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A Self-Paired Comparison of Perioperative Outcomes Before and After Implementation of a Clinical Pathway in Patients Undergoing Total Knee Arthroplasty
  1. Christopher M. Duncan, MD*,
  2. Susan M. Moeschler, MD*,
  3. Terese T. Horlocker, MD*,
  4. Arlen D. Hanssen, MD and
  5. James R. Hebl, MD*
  1. *Department of Anesthesia and †Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
  1. Address correspondence to: Christopher M. Duncan, MD, Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First St, SW, Rochester, MN 55905 (e-mail: duncan.christopher{at}


Background and Objectives Clinical pathways commonly modify multiple variables and deviate from long-established clinical practices. Therefore, it is difficult to perform prospective, randomized clinical trials comparing “standard care” to the “new clinical pathway.” The goal of this investigation was to examine the impact of clinical pathways implementation on perioperative outcomes and institutional costs in patients undergoing total knee arthroplasty (TKA).

Methods This before-and-after study evaluated patient clinical outcomes and economic costs after the implementation of institutional clinical pathway. The primary outcome was hospital length of stay (LOS). Clinical and economic outcomes were analyzed as continuous variables using paired t test.

Results Fifty-four patients were identified for study inclusion. Patients undergoing their TKA after implementation of the clinical pathway had a significantly shorter hospital LOS (3.4 vs 4.4 days; P < 0.001). Patients reported significantly less postoperative pain, less postoperative confusion, and an easier time participating in physical therapy sessions after their second (after the clinical pathway implementation) TKA. Patients undergoing their TKA after the clinical pathway implementation had reduced total direct hospital costs ($956; 95% confidence interval, $233–$1785; P = 0.02).

Conclusions Our findings demonstrated that the use of a standardized clinical pathway reduced hospital LOS, improved clinical outcomes and patient satisfaction while reducing costs for identical surgical procedures.

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  • The authors declare no conflict of interest.

    Funding was provided by the Mayo Clinic Foundation for Education and Research and Mayo Clinic Department of Orthopedic Surgery.

    Presented at the 37th Annual Regional Anesthesia Meeting and Workshops, San Diego, CA.

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