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

Abstract

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.

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

“…In many hospitals, ERAS is not yet the standard of care. For example, LOS is still around four days after hip and knee replacement in countries such as England and Spain [ 13 , 14 ], compared with 0–2 days in extensive epidemiological studies from Denmark and USA [ 7 , 15 ]. The restarting of services, therefore represents an opportunity to “reset” pathways at a time when limited capacity and increased demand may help to drive positive changes.…”

The Quality Improvement Challenge—How Nurses and Allied Health Professionals Can Solve the Knowing–Doing Gap in Enhanced Recovery after Surgery (ERAS)

“…There is a perception that ERAS strategies have been universally adopted in England; however, recently published data suggest that this is not a reality [6]. For some hospitals, ERAS protocols have become so embedded into practice it is now considered the standard care, yet for others, there has been a significant decline in compliance to ERAS protocols since the end of the national programme [7].…”

“…Recent research has highlighted that the programme had no discernible independent effect on decreasing LOS nationally for both THA and TKA [6]. Despite the scientific evidence for ERAS, there is still a knowing-doing gap, and widespread implementation within the NHS has not occurred.…”

Reduced Length of Stay Following Patient Pathway Optimization for Primary Hip and Knee Arthroplasty at a Swiss Hospital

“…12,15,16 In the joint replacement setting, ERPs have demonstrated benefits such as reduced length of hospital stay and increased quality of life. [17][18][19][20] The objective of this study was to evaluate the impact of implementing five ERP principles within a Patient Pathway Optimization (PPO) program for patients undergoing TKA or THA in Cantonal Hospital Münsterlingen, a large public hospital in Switzerland. To address this, we sought to determine whether implementation of the PPO for patients undergoing TKA or THA could (1) Reduce length of stay (LOS) during the index hospitalization, (2) Reduce hospital inpatient costs, (3) Impact the rate of complications and readmissions, and/or (4) Result in more patients being discharged to home vs alternative health-care settings.…”