Evolving reimbursement policies are driving health systems to improve quality and efficiency. Transitioning to an electronic health record (EHR) provided Dartmouth-Hitchcock Medical Center (DHMC) an opportunity to redesign staff roles and care path for Total Knee Replacement (TKR). The organization implemented a coordinated team-based care delivery model that integrated real-time measurement of: (1) compliance with trusted guidelines, (2) process of Shared Decision-Making (SdM), and (3) use of Patient-Reported Outcomes (PROs). The investigators present the implementation protocol and data.
Patient-reported outcome measures were completed 1 month preceding TKR and also at 1 and 12 months following surgery. The primary outcome was change in physical function from baseline to 1-year following surgery in the Physical Component Summary (PCS) of the Veterans-Rand (VR-12) Survey. Preoperative measures were: (1) general demographics (patient age, sex, height, weight, body mass index (BMI); (2) treatments tried before surgery; (3) health habits (tobacco use, alcohol use); (4) pre-existing medical conditions (Charlson score); (5) physical exam findings (knee range of motion, knee laxity); (7) lab tests (hemoglobin); and (7) radiographic measures (severity of osteoarthritis on standing x-rays). Secondary outcomes included Physical Score (PS) of the Patient Reported Outcome Measurement Information System Global Survey (PROMIS-10), knee function (Knee Osteoarthritis Outcome Score, KOOS), safety (reoperations, readmissions, emergency visits, and infection) and measures of patient experience (Clinician Group and Hospital Consumer Assessment of Healthcare Providers and Systems).
Study Type
OBSERVATIONAL
Enrollment
545
Primary total knee arthroplasty for knee osteoarthritis
Health Gain as measured by the change in Physical Component Summary (PCS) Score
Health Gain from baseline to 12 months (from 300 to 400 days following the date) following surgery, as measured by the change in Physical Score based on standardized US adult population benchmarks for the VR12 survey
Time frame: 1-year following surgery
Health Gain as measured by the change in Global Physical Health (GPH)
Health Gain from baseline to 12 months following surgery, as measured by the change in Physical Score based on standardized US adult population benchmarks for the PRIOMIS10 survey
Time frame: 1-year
Health Gain as measured by the change in Percentile Rank, TKR age and gender matched
Health Gain from baseline to 12 months following surgery, as measured by the change in Physical Score Percentile Rank based on age and gender-matched beta distributions for the Dartmouth TKR population, for the PRIOMIS10 or VR12 survey
Time frame: 1 year
Emotional Health
Mental Component Summary (MCS) Score change from baseline to 12 months following surgery, as measured by the change in Mental Score based on standardized US adult population benchmarks for the PRIOMIS10 or VR12 survey
Time frame: 1 year
Knee Osteoarthritis Outcome Score (KOOS)
Change in KOOS score from baseline to 12 months following surgery
Time frame: 1 year
Reoperation
From 0 to 90 days following the date of surgery
Time frame: 3 months
Readmission
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From 0 to 90 days following the date of surgery
Time frame: 3 months
ER visits after surgery
From 0 to 90 days following the date of surgery
Time frame: 3 months
Infection
From 0 to 90 days following the date of surgery
Time frame: 3 months
Patient Satisfaction with Hospital
HCAHPS survey in 10% random subsample completed between 20 to 40 days following the date of surgery
Time frame: 1 month
Patient Satisfaction with Surgeon
Clinician Group CAHPS survey in 10% random subsample completed between 300 to 400 days following the date of surgery
Time frame: 10 months
Cost of care
Episode-based costs for 0 to 90 days following the date of surgery, and also per visit outpatient costs
Time frame: 3 months
Length of hospital stay
Number of days between date of admission and date of discharge
Time frame: Acute hospitalization
Discharge to home
Disposition at time of discharge from acute hospitalization
Time frame: Acute hospitalization
Mortality
Time frame: 1 year
Range of motion
Knee range of motion measured by a clinician between 60 and 120 days following surgery
Time frame: 90 days