Mayer Marcel, Naylor Justine, Harris Ian, Badge Helen, Adie Sam, Mills Kathryn, Descallar Joseph
Whitlam Orthopaedic Research Centre, Liverpool Hospital, Sydney, New South Wales, Australia.
South Western Sydney Clinical School, UNSW, Randwick, Australia.
PLoS One. 2017 Jul 19;12(7):e0180090. doi: 10.1371/journal.pone.0180090. eCollection 2017.
Lack of evidence contributes to unnecessary variation in treatment costs and outcomes. This study aimed to identify from interventions historically used for total knee or hip arthroplasty (TKA, THA): i) if routine use is supported by high-level evidence; ii) whether surgeon use aligns with the evidence.
Part 1: Systematic search of electronic library databases for systematic reviews and practice guidelines concerning seven acute-care interventions. Intervention-specific recommendations concerning routine use were extracted by assessors. Part 2: Prospective medical record audit of the acute-care received by 1900 patients involving 120 orthopaedic surgeons. Surgeon use per intervention was summarized using caterpillar plots. Surgeon-specific routine and non-routine use was defined as use in ≥ 90% and ≤ 10% of patients, respectively. Primary analysis included only surgeons contributing ≥ 10 patients.
Continuous passive motion (TKA): Routine use not recommended; 85.7% of surgeons did not use it routinely. Tranexamic Acid: Routine use recommended; 26.9% of surgeons used it routinely. Cryotherapy: Routine use not recommended; 45.7% of surgeons used it routinely for TKA; 31.8% used it routinely for THA. Intra-articular drainage: Routine use not recommended for TKA, but possible benefits for THA; 5.7% of surgeons used it routinely for TKA, 0.0% used it routinely for THA. Antibiotic loaded bone cement: Routine use for TKA not supported, recommendations for use for THA are inconsistent; 90.0% of surgeons used it routinely for TKA, 100.0% used it routinely for THA. Patella resurfacing (TKA): No recommendation could be made; 57.1% of surgeons routinely resurfaced the patella. Indwelling urinary catheterisation: Routine use recommended; 59.6% of surgeons used it routinely.
Recommendations for routine use or not exist for some of the acute-care interventions examined. Surgeon practices vary widely even in the presence of high-level recommendations. It is unclear whether further evidence alone would lessen unwarranted practice variation.
缺乏证据导致治疗成本和结果出现不必要的差异。本研究旨在从历史上用于全膝关节置换术或全髋关节置换术（TKA、THA）的干预措施中确定：i）常规使用是否有高级别证据支持；ii）外科医生的使用是否与证据一致。
第1部分：系统检索电子图书馆数据库，查找有关七种急性护理干预措施的系统评价和实践指南。评估人员提取了有关常规使用的特定干预措施建议。第2部分：对1900例患者接受的急性护理进行前瞻性病历审核，这些患者涉及120名骨科医生。使用毛虫图总结每种干预措施的外科医生使用情况。外科医生特定的常规和非常规使用分别定义为在≥90%和≤10%的患者中使用。主要分析仅包括贡献≥10例患者的外科医生。
持续被动运动（TKA）：不建议常规使用；85.7%的外科医生未常规使用。氨甲环酸：建议常规使用；26.9%的外科医生常规使用。冷冻疗法：不建议常规使用；45.7%的外科医生在TKA中常规使用；31.8%的外科医生在THA中常规使用。关节内引流：TKA不建议常规使用，但对THA可能有益；5.7%的外科医生在TKA中常规使用，0.0%的外科医生在THA中常规使用。抗生素骨水泥：TKA常规使用不被支持，THA的使用建议不一致；90.0%的外科医生在TKA中常规使用，100.0%的外科医生在THA中常规使用。髌骨表面置换（TKA）：无法给出建议；57.1%的外科医生常规进行髌骨表面置换。留置导尿：建议常规使用；59.6%的外科医生常规使用。
对于所检查的一些急性护理干预措施，存在是否常规使用的建议。即使存在高级别建议，外科医生的做法仍存在很大差异。尚不清楚仅靠进一步的证据是否会减少不必要的实践差异。
