Non-compliance with clinical guidelines increases the risk of complications after primary total hip and knee joint replacement surgery

Journal article

Badge, Helen Mary, Churches, Tim, Naylor, Justine M., Xuan, Wei, Armstrong, Elizabeth, Gray, Leeanne, Fletcher, John, Gosbell, Iain, Lin, Christine and Harris, Ian A.. (2021). Non-compliance with clinical guidelines increases the risk of complications after primary total hip and knee joint replacement surgery. PLoS ONE. 16(11), p. Article e0260146. https://doi.org/10.1371/journal.pone.0260146
AuthorsBadge, Helen Mary, Churches, Tim, Naylor, Justine M., Xuan, Wei, Armstrong, Elizabeth, Gray, Leeanne, Fletcher, John, Gosbell, Iain, Lin, Christine and Harris, Ian A.
Abstract

Background
Total hip and total knee replacement (THR/TKR) are common and effective surgeries to reduce the pain and disability associated with arthritis but are associated with small but significant risks of preventable complications such as surgical site infection (SSI) and venous-thrombo-embolism (VTE). This study aims to determine the degree to which hospital care was compliant with clinical guidelines for the prevention of SSI and VTE after THR/TKR; and whether non-compliant prophylaxis is associated with increased risk of complications.

Methods and findings
A prospective multi-centre cohort study was undertaken in consenting adults with osteoarthritis undergoing elective primary TKR/THR at one of 19 high-volume Australian public or private hospitals. Data were collected prior to surgery and for one-year post-surgery. Four adjusted logistic regression analyses were undertaken to explore associations between binary non-compliance and the risk of surgical complications: (1) composite (simultaneous) non-compliance with both (VTE and antibiotic) guidelines and composite complications [all-cause mortality, VTE, readmission/reoperation for joint-related reasons (one-year) and non-joint-related reasons (35-days)], (2) VTE non-compliance and VTE outcomes, (3) antibiotic non-compliance and any SSI, and (4) antibiotic non-compliance and deep SSI. Data were analysed for 1875 participants. Guideline non-compliance rates were high: 65% (VTE), 87% (antibiotics) and 95% (composite guideline). Composite non-compliance was not associated with composite complication (12.8% vs 8.3%, adjusted odds ratio [AOR] = 1.41, 95%CI 0.68–3.45, p = 0.40). Non-compliance with VTE guidelines was associated with VTE outcomes (5% vs 2.4%, AOR = 2.83, 95%CI 1.59–5.28,p < 0.001). Non-compliance with antibiotic guidelines was associated with any SSI (14.8% vs 6.1%, AOR = 1.98, 95%CI 1.17–3.62,p = 0.02) but not deep infection (3.7% vs 1.2%,AOR = 2.39, 95%CI 0.85–10.00, p = 0.15).

Conclusions
We found high rates of clinical variation and statistically significant associations between non-compliance with VTE and antibiotic guidelines and increased risk of VTE and SSI, respectively. Complications after THR/TKR surgery may be decreased by improving compliance with clinical guidelines.

Year2021
JournalPLoS ONE
Journal citation16 (11), p. Article e0260146
PublisherPublic Library of Science
ISSN1932-6203
Digital Object Identifier (DOI)https://doi.org/10.1371/journal.pone.0260146
PubMed ID34793555
Scopus EID2-s2.0-85119482672
PubMed Central IDPMC8601457
Open accessPublished as ‘gold’ (paid) open access
Page range1-18
FunderHCF Health and Medical Research Foundation
Research Training Program Scholarship (RTP), Australian Government
National Health and Medical Research Council (NHMRC)
Publisher's version
License
File Access Level
Open
Output statusPublished
Publication dates
Online18 Nov 2021
Publication process dates
Accepted03 Nov 2021
Deposited23 Nov 2022
Grant IDIHIIAMR2012073043
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