Background/Purpose: Rehabilitation before and after total hip (THA) and knee arthroplasty (TKA) surgery has been shown to decrease pain and impairment, and improve mobility, activity and participation. Yet there are reports of marked variation in clinical practices, outcomes and resources allocated for rehabilitation services. This project aimed to develop core sets of quality indicators (QIs) reflecting the minimum acceptable standard of rehabilitation care before and after elective THA and TKA for osteoarthritis.  

Methods: We assembled an 18-member Canada-wide panel of clinicians, researchers and patients and used a modified RAND-UCLA Delphi approach to establish consensus on 82 proposed QIs (40 for THA, 42 for TKA). Indicators were derived from the authors’ previous work and the literature and reflected the rehabilitation continuum (pre-operative, acute care and post-acute up to 1 year post-surgery). Panelists completed 2 rounds of rating using an online survey interspersed by a moderated online discussion forum over a 3-month period. Prior to rating, panelists received a synthesis of high quality evidence (practice guidelines, systematic reviews, randomized controlled trials) supporting each QI. They were instructed to review the evidence before accessing the survey. Each QI was rated for its importance and validity on a 9-point Likert scale. Individual and group ratings from Round 1 were summarized and provided to panelists in order to inform the subsequent online discussion. During Round 2, panelists were asked to participate in the forum anonymously, share their views on the proposed QIs and debate each others’ comments. This was immediately followed by the final round of ratings. Those QIs with median ratings of 7 or higher for both importance and validity, and with no disagreement were included in the final sets. 

Results: Fifteen panelists representing 7 provinces and varied practice settings completed the Delphi process. Of the 82 proposed QIs, 67 (82%) were rated as both important and valid (31 for THA, 36 for TKA). For THA, 14 pre-op, 6 acute and 8 post-acute QIs were accepted. For TKA, 16 pre-op, 10 acute and 8 post-acute indicators were accepted. The majority of these QIs address assessment and screening activities (74%) while the remainder pertain to rehabilitation interventions. Three ‘across-continuum’ QIs were rated appropriate for THA and 2 of 3 for TKA. Engagement was high with 83% of panelists participating in the discussion forum. 

Conclusion: These QIs represent an important first step in addressing rehabilitation practice and outcome variation and will serve as a tool with which to measure, report and benchmark quality of care in patients receiving rehabilitation before and after THA/TKA surgery. Online technology facilitated broad geographical representation, panelist anonymity and engagement, and decreased panelist burden and administration costs compared to the traditional RAND/UCLA method. The QIs will be further tested for reliability and feasibility before being widely disseminated in clinical settings and used to assess care gaps.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/development-of-quality-indicators-for-hip-and-knee-arthroplasty-rehabilitation/