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Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation.

ABSTRACT: OBJECTIVES:We assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety. DESIGN:Preimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts. SETTING:Regional, provincial health authority. PARTICIPANTS:Patients awaiting total joint replacement of the hip or knee. INTERVENTIONS:The WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood. PRIMARY AND SECONDARY OUTCOME MEASURES:Primary outcomes related to 'accessibility': waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression. RESULTS:Variability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee). CONCLUSIONS:The WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality.

SUBMITTER: Damani Z

PROVIDER: S-EPMC7008436 | biostudies-literature | 2019 Dec

REPOSITORIES: biostudies-literature

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Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation.

Damani Zaheed Z Bohm Eric E Quan Hude H Noseworthy Thomas T MacKean Gail G Loucks Lynda L Marshall Deborah A DA

BMJ open 20191223 12

<h4>Objectives</h4>We assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety.<h4>Design</h4>Preimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts.<h4>Setting</h4>Regional, provincial health authority.<h4 ...[more]

PMID: 31874866

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Project description:BackgroundVariation in access to joint replacement surgery has been widely reported but less attention has been given to the impact of comorbidities on the patient journey to joint replacement surgery. There is a lack of consensus amongst healthcare professionals and commissioners about how patients with comorbidities should be referred or selected for joint replacement surgery. It is therefore important to understand the views of healthcare professionals on the management, referral and selection of patients with comorbidities for joint replacement surgery.MethodsAn exploratory qualitative study involving semi-structured interviews with 20 healthcare professionals in England across the referral pathway to joint replacement surgery. They were asked to talk about their experiences of referring and selecting patients with comorbidities for joint replacement surgery. The interviews were audio-recorded and transcribed verbatim. Data analysis followed a thematic analysis approach based on the principles of grounded theory.ResultsIn general, the presence of comorbidities was not seen as a barrier to being referred or selected for joint replacement but was seen as a challenge to manage the patients' journey across the referral pathway. Each professional group, concentrated on different aspects of the patients' condition which appeared to affect how they managed patients with comorbidities. This implied there was a disagreement about roles and responsibilities in the management of patients with comorbidities. None of the professionals believed it was their responsibility to address comorbidities in preparation for surgery. This disagreement was identified as a reason why some patients seem to 'get lost' in the referral system when they were considered to be unprepared for surgery. Patients were then potentially left to manage their own comorbidities before being reconsidered for joint replacement.ConclusionsAt the clinician-level, comorbidities were not perceived as a barrier to accessing joint replacement surgery but at the pathway-level, it may create an implicit barrier such that patients with comorbidities may get 'lost' to the system. Further study is needed to explore the roles and responsibilities of professionals across the current orthopaedic referral pathway which may be less suitable for patients with comorbidities.

Project description:In Ghana, Community-based Health Planning and Services (CHPS) compounds managed by trained nurses and midwives called community health officers (CHOs) play a major role in malaria service delivery. With heavy administrative burdens and minimal training in providing patient care, particularly for febrile illnesses, including malaria, CHOs struggle to comply with the World Health Organization's test, treat, and track initiative guidelines and appropriate referral practices. A clinical training and mentorship program was implemented for CHOs to prevent and manage uncomplicated malaria and offer appropriate pre-referral treatment and referrals to district hospitals. Medical officers, pharmacists, midwives, health information officers, and medical laboratory scientists at 52 district referral hospitals were trained as mentors; CHOs from 520 poorly performing CHPS compounds underwent a 5-day internship at their assigned district referral hospital to improve knowledge and clinical skills for malaria case management. Three months later, mentors conducted post-training mentoring visits to assess knowledge and skill retention and provide ongoing on-the-job guidance. Significant percentage-point increases were observed immediately post-internship for history taking (+12.0, 95% confidence interval [CI]=8.3, 15.1; P<.001); fever assessment (+24.9, 95% CI=20.9, 29.3; P<.001); severe malaria assessment and referral (+32.0, 95% CI=28.2, 35.8; P<.001); and knowledge assessment (+15.8, 95% CI=10.0, 21.3; P<.001). Three months later, a third assessment revealed these gains were largely maintained. Analysis of national health management information system data showed statistically significant improvements in testing, treatment, and referral indicators at intervention CHPS compounds after the intervention that were not observed in comparison CHPS compounds. This training and mentorship approach offers a replicable model to build primary care provider competencies in malaria prevention and management and demonstrates how developing relationships between primary care and first-level referral facilities benefits both providers and clients. More methodologically rigorous studies are needed to measure the impact of this approach.

Project description:BackgroundNo validated pre-operative cardiac risk stratification tool exists that is specific for total hip and total knee arthroplasty (THA and TKA, respectively). To reduce the risk of post-operative cardiac complication, surgeons need clear guidance on which patients are likely to benefit from pre-operative cardiac optimisation. This is particularly important for asymptomatic patients, where the need is harder to determine.MethodsPrimary THA and TKA performed between January 1, 2010, and December 31, 2017, were identified from a single orthopaedic practice. Over 25 risk factors were evaluated as predictors for patients requiring additional cardiac investigation beyond an ECG and echocardiogram, and for cardiac abnormality detected upon additional investigation. A multivariate logistic regression was conducted using significant predictor variables identified from inferential statistics. A series of predictive scores were constructed and weighted to identify the influence of each variable on the ability to predict the detection of cardiac abnormality pre-operatively.ResultsThree hundred seventy-four patients were eligible for inclusion. Increasing age (p < 0.001), history of cerebrovascular accident (p = 0.018), family history of cardiovascular disease (FHx of CVD) (p < 0.001) and decreased ejection fraction (EF) (p < 0.001) were significant predictors of additional cardiac investigation being required. Increasing age (p = 0.003), male gender (p = 0.042), FHx of CVD (p = 0.001) and a reduced EF (p < 0.001) were significantly predictive for the detection of cardiac abnormality upon additional cardiac investigation.ConclusionsIncreasing age, male gender, FHx of CVD and decreased ejection fraction are important risk factors to consider for pre-operative cardiac optimisation in THA and TKA patients. These findings can be applied towards future predictive models, to determine which asymptomatic patients are likely to benefit from pre-operative cardiac referral.

Project description:BACKGROUND:In 2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), a national mandatory bundled-payment model for hip or knee replacement in randomly selected metropolitan statistical areas. Hospitals in such areas receive bonuses or pay penalties based on Medicare spending per hip- or knee-replacement episode (defined as the hospitalization plus 90 days after discharge). METHODS:We conducted difference-in-differences analyses using Medicare claims from 2015 through 2017, encompassing the first 2 years of bundled payments in the CJR program. We evaluated hip- or knee-replacement episodes in 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program (bundled-payment metropolitan statistical areas, hereafter referred to as "treatment" areas) as compared with those in 121 control areas, before and after implementation of the CJR model. The primary outcomes were institutional spending per hip- or knee-replacement episode (i.e., Medicare payments to institutions, primarily to hospitals and post-acute care facilities), rates of postsurgical complications, and the percentage of "high-risk" patients (i.e., patients for whom there was an elevated risk of spending - a measure of patient selection). Analyses were adjusted for the hospital and characteristics of the patients and procedures. RESULTS:From 2015 through 2017, there were 280,161 hip- or knee-replacement procedures in 803 hospitals in treatment areas and 377,278 procedures in 962 hospitals in control areas. After the initiation of the CJR model, there were greater decreases in institutional spending per joint-replacement episode in treatment areas than in control areas (differential change [i.e., the between-group difference in the change from the period before the CJR model], -$812, or a -3.1% differential decrease relative to the treatment-group baseline; P<0.001). The differential reduction was driven largely by a 5.9% relative decrease in the percentage of episodes in which patients were discharged to post-acute care facilities. The CJR program did not have a significant differential effect on the composite rate of complications (P=0.67) or on the percentage of joint-replacement procedures performed in high-risk patients (P=0.81). CONCLUSIONS:In the first 2 years of the CJR program, there was a modest reduction in spending per hip- or knee-replacement episode, without an increase in rates of complications. (Funded by the Commonwealth Fund and the National Institute on Aging of the National Institutes of Health.).

Project description:Total hip replacements (THR) have been performed in the UK from the 1960s and since then we have seen surgical techniques, the design of implants, and imaging modalities rapidly develop. This paper will aim to review the different complications and imaging appearance which help to evaluate each problem. As for all investigations for bone and joints, a radiograph is the first imaging to be performed for any patient with a THR and can detect a majority of complications. CT is relatively low-cost, simple to perform and easily available making it an excellent tool to supplement radiographs when trying to evaluate a hip prosthesis. Single photon emission computed tomography with CT (SPECT-CT) is an emerging modality which has shown to combine the sensitivity that bone scintigraphy offers with the high specificity of CT. SPECT imaging also has the advantage of showing the bone's metabolic activity and is less prone to metal artifact than Magnetic resonance imaging (MRI). MRI has evolved to become an important diagnostic tool for the evaluation of THR in the post-operative period. Optimized pulse sequences and metal artifact reduction techniques have made MRI a useful tool in diagnosis of soft tissue abnormalities and is particularly useful in identifying adverse local tissue reactions in metal on metal implants. CT and MRI are accurate in identifying the diagnosis of most causes of THR complications except infection. Research confirms that leukocyte-marrow scintigraphy is the modality of choice for accurately diagnosing prosthetic joint infection and reassures us of its superiority over other nuclear medicine imaging. However, due to the limited availability and increased costs when performing leukocyte-marrow scintigraphy, CT and SPECT-CT would be a more preferred option when suspecting prosthesis infection. Ultrasound (US) has a limited role in the assessment of most THR complications but can be useful to identify peri-prosthetic fluid collections and the presence of soft tissue sinus tracts. Being aware of the imaging modalities that are available to orthopedic surgeons, and discussing these challenging cases with specialist radiologists will enable optimal management of THR complications.

Dataset Information

Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation.

Publications

Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation.

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