Following standardized TJA processes leads to better quality care, study finds

Researchers learned that close compliance with evidence-based TJA processes was associated with shorter length of stay and improved clinical outcomes.

NEW ORLEANS — A recent study identifying a strong association between process standardization and better quality and efficiency of medical care suggests that standardizing the processes used when performing total joint arthroplasty is critical for optimizing the quality and efficiency of these procedures, regardless of surgeon or hospital procedure volume.

“Surgeon volume is highly correlated with patient outcomes in total joint arthroplasty. Individual process of care measures are of questionable and variable importance, however maximizing adherence to process of care measures appears to be strongly associated with better patient outcomes. This suggests that systematizing care or standardizing processes is important,” Kevin J. Bozic, MD, MBA, of San Francisco, said.

He presented study results at the Knee Society Specialty Day Meeting held here during the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons.

Bozic noted during his presentation that other investigators have already shown that a strong relationship exists between higher surgeon and hospital volume of total joint arthroplasty (TJA) and improved outcomes.

Database study

Kevin J. Bozic

Bozic and colleagues analyzed data from the Premier Perspective database for 182,146 TJA procedures performed by 3,421 physicians at 312 hospitals between October 1, 2003 and September 30, 2005.

They defined compliance with or adherence to evidence-based processes as whether patients received appropriate perioperative beta-blockades, antibiotic prophylaxis and venous thromboembolism (VTE) prophylaxis.

Bozic and colleagues then assessed whether or not outcomes were associated with differences in mortality, length of stay (LOS), discharge, operative complications, re-admissions and reoperations within 30 days of the index procedure. Among their findings related to a high hospital volume of TJA cases were a lower risk of mortality and lower rates of readmission, and a greater likelihood of patients being discharged to home.

Higher surgeon volume also corresponded to lowered risk of complications, re-admissions, reoperations, shorter LOS and greater likelihood of being discharged to home, they found.

Using processes has impact

Researchers identified an association between adhering to evidence-based care processes and improved clinical outcomes and shorter LOS, which they determined was independent of hospital or surgeon procedure volume.

Bozic told Orthopedics Today, “We chose to study this issue because we were interested in understanding if adherence to ‘process of care’ measures (such as administration of antibiotics, VTE prophylaxis, and beta-blockers) correlate with better patient outcomes in TJA. What we found was that although the individual process of care measures had inconsistent correlation with patient outcomes, maximizing adherence to process of care measures resulted in improved patient outcomes, which suggests that implementing care pathways and/or systems of care could improve patient outcomes in both low and high volume hospitals.” – by Susan M. Rapp

References:

• Bozic KJ, Maselli J, Vail TP, Auerbach A. The influence of procedure volumes and adherence to process of care “quality” measure on patient outcomes in total joint arthroplasty (TJA). Presented at the Knee Society Specialty Day Meeting. March 13, 2010. New Orleans.

• Kevin J. Bozic, MD, MBA, can be reached at University of California, San Francisco, 500 Parnassus, MU-320 W, San Francisco, CA 94143; 415-476-3320; e-mail: bozick@orthosurg.ucsf.edu.

Jack M. Bert

I agree with Dr. Bozic that volume begets quality as a result of experience, but does not necessarily render efficient patient care. There are multiple hospital systems that do a large volume of cases that quite frankly have not figured it out yet. As Fred Taylor, who developed the assembly line process in the late 1800s, said, “In order to improve the performance of a machine, you have to improve the performance of the workers that run the machine.” This includes the physician, his assistant, the operating room staff and all the nursing care before and after a surgical procedure has occurred.

If the health care “workers” are unwilling or unable to improve their performance, the system will remain dysfunctional and inefficient. As Dr. Bozic implied, process standardization is critical in order to improve efficiency and care quality to avoid complications and poor outcomes. The surgeon, however, must be willing to agree and adapt to these process changes in order to improve his performance or the system, and eventually the patient, will suffer as well.

— Jack M. Bert, MD
Orthopedics Today Business of Orthopedics Section Editor