Guideline Implementation: Part 1 of an Analysis of 12,355 Patients After Total Knee Arthroplasty

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Lippincott, Williams & Wilkins

Source Publication

Journal of Orthopaedic & Sports Physical Therapy

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Original Item ID

DOI: 10.2519/jospt.2022.11369


OBJECTIVE: To describe the application and examine the influence of a continuous quality improvement intervention, which had a goal of standardizing care to reduce the proportion of patients who do not have a meaningful improvement in patient-reported outcomes following total knee arthroplasty (TKA).

DESIGN: Continuous quality improvement.

METHODS: A physical therapy (PT) care guideline was initiated in 2013 for patients following TKA. The Knee Outcome Survey – Activities of Daily Living (KOS-ADL) was measured at every visit, and scores were extracted from a clinical outcomes database to calculate the proportion of patients who did not achieve a minimal clinically important difference. Based on logistic regression analysis, we compared the proportion of patients who did not progress on the KOS-ADL in a non-care guideline group (2008–2012) to a care guideline (CG) group (2014–2019).

RESULTS: This study included 12 355 patients (aged 18–92 years) following TKA incurring at least 3 PT visits from 2008 to 2019. The percentage of patients who did not progress in the non-care guideline group was 25.8% and in the care guideline group 14.3% (P<0.001). The relationship between care guideline adherence and lack of progression on the KOS-ADL was statistically significant, X2 (df = 1) = 148.7, P<.001.

CONCLUSION: The percentage of patients who did not achieve meaningful progress on the KOS-ADL declined significantly in the 6 years after implementing a TKA care guideline without an increase in the number of clinical visits. The standardized care guideline was associated with meaningful improvements for patients following TKA when applied in conjunction with PT access to outcome data, feedback through audits, performance goals, and financial incentives.


Journal of Orthopaedic & Sports Physical Therapy, Vol. 53, No. 3 (March 2023): 107-158. DOI.