Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial

Abstract

ObjectiveTo assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).DesignCluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients.Setting20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands.Participants32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care).InterventionThe intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken.Main outcome measuresThe primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS). The individual indicators were analysed as secondary outcomes. Changes in outcomes from pre-intervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII.Results16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 4.32% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95%CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95%CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95%CI 0.67-1.30).ConclusionThe multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes.Trial registration numberNCT04055103.

Grand rounds in methodology: four critical decision points in statistical process control evaluations of quality improvement initiatives

“…SPC charts are then often used as an approach to measurement, where data will give feedback and inform further development of the intervention. Previous studies have shown that using SPC charts as part of the intervention (formative evaluation) can be effective to improve patient outcomes 28 29. Even though then primarily a tool for monitoring rather than to draw inferences about the effect of each implemented improvement initiative, this also requires planning the feedback, defining what constitutes special cause variation and so on.…”

Towards comprehensive fidelity evaluations: consideration of enactment measures in quality improvement interventions

“…Methods have included: participant and provider self-report, reviewing attendance and other intervention records, direct observation and reviewing how many of the intervention components were used by participants. 3 8-10 Within healthcare service research, registry data (eg, Stephens et al 11 ) and selfreport methods (eg, van Schie et al 12 ) have been used to explore the use of implementation strategies within hospitals following quality improvement interventions. Self-report methods have also been used to determine whether patients enacted COVID-19 remote home monitoring activities (eg, Walton et al 13 ).…”

You can lead clinicians to water, but you can’t make them drink: the role of tailoring in clinical performance feedback to improve care quality

“…Once values align and clinicians are engaged, supports are needed to help close the intention-to-action gap. Action planning can be facilitated by identifying common barriers and proactively providing goal-oriented actions to overcome them—a strategy that has proven to significantly enhance the impact of CPF on clinical behaviour and patient outcomes 8 9. Leaders and those implementing CPF purposefully design and facilitate opportunities for clinicians to engage with their colleagues to share practices and identify those who may have discovered more effective strategies or approaches to care 10…”

“…It is important that this be designed for and embedded within existing workflows and care pathways35—guidance that is rarely put into practice. Additionally, design should account for clinician preferences which can be achieved using a participatory design approach to help illuminate values and beliefs and inform cointerventions 8 9 36. For example, understanding that the initial reaction to poor performance is shame can inform how feedback is framed and communicated to clinicians 36.…”