Hostname: page-component-586b7cd67f-vdxz6 Total loading time: 0 Render date: 2024-11-28T01:00:17.312Z Has data issue: false hasContentIssue false
  • English
  • Français

The Alberta hip and knee replacement project: A model for health technology assessment based on comparative effectiveness of clinical pathways

Published online by Cambridge University Press:  15 April 2009

Katherine L. Gooch ,
Douglas Smith ,
Tracy Wasylak ,
Peter D. Faris ,
Deborah A. Marshall ,
Hoa Khong ,
Julie E. Hibbert ,
Robyn D. Parker ,
Ronald F. Zernicke  and
Lauren Beaupre
...Show all authors
Katherine L. Gooch
Affiliation:
Alberta Bone and Joint Health Institute and Curtin University of Technology
Douglas Smith
Affiliation:
Alberta Bone and Joint Health Institute
Tracy Wasylak
Affiliation:
Alberta Health Services
Peter D. Faris
Affiliation:
Alberta Bone and Joint Health Institute
Deborah A. Marshall
Affiliation:
Alberta Bone and Joint Health Institute
Hoa Khong
Affiliation:
Alberta Bone and Joint Health Institute
Julie E. Hibbert
Affiliation:
Alberta Bone and Joint Health Institute
Robyn D. Parker
Affiliation:
Alberta Bone and Joint Health Institute
Ronald F. Zernicke
Affiliation:
University of Michigan
Lauren Beaupre
Affiliation:
Capital Health/Alberta Health Services
Tim Pearce
Affiliation:
Alberta Health Services
D. W. C. Johnston
Affiliation:
Alberta Health Services
Cyril B. Frank
Affiliation:
Alberta Bone and Joint Health Institute
Get access Rights & Permissions [Opens in a new window]

Abstract

Background: The Alberta Hip and Knee Replacement Project developed a new evidence-based clinical pathway (NCP) for total hip (THR) and knee (TKR) replacement. The aim was to facilitate the delivery of services in a timely and cost-effective manner while achieving the highest quality of care for the patient across the full continuum of care from patient referral to an orthopedic surgeon through surgery, recovery, and rehabilitation. The purpose of this article is to provide an overview of the study design, rationale, and execution of this project as a model for health technology assessment based on comparative effectiveness of alternative clinical pathways.

Methods: A pragmatic randomized controlled trial study design was used to evaluate the NCP compared with the standard of care (SOC) for these procedures. The pragmatic study design was selected as a rigorous approach to produce high quality evidence suitable for informing decisions between relevant interventions in real clinical practice. The NCP was evaluated in three of the nine regional health authorities (RHAs) in Alberta with dedicated central intake clinics offering multidisciplinary care teams, constituting 80 percent of THR and TKR surgeries performed annually in Alberta. Patients were identified in the offices of twenty orthopedic surgeons who routinely performed THR or TKR surgeries. Evaluation outcome measures were based on the six dimensions of the Alberta Quality Matrix for Health (AQMH): acceptability, accessibility, appropriateness, effectiveness, efficiency and safety. Data were collected prospectively through patient self-completed questionnaires at baseline and 3 and 12 months after surgery, ambulatory and inpatient chart reviews, and electronic administrative data.

Results: The trial design was successful in establishing similar groups for rigorous evaluation. Of the 4,985 patients invited to participate, 69 percent of patients consented. A total of 3,434 patients were randomized: 1,712 to SOC and 1,722 to the NCP. The baseline characteristics of patients in the two study arms, including demographics, comorbidity as measured by CDS and exposure to pain medications, and health-related quality of life, as measured by Western Ontario and McMaster Universities Osteoarthritis Index and Short Form-36, were similar.

Conclusions: The Alberta Hip and Knee Replacement Project demonstrates the feasibility and advantages of applying a pragmatic randomized controlled trial to ascertain comparative effectiveness. This is a model for health technology assessment that incorporates how clinical pathways can be effectively evaluated.

Keywords

Clinical pathwaysHealth technology assessmentPragmatic randomized controlled trialArthroplastyQuality indicatorsOutcome measures
Type
General Essays
Information
International Journal of Technology Assessment in Health Care , Volume 25 , Issue 2 , April 2009 , pp. 113 - 123
Copyright
Copyright © Cambridge University Press 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Aaronson, NK, Acquadro, C, Alonso, J et al. , International quality of life assessment (IQOLA) project. Qual Life Res. 1992;1:349–351.Google Scholar
2. Agency for Healthcare Research & Quality. US Department of Health & Human Services. National Guideline Clearinghouse. www.guideline.gov (accessed December 18, 2008).Google Scholar
3. Alberta Regional Health Authorities. The careguide source for seniors. www.thecareguide.com/Resources (accessed November 14, 2008).Google Scholar
4. Australian Orthopaedic Association. National Joint Replacement Registry Annual Report 2007. http://www.dmac.adelaide.edu.au/aoanjrr/documents/aoanjrrreport_2007.pdf (accessed November 23, 2008).Google Scholar
5. Bellamy, N. WOMAC osteoarthritis index- user guide VII. Brisbane, Australia: 2004.Google Scholar
6. Bellamy, N, Buchanan, WW, Goldsmith, CH, Campbell, J, Stitt, LW. Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988;15:1833–1840.Google ScholarPubMed
7. Berry, DJ, Harmsen, WS, Cabanela, ME, Morrey, BF. Twenty-five-year survivorship of two thousand consecutive primary Charnley total hip replacements: Factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am. 2002;84:171–177.Google Scholar
8. Boutron, I, Moher, D, Altman, DG, Schulz, KF, Ravaud, P, CONSORT Group. Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: Explanation and elaboration. Ann Intern Med. 2008;148:295–309.CrossRefGoogle Scholar
9. Brunenberg, DE van Steyn, MJ, Sluimer, JC et al. , Joint recovery programme versus usual care: An economic evaluation of a clinical pathway for joint replacement surgery. Med Care. 2005;43:1018–1026.Google Scholar
10. Canadian Institute of Health Information (CIHI). Canadian Joint Replacement Registry (CJRR) 2006 annual report. Hip and knee replacements in Canada 2006. http://dsp-psd.pwgsc.gc.ca/Collection/H115-7-2006E.pdf.Google Scholar
11. Clark, DO, Von Korff, M, Saunders, K, Baluch, WM, Simon, GE. A chronic disease score with empirically derived weights. Med Care. 1995;33:783–795.CrossRefGoogle ScholarPubMed
12. Cushnaghan, J, Bennett, J, Reading, I et al. , Long-term outcome following total knee arthroplasty: A controlled longitudinal study. Ann Rheum Dis. 2008 [Epub ahead of print].CrossRefGoogle Scholar
13. Darer, J, Pronovost, P, Bass, EB. Use and evaluation of critical pathways in hospitals. Eff Clin Pract. 2002;5:114–119.Google ScholarPubMed
14. Dixon, T, Shaw, ME, Dieppe, PA. Analysis of regional variation in hip and knee joint replacement rates in England using hospital episodes statistics. Public Health. 2006;120:83–90.CrossRefGoogle ScholarPubMed
15. Dowsey, MM, Kilgour, ML, Santamaria, NM, Choong, PF. Clinical pathways in hip and knee arthroplasty: A prospective randomised controlled study. Med J Aust. 1999;170:59–62.CrossRefGoogle ScholarPubMed
16. Dy, SM, Garg, P, Nyberg, D et al. , Critical pathway effectiveness: Assessing the impact of patient, hospital care, and pathway characteristics using qualitative comparative analysis. Health Serv Res. 2005;40:499–516.Google Scholar
17. El Baz, N, Middel, B, van Dijk, JP et al. , Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research. J Eval Clin Pract. 2007;13:920–929.Google Scholar
18. Ernst, E, Canter, PH. Limitations of “pragmatic” trials. Postgrad Med J. 2005;81:203.CrossRefGoogle ScholarPubMed
19. Freemantle, N, Blonde, L, Bolinder, B et al. , Real-world trials to answer real-world questions. Pharmacoeconomics. 2005;23:747–754.CrossRefGoogle ScholarPubMed
20. Garrison, LP Jr, Neumann, PJ, Erickson, P, Marshall, D, Mullins, CD. Using real-world data for coverage and payment decisions: The ISPOR real-world data task force report. Value Health. 2007;10:326–35.Google Scholar
21. Glasgow, RE, Magid, DJ, Beck, A, Ritzwoller, D, Estabrooks, PA. Practical clinical trials for translating research to practice: Design and measurement recommendations. Med Care. 2005;43:551–557.Google Scholar
22. Health Quality Council of Alberta. Alberta Quality Matrix for Health (AQMH) user guide 2005. http://www.hqca.ca/index.php.Google Scholar
23. Healy, WL, Ayers, ME, Iorio, R et al. , Impact of a clinical pathway and implant standardization on total hip arthroplasty: A clinical and economic study of short-term patient outcome. J Arthroplasty. 1998;13:266–276.CrossRefGoogle ScholarPubMed
24. Jain, NB, Higgins, LD, Ozumba, D et al. , Trends in epidemiology of knee arthroplasty in the United States, 1990–2000. Arthritis Rheum. 2005;52:3928–3933.CrossRefGoogle ScholarPubMed
25. Joint Replacement Unit, Sahlgrenska University Hospital. Swedish Hip Arthroplasty Register annual report 2006. www.jru.orthop.gu.se (accessed November 21, 2008).Google Scholar
26. Lin, YK, Su, JY, Lin, GT et al. , Impact of a clinical pathway for total knee arthroplasty. Kaohsiung J Med Sci. 2002;18:134–140.Google Scholar
27. Lingard, EA, Berven, S, Katz, JN, Kinemax Outcomes Group. Management and care of patients undergoing total knee arthroplasty: Variations across different health care settings. Arthritis Care Res. 2000;13:129–136.3.0.CO;2-6>CrossRefGoogle ScholarPubMed
28. Macario, A, Horne, M, Goodman, S et al. , The effect of a perioperative clinical pathway for knee replacement surgery on hospital costs. Anesth Analg. 1998;86:978–984.Google Scholar
29. Macdonald, SJ, Charron, KD, Bourne, RB et al. , The John Insall Award: Gender-specific total knee replacement: Prospectively collected clinical outcomes. Clin Orthop Relat Res. 2008;466:2612–2616.Google Scholar
30. Macpherson, H. Pragmatic clinical trials. Complement Ther Med. 2004;12:136–140.CrossRefGoogle ScholarPubMed
31. McMahon, AD. Study control, violators, inclusion criteria and defining explanatory and pragmatic trials. Stat Med. 2002;21:1365–1376.CrossRefGoogle ScholarPubMed
32. National Health Services Scotland. Scottish Arthroplasty Project annual report 2008. http://www.arthro.scot.nhs.uk/Reports/Main.html (accessed November 23, 2008).Google Scholar
33. Panella, M, Marchisio, S, Di Stanislao, F. Reducing clinical variations with clinical pathways: Do pathways work? Int J Qual Health Care. 2003;15:509–521.Google Scholar
34. Pearson, SD, Kleefield, SF, Soukop, JR, Cook, EF, Lee, TH. Critical pathways intervention to reduce length of hospital stay. Am J Med. 2001;110:175–180.CrossRefGoogle ScholarPubMed
35. Pennington, JM, Jones, DP, McIntyre, S. Clinical pathways in total knee arthroplasty: A New Zealand experience. J Orthop Surg (Hong Kong). 2003;11:166–173.CrossRefGoogle ScholarPubMed
36. Renholm, M, Leino-Kilpi, H, Suominen, T. Critical pathways. A systematic review. J Nurs Adm. 2002;32:196–202.CrossRefGoogle ScholarPubMed
37. Rissanen, P, Aro, S, Sintonen, H, Slatis, P, Paavolainen, P. Quality of life and functional ability in hip and knee replacements: A prospective study. Qual Life Res. 1996;5:56–64.CrossRefGoogle ScholarPubMed
38. Roland, M, Torgerson, DJ. What are pragmatic trials? BMJ. 1998;316:285.CrossRefGoogle ScholarPubMed
39. Roos EM. Effectiveness and practice variation of rehabilitation after joint replacement. Curr Opin Rheumatol. 2003;15:160–162.Google Scholar
40. Schwartz, D, Lellouch, J. Explanatory and pragmatic attitudes in therapeutical trials. J Chronic Dis. 1967;20:637–648.CrossRefGoogle ScholarPubMed
41. Teutsch, SM, Berger, ML, Weinstein, MC. Comparative effectiveness: Asking the right questions, choosing the right method. Health Aff (Millwood). 2005;24:128–132.Google Scholar
42. Tunis, SR, Stryer, DB, Clancy, CM. Practical clinical trials: Increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003;290:1624–1632.CrossRefGoogle ScholarPubMed
43. Vanhaecht, K, Sermeus, W, Tuerlinckx, G et al. , Development of a clinical pathway for total knee arthroplasty and the effect on length of stay and in-hospital functional outcome. Acta Orthop Belg. 2005;71:439–444.Google ScholarPubMed
44. Walter, FL, Bass, N, Bock, G, Markel, DC. Success of clinical pathways for total joint arthroplasty in a community hospital. Clin Orthop Relat Res. 2007;457:133–137.CrossRefGoogle Scholar
45. Wertheimer, AI. The defined daily dose system (DDD) for drug utilization review. Hosp Pharm. 1986;21:233–234, 239–241, 258.Google ScholarPubMed
46. WHO Collaborating Centre for Drug Statistics Methodology. ATC/DDD applications. http://www.whocc.no/atcddd/ (accessed January 16, 2009).Google Scholar
47. Wilensky, GR. Developing a center for comparative effectiveness information. Health Aff (Millwood). 2006;25:w572–w585.CrossRefGoogle ScholarPubMed
48. Zwarenstein, M, Treweek, S, Gagnier, JJ et al. , Improving the reporting of pragmatic trials: An extension of the CONSORT statement. BMJ. 2008;337:a2390.Google Scholar
Supplementary material: File

Gooch supplementary materials

Supplementary lists

Download Gooch supplementary materials(File)
File 56.3 KB