Dartmouth-Hitchcock GreenCare Registry for Total Knee Replacement (GreenCare)

The Dartmouth GreenCare Program: Implementation of Shared Decision Making and Patient-reported Outcomes in a Standardized Care Path for Knee Replacement

Evolving reimbursement policies are driving health systems to improve quality and efficiency. Transitioning to an electronic health record (EHR) provided Dartmouth-Hitchcock Medical Center (DHMC) an opportunity to redesign staff roles and care path for Total Knee Replacement (TKR). The organization implemented a coordinated team-based care delivery model that integrated real-time measurement of: (1) compliance with trusted guidelines, (2) process of Shared Decision-Making (SdM), and (3) use of Patient-Reported Outcomes (PROs). The investigators present the implementation protocol and data.

Study Overview

• Status: Completed
• Conditions: Arthroplasty, Replacement, Knee
• Intervention / Treatment: Procedure: Total Knee Replacement

Detailed Description

Patient-reported outcome measures were completed 1 month preceding TKR and also at 1 and 12 months following surgery. The primary outcome was change in physical function from baseline to 1-year following surgery in the Physical Component Summary (PCS) of the Veterans-Rand (VR-12) Survey. Preoperative measures were: (1) general demographics (patient age, sex, height, weight, body mass index (BMI); (2) treatments tried before surgery; (3) health habits (tobacco use, alcohol use); (4) pre-existing medical conditions (Charlson score); (5) physical exam findings (knee range of motion, knee laxity); (7) lab tests (hemoglobin); and (7) radiographic measures (severity of osteoarthritis on standing x-rays). Secondary outcomes included Physical Score (PS) of the Patient Reported Outcome Measurement Information System Global Survey (PROMIS-10), knee function (Knee Osteoarthritis Outcome Score, KOOS), safety (reoperations, readmissions, emergency visits, and infection) and measures of patient experience (Clinician Group and Hospital Consumer Assessment of Healthcare Providers and Systems).

• Study Type: Observational
• Enrollment (Actual): 545

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Patients scheduling primary TKR for osteoarthritis of the knee at a regional tertiary care hospital

Description

Inclusion Criteria:

• Scheduled TKR
• Osteoarthritis of the knee

Exclusion Criteria:

• previous TKR on the affected knee
• diagnosis other than osteoarthritis
• age less than 18 years
• declined consent

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Health Gain as measured by the change in Physical Component Summary (PCS) Score	Health Gain from baseline to 12 months (from 300 to 400 days following the date) following surgery, as measured by the change in Physical Score based on standardized US adult population benchmarks for the VR12 survey	1-year following surgery

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mortality		1 year
Health Gain as measured by the change in Global Physical Health (GPH)	Health Gain from baseline to 12 months following surgery, as measured by the change in Physical Score based on standardized US adult population benchmarks for the PRIOMIS10 survey	1-year
Health Gain as measured by the change in Percentile Rank, TKR age and gender matched	Health Gain from baseline to 12 months following surgery, as measured by the change in Physical Score Percentile Rank based on age and gender-matched beta distributions for the Dartmouth TKR population, for the PRIOMIS10 or VR12 survey	1 year
Emotional Health	Mental Component Summary (MCS) Score change from baseline to 12 months following surgery, as measured by the change in Mental Score based on standardized US adult population benchmarks for the PRIOMIS10 or VR12 survey	1 year
Knee Osteoarthritis Outcome Score (KOOS)	Change in KOOS score from baseline to 12 months following surgery	1 year
Reoperation	From 0 to 90 days following the date of surgery	3 months
Readmission	From 0 to 90 days following the date of surgery	3 months
ER visits after surgery	From 0 to 90 days following the date of surgery	3 months
Infection	From 0 to 90 days following the date of surgery	3 months
Patient Satisfaction with Hospital	HCAHPS survey in 10% random subsample completed between 20 to 40 days following the date of surgery	1 month
Patient Satisfaction with Surgeon	Clinician Group CAHPS survey in 10% random subsample completed between 300 to 400 days following the date of surgery	10 months
Cost of care	Episode-based costs for 0 to 90 days following the date of surgery, and also per visit outpatient costs	3 months
Length of hospital stay	Number of days between date of admission and date of discharge	Acute hospitalization
Discharge to home	Disposition at time of discharge from acute hospitalization	Acute hospitalization
Range of motion	Knee range of motion measured by a clinician between 60 and 120 days following surgery	90 days

Collaborators and Investigators

• Sponsor: Dartmouth-Hitchcock Medical Center
• Investigators: Principal Investigator: Sohail K Mirza, MD, MPH, Dartmouth-Hitchcock Medical Center

Study record dates

Study Major Dates

• Study Start: January 1, 2013
• Primary Completion (Actual): May 1, 2015
• Study Completion (Actual): April 1, 2016

Study Registration Dates

• First Submitted: September 20, 2016
• First Submitted That Met QC Criteria: September 22, 2016
• First Posted (Estimate): September 23, 2016

Study Record Updates

• Last Update Posted (Estimate): September 23, 2016
• Last Update Submitted That Met QC Criteria: September 22, 2016
• Last Verified: September 1, 2016

More Information

Terms related to this study

• Keywords: Total knee replacement; Knee osteoarthritis; Knee Arthroplasty; Shared Decision Making; Cohort Studies; Patient Reported Outcomes; Patient-Outcomes Measurement Program; Surgical Registries; Patient Experience
• Other Study ID Numbers: CPHS23310

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: The consented data that has been collected will be stripped of all identifiers and kept as a dataset appropriate for sharing with future researchers for secondary analyses. A Project Proposal form and Data Use Agreement will be required.