title: Decreasing medical complications for total knee arthroplasty: effect of critical pathways on outcomes.
abstract: BACKGROUND
  Studies on critical pathway use have demonstrated decreased length of stay and cost without compromise in quality of care. However, pathway effectiveness is difficult to determine given methodological flaws, such as small or single center cohorts. We studied the effect of critical pathways on total knee replacement outcomes in a large population-based study.
  
  
  METHODS
  We identified hospitals in four US states that performed total knee replacements. We sent a questionnaire to surgical administrators in these hospitals including items about critical pathway use and hospital characteristics potentially related to outcomes. Patient data were obtained from Medicare claims, including demographics, comorbidities, 90-day postoperative complications and length of hospital stay. The principal outcome measure was the risk of having one or more postoperative complications.
  
  
  RESULTS
  Two hundred ninety five hospitals (73%) responded to the questionnaire, with 201 reporting the use of critical pathways. 9,157 Medicare beneficiaries underwent TKR in these hospitals with a mean age of 74 years (+/- 5.8). After adjusting for both patient and hospital related variables, patients in hospitals with pathways were 32% less likely to have a postoperative complication compared to patients in hospitals without pathways (OR 0.68, 95% CI 0.50-0.92). Patients managed on a critical pathway had an average length of stay 0.5 days (95% CI 0.3-0.6) shorter than patients not managed on a pathway.
  
  
  CONCLUSIONS
  Medicare patients undergoing total knee replacement surgery in hospitals that used critical pathways had fewer postoperative complications than patients in hospitals without pathways, even after adjusting for patient and hospital related factors. This study has helped to establish that critical pathway use is associated with lower rates of postoperative mortality and complications following total knee replacement after adjusting for measured variables.
authors.affiliation: Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA. husnie@ccf.org
authors.forename: M Elaine
authors.initials: ME
authors.lastname: Husni
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Anne H
authors.initials: AH
authors.lastname: Fossel
authors.forename: Daniel H
authors.initials: DH
authors.lastname: Solomon
authors.forename: Nizar N
authors.initials: NN
authors.lastname: Mahomed
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Katz
mesh_terms: D000368:Aged; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects* / Q000379:methods* / Q000401:mortality; D015331:Cohort Studies; D019091:Critical Pathways / Q000592:standards; D005260:Female; D006761:Hospitals / Q000592:standards; D006801:Humans; D007902:Length of Stay; D008297:Male; D006278:Medicare; D017063:Outcome Assessment, Health Care / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D011787:Quality of Health Care / Q000592:standards; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D014481:United States