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The Alberta hip and knee replacement project: A model for health technology assessment based on comparative effectiveness of clinical pathways

Published online by Cambridge University Press:  15 April 2009

Katherine L. Gooch ,
Douglas Smith ,
Tracy Wasylak ,
Peter D. Faris ,
Deborah A. Marshall ,
Hoa Khong ,
Julie E. Hibbert ,
Robyn D. Parker ,
Ronald F. Zernicke  and
Lauren Beaupre
...Show all authors
Katherine L. Gooch
Affiliation:
Alberta Bone and Joint Health Institute and Curtin University of Technology
Douglas Smith
Affiliation:
Alberta Bone and Joint Health Institute
Tracy Wasylak
Affiliation:
Alberta Health Services
Peter D. Faris
Affiliation:
Alberta Bone and Joint Health Institute
Deborah A. Marshall
Affiliation:
Alberta Bone and Joint Health Institute
Hoa Khong
Affiliation:
Alberta Bone and Joint Health Institute
Julie E. Hibbert
Affiliation:
Alberta Bone and Joint Health Institute
Robyn D. Parker
Affiliation:
Alberta Bone and Joint Health Institute
Ronald F. Zernicke
Affiliation:
University of Michigan
Lauren Beaupre
Affiliation:
Capital Health/Alberta Health Services
Tim Pearce
Affiliation:
Alberta Health Services
D. W. C. Johnston
Affiliation:
Alberta Health Services
Cyril B. Frank
Affiliation:
Alberta Bone and Joint Health Institute
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Abstract

Background: The Alberta Hip and Knee Replacement Project developed a new evidence-based clinical pathway (NCP) for total hip (THR) and knee (TKR) replacement. The aim was to facilitate the delivery of services in a timely and cost-effective manner while achieving the highest quality of care for the patient across the full continuum of care from patient referral to an orthopedic surgeon through surgery, recovery, and rehabilitation. The purpose of this article is to provide an overview of the study design, rationale, and execution of this project as a model for health technology assessment based on comparative effectiveness of alternative clinical pathways.

Methods: A pragmatic randomized controlled trial study design was used to evaluate the NCP compared with the standard of care (SOC) for these procedures. The pragmatic study design was selected as a rigorous approach to produce high quality evidence suitable for informing decisions between relevant interventions in real clinical practice. The NCP was evaluated in three of the nine regional health authorities (RHAs) in Alberta with dedicated central intake clinics offering multidisciplinary care teams, constituting 80 percent of THR and TKR surgeries performed annually in Alberta. Patients were identified in the offices of twenty orthopedic surgeons who routinely performed THR or TKR surgeries. Evaluation outcome measures were based on the six dimensions of the Alberta Quality Matrix for Health (AQMH): acceptability, accessibility, appropriateness, effectiveness, efficiency and safety. Data were collected prospectively through patient self-completed questionnaires at baseline and 3 and 12 months after surgery, ambulatory and inpatient chart reviews, and electronic administrative data.

Results: The trial design was successful in establishing similar groups for rigorous evaluation. Of the 4,985 patients invited to participate, 69 percent of patients consented. A total of 3,434 patients were randomized: 1,712 to SOC and 1,722 to the NCP. The baseline characteristics of patients in the two study arms, including demographics, comorbidity as measured by CDS and exposure to pain medications, and health-related quality of life, as measured by Western Ontario and McMaster Universities Osteoarthritis Index and Short Form-36, were similar.

Conclusions: The Alberta Hip and Knee Replacement Project demonstrates the feasibility and advantages of applying a pragmatic randomized controlled trial to ascertain comparative effectiveness. This is a model for health technology assessment that incorporates how clinical pathways can be effectively evaluated.

Keywords

Clinical pathwaysHealth technology assessmentPragmatic randomized controlled trialArthroplastyQuality indicatorsOutcome measures
Type
General Essays
Information
International Journal of Technology Assessment in Health Care , Volume 25 , Issue 2 , April 2009 , pp. 113 - 123
Copyright
Copyright © Cambridge University Press 2009

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