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Hip and Knee

ALBERTA’S HIP AND KNEE REPLACEMENT PILOT DEMONSTRATED SUPERIORITY OF CARE PATH

ABJHI’s internationally recognized work in raising the quality of care for hip and knee replacement patients began with designing a care path for Alberta based on the best evidence available worldwide. The new care path was designed in 2004 in collaboration with the Alberta Orthopaedic Society, representing the province’s orthopaedic surgeons, and with provincial health authorities.

The hip and knee care path set out the practices and protocols for treatment, beginning with referral by a family doctor to a specialist, and extending through:

  • Assessment by a specialist,
  • a treatment plan for non-surgical patients,
  • a plan to get surgical patients to their optimal readiness,
  • surgery,
  • recovery, and
  • rehabilitation in the community.

All services, other than family doctor and in-hospital, are provided in or through a hip and knee clinic. Care is fully integrated, provided by a multidisciplinary team, and coordinated by a case manager in the clinic.

The care path was tested in a provincial pilot in 2005-06, which was managed by ABJHI. Patients who followed the new care path had significantly greater improvement in general health, less pain after surgery, and greater ability to perform normal daily activities than those who received conventional care. Waiting times for consultation with a specialist and for surgery declined dramatically.

The hip and knee care path is now the standard across Alberta and has helped shape care in other areas of Canada.

MEASUREMENT FRAMEWORK AN ESSENTIAL TOOL FOR IMPROVING QUALITY OF HIP AND KNEE CARE

Hip and knee care in Alberta is measured using a framework designed by ABJHI and built around the six essential dimensions of health care quality: safety, access, appropriateness, effectiveness, efficiency and acceptability.

ABJHI REPORTS SPUR CONTINUOUS IMPROVEMENT IN HIP AND KNEE REPLACEMENT

You can’t improve what you don’t measure. That truism is behind a novel approach developed by ABJHI to stimulate continuous improvement in hip and knee replacement by surgeons and hospitals in Alberta.

ABJHI sifts through surgeon and hospital data to track performance against benchmarks in key areas of service and patient outcomes, including:

  • how long patients waited for surgery,
  • how long the surgery took,
  • how long patients were in hospital after surgery,
  • how much patients improved in critical areas such as pain and physical function,
  • how many were readmitted to hospital because of complications,
  • how satisfied patients were with their treatment, and
  • how many had serious side-effects, such as infection, blood clot and heart attack.

ABJHI compiles and analyzes the data for each surgeon. The results are compared with provincial benchmarks and with the aggregated scores for the surgeon’s peer group after adjusting for the complexity of the cases. ABJHI presents the results in the form of a confidential Continuous Improvement Report to each surgeon.

ABJHI also groups the surgeon reports by health care zone. This information is aggregated and de-identified to produce a Continuous Improvement Report for each of the five health zones in the province.

Alberta is the only jurisdiction in Canada where surgeons are receiving reports on the results of their work tied to benchmarks. Data from approximately 95% of the 10,000 hip and knee replacements performed annually in Alberta are included in the Continuous Improvement Reports.

In Brief

Alberta is the only jurisdiction in Canada where surgeons receive personal performance reports.

  • ABJHI tracks and reports surgeon performance against benchmarks.
  • Critical areas of care measured – e.g. wait times, patient outcomes, health complications.
  • ABJHI also reports health zone performance.
  • The reports flag opportunities to improve care.
  • The reports help surgeons align personal performance targets with AHS targets.

ANNUAL REVIEW ENSURES HIP AND KNEE CARE PATH REMAINS EVIDENCE-BASED

Evidence-based health care is, by definition, subject to change. Better drugs, more effective practices and safer protocols are being developed and introduced in health care with unprecedented rapidity. The best health care stays on top of these developments and takes advantage of them.

ABJHI set up a formal process in early 2007 to ensure its evidence-based care path for hip and knee replacements is truly evidence-based all the time. It struck a Clinical Committee, mandated by the Alberta Orthopaedic Society, which acts as an independent body of experts on patient care.

The committee comprises eight of Alberta’s top orthopaedic surgeons. The surgeons review new evidence related to hip and knee replacements. This evidence is gathered by ABJHI. It comes from research studies and scientific papers and directly from health care providers involved in patient care, including surgeons and other doctors, nurses and therapists.

ABJHI updates the care path based on the Clinical Committee’s decisions. A measurement framework, which is used to track the hip and knee care path’s performance, and patient guides are also updated to reflect changes in the care path.

Both the revised care path and measurement framework are submitted to Alberta Health Services for approval and provincial implementation. ABJHI advises orthopaedic surgeons across the province of the changes and how to access the updated care path in a secure portal on its website.

In Brief

ABJHI ensures the hip and knee care path remains evidence-based.

  • Set up committee of Alberta’s top orthopaedic surgeons, endorsed by Alberta Orthopaedic Society.
  • Gathers new evidence and presents it to the committee.
  • Revises the care path based on committee decisions.
  • Advises surgeons across Alberta of the care path changes.

eREFERRAL SYSTEM GIVES ACCURATE, REAL-TIME SNAPSHOT OF PATIENTS WAITING FOR HIP AND KNEE REPLACEMENTS

ABJHI has helped the Bone and Joint Health Strategic Clinical Network develop Alberta’s first automated provincial referral system. The new eReferral will simplify the referral process while providing physicians with reliable wait times at the moment they make a referral. It will also make status updates available in real time, any time.

The eReferral system will be used to refer patients for consultation with a specialist for hip and knee joint problems as well as for lung conditions and suspected breast cancer.

eReferral is scheduled to be introduced on a limited basis in March 2014 and evaluated to ensure it is functioning as intended. Physicians will be encouraged to adopt the system, giving up paper-based referrals. A full provincial roll-out will occur later in 2014.

With eReferral, Alberta Health Services (AHS) is introducing to Alberta’s physicians standardized referral forms and standardized wait times rules, terminologies and metrics. This standardization will bring an end to the wide variability in what is being measured and how it is being measured when tracking wait times for hip and knee replacements. The high degree of variability made wait time reports unreliable.

Instead, the new system will make the definitions of key events during the wait, the start and end times of these events, and the practices used to measure data the same across the province.

Using eReferral, reported wait times will be highly accurate, always current and available for each specialist.

Importantly, lost referrals will be a problem of the past as the transmission and exchange of paper is eliminated.

In Brief

An automated referral system that gives Alberta unprecedented opportunity to reduce wait times for hip and knee replacements.

  • A reliable snapshot of wait times in any area of the province – who is waiting, why and how long they have been waiting.
  • Quickly identifies wait time trends, identifies trouble spots.
  • Enables service planners to take targeted measures to counter delays.
  • Weeds out delays caused by patients for a true profile of health system performance.

PROGRAM SAVES HOSPITAL BED-DAYS VALUED AT $33 MILLION

A provincial project initiated by the BJHSCN and managed by ABJHI has saved tens of thousands of bed-days in Alberta hospitals valued at $33 million in the three years since it was launched.

The project is helping to speed up access to hip and knee replacements in Alberta by freeing up bed space for patients waiting to have surgery.

A patient cannot have surgery if an acute-care hospital bed is not available. Research by ABJHI revealed that hip and knee patients were routinely staying in acute care beyond the four days specified in the province’s standardized care path. The most common reason: patients had not made arrangements for help with their recovery at home. Having support in place at home is a required step in Alberta’s standardized care path for hip and knee replacements.

ABJHI and the BJHSCN responded with a strategy to create multidisciplinary frontline teams in hospitals whose members would commit to following the care path, including applying the four-day length of stay. There are 12 hospitals in Alberta where hip and knee replacements are performed.

ABJHI estimates total savings of approximately 33,000 bed-days from April 1, 2010, when the project was launched, to March 31, 2013. The bed-day savings have a value to Alberta’s public health care system of $33 million.

The project has become an important part of the measures being taken by the BJHSCN to meet annual wait time reduction targets for hip and knee replacements.

In Brief

Shorter stay in hospital for hip and knee replacement patients – a 4-day standard.

  • Freed up approximately 33,000 bed-days in Alberta hospitals.
  • Saved bed-days valued at $33 million.
  • Added capacity for 8,625 more surgeries without a single extra hospital bed.
  • More surgeries mean shorter wait times for Albertans.
  • Patient Guides for different bone and joint surgery types, such as hip and knee replacements.