Original Articles
Effectiveness of clinical pathways for total knee and total hip arthroplastyLiterature review,☆☆

https://doi.org/10.1054/arth.2003.50030Get rights and content

Abstract

Although many hospitals have implemented clinical pathways to standardize the process of care, the effectiveness of clinical pathways for total hip and knee arthroplasties has not been reviewed critically. We searched for articles comparing outcomes of total hip or knee arthroplasty for patients who were treated using clinical pathways as opposed to patients treated without these pathways. Eleven studies met criteria for inclusion. Ten used historical controls, and 1 was a randomized trial. The studies had important methodological limitations. In general, the articles showed that patients treated using pathways experienced shorter hospital stays and lower costs, with comparable clinical outcomes as compared with patients treated without clinical pathways. We concluded that clinical pathways appear successful in reducing costs and length of stay in the acute care hospital, with no compromise in patient outcomes. However, interpretation of these studies is complicated by substantial methodological limitations, particularly the use of historical controls and failure to account for length of stay in rehabilitation facilities. Copyright 2003, Elsevier Science (USA). All rights reserved.

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Search strategy for identification of studies

We used the OVID search engine to search the MEDLINE (1966 through July 30, 2001) and HealthSTAR/Ovid Healthstar (1975 through June 2001) databases for relevant studies. The key words used in the search were clinical pathways, critical pathways, clinical paths, total joint replacement, arthroplasty, total knee replacement, and total hip replacement. Only articles published in English were included. Two independent reviewers screened the title and abstract of each article identified in the

Results

A total of 11 articles were included in the review. Eight of the studies were undertaken in the United States, 2 in Australia, and 1 in Canada. Seven studies 3, 4, 5, 6, 7, 8, 12 used historical controls. Of these, 3 were both retrospective and prospective 5, 8, 12 and 4 were retrospective in design 3, 4, 6, 7 (Table 1). Three studies 1, 2, 10 used both historical and concurrent controls. Of these 3, 1 was both retrospective and prospective [2], and 2 were prospective in design 1, 10. One study

Length of stay

All of the studies that reported on LOS showed reductions in acute hospital LOS with the implementation of clinical pathways. However, considerable variability was seen in these reported reductions in LOS, ranging from 1.5 to 6.2 days for TKA and from 1.5 to 4.3 days for THA. These absolute reductions in length of stay correspond to percent reductions ranging from 15% to 57%, with a median of 30% fewer days in the hospital with path management (Table 2). Card and Herrling et al. [10] reported a

Discussion

Eleven studies met eligibility criteria and were selected for this review. Each study examined the effects of using clinical pathways on 1 or more outcome measures of TKA or THA, including LOS in the acute hospital, cost of acute hospitalization, complications, and functional outcomes. Each study was controlled using either historical or concurrent controls and each had a retrospective, prospective, mixed retrospective and prospective, or randomized design (Table 1). We found that

Conclusions

Most studies of the use of clinical pathways for TKA and THA reported a trend towards decreased LOA in the acute hospital and hospital costs, and either improved or unchanged frequency of complications and functional outcomes. These findings support the use of pathways. However, the studies should be interpreted cautiously because of methodologic challenges inherent in evaluating clinical pathways. We support the goal of reducing variations in the process of care. However, we believe that the

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Supported by a Summer Research Fellowship from Albert Einstein College of Medicine, NIH Grants K24 AR 02123, P60 AR 47782, and a Clinical Science Grant from the Arthritis Foundation.

☆☆

Reprint requests: Jeffrey N. Katz, MD, MS, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, 75 Francis Street, B-3, Boston, MA 02115. E-mail: [email protected]

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