Clinical Orthopaedics and Related Research: May 2014 - Volume 472 - Issue 5 - p 1619–1635 doi: 10.1007/s11999-013-3398-4 Clinical Research

Developing a Pathway for High-value, Patient-centered Total Joint Arthroplasty

Van Citters, Aricca, D., MS1; Fahlman, Cheryl, PhD3; Goldmann, Donald, A., MD4; Lieberman, Jay, R., MD6; Koenig, Karl, M., MD, MS7; DiGioia, Anthony, M., III, MD2; O'Donnell, Beth, MPH4; Martin, John, MPH3; Federico, Frank, A., RPh4; Bankowitz, Richard, A., MD3; Nelson, Eugene, C., DSc, MPH5; Bozic, Kevin, J., MD, MBA8,a
Ankle Elbow Hip Knee Shoulder

Background Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed.


Questions/purposes The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA.


Methods We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9).


Results The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level.


Conclusions We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation.


Level of Evidence Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

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