Mixed-Methods Feasibility Study to Test Implementation of Quality Indicator Toolkits for Total Hip and Knee Replacement Rehabilitation: Impact on Clinician Behavior, Patient Outcomes and Experiences

Objectives We developed evidence-based, consensus-generated quality indicators (QIs) to address care gaps in total hip (THR) and knee replacement (TKR) rehabilitation.[1] This paper describes the effects of implementing the QIs using clinician (QUICK-TJR) and patient (EQUIP-TJR) targeted online toolkits on clinician behavior (QI adherence), patient-reported outcomes, and patient experience and satisfaction with rehabilitation. Methods We conducted a mixed methods feasibility study in 2 outpatient settings. Following 3 months of usual care, clinicians completed an online questionnaire to capture baseline QI adherence.[2] With help from “clinical champions,” we introduced the QUICK toolkit and 6 weeks later the EQUIP toolkit. After a 3-month transition phase, the clinics entered a maintenance phase with continued access to toolkit resources (video, checklist, infographic, QUICK guides). We collected QI adherence data continuously over 9 months (chart audits and patient questionnaires) and pre-post study (clinician questionnaires). We performed descriptive analyses for participant demographics and QI adherence. For effectiveness data (HOOS/KOOS-4 subscales), we explored relationships between QI adherence, outcomes and experience using SAS (V9.4, Cary, NC). Results We consented 46 THR/TKR patients: mean age 71.7 (7.2) years, mostly female (63%), retired (76%), living with ≥1 family member (79%) and ≥1 comorbidity (50%). All agreed to have their charts audited using a standardized REDCap form and 31 complete questionnaires. Fifteen physiotherapists and 1 rehabilitation assistant gave consent and 14 completed pre/post QI questionnaires. Clinicians were 50% female, and 63% were ≥40 years and had >10 years THR/TKR treatment experience. Mean (SD) baseline QI adherence was THR 12% (8.4%) and TKR 8.1% (11.1%) (chart audit) and 55.0% (12.9%) and 42.9% (27.3%) (patient questionnaire) (Figure 1). During the maintenance phase, mean QI adherence was not significantly different for THR and TKR by either data source. Mean clinician-reported pre/post QI data was THR 17.3% (12.8%) and 28.2% (24.8%) (p=0.06) and TKR 18.0% (13.2%) and 26.7% (25.7%) (p=0.09). In univariate analyses, there were no notable differences in HOOS/KOOS subscale values between baseline and maintenances phases. Overall, 73% of patients rated their rehabilitation experience as excellent and 47% were very satisfied with their outcomes. Patient reported QI adherence was strongly associated with overall satisfaction (p=0.004) and positively associated with overall experience (p=0.10). Figure 1 Comparing QI adherence for THR and TKR by data source and study phase Conclusion Overall, adherence to 10 THR/TKR rehabilitation QIs was low, regardless of data source, with minimal improvement after introduction of QI toolkits and resources. Positive associations between QI adherence and patient experience and satisfaction are promising. Implementation issues need to be addressed before conducting a definitive implementation trial. References [1.] Westby MD. Osteoarthritis Cartilage 2018;26:370-82. [2.] Westby MD. Physiother Can 2025;77:28-41.