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Effectiveness of a multifaceted quality improvement intervention to improve patient outcomes after total hip and knee arthroplasty: a registry nested cluster randomised controlled trial
  1. Peter van Schie1,2,
  2. Leti van Bodegom-Vos2,
  3. Tristan M Zijdeman2,
  4. Rob G H H Nelissen1,
  5. Perla J Marang-van de Mheen2
  6. IQ Joint study group
    1. 1 Orthopaedics, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
    2. 2 Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
    1. Correspondence to Dr Peter van Schie, Orthopaedics, Leiden University Medical Center, 2333 ZA Leiden, Zuid-Holland, The Netherlands; p.van_schie{at}


    Objective To assess the effectiveness of a prospective multifaceted quality improvement intervention on patient outcomes after total hip and knee arthroplasty (THA and TKA).

    Design Cluster randomised controlled trial nested in a national registry. From 1 January 2018 to 31 May 2020 routinely submitted registry data on revision and patient characteristics were used, supplemented with hospital data on readmission, complications and length of stay (LOS) for all patients.

    Setting 20 orthopaedic departments across hospitals performing THA and TKA in The Netherlands.

    Participants 32 923 patients underwent THA and TKA, in 10 intervention and 10 control hospitals (usual care).

    Intervention The intervention period lasted 8 months and consisted of the following components: (1) monthly updated feedback on 1-year revision, 30-day readmission, 30-day complications, long (upper quartile) LOS and these four indicators combined in a composite outcome; (2) interactive education; (3) an action toolbox including evidence-based quality improvement initiatives (QIIs) to facilitate improvement of above indicators; and (4) bimonthly surveys to report on QII undertaken.

    Main outcome measures The primary outcome was textbook outcome (TO), an all-or-none composite representing the best outcome on all performance indicators (ie, the absence of revision, readmissions, complications and long LOS). The individual indicators were analysed as secondary outcomes. Changes in outcomes from pre-intervention to intervention period were compared between intervention versus control hospitals, adjusted for case-mix and clustering of patients within hospitals using random effect binary logistic regression models. The same analyses were conducted for intervention hospitals that did and did not introduce QII.

    Results 16,314 patients were analysed in intervention hospitals (12,475 before and 3,839 during intervention) versus 16,609 in control hospitals (12,853 versus 3,756). After the intervention period, the absolute probability to achieve TO increased by 4.32% (95% confidence interval (CI) 4.30-4.34) more in intervention than control hospitals, corresponding to 21.6 (95%CI 21.5-21.8), i.e., 22 patients treated in intervention hospitals to achieve one additional patient with TO. Intervention hospitals had a larger increase in patients achieving TO (ratio of adjusted odds ratios 1.24, 95%CI 1.05-1.48) than control hospitals, a larger reduction in patients with long LOS (0.74, 95%CI 0.61-0.90) but also a larger increase in patients with reported 30-day complications (1.34, 95%CI 1.00-1.78). Intervention hospitals that introduced QII increased more in TO (1.32, 95%CI 1.10-1.57) than control hospitals, with no effect shown for hospitals not introducing QII (0.93, 95%CI 0.67-1.30).

    Conclusion The multifaceted QI intervention including monthly feedback, education, and a toolbox to facilitate QII effectively improved patients achieving TO. The effect size was associated with the introduction of (evidence-based) QII, considered as the causal link to achieve better patient outcomes.

    Trial registration number NCT04055103.

    • Quality improvement
    • Continuous quality improvement
    • Audit and feedback
    • Cluster trials
    • Performance measures

    Data availability statement

    Data are available upon reasonable request. Data are not publicly available for privacy reasons, however, data are available on reasonable request.

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    Data availability statement

    Data are available upon reasonable request. Data are not publicly available for privacy reasons, however, data are available on reasonable request.

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    • Collaborators We gratefully acknowledge the Dutch Arthroplasty Register (L.N. van Steenbergen, PhD) and the 20 hospitals who provided their data to complete this study, as part of the IQ Joint study group (in alphabetic order): Antonius Hospital, Sneek (S.T. Hokwerda, MD); Bergman Clinics (P.M. van Kampen, PhD); Bergman Clinics, Arnhem (I. Buchholz, MD); Bergman Clinics, Breda (J. Schrier, MD); Bergman Clinics, Delft (F. de Graaff, MD); Bergman Clinics, Naarden (H. Bouma, MD); Bergman Clinics, Rijswijk (T. Hogervorst, MD, PhD and J. Wolkenfelt, MD); Bergman Clinics, Rotterdam (M. Vischjager, MD, PhD); Catharina Hospital, Eindhoven (R.W.T.M. van Kempen, MD); Dijklander Hospital, Hoorn (G.C. Huitema, MD); Dijklander Hospital, Hoorn (L. de Vries, PhD); Elisabeth-TweeSteden Hospital (T. Gosens, MD, PhD); Gelderse Vallei Hospital, Ede (W. Beijneveld, MD); Maxima Medical Centre, Eindhoven (M. van den Besselaar, MD); Medical Spectrum Twente, Enschede (W. Verra, MD, PhD); OLVG, Amsterdam (R.W. Poolman, MD, PhD); OLVG, Amsterdam (V.A. Scholtes, PhD); Sint Anna Hospital, Geldrop (W. van der Weegen, PhD); Sint Franciscus Hospital, Schiedam (A. Polak, MD); Tjongerschans Hospital, Heerenveen (M. Mulder, PhD); University of Groningen, University Medical Center Groningen, Groningen (M. Stevens, PhD); Zuyderland Hospital, Sittard (B. Boonen, MD, PhD).

    • Contributors PvS: Conceptualisation of manuscript; methodology; formal analysis;data curation; writing (original draft); project administration. LvB-V: Conceptualisation of project; writing (review and editing); supervision. TZ: Data curation; writing (original draft). RN: Writing (review and editing); supervision; funding acquisition. PM-vdM: Conceptualisation of project; conceptualisation of manuscript; methodology; formal analysis; writing (review and editing); supervision; project administration; funding acquisition.

    • Funding This study was supported by a grant from the Van Rens Foundation (VRF-2018-001).

    • Disclaimer The funder of the study had no role in considering the study design or in the collection, analysis, and interpretation of the data, writing of the report or decision to submit the article for publication.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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