Nelson F. SooHoo, MD, and his colleagues are conducting research to identify aspects of high-quality care related to total joint replacement that are currently not optimally employed or that are being employed only intermittently.Dr. SooHoo, associate professor of orthopaedic surgery at the University of California Los Angeles (UCLA), has received two grants from the Orthopaedic Research and Education Foundation (OREF) to support this work—a 2006 OREF Research Grant and a 2009 OREF Career Development Award.


Published 12/1/2009
Jay D. Lenn

OREF-funded study measures quality care in joint replacement

Studies suggest that the more knee and hip replacements performed in a hospital, the less likely that complications will result from the procedures. This may be due to differences in the quality of care before, during, and after total knee or hip replacement.

Clinical practice and public health policy
“Our main objective is to figure out how to improve the quality and safety of patient care,” Dr. SooHoo said, adding that his work addresses a current trend in healthcare policy to develop standards in quality care and pay-for-performance programs.

If standards are developed by bureaucrats or policy wonks, they may result in checklists for “appropriate care” that don’t reflect the realities of clinical practice and judgment.

“I do this because I see patients and take care of them,” said Dr. SooHoo. “I want to bring that perspective to this work because I think a lot of people advocating pay-for-performance or quality measurement don’t practice medicine and may not see it as an art and science.”

Dr. SooHoo urges orthopaedic surgeons to engage in the process to ensure the best possible outcomes. “I believe the only way to have useful quality measurement that is anything other than administrative busywork is to persuade orthopaedists who treat patients on a daily basis to invest in the process.” His work has brought together collaborators from both orthopaedic surgery and public health policy.

Defining high-quality care
Dr. SooHoo began his research with the following question: What is high-quality care?

“We tried to apply the most rigorous methods used by other disciplines to develop a set of quality measures,” explained Dr. SooHoo.

With funding from the 2006 OREF grant, the research team developed a set of evidence-based indicators of quality care for total knee and hip replacement using the RAND modified-Delphi methodology, a multi-step process developed by the RAND Corp. The first step was a comprehensive literature review on procedures and outcomes for total knee and hip replacement. The researchers also conducted structured interviews with nationally recognized leaders in orthopaedic surgery.

Based on the outcome of this preliminary work, Dr. SooHoo and his colleagues created a set of 101 candidate quality indicators. They presented the indicators to a panel of 10 leading orthopaedic surgeons who independently rated each factor. The 10 panelists met to review the scores and discuss the validity and feasibility of each indicator, then rated each of the 101 indicators again.

The researchers statistically combined the ratings to create a final set of 68 quality indicators relating to the actual care processes, the characteristics of the hospital providing care, and the outcomes of care. The spectrum of issues covered include the following:

  • Preoperative processes, such as minimum standards for medical history, risk assessment, and patient education
  • Intraoperative processes, such as a protocol for the prophylactic use of antibiotics and standards for final examination of knee function
  • Postoperative processes, such as minimum standards for follow-up clinical care
  • Standards for the selection of devices and the use of new technologies
  • Minimum staffing requirements
  • Surgeon training and experience
  • Protocols for documenting complications of hip and knee replacement

Reducing variability to increase quality
The next phase of the research was a pilot evaluation to determine how well hospitals followed these practices in total knee and hip replacement surgeries. The researchers focused on 31 indicators that could be measured by reviewing the medical charts of 225 patients from three UCLA-affiliated medical centers. The researchers found that the rate of compliance varied significantly among the hospitals.

“These findings warranted further examination of the variability of care in a larger sample of patients undergoing total joint replacement at hospitals in a variety of practice settings,” Dr. SooHoo said.

The next phase of the research, supported by the 2009 OREF Career Development Award, will determine the level of adherence to these quality measures in a multicenter study with institutions in the Northeast, Midwest, South, and West. From each of the four regions, Dr. SooHoo’s group will recruit three hospitals—an academic institution that performs more than 100 total joint replacements annually, a private hospital that performs more than 100 replacements annually, and a private hospital that performs fewer than 50 procedures annually.

This approach will account for key variables of geography, practice setting, and hospital volume. Statistical analysis should reveal the rate of compliance among the different institutions and identify indicators that are most likely and least likely to be used consistently.

Engaging the orthopaedic community
Dr. SooHoo anticipates using data from this second phase to conduct randomized, controlled trials of interventions to improve quality of care and to establish standards of care that could be implemented nationwide.

Dr. SooHoo recently received the 2009 OREF/Current Concepts in Joint Replacement Award for his work in this field. The award recognizes excellence in investigations focusing on healthcare policy, clinical outcomes, or translational research that has immediate clinical impact on the diagnosis or treatment of patients.

Jay D. Lenn is a contributing writer for OREF and can be contacted at