Adherence to Processes of Care Measures Pay Off with Successful Outcomes

Standardized measures of patient care can provide a higher rate of
patient outcome success, according to investigators.

Kevin J. Bozic, MD, MBA presented his group’s findings at the
2010 Annual Meeting of the American Academy of Orthopaedic
. He hypothesized that performing and adhering to standards of care
can positively influence patient outcomes.

  Kevin J. Bozic
  Kevin J. Bozic

“Clinicians have questioned the logic and the clinical correlation
between adherence to process measures and clinical outcomes,” Bozic said.
“So we proposed a study to evaluate the independent contributions of
surgeon volume, hospital volume and adherence to specific processes of care on
patient outcomes.”

The researchers assessed a group of 312 hospitals ranging from small to
large; small hospitals having approximately 100 beds and large, more than 500
beds. The study included 3,421 physicians and 182,146 consecutive
total joint arthroplasty (TJA) patients. The average age of
the patients was 66 years and the majority of participants were women. The
average length of stay was 4 days.

Statistical models were used to estimate the effects of procedure volume
for both the hospital, the surgeon and adherence to process of care measures on
both individual and combined surgical outcomes.

Adherence to the evidence-based processes of care was defined by whether
or not patients received appropriate preoperative beta-blockade, prophylactic
antibiotics and venous thromboembolism (VTE) prophylaxis. Possible patient
outcomes included mortality, length of hospital stay, discharge disposition,
surgical complications, re-admission and re-operations within the first 30

The hospitals and surgeons were divided into groups based on procedure
volume; low-volume hospitals conducted an average of 181 procedures per year
and high-volume hospitals conducted more than 1000. Low-volume surgeons
performed 24 procedures per year and high-volume surgeons performed 300.

Investigators found the following: 5% of patients did not receive an
antibiotic on the day of surgery; 27% received antibiotics beyond 24 hours; 5%
of patients with cardiac risk factors did not receive beta blockers; and 14% of
patients did not receive guideline-approved VTE prophylaxis. An aggregate 58%
of patients had all of the measures correct, 33% missed one, 8% missed two and
less than 1% of patients missed three or more.

Data showed a strong correlation between the adherence to standards of
care and better patient outcomes in both high- and low-volume hospitals. The
same was true for high- and low-volume surgeons. Similarly, the total number of
process measures missed strongly correlated with worse outcomes, regardless of
hospital or surgeon volume.

“I think what we’ve shown what is different is that process
standardization is an independent contributor to improved outcomes. Our group
and others have previously shown that the process measures alone —
individual process measures — are not a good surrogate for outcome,”
Bozic said.

Maximizing adherence to all processes of care is associated with better
patient outcomes. This research shows the standardization of care could help
optimize clinical outcomes independent of hospital or surgeon procedure volume,
Bozic said. — by Caitlin Langley

For more information:

  • Bozic KJ, Maselli J, Vail TP, et al. Influence of procedure volume
    and adherence to process of care measures on patient outcomes in TJA. Paper
    #235. Presented at the 2010 Annual Meeting of the American Academy of
    Orthopaedic Surgeons. March 9-13, 2010. New Orleans.


I agree with Dr. Bozic that volume begets quality as a result of
experience, but does not necessarily render efficient patient care. There are
multiple hospital systems that do a large volume of cases that quite frankly
have not figured it out yet. As Fred Taylor, who developed the assembly line
process in the late 1800s, said, “In order to improve the performance of a
machine, you have to improve the performance of the workers that run the
machine.” This includes the physician, his assistant, the operating room
staff and all the nursing care before and after a surgical procedure has

If the health care “workers” are unwilling or unable to
improve their performance, the system will remain dysfunctional and
inefficient. As Dr. Bozic implied, process standardization is critical in order
to improve efficiency and care quality to avoid complications and poor
outcomes. The surgeon, however, must be willing to agree and adapt to these
process changes in order to improve his performance or the system, and
eventually the patient, will suffer as well.

— Jack M. Bert, MD
Business of Orthopedics Section Editor

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