title: A self-paired comparison of perioperative outcomes before and after implementation of a clinical pathway in patients undergoing total knee arthroplasty.
abstract: OBJECTIVE
  Clinical pathways commonly modify multiple variables and deviate from long-established clinical practices. Therefore, it is difficult to perform prospective, randomized clinical trials comparing "standard care" to the "new clinical pathway." The goal of this investigation was to examine the impact of clinical pathways implementation on perioperative outcomes and institutional costs in patients undergoing total knee arthroplasty (TKA).
  
  
  METHODS
  This before-and-after study evaluated patient clinical outcomes and economic costs after the implementation of institutional clinical pathway. The primary outcome was hospital length of stay (LOS). Clinical and economic outcomes were analyzed as continuous variables using paired t test.
  
  
  RESULTS
  Fifty-four patients were identified for study inclusion. Patients undergoing their TKA after implementation of the clinical pathway had a significantly shorter hospital LOS (3.4 vs 4.4 days; P < 0.001). Patients reported significantly less postoperative pain, less postoperative confusion, and an easier time participating in physical therapy sessions after their second (after the clinical pathway implementation) TKA. Patients undergoing their TKA after the clinical pathway implementation had reduced total direct hospital costs ($956; 95% confidence interval, $233-$1785; P = 0.02).
  
  
  CONCLUSIONS
  Our findings demonstrated that the use of a standardized clinical pathway reduced hospital LOS, improved clinical outcomes and patient satisfaction while reducing costs for identical surgical procedures.
authors.affiliation: From the *Department of Anesthesia and †Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Duncan
authors.forename: Susan M
authors.initials: SM
authors.lastname: Moeschler
authors.forename: Terese T
authors.initials: TT
authors.lastname: Horlocker
authors.forename: Arlen D
authors.initials: AD
authors.lastname: Hanssen
authors.forename: James R
authors.initials: JR
authors.lastname: Hebl
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects / Q000191:economics / Q000534:rehabilitation; D003221:Confusion / Q000209:etiology / Q000517:prevention & control; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D019091:Critical Pathways / Q000191:economics; D017721:Hospital Costs; D006801:Humans; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery*; D007902:Length of Stay; D010149:Postoperative Pain / Q000209:etiology / Q000517:prevention & control; D010351:Patient Discharge; D026741:Physical Therapy Modalities; D015397:Program Evaluation; D020127:Recovery of Function; D012042:Registries; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000701:Analgesics, Opioid