title: Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review.
abstract: SUMMARY RATIONALE, AIMS AND OBJECTIVES: Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway?
  
  
  METHODS
  Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included.
  
  
  RESULTS
  Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking.
  
  
  CONCLUSIONS
  A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta-analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.
authors.affiliation: Centre for Health Services and Nursing Research, Catholic University Leuven, Kapucijnenvoer 35 4th floor, 3000 Leuven, Belgium. Pieter.vanherck@med.kuleuven.be
authors.forename: Pieter
authors.initials: P
authors.lastname: Van Herck
authors.forename: Kris
authors.initials: K
authors.lastname: Vanhaecht
authors.forename: Svin
authors.initials: S
authors.lastname: Deneckere
authors.forename: Johan
authors.initials: J
authors.lastname: Bellemans
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Panella
authors.forename: Antonietta
authors.initials: A
authors.lastname: Barbieri
authors.forename: Walter
authors.initials: W
authors.lastname: Sermeus
mesh_terms: D019643:Arthroplasty, Replacement / Q000191:economics / Q000379:methods* / Q000534:rehabilitation; D019644:Arthroplasty, Replacement, Hip; D019645:Arthroplasty, Replacement, Knee; D019091:Critical Pathways; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D019990:Perioperative Care