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Question Does the use of a clinical pathway improve patient outcomes after hip or knee arthroplasty?
Randomised, unblinded, controlled trial with ≥3 months follow up.
A tertiary referral hospital in Melbourne, Victoria, Australia.
175 patients who had hip or knee arthroplasty between January 1996 and December 1997. 12 patients (6.9%) were excluded after randomisation because they were having revision arthroplasty, simultaneous bilateral joint arthroplasty, arthroplasty for acute trauma, or complex tumour surgery. The remaining 163 patients (mean age 66 y, 66% women) completed ≥3 months of follow up.
92 patients were allocated to the clinical pathway group and 71 were allocated to the control group. Patients in the clinical pathway group received “proactive” treatment whereby specific daily goals were set for the patient and the healthcare team. A written protocol identified milestones to be achieved, tests to be ordered, and daily tasks for patients and the healthcare team. Patients in the control group received “reactive” treatment, whereby the healthcare team provided care in response to the patient's condition and wants.
Main outcome measures
Length of hospital stay, time to sitting out of bed, time to ambulation, complications (wound infections, chest infections, deep venous thrombosis, joint dislocation, decubitus pressure areas, failure to cope at home, and decreased range of motion after discharge), readmission for complications, and discharge matching (between discharge destination as planned at pre-admission and actual destination after discharge).
Patients in the clinical pathway group had a shorter mean length of stay (7.1 v 8.6 d, p=0.01), sat out of bed earlier (1.9 v 3.4 d, p=0.001), and walked earlier (2.2 v 3.6 d, p=0.02) than patients in the control group. Fewer patients in the clinical pathway group had complications (table). The groups did not differ for number of patients who were readmitted (4.3% v 13%, p=0.06) or number of patients matched to their planned discharge destination (70% v 61%, p=0.3).
Among patients who had hip or knee arthroplasty, proactive post-operative care guided by a clinical pathway reduced length of hospital stay, time to sitting out of bed and ambulation, and complications compared with patients who received standard reactive care.
Clinical pathways are becoming important to the provision of efficient and effective health care. A clinical pathway is a tool by which a clinical practice guideline based on the best available evidence is adapted for implementation in a specific setting. Pathways involve input from all members of the healthcare team and form part or all of the patient's record, allowing documentation of interventions, progress, and outcome. Pathways promote standardisation of care and may be based on diagnoses, symptoms, or procedures.1 Campbell et al suggest that although a sizeable literature exists about the development of care pathways, there are few evaluations of their effectiveness in changing practice and improving patient outcomes.2 The study by Dowsey et al is one of the first randomised controlled trials to evaluate the effectiveness of a clinical pathway.
Strengths of the study include random allocation to comparison groups by a clerical assistant who was unaware of the patients' clinical profile and follow up of all study participants for a minimum of 3 months. With respect to study limitations, we do not know whether chart abstractors were blind to patient allocation or whether the quality of charting differed between groups and could have affected the results. The study would have been strengthened if patient satisfaction with care had been examined.
Patients in both groups who attended the pre-admission clinic or the patient information seminar had shorter hospital stays. It would have been interesting to compare the patients in the clinical pathway group who did and did not attend these education sessions to determine whether pre-admission education influenced the study outcomes.
Clinical pathways may be part of the way forward for healthcare provision but their evaluation is essential. Dowsey et al contribute towards evaluation by showing that a clinical pathway for hip and knee arthroplasty may improve patient outcomes.
Source of funding: no external funding.
For correspondence: Professor P F Choong, Department of Orthopaedics, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia. Fax +61 3 9415 8677.
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