid Discharge

INTRODUCTION

In patients undergoing total knee arthroplasty (TKA), it is unclear whether a difference in complication rates exists between patients discharged the day of surgery compared with subsequent postoperative days.

METHODS

Data were collected from the PearlDiver Patient Records Database from 2007 to 2017. Subjects were identified using International Classification of Diseases codes. Eligible patients were stratified into the following three groups: (1) same day discharge (<24 hours postoperatively), (2) rapid discharge (1 to 2 days), and (3) traditional discharge (3 to 4 days) based on the length of stay.

RESULTS

In total, 84,864 patients were identified as having undergone primary TKA. The incidence of same day discharge, rapid discharge, and traditional discharge was 2.36% (2,004/84,864), 28.56% (24,235/84,864), and 69.08% (58,625/84,864), respectively. After adjustment, no notable differences were observed in the overall complication and revision rates between the same day discharge group and either the rapid discharge or the traditional discharge group. On multivariate analysis, patients in the rapid discharge cohort were less likely to require manipulation under anesthesia or develop periprosthetic joint infection when compared with the traditional discharge group at 1 year postoperatively.

CONCLUSIONS

For those who qualify after careful selection, same day and rapid discharge TKA may be a feasible alternative to the traditional inpatient TKA.

LEVEL OF EVIDENCE

A level 3 retrospective, prognostic study.

Factors Influencing Patient Selection of a Foot and Ankle Surgeon

An increasingly consumer-centric health insurance market has empowered patients to select the providers of their choice. There is a lack of studies investigating the rationale by which patients select a foot and ankle surgeon. In the present study, 824 consecutive new patients seeking treatment from 3 foot-ankle surgeons were consecutively administered an anonymous questionnaire prior to their first appointment. It included rating the importance of 15 factors regarding specialist selection on a 1 to 10 scale, with 10 designated " Very important" and 1 designated " Not important at all." The remaining questions were multiple choice regarding patient perspectives on other surgeon aspects (appointment availability, waiting room times, clinic proximity, etc). Of 824 consecutive patients administered the survey, 305 (37%) responded. Patients rated board certification (9.24 ± 1.87) and on-site imaging availability (8.48 ± 2.37)-on a 1 to 10 scale, with 10 designated "Very important- as the 2 most important criteria in choosing a foot and ankle surgeon. Patients rated advertisements as least important. Among the patients, 91% responded that a maximum of 30 minutes should elapse between clinic check-in and seeing their physician; 61% responded that a maximum of 20 minutes should elapse between clinic check-in and seeing their physician. In the context of an increasingly consumer-driven paradigm of health care delivery and reimbursement, it is important to understand patients' preferences in specialist selection.

LEVELS OF EVIDENCE

Level III: Prospective questionnaire.

Using a Comanagement Model to Develop a Hip Fracture Integrated Care Pathway

EXECUTIVE SUMMARY

Hip fracture care represents a service line that profoundly affects patients' quality of life. As hospitals and physicians are motivated to improve quality, reduce costs, and maximize efficiency of care, several alignment models have been proposed under new healthcare legislation. Evaluation of such models as they pertain to hip fracture care warrants further investigation. In this article, we identify the current model of operations present in large healthcare organizations, examine the reasoning behind hospital-physician alignment, and describe specific comanagement principles that are common in healthcare settings. Furthermore, the effects of a comanagement model on a hip fracture integrated care pathway will be demonstrated through a case study. A comanagement team was formed at a Level I academic trauma center to create an integrated care pathway for the hip fracture service line. An internal data review of hip fracture cases before and after implementation of the pathway was undertaken to assess the impact of this model in terms of postoperative outcomes and resource utilization. The postimplementation group displayed more observant care while consuming fewer resources. Thus, the comanagement model described in this article serves as a powerful tool, allowing hospitals and physicians to improve the quality of care. This study provides recommendations based on our success in the hip fracture setting that may be extrapolated to improve service lines and healthcare efficiency nationally.

Using systems thinking to support clinical system transformation

Purpose

– The British Columbia Ministry of Health’s Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC’s health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings.

Design/methodology/approach

– Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey.

Findings

– The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system.

Research limitations/implications

– The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels – policy, management and practice – about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue.

Practical implications

– Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues.

Originality/value

– Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

Orthopaedic Surgery Under National Health Reform: An Analysis of Power, Process, Adaptation, and Leadership: AOA Critical Issues

Morrison argued that demography, economy, and technology drive the evolution of industries from a formative first-generation state ("First Curve") to a radically different way of doing things ("Second Curve") that is marked by new skills, strategies, and partners. The current health-reform movement in the United States reflects these three key evolutionary trends: surging medical needs of an aging population, dramatic expansion of Medicare spending, and care delivery systems optimized through powerful information technology. Successful transition from a formative first-generation state (First Curve) to a radically different way of doing things (Second Curve) will require new skills, strategies, and partners. In a new world that is value-driven, community-centric (versus hospital-centric), and prevention-focused, orthopaedic surgeons and health-care administrators must form new alliances to reduce the cost of care and improve durable outcomes for musculoskeletal problems. The greatest barrier to success in the Second Curve stems not from lack of empirical support for integrated models of care, but rather from resistance by those who would execute them. Porter's five forces of competitive strategy and the behavioral analysis of change provide insights into the predictable forms of resistance that undermine clinical and economic success in the new environment of care. This paper analyzes the components that will differentiate orthopaedic care provision for the Second Curve. It also provides recommendations for future-focused orthopaedic surgery and health-care administrative leaders to consider as they design newly adaptive, mutually reinforcing, and economically viable musculoskeletal care processes that drive the level of orthopaedic care that our nation deserves-at a cost that it can afford.

Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients

PURPOSE

Modern management of the elderly with a hip fracture is complex and costly. The aim of this study was to compare the treatment-related hospital length of stay (HLOS) before and after implementing a clinical pathway for patients undergoing hip fracture surgery.

METHODS

This was a retrospective, before-and-after study. The first period ranged from June 21, 2008 to November 1, 2009 (N = 212), and the second was from January 7, 2010 to July 7, 2011 (N = 314). The electronic hospital system and patients records were reviewed for demographics, HLOS, mortality, complications and readmissions.

RESULTS

In the first period 53 % had a femoral neck fracture, of which 57 % were treated with hemiarthroplasty. In the second period this was 46 % and 71 %. Pertrochanteric fractures were treated with a Gamma nail in 85 % in the first period, and in 92 % in the second period. The median HLOS decreased from nine to six days (p < 0.001). For the hemiarthroplasty group HLOS decreased from nine to seven days (p < 0.001); for internal fixation there was no significant difference (five versus six days, p = 0.557) and after Gamma nailing it decreased from ten to six days (p < 0.001). For mortality no statistically significant difference was found (6 % versus 5 %, p = 0.698). Complications decreased for the Gamma nail group (44 % versus 31 %, p = 0.049). Readmissions for the total group were not different (16 % versus 17 %, p = 0.720).

CONCLUSIONS

Implementing a clinical pathway for hip fractures is a safe way to reduce the HLOS and it improves the quality of care.