Abstract
BackgroundStudies on critical pathway use have demonstrated decreased length of stay and cost without compromise in quality of care. However, pathway effectiveness is difficult to determine given methodological flaws, such as small or single center cohorts. We studied the effect of critical pathways on total knee replacement outcomes in a large population-based study.MethodsWe identified hospitals in four US states that performed total knee replacements. We sent a questionnaire to surgical administrators in these hospitals including items about critical pathway use and hospital characteristics potentially related to outcomes. Patient data were obtained from Medicare claims, including demographics, comorbidities, 90-day postoperative complications and length of hospital stay. The principal outcome measure was the risk of having one or more postoperative complications.ResultsTwo hundred ninety five hospitals (73%) responded to the questionnaire, with 201 reporting the use of critical pathways. 9,157 Medicare beneficiaries underwent TKR in these hospitals with a mean age of 74 years (± 5.8). After adjusting for both patient and hospital related variables, patients in hospitals with pathways were 32% less likely to have a postoperative complication compared to patients in hospitals without pathways (OR 0.68, 95% CI 0.50-0.92). Patients managed on a critical pathway had an average length of stay 0.5 days (95% CI 0.3-0.6) shorter than patients not managed on a pathway.ConclusionMedicare patients undergoing total knee replacement surgery in hospitals that used critical pathways had fewer postoperative complications than patients in hospitals without pathways, even after adjusting for patient and hospital related factors.This study has helped to establish that critical pathway use is associated with lower rates of postoperative mortality and complications following total knee replacement after adjusting for measured variables.
Highlights
Studies on critical pathway use have demonstrated decreased length of stay and cost without compromise in quality of care
Medicare claims data were obtained with a Data Use Agreement with the Center for Medicare and Medicaid Services (CMS)
A multivariable logistic regression model was constructed to evaluate the odds of a postoperative complication or death in the pathway and non pathway groups, adjusting for patient age, gender, co-morbidity index, Medicaid eligibility and hospital volume
Summary
Studies on critical pathway use have demonstrated decreased length of stay and cost without compromise in quality of care. We studied the effect of critical pathways on total knee replacement outcomes in a large population-based study. The demand is increasing for greater quality and efficiency of heath care. For this reason, critical pathways have gained tremendous popularity for hospital care especially in the surgical arena. Critical pathways take many formats, but often are incorporated into daily hospital progress notes either as multi-page forms with space for documentation or as single pages used as checklists of daily items. Despite widespread acceptance of critical pathways for surgical procedures, there has been relatively little rigorous evaluation of the effectiveness of these critical pathways on outcomes [3,4,5,6]
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