Enhanced recovery pathways can bridge the outcome gap between high and low volume orthopaedic units

In an article published last month in the BMJ (BMJ 2010; 340:C165 DOI: 10.1136/BMJ.C165) the authors showed that hospitals in the USA which specialised in orthopaedic surgery had better outcomes for hip and knee replacement compared to less specialised hospitals.

The study looked at data for 1,273,081 patients from 3818 hospitals in the period 2001-05. The results show that patients who had a hip or knee replacement were less likely to die and had fewer complications in more specialised hospitals compared to less specialised hospitals. Specialisation in orthopaedics was defined by looking at the proportion of all patients who were admitted to the hospital against the number who were admitted with a musculoskeletal condition.

Perhaps the most interesting finding of the article was that low volume surgeons who operated in the specialist (or high volume) hospitals had better outcomes than equivalent volume surgeons in less specialised (low volume) hospitals.  The reason for this difference was proposed to be a result of improved care processes within the higher volume hospitals.

This research and other works clearly indicate that outcomes are influenced by specialisation, and that the more specialised units get better results. This presents an interesting challenge. Not all units can be high volume specialist units, so how do we ensure improved quality of outcomes in lower surgical volume units that is equivalent to high volume centres?

The answer is the pathway. The specialised centres have to have them, as there is no way they could manage their numbers without them.  The low volume centres don’t, as they don’t have the same pressure on them and think that they are therefore not needed.  This is a mistake, because without a pathway you get inconsistency in the way individual patients are treated. The pathway that patients follow is not by design but dependent on external and random factors such as the day of the week, the staff working that shift, or the particular case-mix that day. There is no defined pathway and things that the clinicians think happen such as antibiotic prophylaxis don’t always happen as there are no process control mechanisms or accounting for variance.

So, design a standardised enhanced recovery pathway that suits your local circumstances and implement it.  I can almost guarantee that whatever your pathway is that it will beat your previous multiple pathways hands down.  Once implemented you can refine it.  All the evidence is that whatever the size of your unit you can compete with the best in the world but provide the service locally.