Employing Standardized Clinical Care Pathways to Improve Health Outcomes and Lower Costs

Employing Standardized Clinical Care Pathways to Improve Health Outcomes and Lower Costs
Prakash Jayakumar, MD, PhD
Eugenia Lin, MD
Kenoma Anighoro, MD, MBA
Karl Koenig, MD, MS, FAAOS
Dr. Koenig or an immediate family member serves as a paid consultant to or is an employee of Surgical Directions. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Jayakumar, Dr. Lin, and Dr. Anighoro.
INTRODUCTION
Standardized care pathways in orthopaedic surgery offer a pragmatic, evidencebased strategy for operationalizing high-value, integrated care for a range of musculoskeletal problems while reducing unwarranted variation and waste, improving outcomes, and lowering costs. This chapter defines and explores concepts behind standardized clinical pathways (SCPs), tools and technologies enabling SCPs, and the evidence to date for SCPs in orthopaedic practice.
BACKGROUND
The transformation of practice and payment models in the United States from volume to value-based health care – defined as care improving health outcomes benefiting patients relative to cost – has been stimulated by an escalation in health care spending (from 7% gross domestic product in 1970 to 17% in 20191) without a commensurate improvement in population health outcomes.2 Underlying this health care paradox is unwarranted variation, inequity, and poor access to evidence-based treatments and preventive and supportive care, patient harm, and waste.3,4 Unwarranted variation – the variation in utilization of services that cannot be explained by variations in a patient’s condition or preferences – is reflected in widely varying outcomes of care. Inequity and poor access derive from underutilization of evidence-based interventions, especially
for the underserved, the vulnerable, and people of color. Harm relates to undertreatment as well as inappropriate diagnosis, overtreatment, and medical error; and waste involves any factor not enhancing patient outcomes or resources that could provide greater value if applied to another population.4 To date, payers, clinicians, and policymakers in US health care have used various strategies to overcome these challenges including cost containment, capitation, prior authorization of expensive services, introducing penalties, intensifying resources, and implementing new technologies. Although these efforts offer variable levels of benefit, they often fail to achieve better value for patients, tackle the inappropriate utilization of treatments and low-value interventions, or equitably distribute resources across the wider system. This is mostly because such strategies are applied to the existing health care delivery system without an emphasis on fundamentally changing the structure. Although challenging, these problems also spark opportunities to deliver greater value through improvement in the systems and processes involved in health care delivery.
Advances in the science of process improvement within complex systems have revolutionized the business sector and manufacturing industry.5 The application of “systems thinking” uses a holistic approach that focuses on the dynamic interplay between the components of various processes within a system to drive function, the changes in system function over time, and their effects on the wider system. This approach has elevated performance in a variety of fields.6,7 Further, it has been identified that more variation within a system leads to more waste, impeding the ability to consistently deliver better results. Such insights have prompted initiatives to reduce variation and increase standardization.5 Simply put, if it is assumed that every system and its processes are intentionally and optimally designed to achieve the results they get, then to improve results, the system and its underlying processes need to be changed. But how does this relate to high-value orthopaedic care?
Concepts of systems thinking and the science of process improvement have been incorporated within the field of health care quality improvement.8 A series of landmark reports in the 1990s and early 2000s, with findings such as 44,000 to 98,000 deaths occurring annually due to medical errors, brought patient safety and systems improvement to the forefront.9,10,11 When designing optimal systems, there is a need to differentiate between normal and “special cause” (or unwarranted) variation as a way to eliminate waste, mitigate harm, and achieve improved quality, outcomes, and lower costs. Orthopaedic surgery has a strong legacy in standardizing care practices, in part due to the high prevalence of conditions that often have an assortment of viable treatment options.12,13 From prophylactic antibiotics prior to total joint arthroplasty (TJA), to enhanced perioperative management of fragility fractures, the field is a rich source of processes and services that can be redesigned, tested, and standardized for improvement.14
The readiness to adopt standardized care pathways and practices has been mixed among stakeholders in health care and orthopaedics who may view such efforts as precursors of so-called cookbook or cookie-cutter medicine, where there may be a perceived loss of clinician autonomy, opportunity to exercise
professional judgement, and ability to provide individualized, patient-centered care.15,16 Instead, standardization can function as a vehicle for delivering highvalue care for patients through system and process improvements. Systemization of repetitive and broadly applicable tasks and interventions allows the measured application of best evidence and practices to create a standardized pathway that can be tweaked or adjusted to the individual, when necessary, without losing the effectiveness of reproducibility. Although each patient is indeed unique, there are sufficient commonalities and evidence-based, best practices that should be standardized in order to more predictably achieve better outcomes and lower costs.17,18 This chapter defines and explores concepts behind standardized clinical pathways (SCPs), tools and technologies enabling SCPs, and the evidence to date for SCPs in orthopaedic practice.
STANDARDIZED CLINICAL PATHWAYS
Definition
SCPs (a term used interchangeably with standardized clinical care pathways, evidence-based care pathways, critical pathways, diagnostic therapeutic pathways, integrated care pathways) can be defined as standardized, multidisciplinary, multifaceted care pathways that incorporate evidence-based guidelines and best practices to improve health care quality, outcomes, and costs for patients.19 An operational definition has also been developed involving four key criteria: (1) structured multidisciplinary plans of care; (2) translation of guidelines or evidence into local structures; (3) detailing of steps in a course of treatment or care within a plan, pathway, algorithm, guideline, or protocol; and (4) standardization for a specific population.19
The Concept of Integration
SCPs within complex systems invariably require different levels of care integration.4,20,21,22 Integrated care is defined as coordinated care across professionals, facilities, and support systems that is continuous over time and between visits, tailored to patients’ needs and preferences and based on shared responsibility between patients and caregivers while systematically measuring outcomes.22,23 Singer et al21,23 classified integration into structural, functional, normative, interpersonal, and process integration, which dynamically interacts with contextual factors to affect quality, efficiency, and patient outcomes and experiences (Figure 1). Integrated care delivery has also been described as horizontal integration and vertical integration.24,25 Horizontal integration describes the integration of organizations that provide similar services, such as single specialty group practices, multispecialty group practices, virtual physician networks, independent practice associations, or multihospital systems. Vertical integration describes the integration of organizations offering differing levels of care, services, or functions such as hospital ownership of physician practices, physician-hospital organizations, management services, clinically integrated networks, foundation models, and financially integrated healthcare organizations. Vertically integrated systems make the clinical case for taking complete clinical and
financial responsibility for the whole patient while improving patient outcomes and experiences. These systems also make an economic case through economies of scale, broadening patient coverage while simultaneously consolidating delivery and administrative processes (reducing duplication), thereby lowering health care costs resulting from process duplication between organizations.26 Whichever form of integration, SCPs may offer more effective payer and clinician access to health data, analytics to guide management, coordination, and individualized clinical and administrative consumer experiences.27 They also serve to bolster the bottom line around meaningful, real-time communication among different clinicians – a feature that must be incentivized, facilitated, and maintained in order to deliver high-value care.
QUALITY IMPROVEMENT
Quality improvement is a framework for systematically improving care delivery to patients through a continuous and cyclical process in order to achieve predictable and sustainable results.8,28 The landmark article by Donabedian
describes the triad of structure, process, and outcome to evaluate the quality of health care alongside seven pillars of quality that aim to inform efforts to improve care.29 Further, the Model for Improvement framework, developed by the Associates in Process Improvement, provides a powerful tool to accelerate selection, testing, and implementation of changes for improvement5,8,28 (Figure 2). Three core questions are posed prior to testing involving improvement teams (discussed in the next paragraphs). Teams executing improvement projects should include members representing three areas of expertise: clinical system leadership, technical expertise, and day-to-day leadership. Clinical system leadership ensures sufficient authority to support development, testing, implementation, and maintenance of the change. Clinical leaders should anticipate implications and effect on the wider system. Technical expertise affords guidance on what to measure and how to measure using effective tools, data collection, synthesis, and visualization. Technical experts will have a deep understanding of the subject, intended change or intervention, and process(es) involved, with support from implementation scientists and improvement experts as needed. Day-to-day leadership drives the project, ensures adherence to the project plan, implements the changes and tests, and monitors the captured data while maintaining close contact with the clinical champions. The day-to-day leader also needs to have a strong understanding of the system, and how changes can trigger effects in other parts of the system. The working members of the improvement team should also work with a project sponsor – a person or group with executive authority that has access to enterprise-level management, other parts of the network, or strategies to overcome barriers, while maintaining accountability and the overarching goal.

Question 1 (Setting Aims): “What Are You Going to Improve, by How Much, Over What Time, and for Whom?”
The 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century,11 outlined six aims for improvement for healthcare systems that continue to form the basis of quality improvement: safety (avoiding injury from care intended to help patients); effectiveness (aligning care with science and avoiding overuse of ineffective care or underuse of effective care); patient-centeredness (respecting patient choices, preferences, values, and needs); timeliness (reducing wait times for patients, caregivers, and clinicians); efficiency (reducing waste); and equity (reducing variation and closing racial and ethnic gaps in health status). Aims can be developed using the SMART criteria (ie, aims that are Specific, Measurable, Achievable, Realistic, Timebound). This question relates to affected patient populations as well as systems.
Question 2 (Choosing Measures): “How Will You Know If Change Is An Improvement?”
Measurement is integral to quality improvement. This question helps define whether initiatives are on track to improve the system via reliable, user-friendly measures.8,28 Measures for improvement include outcome, process, and balancing measures. Outcome measures reflect how the system affects the patient as well as other health care stakeholders. Process measures relate to the effect on processes or systems behind the aim. Balance measures view the whole system and whether change designed to improve one or more parts of the system triggers unintended consequences elsewhere in the system. Although there are several commonalities between measurement for learning and improvement compared to measurement for research, improvement measures differ in terms of purpose (ie, knowledge to drive daily practice), process (ie, iterative testing with multiple sequential and observable tests), and practicality (ie, controlling biases from test to test and gathering just enough information to swiftly complete test cycles).
Question 3 (Selecting Changes): “What Changes Can You Make That Will Lead to An Improvement?”
Changes leading to improvement relevant to patients, health care professionals, or administrators usually relate to one or more change concepts—approaches that can develop ideas (both creatively and through application of knowledge and evidence) to inform testable interventions.8
The elimination of waste concept is defined as the removal of non-value—adding activities within organizations. Orthopaedic practices may draw upon the seven wastes exemplified by the Toyota production system in improving their processes and systems: waste of overproduction, waiting, transportation, processing (redundancy), inventory, motion, and production of defective parts or products.30 The workflow improvement concept relates to targeting workflow planning and process components that can lead to better pathways, products, and services. Changes involving the optimization of inventory require a comprehensive understanding of relevant inventory, associated capital investment, storage, handling, tracking,
access, and maintenance before reducing any surplus to minimize waste. Concepts examining change in the working environment may identify real-world opportunities to develop, test, support, and implement changes more effectively. Change concepts improving the producer/customer interface can enable stakeholders to better understand customer needs and expectations before reaping the benefits of products and services. Although many ideas for improvement can come from suppliers (ie, medical device companies, recruitment agencies), customers (ie, patients, surgeons) often provide the most valuable input. Time management concepts offer opportunities to focus on aspects such as reduction in wait times for services, cycle times for various functions and assets, lead time for obtaining supplies and deliveries, and development time for new products. Enhancing this change concept can provide a competitive advantage for practices. Reducing variation is a critical change concept that fosters improvement through increasing the predictability of quality, outcomes, and costs, related to processes and products. Strategies for handling variations often center on evidence and best practices. Error reduction is an important change concept that recognizes factors causing uncertainty within real-world settings (such as human error through handling of multiple tasks sequentially, simultaneously and/or rapidly in clinical situations). Human error is frequently associated with an individual; however, errors often trace back to failures within the system. The number of opportunities to make errors within a system combined with the probability of making an error culminate in a total error frequency. System redesign and implementing specific changes can reduce the probability of individuals making an error for a given opportunity (known as error proofing). Strategies for error proofing include reducing the number of steps within a process, incorporating safety champions and adverse event response teams, instituting periodic safety briefings and safety reporting, integrating technology to automate repetitive tasks, and implementing checks to limit errors from actions performed almost subconsciously within pathways. Finally, focusing on products and services can promote change for improvement beyond targeting processes alone. The three key questions from the Model for Improvement framework are illustrated in the context of various orthopaedic practice scenarios (Figure 3).
PLAN-DO-STUDY-ACT CYCLE
Plan-Do-Study-Act (PDSA) cycles help test change in real-world settings once team members are defined and the aims, measures, and change concepts are established. PDSA frameworks provide a cyclical, iterative, and action-oriented approach to planning, implementing, studying, learning, and acting on changes (Figure 2). “Plan” denotes plans for testing, observation, and data collection; “Do” reflects executing the test at a smaller scale while recording issues and commencing data analysis; “Study” focuses on data analysis and synthesis of results; and “Act” pertains to refinement of changes, defining modifications, assimilating learnings from the test, and preparing for the next test. The team and organization conducting the project then decides whether the change is an improvement, and to adapt, adopt, or abandon the change. After testing, learning, refining, and implementing changes at a smaller scale through several PDSA cycles, the organization

may then choose to implement changes at scale. A PDSA cycle is illustrated in the context of applying a telehealth service within an orthopaedic practice (Figure 4).
Following cycles of testing, learning, and refining changes at a relatively small scale, the change may be ready for wider implementation and spread. Spread is defined as the process of taking effective implementation processes from a pilot population and replicating the change or changes in other areas of the organization or organizational network at a local, regional, or national level. Scaling for an orthopaedic practice may require further adaptations to optimize infrastructure, sequences of tasks, and processes, resources, hiring policies, training, and financial renumeration. A range of techniques including Lean, Six Sigma, and Total Quality Management offer approaches to quality improvement and development of optimal care pathways. Regardless of which techniques are adopted, working rapidly, learning iteratively, and adhering to a systematic process of quality improvement offers the best chances of success.
TOOLS AND TECHNOLOGIES FOR ENABLING SCPs
A variety of quality and process improvement tools and technologies can help enable SCPs in orthopaedic practices. These tools and technologies can be applied to specific phases of the care pathway, to the whole pathway, or to the system in its entirety.12 Assets can be characterized at the patient, physician, and systems level and orthopaedic surgeons should leverage tools at each level in quality improvement efforts and SCP development.31,32 Many of these tools and technologies are discussed elsewhere in this book.
Patient-Facing Tools
Tools enabling the capture of patient-generated health data, defined as health-related data created, recorded, and gathered from patients (or caregivers) to help establish a patient’s health status, are integral to value-based care and SCPs.33,34

Patient-Reported Outcome Measures/Patient-Reported Experience Measures
Patient-reported outcome measures (PROMs) are validated measures of capability, mindset, and circumstances, reported by the patient, enabling quantification of the effect of medical interventions from the patient’s perspective.32,35 Similarly, patient-reported experience measures (PREMs) are subjective measures of patient experiences of healthcare systems ranging from measures of satisfaction with various structural and functional aspects of health care, such as waiting times, access to facilities, and ability to navigate services, to the quality of communication and relationships with health care professionals and teams.34,36,37 Both PROMs and PREMs have made a shift from research settings to clinical practice and policy making as indicators of patient-centered performance improvement. PROMs, for instance, are fast becoming standardized performance measures, administered at designated time points with an established risk-adjusted scoring methodology.38 Such tools will play an increasing role in reimbursement as health care shifts from volume-driven care toward outcomes and value-based care. Because reducing variation remains integral to this transformation, longitudinal data generated by PROMs can be a useful component in tracking, monitoring, and decision support within SCPs.35 Several general health-specific and condition-specific PROMs have been applied across orthopaedic practices, most commonly to measure symptoms and functional outcomes before and after surgical interventions.39 Professional societies such as the American Academy of Orthopaedic Surgeons (AAOS) and International Consortium for Health Outcome Measurement have compiled standardized outcome measures and measurement sets including PROMs for clinical application.40,41 National payers such as the Centers for Medicare & Medicaid Services incentivize PROMs collection through standardized processes of quality reporting and bonus payment initiatives.42 Further, the Consumer Assessment of Healthcare Providers and Systems provide a suite of PREMs developed by the Agency for Healthcare Research and Quality, rating key areas of patient experience related to structural, functional, and interpersonal aspects of care delivery.
Shared Decision Making-Related Outcome Measures and Patient Decision Aids
Shared decision-making (SDM) is a concept that empowers patients to become active participants in developing management plans and selecting appropriate treatments for their condition with clinical teams.43,44 In SDM, informed treatment decisions, aligned with a patient’s preferences, needs and values, are made through expert communication and high-quality patient education. SDM may be incorporated into SCPs to improve patient satisfaction, decision quality, patient outcomes, and appropriate utilization of health care resources. Shared decision making-related outcome measures can be utilized as part of an orthopaedic service’s SDM initiative alongside decision aids. In a manner similar to PROMs, shared decision making-related outcome measures provide a measure of the patient’s perspective in relation to various elements of the decision-making process, from decision
quality, level of collaboration during SDM, preparing for decision making, and decisional conflict, to decision support and satisfaction with the clinical consultation. Patient decision aids (PDAs) are tools designed to facilitate SDM by helping patients better understand evidence-based information, the potential benefits and harms of various treatments, and facilitate communication between patients and clinicians.45,46,47 Importantly, these tools are distinct from patient education materials in that they more actively direct patients toward making an informed choice, aligned with their preferences, between multiple treatment options. In orthopaedic practice, PDAs have been studied most frequently in persistently painful preference sensitive conditions (ie, where multiple valid treatment options exist) such as degenerative disease of the spine and osteoarthritis (OA) of the hip and knee.47,48,49 Decision aids take multiple forms, including written booklets, videos, and interactive digital tools, provided to patients before, during, or after encounters with orthopaedic surgeons. PDAs may also be effective in empowering patients to make informed decisions at a given point in time as well as providing ongoing guidance along different phases of a care pathway. Payers, clinicians, and policymakers are increasingly encouraging the standardization of these value-adding tools in orthopaedic practice.43,44,50 Tools and checklists for the development and application of PDAs are also provided by the International Patient Decision Aid Standards initiative.51
Physician-Facing Tools
Physician-facing tools enabling clinical decision support provide timely and relevant person-specific information to inform clinically oriented decisions that can also improve efficiency, utilization, quality, outcomes and costs of care.52,53 Such tools can be divided into clinical risk assessment tools, web-based orthopaedic personalized predictive tools, standardized clinical checklists, clinical practice guidelines (CPGs), and standardized clinical assessment and management plans (SCAMPs).
Clinical risk assessment tools provide validated metrics that can be utilized by surgeons to better assess the risks associated with a given treatment option. In orthopaedic practice, clinical risk assessment tools such as the Risk Assessment and Predictor Tool, predict length of stay and discharge destination following total joint arthroplasty.54 This function assists patients, clinicians, administrators, and caregivers in taking necessary clinical actions (eg, preparing patient charts and orders), nonclinical actions (eg, preparing for an overnight stay), and allocating resources more effectively. Similar risk assessment tools have been developed for frail, elderly patients with hip fractures to predict postoperative morbidity and mortality.55
Web-based orthopaedic personalized predictive tools provide personalized predictions of clinical outcomes based on the analysis of large volumes of data utilizing algorithmic mathematical modeling and predictive analytics.54,56,57,58,59 A recent study identified 31 discrete web-based orthopaedic personalized predictive tools designed to provide personalized prediction in various orthopaedic specialties including trauma and fracture management, spinal surgery, total joint arthroplasty, and musculoskeletal oncology.60

Standardized Checklists
Standardized clinical checklists in health care and orthopaedics, analogous to those routinely used in the aviation industry, have now become widely adopted.61 The World Health Organization Surgical Safety Checklist, since its introduction in 2008, has transformed perioperative patient safety in surgical care.61 Although this checklist is primarily designed to increase safety awareness and reduce perioperative medical error, it also enhances team communication and consistent execution of procedural steps along the surgical care pathway.62 The AAOS has developed multiple checklists through their appropriate use criteria initiative, which uses a modified Delphi method to create standardized tools, such as a preoperative checklist to facilitate hip fracture management in elderly patients.63 Further, in a move to address the social determinants of health and social unmet needs, a set of checklists and screening tools have also been developed, including the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences, developed by the National Association of Community Health Centers,64 and the Accountable Health Communities Health-Related Social Needs Screening Tool developed by Centers for Medicare & Medicaid Services.65
CPGs and SCAMPs
CPGs are statements developed by the systematic distillation of high-quality evidence into clinical recommendations to support decision making around specific clinical scenarios.66 SCAMPs are clinician-driven tools, created by multidisciplinary teams, based on iterative and evolving analyses of internally collected data, emerging evidence, best practices, and sound expert opinion when evidence is limited. CPGs are centered on the best available evidence at a point in time and are less frequently updated compared to SCAMPs. Although CPGs provide a more rigid tool where adherence is key and deviations from guidelines are generally discouraged, their design costs are relatively low and adoption less labor intensive. In contrast, SCAMPs are dynamic entities designed around decision tree frameworks where deviations from the care pathway based on a physician’s clinical acumen is encouraged at any stage.67,68 This flexibility assumes higher design and implementation costs and tends to be more labor intensive.
Both CPGs and SCAMPs can help reduce practice pattern variations, optimize resource utilization, reduce costs, and improve patient health outcomes.69,70,71 Professional societies such as the AAOS and American College of Chest Physicians have developed numerous CPGs spanning a range of conditions and interventions69 from venous thromboembolism and antibiotic prophylaxis, to the prevention of surgical site infections.66 However, CPGs have also met with some resistance and disengagement from clinicians due to their rigid dependence on the strength of supporting evidence, the need for repeated updates every few years, and questions around their usability in more diverse patient populations.69,72 In contrast, SCAMPs may serve as a more effective and continuous process improvement tool capable of targeting diverse populations and complex clinical scenarios, as long as resources are sufficient and there is
adequate buy-in from the wider healthcare organization alongside any payers or regulatory agencies with a stake in the system.16,71
System-Level Tools
Electronic Medical Records and Data Analytic Engines
Robust, interoperable, and user-friendly electronic medical records (EMRs) are foundational tools for SCPs that enable advanced administrative and management capabilities, improved learning, and reduction in variation and waste within health systems. EMRs can also standardize care and provide a more holistic, longitudinal view of patients while improving coordination and continuity of care within multidisciplinary teams. The functions of these platforms now extend beyond basic repositories of health information, toward the administration and collection of detailed clinical metrics, patient outcomes, and other forms of data including social determinants of health. EMRs should ideally be supported by a strong data analytics engine, advanced enterprise-level data warehouse, and/or cloud systems. This will often serve as a foundational asset for most orthopaedic practices and quality improvement projects.
Patient Portals
Patient portals facilitating patient education, enabling channels for communication, and continuity of care may be part of the EMR or stand-alone, enhancing patient engagement in the care delivery process. Such portals are usually secure websites that allow patients to access personal health information online using a secure username and password.73,74 These platforms can facilitate patient-centered SCPs and quality improvement projects by providing patients with open access to a standardized set of records related to visits, medication lists, and laboratory results, as well as a secure means of communication with clinicians to request prescription refills, ask questions about their care, and schedule appointments.
Outcome Measurement Platforms
Myriad commercial and research-grade patient outcome measurement platforms exist, enabling electronic capture of PROMs and other forms of patient-generated health data. Digitization enables functionalities (eg, data visualization and analysis) and efficiencies (eg, time saving, automation). Most electronic PROM platforms support remote delivery, allowing patients to complete questionnaires by text, email, smartphone, tablet, or their desktop computers at home.75 In addition, these electronic platforms offer integration into EMRs, enabling the review of information in real time with patients and team members.39
Clinical Registries
Local, regional, and national clinical registries and databases capturing various clinical, process, and patient-level metrics may support efforts to standardize aspects of orthopaedic practices and networks.76 Several registries have been developed in the United States since the Mayo Clinic Total Joint Arthroplasty (TJA) registry in 1969, ranging from those at a regional level, such as the Michigan
Arthroplasty Registry Collaborative Quality Initiative, to national initiatives including the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry and the AAOS/American Joint Replacement Registry.77,78,79,80 These registries variably capture PROMs alongside clinical outcomes, including readmission rates, complications, and implant survivorship.39 Other registries, including those sponsored by industry, capture data around medical devices, enabling surveillance for safety and performance.81 The big data housed within many registries offers a powerful source of information for generating substantial clinical insights as well as opportunities for advanced decision support.77,82,83 The UK National Hip Fracture Database provides evidence to drive SCPs, influencing the development of CPGs to influence the standardized management of these common injuries.76 The UK National Joint Registry has been utilized extensively for benchmarking, reporting TJA performance in a standardized fashion, and has more recently been used to develop a patient-facing decision support tool for those considering TJA.84
SCPs in Orthopaedic Practice
Significant variation in orthopaedic practice patterns have resulted in escalating costs without necessarily achieving a corresponding improvement in patient or clinical outcomes, patient experiences, or patient safety.72 Those developing SCPs to confront this issue should have a robust understanding around the level of complexity involved in pathways and processes, organizational capacity to implement the SCP and change, and ways to maintain improvement, instead of reverting back to quick fixes such as cost containment without regard to patient outcomes or maximizing value.17,85 Numerous SCPs have been implemented in orthopaedics to date, targeting improvement across a variety of metrics.14,86 Systematic reviews examining the implementation of SCPs show that most trials and improvement efforts focus on lowering postoperative length of stay, complications, and costs; improving processes such as clinical documentation; improving adherence to evidence-based guidelines; or exceeding quality and safety benchmarks.87,88 Orthopaedic practices could also learn from the experiences of other specialties in implementing SCPs. For instance, considerable advances have been made in oncology around multidisciplinary team-based SCPs providing standardized care and utilization of novel pharmaceutical and biologic therapies.89
EFFECT OF SCPs FOR MUSCULOSKELETAL CARE IN GENERAL
Systematic reviews and meta-analyses have highlighted the variability and nonlinear nature of musculoskeletal care pathways for various conditions, including the management of hip and knee pain.90 This signals the need for a systems approach to process improvement and standardization, with increased development and access to SCPs, particularly those delivering 360° whole-person care. Although most musculoskeletal SCPs target the surgical pathway, there remain a few important examples that focus on primary care, prevention, and nonsurgical management.91,92,93

Quality improvement involving the primary care of musculoskeletal conditions has focused on quality of triage, referral management processes, and bolstering primary care provider education.91,94 A multifaceted intervention based on Cochrane reviews involving musculoskeletal educational programs for general practitioners, alongside locally agreed-on clinical pathways, increased transparency and feedback around referral rates, and improved clinical audit and peer review.91 Underpinned by quality improvement and behavioral change theories, the intervention observed improved quality in referral letter content and pathway adherence, reduced variability in referral rates, higher patient ratings of how well general practitioners explained musculoskeletal conditions, and increased patient satisfaction with the appointment in general.91
Comprehensive management of osteoarthritis (OA) in the form of an OA physical activity care pathway has been developed to support patients with OA of the hip and knee.92 Individuals reporting less than 150 minutes per week of moderate-to-vigorous physical activity at baseline were recruited from primary care clinics and underwent a 3-month OA physical activity care pathway intervention. This included three physical activity goal-setting coaching calls, three check-in emails, and links made to community-based and online physical activity resources (Figure 5). The pathway demonstrated improvements in time spent performing physical activities per week (assessed using an accelerometer), PROMs (measured using the Western Ontario and McMaster Universities Arthritis Index), and satisfaction after 4 months.92 Findings were fed back into modifying the pathway, enhancing patient self-monitoring processes, and generating further impact through positive behavioral change around physical activity.

SCPs have been developed in primary care management of low back pain using a stratified approach involving best-practice pathways and prognostic screening.95 The STarT Back program has shown, in randomized controlled trials, both clinical effectiveness with improved disability at 12 months (Roland-Morris Disability Questionnaire) and cost-effectiveness in terms of incremental quality-adjusted life years (QALYs) compared to nonstratified current best practices.95 SCPs have also been developed in the management of common soft-tissue conditions that can be challenging when there are limited evidence-based treatment options and often longer and more protracted courses of rehabilitation.93 A standardized, therapist-led Achilles tendon pathway for Achilles tendinopathy, developed and implemented using elements of the Model of Improvement framework and a series of PDSA cycles, showed improvement in patient satisfaction, reduced variation and duplication of treatments, investigations, and consultations, with lower costs.93
EFFECT OF SCPs FOR ORTHOPAEDIC SURGICAL CARE
An array of SCPs have been developed in orthopaedic surgery, mostly focused on primary TJA for hip and knee OA – two of the most commonly performed elective surgical procedures.14,96 There has been growing national interest in improving value and appropriate utilization of total hip and total knee arthroplasty (THA and TKA), with almost 1.3 million THAs and TKAs performed in the United States in 2014 and total hospital costs exceeding $20 billion.97 TJA has a strong track record in benefiting individuals with advanced hip or knee OA and consistently demonstrates improvements in symptom intensity, level of incapability, and quality of life.98,99,100 However, the escalation and variation in utilization of TJA surgery, outcomes (eg, complications, utilization, PROMs), adherence to evidence-based processes (eg, surgical times, length of stay, discharge disposition, and post-acute care) and costs (risk-adjusted episode payments) across the United States has caused concern.101,102 Further, the rise in revision surgery adds to this burden. Van Citters et al14 describe a staged process for developing multidisciplinary SCPs that aim to deliver highvalue, patient-centered care for those undergoing TJA. In a process involving clinical leaders from high-performing institutions (eg, those with lower inpatient costs, 30-day readmissions, shorter length of stay, improved adherence to quality metrics), and experts in patient safety, patient experience, and improvement science, the investigators applied a combination of quantitative and qualitative methods to design a care pathway extending from presurgical office visits to 12 months postdischarge. Multiple change opportunities were identified, from ways to enhance communication, collaboration, and team and patient engagement, to standardizing care protocols and information flows. A range of SCPs have now been developed to improve the preoperative, perioperative, and postoperative TJA care pathway.103,104,105,106 These include various forms of fast-track, rapid recovery, rapid mobilization, outpatient surgery, and enhanced recovery after surgery protocols. Meta-analysis evaluating SCPs in THA and TKA demonstrate such pathways invariably achieve shorter lengths of stay and fewer complications.96 These pathways include various combinations of standardized patient selection criteria, preoperative medical risk
assessment, testing, and optimization, patient and clinician education and engagement, expectation management and goal setting, multidisciplinary team-based coordination (including role setting, timing of surgeries, operating room on-time starts and utilization, preprinted care plans), opioid-sparing analgesia and multimodal pain management, standardized anesthetic and surgical techniques, standardized postoperative management (catheterization, venous thromboembolism and antibiotic prophylaxis, blood management and fluid resuscitation protocols), accelerated mobilization (including postoperative day 0 mobilization and multiple day inpatient physical therapy sessions), early postdischarge planning, home assessment, and optimization of home self-care over postacute care utilization.107,108,109,110,111 Large database studies exploring optimal use of process standards (eg, adherence to venous thromboembolism and antibiotic prophylaxis) serve as important predictors of clinical and process level outcomes over surgical volume alone.112,113
SCPs in TJA have demonstrated significant reductions in length of stay,106,107,108,109,110,111,114,115,116,117,118,119,120,121,122 earlier mobilization,109 improved functional outcomes,123 less pain and confusion,109,115 reduced postsurgical use of opiates,120,124 increased rates of discharge directly home over post-acute care facilities (ie, skilled nursing facilities, or inpatient rehabilitation facilities),121,122,124 reduced total costs of perioperative and postoperative care105,108,109,110,112,113,122 without an increase in readmissions or overall complications,107,108,109,110,114,115,116,120,121,122,124 improved patient satisfaction,116,121,124 and greater ease in performing physical therapy during rehabilitation.115 Such findings have been demonstrated in a range of patient populations including those managed via Veterans Health Administration facilities115 and those under Medicare or Medicaid insurance programs.107,124,125 Studies have also shown effective utilization of SCPs to drive down costs and improve postsurgical pain and functional outcomes through enhanced recovery at home and in the community:126 by incorporating virtual clinics for postoperative follow-up,127 advanced musculoskeletal physical therapist-led postoperative follow-up,128,129 management of persistent knee pain post-TKR,130 and technology-enabled rehabilitation (including exercise programs using tablet devices, health coaching using video calls and motivational text messages, physical activity trackers with goal-setting and motivational reminders using wearable sensors, and smartphone-based knee joint motion self-monitoring via goniometer application).131 Standardization initiatives claiming cost-effectiveness should quantify development, implementation, and maintenance costs of SCPs.96
SCPs for TJA that consistently deliver improved outcomes and/or lower costs of care have been scaled at local, regional, and national levels.128 The Dartmouth Hitchcock “Green Care” model14 serves as an exemplar of a SCP for TJA applied across institutions and clinician networks, spanning care from initial referral to the surgeon through to 1 year postsurgery.96 The development of such models focuses on development of generalizable clinical care pathways for primary TJA using inputs from clinical, academic, and patient stakeholders; and identifying system-level and patient-level processes that may provide safe, effective, efficient, patient-centered care for patients undergoing TJA.
In the United States, alternative payment models such as the Centers for Medicare & Medicaid Services Bundled Payment for Care Improvement Initiative
and Comprehensive Care for Joint Replacement model have also been developed to standardize payments for all services related to the TJA episode of care in an effort to reduce procedural variation and incentivize clinicians to administer effective care at lower cost compared to fee-for-service reimbursement.132,133,134 Such models have shown moderate savings through reduced utilization and operational efficiency (eg, decreased utilization of post-acute care and hospital readmissions) without negatively affecting clinical outcomes.133,134,135,136,137,138 However, these procedure-based bundles do not address the potential for overuse of TJA and the risk of “cherry-picking” (choosing healthier or more adherent patients and referring more complex, time-consuming patients to others) and “lemon-dropping” (rejecting complex or less adherent patients, especially those who might use a lot of resources) within environments (and payment systems) that incentivize clinicians based on procedural volume.139,140 Widespread improvement and financial alignment toward better value for patients is only likely to stem from a shift toward standardized condition-based models of payment and practice incentivizing cost-effective management of patient populations using a range of evidence-based nonsurgical and surgical strategies.18,140,141,142,143,144,145,146 SCPs further lend themselves to the development of episode-based pricing and selecting high-value services, including nontraditional strategies, for example, nutritional guidance and behavioral therapies, in developing effective condition-based episodic payment models.
Integrated practice units are one way to organize and standardize care pathways to generate improved outcomes and lower costs while centering care around the patient’s condition. The delivery of greater value for populations across healthcare systems may also depend on effective and standardized integration of primary and secondary care pathways.147 Several value-adding and evidence-based components of advanced TJA pathways described earlier could serve as drivers for success in operating under such alternative payment models.113,147
Integrated practice units have been developed at Dell Medical School at the University of Texas at Austin to provide high-value, coordinated, multidisciplinary care for patients with a range of musculoskeletal conditions, financed by condition-based bundled episode payments148 (Figure 6). All patients attending these integrated practice units have access to a team of health professionals (orthopaedic surgeon, associate clinician [eg, advance practitioner, chiropractor, or nurse practitioner], physical therapist, a dietician, and a behavioral health-trained social worker and medical assistants) throughout the full cycle of care. The standardized episode of care from initial referral up to 1 year includes a range of services from physical therapy and exercise, imaging, intra-articular injections, lifestyle modification (including dietary advice and weight loss counselling), and social support (case management, smoking and alcohol cessation, behavioral health, and psychotherapy – including cognitive behavioral therapy and pain coping skills training). A technology-enabled shared decision-making approach has been integrated into the pathway for patients considering surgery. The care pathway also incorporates the longitudinal collection of PROMs measuring physical and psychosocial outcomes as an integral component of care delivery and requisite for the condition-based alternative payment model.149,150 For surgical patients, a
mandatory component of perioperative management includes the Preoperative Assessment and Global Optimization program151 (Figure 7). This program covers the entire perioperative phase and includes design features to guide not only patients, but family members and caregivers. The Preoperative Assessment and Global Optimization process begins following the decision to pursue TJA. A registered nurse conducts telephone interviews, coordinates and registers activities

with the patient’s EMR, and updates a preoperative dashboard, accessible by all relevant clinicians, that tracks the patient’s progress. The patient is then risk-stratified and directed to various preoperative optimization activities or channeled directly toward surgery. This model and the alignment achieved between financial and clinical incentives have improved patient flow, outcomes, costs, and system performance and decreased perioperative variability.152
SCPs have also been developed using evidence-based protocols to improve outcomes, costs, and practice variation in spinal surgery.153 Demographic factors (eg, being female), surgical factors (eg, longer surgical times, increased number of fusion levels, greater volumes of crystalloid administration), and patient factors (eg, higher average pain scores on the first postoperative day, and higher cumulative morphine use) are shown to influence procedural outcomes.154 Similar to TJA, SCPs in spinal surgery incorporate different elements of rapid or enhanced recovery. SCPs for posterior spinal fusion in patients with adolescent idiopathic scoliosis have shown reduced length of stay,153,155,156 lower perioperative transfusion requirements,153 reduced time to ambulation,156 reduced use of patient-controlled analgesia,154,157 lower postoperative pain scores, earlier return to regular diet, and improved quality of life without an increase in complications rates.155,156
The complexity and duration of SCPs designed around surgical procedures can range from those focused on the in-hospital surgical pathway to those spanning several weeks before and after the surgical intervention within models such as anesthetic perioperative care services and perioperative surgical homes.108,124 Whatever the configuration, SCPs should have the right fit for the organization to enable sustainable change – something that can be evaluated using health technology assessments.118,157 Undertaking comprehensive evaluations may also elucidate wider effects on other service lines secondary to planned process and pathway changes. For instance, physical therapists providing accelerated rehabilitation for patients following TJA may have reduced capacity to deliver therapy to other patients; and performing enhanced recovery after surgery protocols on a subset of patients can complicate broader surgical scheduling and burden staff caring for patients not under enhanced recovery after surgery protocols.
EFFECT OF SCPs FOR ORTHOPAEDIC TRAUMA CARE
SCPs in orthopaedic trauma have predominantly focused on fracture management in outpatient and ambulatory surgical settings.158,159 Strategies entailing changes to booking protocols for outpatient surgery and clinician education have demonstrated a reduction in unnecessary hospitalizations for stable, healthier patients awaiting surgical treatment of a fracture by focusing on timely, efficient, and coordinated care.86,158 Shifting toward preoperative optimization at home, other SCPs have demonstrated lower complication rates, improved patient satisfaction, and lower costs of prehabilitation and coordination of outpatient-inpatient services compared to standard inpatient admission for select patients.86 Aside from the benefits of performing safe fracture fixation with reduced tissue swelling and maintaining safe movement of other joints to prevent stiffness, there are systemwide benefits in increasing bed capacity.159 Virtual fracture clinics
have been developed to improve waiting times,159 patient experience,159 costs of care through reducing standard face-to-face, outpatient, and inpatient care159,160 and reducing the burden on emergency departments without an increase in reattendance rates161 (Figure 8). Discrete event simulation and modeling of such pathways using an activity-based costing approach demonstrates the feasibility
of this approach with significant reductions in initial in-person outpatient attendances, daily resource costs for all staff groups, reduction in duplicative testing, and overall cost per patient160 Systematic reviews show virtual fracture clinics for the management of fifth metatarsal fractures and radial head and neck fractures as highly effective, with opportunities to translate such models to other more stable fracture patterns in appropriate patients. SCPs have also been developed for prehospital and trauma care involving standardized resuscitation parameters for the severely injured patient, improving care coordination and expediting definitive fracture fixation, resulting in reduced complications, hospital length of stay, and costs of care.162
A range of SCPs have also been developed for the management of fragility fractures of the hip in elderly patients – a common injury with high morbidity and mortality and traditionally long wait times for emergent surgery, leading to the increased risk of complications. Elderly patients with these injuries are prone to pneumonia, deep vein thrombosis/pulmonary embolus, delirium, pressure sores, and malnutrition, among other complications.129 Cognitive impairment and poor balance control are strongly associated with delayed recovery of ambulatory function in these patients.163 Several comprehensive hip fracture SCPs have been developed collaboratively between orthopaedic surgeons, specialists in care of the elderly, anesthesiologists, therapists (physical therapists, occupational therapists), nurses, emergency medicine and internal medicine physicians, and hospital management with variable guidance from professional societies.129 Recommendations have targeted earlier intensive medical and surgical management, individualized and accelerated rehabilitation, patient engagement and education around falls prevention, earlier consideration of home support, discharge planning, and stratified rehabilitation. Such pathways have demonstrated improvements in early access to specialist medical care,164 targeted medical optimization (improved fluid resuscitation),164,165 and management of physiological parameters using clinical decision support tools (eg, modified early warning scores), improved utilization of diagnostic tests and physician consultations,166,167 earlier surgical intervention or increased surgical intervention within 48 hours of admission,129,165,166,167,168,169,170, improved utilization of medical products (eg, blood products165), reduced length of stay,166,168 reduced complications,166 greater uptake of secondary prevention such as antiosteoporosis treatments in-hospital,169 discharge home over transfer to skilled nursing facilities,129,170 improved medium to longer-term functional outcomes (including balance and physical activity)170 and mental health outcomes,129,163 and reduced morbidity171 and mortality rates.129,168 Benefits of multidisciplinary SCPs for fragility hip fractures include more expedient timing from the emergency room admission to the operating room, lower length of stay and lower complications rates even in more medically complex patients,151,152 accounting for fracture configuration and severity. SCPs demonstrating positive effects in many of these outcomes have been scaled across hospital networks as regional and national hip fracture management programs.170

SUMMARY
Development of SCPs should involve a systematic process utilizing the best available evidence, principles and practices of quality improvement, and “systems thinking” alongside tools and frameworks for improvement. The ability to develop, test, and implement changes is essential for any individual, group, practice, organization, or network involved in orthopaedic care that wants to continuously improve. Thus, the benefits of care pathway standardization within a framework of value-based, personalized medicine can be achieved at the level of the clinical pathway as well as the entire system. Ongoing efforts are needed to develop, test, and implement innovative SCPs within value-oriented condition-based models of care, while actively involving patients as part of an interdisciplinary team in the SCP development process and evaluating their impact on patient outcomes and costs.
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Nov 2, 2025 | Posted by in ORTHOPEDIC | Comments Off on Employing Standardized Clinical Care Pathways to Improve Health Outcomes and Lower Costs

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