scholarly journals The impact of the enhanced recovery pathway and other factors on outcomes and costs following hip and knee replacement: routine data study

2020 ◽  
Vol 8 (4) ◽  
pp. 1-188
Author(s):  
Andrew Judge ◽  
Andrew Carr ◽  
Andrew Price ◽  
Cesar Garriga ◽  
Cyrus Cooper ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Patient Outcomes ◽  
Knee Replacement ◽  
Natural Experiment ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Post Discharge ◽  
Replacement Surgery ◽  
Patient Reported ◽  
And Function

Background There is limited evidence concerning the effectiveness of enhanced recovery programmes in hip and knee replacement surgery, particularly when applied nationwide across a health-care system. Objectives To determine the effect of hospital organisation, surgical factors and the enhanced recovery after surgery pathway on patient outcomes and NHS costs of hip and knee replacement. Design (1) Statistical analysis of national linked data to explore geographical variations in patient outcomes of surgery. (2) A natural experimental study to determine clinical effectiveness of enhanced recovery after surgery. (3) A qualitative study to identify barriers to, and facilitators of, change. (4) Health economics analysis to establish NHS costs and cost-effectiveness. Setting Data from the National Joint Registry, linked to English Hospital Episode Statistics and patient-reported outcome measures in both the geographical variation and natural experiment studies, together with the economic evaluation. The ethnographic study took place in four hospitals in a region of England. Participants Qualitative study – 38 health professionals working in hip and knee replacement services in secondary care and 37 patients receiving hip or knee replacement. Interventions Natural experiment – implementation of enhanced recovery after surgery at each hospital between 2009 and 2011. Enhanced recovery after surgery is a complex intervention focusing on several areas of patients’ care pathways through surgery: preoperatively (patient is in best possible condition for surgery), perioperatively (patient has best possible management during and after operation) and postoperatively (patient experiences best rehabilitation). Main outcome measures Patient-reported pain and function (Oxford Hip Score/Oxford Knee Score); 6-month complications; length of stay; bed-day costs; and revision surgery within 5 years. Results Geographical study – there are potentially unwarranted variations in patient outcomes of hip and knee replacement surgery. This variation cannot be explained by differences in patients, case mix, surgical or hospital organisational factors. Qualitative – successful implementation depends on empowering patients to work towards their recovery, providing post-discharge support and promoting successful multidisciplinary team working. Care processes were negotiated between patients and health-care professionals. ‘Good care’ remains an aspiration, particularly in the post-discharge period. Natural experiment – length of stay has declined substantially, pain and function have improved, revision rates are in decline and complication rates remain stable. The introduction of a national enhanced recovery after surgery programme maintained improvement, but did not alter the rate of change already under way. Health economics – costs are high in the year of joint replacement and remain higher in the subsequent year after surgery. There is a strong economic incentive to identify ways of reducing revisions and complications following joint replacement. Published cost-effectiveness evidence supports enhanced recovery pathways as a whole. Limitations Short duration of follow-up data prior to enhanced recovery after surgery implementation and missing data, particularly for hospital organisation factors. Conclusion No evidence was found to show that enhanced recovery after surgery had a substantial impact on longer-term downwards trends in costs and length of stay. Trends of improving outcomes were seen across all age groups, in those with and without comorbidity, and had begun prior to the formal enhanced recovery after surgery roll-out. Reductions in length of stay have been achieved without adversely affecting patient outcomes, yet, substantial variation remains in outcomes between hospital trusts. Future work There is still work to be done to reduce and understand unwarranted variations in outcome between individual hospitals. Study registration This study is registered as PROSPERO CRD42017059473. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

scholarly journals Can the introduction of Enhanced Recovery After Surgery (ERAS) reduce the variation in length of stay after total ankle replacement surgery?

2019 ◽  
Vol 25 (3) ◽  
pp. 294-297 ◽  
Author(s):  
Thomas W. Wainwright ◽  
Tikki Immins ◽  
Johannes H.A. Antonis ◽  
Heath Taylor ◽  
Robert G. Middleton
Keyword(s):  
Length Of Stay ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Total Ankle Replacement ◽  
Replacement Surgery ◽  
Ankle Replacement

scholarly journals Early Results of ERAS (Enhanced Recovery After Surgery) Protocol in Orthopaedic Surgery

The Physician ◽  
2012 ◽  
Vol 1 (1) ◽  
pp. 28-32
Author(s):  
Jaydeep Shah ◽  
Keshav Singhal
Keyword(s):  
Colorectal Surgery ◽  
Knee Replacement ◽  
Orthopaedic Surgery ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Hospital Inpatient ◽  
Inpatient Stay ◽  
Average Hospital ◽  
Replacement Surgery ◽  
Eras Protocol

Background: The concept of a fast track (Enhanced Recovery After Surgery, ERAS) was introduced to colorectal surgery in Denmark by Kehlet in 1999 which improved the quality of the care and reduced the length of hospital stay following major colorectal surgery. The same principles of ERAS have been applied to the orthopaedic surgery particularly the hip and knee replacement surgery and fracture neck of femur surgery. It is a relatively new approach in orthopaedics to the preoperative, intraoperative and postoperative care of the patients undergoing surgery.   Methods: We have compared the length of inpatient stay, day of mobilisation, postoperative blood transfusion and adverse outcome for the patients undergoing hip or knee replacement by a single surgeon (KS) between ERAS and NON ERAS patients.   Results: A total of 138 patients underwent hip or knee replacement, hip resurfacing arthroplasty or oxford unicompartmental arthroplasty between July 2011 and June 2012 with ERAS protocol. In the Non-ERAS group, 140 patients underwent hip or knee arthroplasty, resurfacing or oxford uni-compartmental knee replacement in the previous year (July 2010 to June 2011) by the same surgeon. Average hospital inpatient stays for the ERAS patients was 4.12 days with 73.10% of the patients having an inpatient hospital stay of less than or equal to 5 days. The average hospital inpatient stays for the NON-ERAS patients was 8.34 days with only 24.08% of the patients being discharged in less than or equal to 5 days.   Conclusions: Our study shows that the implementation of the ERAS protocol in hip and knee replacement surgery is associated with improved patient experience, faster recovery and shorter hospital inpatient stay with no increase in complication.

scholarly journals Enhanced Recovery after Surgery (ERAS) for Hip and Knee Replacement—Why and How It Should Be Implemented Following the COVID-19 Pandemic

Medicina ◽  
2021 ◽  
Vol 57 (1) ◽  
pp. 81
Author(s):  
Thomas W. Wainwright
Keyword(s):  
Hospital Stay ◽  
Knee Replacement ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Surgical Stress ◽  
Model Of Care ◽  
Replacement Surgery ◽  
Use Of Technology ◽  
Wearable Activity Trackers ◽  
Outpatient Appointments

The COVID-19 pandemic has led to a reduction in hip and knee replacement surgery across healthcare systems. When regular operating returns, there will be a large volume of patients and an emphasis on a short hospital stay. Patients will be keen to return home, and capacity will need to maximised. Strategies to reduce the associated risks of surgery and to accelerate recovery will be needed, and so Enhanced Recovery after Surgery (ERAS) should be promoted as the model of care. ERAS protocols are proven to reduce hospital stay safely; however, ERAS pathways may require adaption to ensure both patient and staff safety. The risk of exposure to possible sources of COVID-19 should be limited, and so hospital visits should be minimised. The use of technology such as smartphone apps to provide pre-operative education, wearable activity trackers to assist with rehabilitation, and the use of telemedicine to complete outpatient appointments may be utilised. Also, units should be reminded that ERAS protocols are multi-modal, and every component is vital to minimise the surgical stress response. The focus should be on providing better and not just faster care. Units should learn from the past in order to expedite the implementation of or adaption of existing ERAS protocols. Strong leadership will be required, along with a supportive organisational culture, an inter-professional approach, and a recognised QI method should be used to contextualize improvement efforts.

scholarly journals Assessing responsiveness of the EQ-5D-3L, the Oxford Hip Score, and the Oxford Knee Score in the NHS patient-reported outcome measures

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Sujin Kang
Keyword(s):  
Outcome Measures ◽  
Knee Replacement ◽  
Oxford Knee Score ◽  
Patient Reported Outcome Measures ◽  
Patient Reported Outcome ◽  
Knee Score ◽  
Paired Data ◽  
Replacement Surgery ◽  
Patient Reported ◽  
Oxford Hip Score

Abstract Background The degree to which a validated instrument is able to detect clinically significant change over time is an important issue for the better management of hip or knee replacement surgery. This study examines the internal responsiveness of the EQ-5D-3L, the Oxford Hip Score (OHS), and the Oxford Knee Score (OKS) by various methods. Data from NHS patient-reported outcome measures (PROMs) linked to the Hospital Episodes Statistics (HES) dataset (2009–2015) was analysed for patients who underwent primary hip surgery (N = 181,424) and primary knee surgery (N = 191,379). Methods Paired data-specific univariate responsiveness was investigated using the standardized response mean (SRM), the standardized effect size (SES), and the responsiveness index (RI). Multivariate responsiveness was furthermore examined using the defined capacity of benefit score (i.e. paired data-specific MCID), adjusting baseline covariates such as age, gender, and comorbidities in the Box-Cox regression models. The observed and predicted percentages of patient improvement were examined both as a whole and by the patients' self-assessed transition level. Results The results showed that both the OHS and the OKS demonstrated great univariate and multivariate responsiveness. The percentages of the observed (predicted) total improvement were high: 51 (54)% in the OHS and 73 (58)% in OKS. The OHS and the OKS showed distinctive differences in improvement by the 3-level transition, i.e. a little better vs. about the same vs. a little worse. The univariate responsiveness of the EQ-5D-3L showed moderate effects in total by Cohen’s thresholds. The percentages of improvement in the EQ-5D-3L were moderate: 44 (48)% in the hip and 42 (44)% for the knee replacement population. Conclusions Distinctive percentage differences in patients’ perception of improvement were observed when the paired data-specific capacity of benefit score was applied to examine responsiveness. This is useful in clinical practice as rationale for access to surgery at the individual-patient level. This study shows the importance of analytic methods and instruments for investigation of the health status in hip and/or knee replacement surgery. The study finding also supports the idea of using a generic measure along with the disease-specific instruments in terms of cross-validation.

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