Justine M. Naylor

Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study

Background Despite the widespread use of accreditation in many countries, and prevailing beliefs that accreditation is associated with variables contributing to clinical care and organisational outcomes, little systematic research has been conducted to examine its validity as a predictor of healthcare performance. Objective To determine whether accreditation performance is associated with self-reported clinical performance and independent ratings of four aspects of organisational performance. Design Independent blinded assessment of these variables in a random, stratified sample of health service organisations. Settings Acute care: large, medium and small health-service organisations in Australia. Study participants Nineteen health service organisations employing 16 448 staff treating 321 289 inpatients and 1 971 087 non-inpatient services annually, representing approximately 5% of the Australian acute care health system. Main measures Correlations of accreditation performance with organisational culture, organisational climate, consumer involvement, leadership and clinical performance. Results Accreditation performance was significantly positively correlated with organisational culture (rho=0.618, p=0.005) and leadership (rho=0.616, p=0.005). There was a trend between accreditation and clinical performance (rho=0.450, p=0.080). Accreditation was unrelated to organisational climate (rho=0.378, p=0.110) and consumer involvement (rho=0.215, p=0.377). Conclusions Accreditation results predict leadership behaviours and cultural characteristics of healthcare organisations but not organisational climate or consumer participation, and a positive trend between accreditation and clinical performance is noted.

A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-organisational design for researching health sector accreditation [LP0560737]

BackgroundAccreditation has become ubiquitous across the international health care landscape. Award of full accreditation status in health care is viewed, as it is in other sectors, as a valid indicator of high quality organisational performance. However, few studies have empirically demonstrated this assertion. The value of accreditation, therefore, remains uncertain, and this persists as a central legitimacy problem for accreditation providers, policymakers and researchers. The question arises as to how best to research the validity, impact and value of accreditation processes in health care. Most health care organisations participate in some sort of accreditation process and thus it is not possible to study its merits using a randomised controlled strategy. Further, tools and processes for accreditation and organisational performance are multifaceted.Methods/designTo understand the relationship between them a multi-method research approach is required which incorporates both quantitative and qualitative data. The generic nature of accreditation standard development and inspection within different sectors enhances the extent to which the findings of in-depth study of accreditation process in one industry can be generalised to other industries. This paper presents a research design which comprises a prospective, multi-method, multi-level, multi-disciplinary approach to assess the validity, impact and value of accreditation.DiscussionThe accreditation program which assesses over 1,000 health services in Australia is used as an exemplar for testing this design. The paper proposes this design as a framework suitable for application to future international research into accreditation. Our aim is to stimulate debate on the role of accreditation and how to research it.

Land-Based Versus Water-Based Rehabilitation Following Total Knee Replacement : A Randomized, Single-Blind Trial

OBJECTIVE To compare outcomes between land-based and water-based exercise programs delivered in the early subacute phase up to 6 months after total knee replacement (TKR). METHODS Two weeks after surgery (baseline), 102 patients were randomized to participate in either land-based (n = 49) or water-based (n = 53) exercise classes. Treatment parameters were guided by current clinical practice protocols. Therefore, each study arm involved 1-hour sessions twice a week for 6 weeks, with patient-determined exercise intensity. Session attendance was recorded. Outcomes were measured at baseline and at 8 and 26 weeks postsurgery. Outcomes included distance on the 6-Minute Walk test, stair climbing power (SCP), the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (n = 85 English-proficient patients), visual analog scale for joint pain, passive knee range of motion, and knee edema (circumference). Planned orthogonal contrasts, with an intent-to-treat approach, were used to analyze the effects of time and time-group interactions. RESULTS Compliance in both groups was excellent with 81% attending 8 or more sessions. Loss to followup was 5%. Significant improvements were observed across time in all outcomes at 8 weeks, with further improvements evident in all variables (except WOMAC pain) at 26 weeks. Minor between-group differences were evident for 4 outcomes (SCP, WOMAC stiffness, WOMAC function, and edema) but these appear clinically insignificant. CONCLUSION A short-term, clinically pragmatic program of either land-based or water-based rehabilitation delivered in the early phase after TKR was associated with comparable outcomes at the end of the program and up to 26 weeks postsurgery.

Cryotherapy after total knee arthroplasty a systematic review and meta-analysis of randomized controlled trials.

Cryotherapy has theoretical and practical applications in the reduction of pain, swelling, and blood loss after trauma. We performed a systematic review and meta-analysis of randomized controlled trials on the efficacy of cryotherapy after total knee arthroplasty (TKA). Eleven studies involving 793 TKAs were included. There was considerable clinical and methodological heterogeneity. Cryotherapy resulted in small benefits in blood loss and discharge knee range of motion. There were no benefits in transfusion and analgesia requirements, pain, swelling, length of stay, and gains in knee range of motion after discharge. Despite some early gains, cryotherapy after TKA yields no apparent lasting benefits. Patient-centered outcomes remain underinvestigated. The current evidence does not support the routine use of cryotherapy after TKA.

Sprint Training Increases Muscle Oxidative Metabolism During High-Intensity Exercise in Patients With Type 1 Diabetes

OBJECTIVE—To investigate sprint-training effects on muscle metabolism during exercise in subjects with (type 1 diabetic group) and without (control group) type 1 diabetes. RESEARCH DESIGN AND METHODS—Eight subjects with type 1 diabetes and seven control subjects, matched for age, BMI, and maximum oxygen uptake (V̇o2peak), undertook 7 weeks of sprint training. Pretraining, subjects cycled to exhaustion at 130% V̇o2peak. Posttraining subjects performed an identical test. Vastus lateralis biopsies at rest and immediately after exercise were assayed for metabolites, high-energy phosphates, and enzymes. Arterialized venous blood drawn at rest and after exercise was analyzed for lactate and [H+]. Respiratory measures were obtained on separate days during identical tests and during submaximal tests before and after training. RESULTS—Pretraining, maximal resting activities of hexokinase, citrate synthase, and pyruvate dehydrogenase did not differ between groups. Muscle lactate accumulation with exercise was higher in type 1 diabetic than nondiabetic subjects and corresponded to indexes of glycemia (A1C, fasting plasma glucose); however, glycogenolytic and glycolytic rates were similar. Posttraining, at rest, hexokinase activity increased in type 1 diabetic subjects; in both groups, citrate synthase activity increased and pyruvate dehydrogenase activity decreased; during submaximal exercise, fat oxidation was higher; and during intense exercise, peak ventilation and carbon dioxide output, plasma lactate and [H+], muscle lactate, glycogenolytic and glycolytic rates, and ATP degradation were lower in both groups. CONCLUSIONS—High-intensity exercise training was well tolerated, reduced metabolic destabilization (of lactate, H+, glycogenolysis/glycolysis, and ATP) during intense exercise, and enhanced muscle oxidative metabolism in young adults with type 1 diabetes. The latter may have clinically important health benefits.

CONSORT compliance in surgical randomized trials: are we there yet? A systematic review.

Objective: We performed a systematic review assessing the reporting quality of trials of surgical interventions, and explored associated trial level variables. Background: Randomized controlled trials (RCTs) provide clinicians with the best evidence for the effects of interventions, but may not be reported with necessary detail. Methods: In May 2009, 3 databases (MEDLINE, EMBASE, and CENTRAL) were searched for RCTs that assessed a surgical intervention using a comprehensive electronic strategy developed by the Cochrane Collaboration. The Consolidated Standards of Reporting Trials (CONSORT) checklist was used as a measure of reporting quality. An overall CONSORT score was calculated and expressed as a proportion. This was supplemented with domains related to external validity. We also collected data on characteristics hypothesized to improve reporting quality, and exploratory regression was performed to determine associations. Results: One hundred fifty recently published RCTs were included. The most commonly represented surgical subspecialties were general (29%), orthopedic (23%), and cardiothoracic (13%). Most (65%) were published in subspecialty surgical journals. Overall reporting quality was low, with only 55% of CONSORT items addressed. Less than half of trials described adequate methods for sample size calculation (45%), random sequence generation (43%), allocation concealment (45%), and blinding (37%). The strongest associations with reporting quality were adequate methods related to methodological domains, an author with an epidemiology/statistics degree, and a longer report length. Conclusions: There remains much room for improvement for the reporting of surgical intervention trials. Authors and journal editors should apply existing reporting guidelines, and guidelines specific to the reporting of surgical interventions should be developed.

Severe other joint disease and obesity independently influence recovery after joint replacement surgery: an observational study

QUESTIONS Are either severe other joint disease or obesity associated with a slower rate of recovery after total hip or knee replacement surgery? Are they associated with less absolute recovery up to one year post-surgery? DESIGN Prospective, longitudinal, observational study over 12 months. PARTICIPANTS Ninety-nine patients (knee=55, hip=44) stratified according to the presence of severe other joint disease and obesity. OUTCOME MEASURES Pain in operated joint, and 15-m Walk Test and Timed Up and Go Test measured pre- and at 2, 6, 12, 26, and 52 weeks post-surgery. Walking aid utilisation and global improvement were measured at 52 weeks. RESULTS For rate of recovery, the participants with severe other joint disease recovered more slowly than the non-severe group in terms of mobility (15-m Walk Test p=0.005). For absolute recovery, participants with severe other joint disease walked 0.27 m/s (95% CI 0.15 to 0.40) more slowly on the 15-m Walk Test, took 4.0 s (95% CI 2.3 to 5.8) longer on the Timed Up and Go Test, and had 6.8 times greater chance (95% CI 2.8 to 16.5) of using a walking aid than the non-severe group at 52 weeks. This profile was similar for the obese group compared with the non-obese group. At 52 weeks, the majority (95%) of participants reported significant (better/much better) global improvement. CONCLUSION Severe other joint disease and obesity are associated with poorer recovery after surgery. Clinician and patient expectations, rehabilitation, and benchmarking can be guided by these findings.

One-to-One Therapy Is Not Superior to Group or Home-Based Therapy After Total Knee Arthroplasty A Randomized, Superiority Trial

BACKGROUND The aim of this study was to determine whether center-based, one-to-one physical therapy provides superior outcomes compared with group-based therapy or a simple monitored home-based program in terms of functional and physical recovery and health-related quality of life after total knee arthroplasty. METHODS Patients awaiting primary total knee arthroplasty at two Sydney metropolitan hospitals were enrolled into this prospective, randomized, superiority trial preoperatively. At two weeks postoperatively, participants were randomly allocated to one of three six-week treatment programs (twelve one-to-one therapy sessions, twelve group-based therapy sessions, or a monitored home program) with use of a computer-generated sequence. Self-reported outcomes (Oxford Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index pain and function subscales, and Medical Outcomes Study 12-Item Short-Form Survey) and performance-based functional outcomes were measured over twelve months postoperatively by a blinded assessor. The primary outcome was knee pain and function measured with use of the Oxford Knee Score at ten weeks postoperatively. Intention-to-treat analysis was conducted. RESULTS Two hundred and forty-nine patients (eighty-five who had one-to-one therapy, eighty-four who had group-based therapy, and eighty who were in the monitored home program) were randomized and 233 were available for their one-year follow-up assessment. Participants who received one-to-one therapy did not have a superior Oxford Knee Score at week ten compared with those who received the alternative interventions; the median score was 32 points for the one-to-one therapy group, 36 points for the group-based therapy group, and 34 points for the monitored home program group (p = 0.20). Furthermore, one-to-one therapy was not superior compared with group-based therapy or monitored home program in improving any of the secondary outcomes across the first postoperative year. No adverse events were associated with any of the treatment arms. CONCLUSIONS One-to-one therapy does not provide superior self-reported or performance-based outcomes compared with group-based therapy or a monitored home program, in the short term and the long term after total knee arthroplasty. LEVEL OF EVIDENCE Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Discordance Between Patient and Surgeon Satisfaction After Total Joint Arthroplasty

We surveyed 331 patients undergoing total hip or knee arthroplasty pre-operatively, and patients and surgeons were both surveyed 6 and 12 months post-operatively. We identified variables (demographic factors, operative factors and patient expectations) as possible predictors for discordance in patient-surgeon satisfaction. At 12 months, 94.5% of surgeons and 90.3% of patients recorded satisfaction with the outcome. The discordance between patient and surgeon satisfaction was mainly due to patient dissatisfaction-surgeon satisfaction. In an adjusted analysis, the strongest predictors of discordance in patient-surgeon satisfaction were unmet patient expectations and the presence of complications. Advice to potential joint arthroplasty candidates regarding the decision to proceed with surgery should be informed by patient reported outcomes, rather than the surgeons opinion of the likelihood of success.

Trends in knee arthroscopy and subsequent arthroplasty in an Australian population: a retrospective cohort study.

BackgroundKnee arthroscopy is a common procedure in orthopaedic surgery. In recent times the efficacy of this procedure has been questioned with a number of randomized controlled trials demonstrating a lack of effect in the treatment of osteoarthritis. Consequently, a number of trend studies have been conducted, exploring rates of knee arthroscopy and subsequent conversion to Total Knee Arthroplasty (TKA) with varying results. Progression to TKA is seen as an indicator of lack of effect of primary knee arthroscopy.The aim of this paper is to measure overall rates of knee arthroscopy and the proportion of these patients that undergo subsequent total knee arthroplasty (TKA) within 24 months, and to measure trends over time in an Australian population.MethodsWe conducted a retrospective cohort study of all adults undergoing a knee arthroscopy and TKA in all hospitals in New South Wales (NSW), Australia between 2000 and 2008. Datasets obtained from the Centre for Health Record Linkage (CHeReL) were analysed using negative binomial regression. Admission rates for knee arthroscopy were determined by year, age, gender and hospital status (public versus private) and readmission for TKA within 24 months was calculated.ResultsThere was no significant change in the overall rate of knee arthroscopy between 2000 and 2008 (-0.68%, 95% CI: -2.80 to 1.49). The rates declined in public hospitals (-1.25%, 95% CI: -2.39 to -0.10) and remained relatively steady in private hospitals (0.42%, 95% CI: -1.43 to 0.60). The proportion of patients 65 years or over undergoing TKA within 24 months of knee arthroscopy was 21.5%. After adjusting for age and gender, there was a significant decline in rates of TKA within 24 months of knee arthroscopy for all patients (-1.70%, 95% CI:-3.13 to -0.24), patients admitted to private hospitals (-2.65%, 95% CI: -4.06 to -1.23) and patients aged ≥65 years (-3.12%, 95% CI: -5.02 to -1.18).ConclusionsRates of knee arthroscopy are not increasing, and the proportion of patients requiring a TKA within 24 months of a knee replacement is decreasing in the age group most likely to have degenerative changes in the knee.