Introduction

Total knee arthroplasty (TKA) is an intervention indicated as treatment for individuals in advanced stages of osteoarthritis, aiming to reduce pain and improve motor function.[1] Its demand has increased and is expected to impact long-term healthcare system costs. In the United States, 670,000 TKA were performed in 2012 at a total cost of 36.1 billion dollars, and due to high rates of primary TKA interventions, number of revisions TKA are also expected to grow 137% from 2005 to 2030. [1,2]

Clinical pathways are as an alternative by which health care efficiency can be achieved. Defined by a structured plan that indicates the sequence of events and actions necessary to achieve better outcomes, it involves the use of clinical protocols to improve management, decrease complication rates and optimize clinical outcomes. [3,4] It has been shown that the use of clinical pathway for total joint replacement results in the reduction of hospital length of stay (LOS), which is related to early rehabilitation protocols, resulting in fewer postoperative complications and without increase of the readmission rate. [2,4]

Recent studies have also shown that, in addition to clinical improvements, the interventions through a clinical pathway could help the healthcare system as a whole to reduce costs.[2,5] Although most clinical pathway for TKA has been implemented in the public health care system, rather than private hospitals, they could benefit from its use, as it is an organizational engagement process, which can add value for health insurance providers. However, there is still no consensus on the effectiveness of clinical pathways for TKA, since some reports have shown conflicting results regarding to efficacy of earlier physical therapy and discharge. [6,7]

The primary purpose of this study was to assess whether the use of a clinical pathway for TKA can contribute to reduce LOS and healthcare costs in a private hospital, without an increase in the hospital readmission rate. We also aimed to assess whether care providers adhered to the recommendations regarding, mainly antibiotic use and physical therapy. We hypothesize that standardization of care process has potential to improve these results.

Methods

Results

We analyzed data of 485 primary TKA, 220 patients in GI and 265 patients in GII. There were no significant differences between two groups regarding gender, age, BMI and comorbidity. There was a higher prevalence of women in both groups (72.3% in GI and 69.8% in GII). Overall mean age was 69.8 years (69.8 in GI and 69.9 in GII). The mean of BMI was 29.1 in GI and 28.7 in GII. The most frequent comorbidity observed in both groups was systemic arterial hypertension (56.8% in GI and 50.6% in GII) followed by diabetes (16.8% in GI and 23.4% in GII). Compression socks were used in all cases in postoperative period, and most of them used pneumatic compressor (98.6% in GI and 98.9% in GII). The most widely used drug for thromboprophylaxis was enoxaparin in both groups. Use of surgical drains was frequent in both groups (98.2% in GI and 91.3% in GII), and withdrawal occurred most often within 48 hours (95.0% in GI and 89.1% in GII).

We observed there was adherence by care providers to recommendations regarding physical therapy and prophylactic ATB usage (Table 1). The physical therapy on the first postoperative day was most frequent in GII than GI (96.2% vs 78.1%, p < 0.001). There was also difference between groups in relation to onset of gait. The median for patients in GI was 3 (2–4) days, and for patients in GII was 2 (2–3) days (Table 1). Prophylactic ATB 60 minutes prior the surgery was significantly more used in GII than GI (99.2% vs 87.4%, p < 0.001). In addition, ATB suspension within 48 hours was significantly more frequent in GII than GI (84.7% vs. 51.6%, p < 0.001).

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Table 1. Comparison between GI and GII regarding main items of the clinical pathway.

https://doi.org/10.1371/journal.pone.0232881.t001

During the time period of the study, we observed that only 1.4% of the patients were re-admitted for up to 30 days in GI and no cases were reported in GII.

Length of stay

We observed that there was a significant reduction in the LOS after implementation of clinical pathway. The median for patients in GII was 4.9 (4.3–5.6) days, and for patients in GI was 6.3 (5.4–7.2) days (p < 0.05). For this analysis, we excluded 3 patients in the GI and 3 patients in the GII who had length of stay greater than 15 days due complications not related to TKA procedure (Fig 1).

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Fig 1. Length of stay.

https://doi.org/10.1371/journal.pone.0232881.g001

Cost analysis

The cost analysis showed a reduction in surgical procedure costs after clinical pathway implantation, from US$ 13,018.92 (12,538.48–13,517.76) in GI to US$11,766.46 (11,370.52–12,176.23) in GII (p <0.001). For this analysis, four patients (2 from GI and 2 from GII) were excluded because total cost included treatment of the other complications not related to TKA. Overall, there was a cost reduction of US$1,252.00 in GII when compared with GI (Fig 2).

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Fig 2. Total cost of the surgical procedure.

https://doi.org/10.1371/journal.pone.0232881.g002

Discussion

This present study has shown that our clinical pathway was able to reduce costs and hospital LOS of TKA patients, without increasing readmission rate. Also, we showed that there was adherence by care providers to recommendations regarding antibiotic use and physical therapy. Our findings are in line with previous studies, showing that standardization of patient’s care process was able to improve medical practice. [3,5,6,8,9]

One of main purposes of clinical pathway is to allow early but safely hospital discharge of the patient, since keeping patients in hospital could increase not only postoperative complications but also direct hospital cost. [5,8] In addition, there is direct association between LOS and patient’s satisfaction.[6,10] However, to reach purpose of reducing LOS is not such simple as many patient characteristics are associated with it, like age, sex, marital status, co-morbidity and early rehabilitation.[6,11] Clinical pathway at our institution focused on early rehabilitation and we believe that this factor was the primarily responsible for reducing LOS. We showed there was a significant increase in the number of patients starting physical therapy within 24 hours of surgery. For being a modifiable factor, accelerated rehabilitation with early physical therapy also is key component of the most clinical pathways and other perioperative protocols with the same purposes.[12]. Tayrose et al. [13] in a study with nine hundred hip and knee arthroplasties, have shown that patients beginning physical therapy still in the recovery room had significantly less LOS than patients who began physical therapy on the first postoperative day. Similar to our results, Ayalon et al. [3] showed that a clinical pathway focused on faster rehabilitation, with onset of range of motion on the same day of surgery, was able to reduce the average LOS from 4.03 to 3.77 days. They also showed there was no significant increase in complications. Our results are also in agreement with results reported by Hertog et al. [9], who reduced LOS was accompanied by fewer adverse events in the group of patients underwent physical therapy on the same day as the TKA surgery.

Besides patient-related factors, as already mentioned, there are also structural-related risk factors influencing LOS.[11] Piuzzi et al. [11] have reported patient-related factors such as sex, age and comorbidities are important but are not the main drivers of the LOS. Our results corroborate with their results, since the two groups did not differ regarding demographic characteristics despite difference found in the LOS. Although our clinical pathway focuses on early rehabilitation, other factors are also important, such as patient education, pain management and anesthesia care.[3,4,14] Ayalon et al.[3] have reported results similar to ours, with a clinical pathway focusing on not only early rehabilitation, but also on better pain and nausea management, standardization of anesthesia care and patient education. These findings highlight the importance of the clinical pathway as a tool to be developed on the health care institutions with help of multidisciplinary team for improving patient outcomes and reducing costs.

There seems to be a clear interaction between the LOS and overall costs of TKA. Barbieri et al. [8], performed a meta-analysis to evaluate clinical pathway for TKA compared with standard medical care. They reported lower costs during hospital stay associated with use of clinical pathway. Also, a shorter LOS was observed in the clinical pathway group. Similar results were reported by Lovald et al. [15] They performed a study comparing outpatient surgery with patients who stayed 3–4 days in the hospital. Costs associated with outpatient procedure, after two years, were US$ 8,527 lower than 3–4 days group. In our study, we observed a cost reduction of almost US$2,000 per surgery during hospital stay, with no increase in readmission rate probably due to decrease in LOS and better medical practice. By standardizing the care process and decreasing LOS without an increase in postoperative complications, we find that adoption of a clinical pathway can become an important strategy in reducing costs of TKA. These benefits reached with clinical pathway, as cost and LOS reduction, are still more important considering setting of a developing country. Difficulties in health care system in many of these countries are even greater and a tool as clinical pathway could help by setting guidelines to be adopted by surgeons. In addition, cost of this procedure is comparable with developed countries, and since the budget of our health system is increasingly limited, there is a growing need for cost reduction programs, by the demand of health system.[16] We did not have cost date for comparison between public and private setting. There is a shortage of Brazilian arthroplasty data in the literature. Ferreira et al. [17] showed date on public care but without data about costs. They have shown the reduction in LOS from 2008 to 2015 in Brazil, being the Midwest region of the country with the highest average of reduction (6.6 days), showing the heterogeneity of health care system in that country.[17]

This study has some limitations. First, data were collected retrospectively, which leaves them prone to information bias. Second, we cannot quantify the real importance of each item of the clinical pathway in the analyzed outcomes. Third, our study was performed in a private hospital, and this may have implications on the generalizability of our findings. Finally, we do not have neither clinical outcomes nor the cost of the development and implementation of the clinical pathway, which makes it impossible to evaluate if all this process is cost-effectiveness. Despite these limitations, our findings suggest that clinical pathways, when they are well structured, can be safely implemented and actively used in TKA patients.

Conclusion

The implementation of a clinical pathway, with focus on early rehabilitation, for patients underwent TKA, contributed to a reduction of LOS and costs during hospital stay, with no increase in the readmission rate. We also concluded that there was adherence to the clinical pathway by care providers in our institution.