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Rising health care expenditures and dissatisfaction with traditional models of reimbursement have driven an interest in alternative payment model (APM) initiatives. Bundled funding, an APM, was implemented province-wide for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Ontario in 2019. In this study, we explored whether procedure volume, quality of care, and cost were affected by the program’s introduction. In this retrospective cohort study, we developed pre- and postimplementation patient cohorts with aggregate data collected from the Canadian Institute for Health Information (CIHI) and Canadian Joint Replacement Registry. We assessed quality via length of stay, 30-day readmissions, emergency department visits, and revision surgeries. We assessed costs using methodology and data provided by CIHI. We performed statistical analysis by comparing patient cohorts via χ2 and Student t tests. After the introduction of the bundle, case volume increased, length of stay decreased, and more patients were discharged directly home following surgery (p ≤ 0.001). Patients with THA were less likely to be readmitted or visit the emergency department in the postbundled cohort (p ≤ 0.009). Despite a reduced length of stay, the cost of THA and TKA increased, with $106 more being spent per patient (p ≤ 0.001). The introduction of bundled funding for THA and TKA in Ontario was associated with preserved quality of care despite shorter lengths of stay in hospital and reduced use of inpatient rehabilitation. Although cost containment is often a goal of bundled funding, Ontario’s model saw a rise in inpatient surgical costs. A shift to outpatient arthroplasty could yield significant cost savings under the current bundle design. La hausse des dépenses en soins de santé et l’insatisfaction à l’égard des modèles de remboursement traditionnels ont éveillé l’intérêt pour les initiatives concernant les nouveaux modèles de paiement dits « alternatifs ». En 2019, un de ces nouveaux modèles, le financement regroupé, a été implanté en Ontario à l’échelle de la province pour les arthroplasties totales de la hanche (ATH) et du genou (ATG) électives. Dans la présente étude, nous avons tenté de déterminer si l’introduction de ce programme avait influé sur le volume des interventions, sur la qualité des soins et sur les coûts. Dans cette étude de cohorte rétrospective, nous avons constitué des cohortes de patientes et patients traités avant et après la mise en œuvre du programme, à partir de données agrégées recueillies auprès de l’Institut canadien d’information sur la santé (ICIS) et du Registre canadien des remplacements articulaires. Nous avons évalué la qualité des soins en fonction de la durée du séjour, des réadmissions dans les 30 jours suivants, des visites au service d’urgence et des chirurgies de révision. Nous avons évalué les coûts à l’aide de la méthodologie et des données fournies par l’ICIS. Nous avons procédé aux analyses statistiques en comparant les cohortes au moyen du test du χ2 et du test t de Student. Après l’introduction du financement regroupé, le volume des interventions a augmenté, la durée des séjours a diminué et un plus grand nombre de personnes ont reçu leur congé et sont retournées directement à leur domicile après la chirurgie (p ≤ 0,001). Les personnes qui avaient subi une ATH étaient moins susceptibles d’être réadmises à l’hôpital ou de se présenter à l’urgence dans la cohorte des personnes opérées après l’implantation du financement regroupé (p ≤ 0,009) que dans la cohorte précédente. Malgré la diminution de la durée des séjours, les coûts de l’ATH et de l’ATG ont augmenté, engendrant une dépense supplémentaire de 106 $ par personne (p ≤ 0,001). L’introduction du financement regroupé pour l’ATH et l’ATG en Ontario était associée au maintien de la qualité des soins malgré des séjours hospitaliers plus brefs et une utilisation moindre de la réadaptation durant l’hospitalisation. Bien que la maîtrise des coûts soit souvent un objectif du financement regroupé, le modèle ontarien a entraîné une hausse des coûts hospitaliers liés à la chirurgie. Une transition vers l’arthroplastie ambulatoire pourrait engendrer des économies importantes dans le cadre du financement regroupé actuel.

BackgroundMedical safety huddles are short, structured meetings for physicians to proactively discuss and respond to profession-specific patient safety concerns, with the goal of decreasing future adverse events. Prior observational studies found associations with improved patient safety outcomes, but no randomised controlled studies have been conducted.ObjectiveThe primary objective was to determine the impact of medical safety huddles on adverse events. Secondary objectives included the fidelity of huddle implementation and the impact on patient safety culture among physicians.DesignStepped-wedge cluster randomised trial with four sequences, and each hospital site was a cluster.SettingInpatient oncology, surgery and rehabilitation programmes in four academic hospitals.ParticipantsPhysicians in participating programmes.InterventionMedical safety huddles were adapted for local context and implemented sequentially based on a computer-generated random sequence every 2 months after a 4-month control period. All sites remained in the intervention phase for at least 9 months.Main outcome and measuresThe primary outcome was the rate of adverse events, as determined through blinded chart audits of 912 randomly selected patients. The fidelity of implementation was assessed through the huddle attendance rate, number of safety issues raised in the huddles and number of actions taken in response. Patient safety culture was assessed using the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety.ResultsThe adjusted rate of adverse events (per 1000 patient days) in the postintervention phase was 12% lower compared with preintervention (RR: 0.88; 95% CI: 0.80 to 0.98; p=0.016). The odds of having adverse events posthuddle implementation were 17% lower in the postintervention period compared with preintervention (OR intervention vs control: 0.83; 95% CI: 0.80 to 0.87; p<0.001). The mean huddle attendance rate at each site ranged from 30% to 85%, and the mean number of issues raised per huddle and the mean number of actions taken per huddle ranged from 1.6 to 3.1. The mean (SD) overall patient safety rating increased from 2.3 (0.53) to 2.8 (0.88), p=0.010. The mean per cent (SD) positive score for the composite measures of ‘Organisational learning’ increased significantly from 35% (26%) to 54% (23%), p=0.00, ‘Response to error’ 37% (24%) to 52% (22%), p=0.025 and ‘Communication about error’ 36% (28%) to 64% (42%), p=0.016 after implementation.Conclusions and relevanceMedical safety huddles decreased adverse events and may improve patient safety culture through engaging physicians.Trial registration numberNCT05365516.

Studies have highlighted inadequate exposure to musculoskeletal education and orthopedic surgery in mandatory medical school curricula; thus, the Canadian Orthopaedic Surgery Medical Education Course (COSMEC) was designed to enhance medical education around orthopedic surgery and common musculoskeletal presentations encountered in primary care. We sought to explore the effectiveness of COSMEC in preparing medical students for clinical training and future practice. Canadian and international medical students were invited to participate in COSMEC, a 12-week virtual course led by orthopedic faculty and senior residents. Teaching objectives were guided by the musculoskeletal objectives of the Medical Council of Canada Qualifying Examination and expert opinion. We administered pre- and postcourse surveys to assess outcomes related to participant knowledge, confidence, and interest in orthopedic surgery. A total of 133 medical students registered and completed COSMEC. Of these, we received 84 paired pre- and postcourse surveys. Knowledge scores improved from 7.9 (standard deviation [SD] 2.6) to 9.7 (SD 2.0) out of 14 ( < 0.001). There were significant improvements in participant-reported confidence in performing a history and physical examination, understanding the basic components of fracture management, managing bone and joint emergencies, and describing fracture radiographs ( < 0.001). Overall, COSMEC enhanced knowledge and confidence in orthopedic and musculoskeletal topics and is an effective extracurricular learning resource for medical students. It can help prepare medical students for future training and practice involving orthopedic and musculoskeletal patient presentations.

BackgroundTotal knee arthroplasty (TKA) is a widely performed procedure, with postoperative pain presenting as a major barrier to early mobilization and patient satisfaction. While single-injection adductor canal blocks (SACB) offer effective short-term analgesia, their limited duration often leads to rebound pain. Continuous adductor canal blocks (CACB) extend analgesic effects but are underexplored in outpatient settings. The objective of this study is to assess whether CACB improves quality of recovery and analgesia, in comparison to SACB in an outpatient or short-stay setting for TKA patients.MethodsDouble-blind randomized controlled trial comparing the Quality of Recovery-15 (QoR-15) score on postoperative day (POD) 2 (primary outcome) and opioid consumption, pain scores, hospital length-of-stay, and complications (secondary outcomes), between patients receiving CACB and SACB, when undergoing primary TKA.Results60 patients were enrolled and randomized to two treatment groups: CACB (30) and SACB (30). Patients in the CACB group had significantly higher QoR-15 scores at PODs 1 (128.83±12.36 vs 109.00±15.90, p<0.001), 2 (131.27±10.23 vs 110.86±15.37, p<0.001) and 3 (131.97±13.94 vs 111.18±18.28, p<0.001). They also had lower opioid consumption and pain scores at rest and with movement during the first three PODs. No major complications or signs of local anesthetic systemic toxicity were observed.ConclusionsIn our study, CACB significantly enhanced early postoperative recovery and analgesia following TKA in an outpatient or short-stay setting, compared with SACB, and these results support its broader adoption in fast-track TKA pathways.

Context Computerized physician order entry (CPOE) with clinical decision support (CDS) has been promoted as an effective strategy to prevent the development of a drug injury defined as an adverse drug event (ADE). Objective To systematically review studies evaluating the effects of CPOE with CDS on the development of an ADE as an outcome measure. Data Sources PUBMED versions of MEDLINE (from inception through March 2007) were searched to identify relevant studies. Reference lists of included studies were also searched. Methods We searched for original investigations, randomized and nonrandomized clinical trials, and observational studies that evaluated the effect of CPOE with CDS on the rates of ADEs. The studies identified were assessed to determine the type of computer system used, drug categories being evaluated, types of ADEs measured, and clinical outcomes assessed. Results Of the 543 citations identified, 10 studies met our inclusion criteria. These studies were grouped into categories based on their setting: hospital or ambulatory ; no studies related to the long-term care setting were identified. CPOE with CDS contributed to a statistically significant ( P  ≤ .05) decrease in ADEs in 5 (50.0%) of the 10 studies. Four studies (40.0%) reported a nonstatistically significant reduction in ADE rates, and 1 study (10.0%) demonstrated no change in ADE rates. Conclusions Few studies have measured the effect of CPOE with CDS on the rates of ADEs, and none were randomized controlled trials. Further research is needed to evaluate the efficacy of CPOE with CDS across the various clinical settings.

Background Patients with a high body-mass index (BMI) are at increased risk for significant complications after total knee arthroplasty (TKA). We explored whether operative time is a modifiable risk factor for infectious and thromboembolic complications. Methods A retrospective observational cohort study of the ACS-NSQIP registry, including all patients who underwent primary TKA (2015–2018), and were morbidly obese (BMI 40 kg/m 2 or greater) was performed. We created four categories of operative time in minutes: less than 60, 60–90, 91–120, and greater than 120. The association of prolonged operative time with superficial/deep surgical site infection (SSI), DVT and PE within 30 days postoperatively was evaluated using multivariate logistic regression. Results 34,190 patients were included (median age 63 [IQR 57–68], mean BMI of 44.6 kg/m 2 [SD 4.4]). The majority of patients had an operative time between 60–90 mins ( n = 13,640, 39.9%) or 91–120 mins ( n = 9908, 29.0%). There was no significant association between longer operative time and superficial/deep/organ-space SSI or PE. DVT risk was significantly increased. Patients with time exceeding 120 mins had nearly 2.5 greater odds of DVT compared to less than 60 minutes (OR 2.47, 95% CI: 1.39–4.39, P = 0.002). Odds of DVT were 1.73 times greater in those with time of 91–120 mins (OR 1.73, 95%CI: 0.98–3.05, P = 0.06). Conclusion Early infection and thromboembolic complications with prolonged operative time in morbidly obese patients remain low. We did not identify a significant association with increased operative time and superficial/deep SSI, or PE. There was a significantly increased risk for deep vein thrombosis with prolonged operative time.

BackgroundHip and knee total joint arthroplasty (TJA) procedures are two of the most common inpatient surgical procedures worldwide. Outpatient TJA has emerged as a feasible option. COVID-19 caused significant constraints on inpatient surgical resources and contributed to a growing surgical backlog. We present a quality improvement (QI) initiative aimed at adding an outpatient TJA pathway to our pre-existing inpatient TJA programme, with the target of performing 25% of our primary TJA as outpatients.MethodsThis was a QI study at a tertiary level arthroplasty centre. To achieve our aim, a patient-centred needs analysis revealed the need to develop patient selection criteria, perform a specific and tailored anaesthetic, provide patient education and conduct virtual care follow-up. Based on these findings, an outpatient TJA intervention bundle was developed and implemented.ResultsAfter implementing the outpatient pathway, 65 patients were scheduled for outpatient TJA. Fifty-five (84.6%) patients were successfully discharged home on the day of surgery. Successful outpatient TJA accounted for 33.3% of all primary TJAs performed at our intuition throughout the study period. There was excellent adherence to the intervention protocols, with the success hinging on multidisciplinary team and supported QI culture. Thirty-day emergency department visits for inpatient and outpatient TJAs were 8.93% and 6.15%, respectively. No outpatient TJA patients required hospital readmission within 30 days.ConclusionOur study demonstrates that implementation of an outpatient TJA pathway in response to inpatient resource constraints during the COVID-19 pandemic is feasible. The findings of this report will be of interest to surgical centres facing surgical backlog and constraints on inpatient resources during and after the pandemic.