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Are accelerated recovery protocols for knee arthroplasty safe and effective? Article review.

Posted on April 14, 2014 by Jaimie Cunningham

Evidence Reviews
pathways

The hospital I was at for my acute care physical therapy clinical had recently started an accelerated recovery program for the treatment of knee arthroplasties.  Overall, I saw great results from the patients that took part in the program.  However, I was left wondering what the research showed about accelerated programs.  Are they safe? What are the outcomes like?  Are they cost-effective?  These questions led me to the following article which I will review below:

Reilly KA, Beard DJ, Barker KL, Dodd CAF, Price AJ, Murray DW.  Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty – a randomised controlled trialThe Knee.  2005; 12: 351-357.

What is an accelerated recovery program?

Accelerated recovery programs, also called rapid recovery or early discharge programs, are a type of clinical pathway.  Clinical pathways were defined by Kinsman et al. in 2010 to include 5 criteria (underlining added by the author of this blog post):

“(1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other ‘inventory of actions’; (4) the intervention had timeframes or criteria-based progression; (5) the intervention aimed to standardize care for a specific clinical problem, procedure or episode of healthcare in a specific population.”

Clinical pathways are commonly used with arthroplastic surgeries in an effort to improve patient outcomes and decrease costs.  The specific goal of an accelerated recovery program is to meet the same discharge criteria in less time in order to decrease length of stay in the hospital, reduce costs, and speed patient recovery.

Why is this important?

Clinical pathways are becoming more widely used, especially for common and costly surgeries such as joint arthroplasties.  Due to the multidisciplinary nature of clinical pathways, it’s important for all members of the healthcare team to understand their role within these clinical pathways.  Also, clinical pathways have the potential to decrease length of stay, reduce costs, improve patient satisfaction, and speed recovery.  Therefore, continued research on the use of clinical pathways may lead to improved patient care and outcomes.

What did this study show?

The study by Reilly et al. included 41 patients who underwent a unicompartmental knee arthroplasty and met strict inclusion criteria.  Twenty-one patients were included in the accelerated discharge group (Group A) and 20 patients were in the standard discharge group (Group S).  The surgical protocol, including anesthesia and analgesics, was the same for both groups.  For patients in Group A, the aim was to discharge within 24 hours after surgery.  Post-operative care included mobilization 2 hours after surgery, a booklet with rehabilitation instructions, a 24 hour emergency contact number, instructions to rest the limb in extension but regularly flex the knee, and use of an extension splint to be used when walking for the first 5 days.  Patients in Group S received the same care but without the deadlines or urgency used for Group A.  Outcome measures included length of stay, patient satisfaction, cost savings, post-operative pain, range of motion, and the Oxford Knee Assessment (OKA) which includes the Oxford Knee Score and the American Knee Society Clinical Rating System.  Results of the study showed a reduced length of stay for Group A (1.5 days for Group A versus 4.3 days for Group S).  There were no differences in functional outcomes as measured by the OKA at 6 months between the 2 groups.  Similarly, there were no differences between groups in post-operative pain or range of motion.  Group A had improved patient satisfaction and a cost savings of approximately 27%.  Based on these results, authors of this study concluded that accelerated recovery programs for unicompartmental knee arthroplasties are effective, accepted by patients, and may be cost effective.

Review of the article:

Overall, I believe the authors of this study did a great job of studying the effectiveness of an accelerated recovery program following unicompartmental knee arthroplasty. I like that they included multiple outcome measures including functional tests, subjective report from the patients, pain scales, and costs.  This gives a broad and more detailed picture of the effects of an accelerated recovery program.  As mentioned by the authors, one limitation of this study is the inability to draw conclusions about the safety of the accelerated protocol.  The number of complications for each group was collected; however, due to the small number of complications and the relatively small sample size, there was not sufficient data to make conclusions regarding safety and complication rates.  Also, strict inclusion criteria limit the ability to generalize these results to a broader population.  I suggest that future studies use less restrictive inclusion criteria and use improved methods for determining safety and complication rates.  Also, future studies of accelerated programs could begin to look at which specific components of clinical pathways are most effective at improving particular outcomes.

What is the take home message?

The take home message is that clinical pathways may be an effective way of improving patient satisfaction and reducing costs while achieving the same outcomes following knee arthroplastic surgery.  As always, it’s necessary to look at more than one study when making clinical decisions.  Therefore, I look forward to reading more studies about the effectiveness and safety of clinical pathways before making any conclusions that will alter my patient care.  Based on the results of this study, the use of clinical pathways following unicompartment knee arthroplasty demonstrates several potential benefits, and I am excited to see if the standard care for patients following joint arthroplasties changes in the future based on studies of clinical pathways.

References:

1.  Reilly KA, Beard DJ, Barker KL, Dodd CAF, Price AJ, Murray DW.  Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty – a randomised controlled trial.  The Knee.  2005; 12: 351-357.

2.  Kinsman L, Rotter T, James E, Snow P, Willis J.  What is a clinical pathway? Development of a definition to inform the debate.  BMC Medicine.  2010; 8:31.

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Jaimie Cunningham

Jaimie Cunningham

I am a third year Doctor of Physical Therapy student at Elon University. I am interested in orthopedics and manual therapy. View more posts from Jaimie

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