Purpose: Optimizing return to work after knee arthroplasty is becoming more important because of the growing incidence of KA among workers and poor return to work outcomes. The purpose of this study is to investigate the feasibility of Back At work After Surgery (BAAS): an integrated clinical pathway for return to work after knee arthroplasty.Method: Working patients who received unicompartmental knee arthroplasty (UKA) or total knee arthroplasty (TKA) between January 2021 and November 2021, younger than 65 years and motivated to return to work were eligible to participate. Feasibility was investigated on five domains: reach, dose delivered, dose received, fidelity and patients’ attitudes. These outcomes were obtained by a patient‐reported questionnaire and an interview with the occupational case manager and medical case manager.Results: Of the eligible 29 patients, eleven were willing to participate (response rate 38%; due to travel distance to and from the hospital). The dose delivered was between 91 and 100%, except information given about return to work from the orthopedic surgeon which was 18%. The dose received was 100%. For fidelity, case managers reported nine shortcomings for which five solutions were mentioned. In terms of patients’ attitude, all patients were satisfied and one patient mentioned an improvement.Conclusions: In terms of reach, participation was low: only 29%. The BAAS clinical pathway seems feasible based on dose delivered, dose received, fidelity and patient attitudes. The next step is to assess the effectiveness of the BAAS clinical pathway for return to work.

Purpose: Considering the increase in the demand from working age patients seeking knee arthroplasty (KA) and the low return-to-work (RTW) rates, optimization of care for patients getting KA with a focus on RTW is essential. We evaluated a work-integrated care pathway—Back At work After Surgery (BAAS)—aimed at improving RTW compared with care-as-usual in the Netherlands. Methods: In this multicenter study of three comparative cohorts, working patients who had primary KA were included. Patients in two Dutch hospitals (BAAS cohort) received integrated medical and occupational care, including structured pre- and postoperative consultations, goal setting, activity tracking, and interdisciplinary team meetings with both medical and occupational health professionals. Two independent control cohorts with comparable patient inclusion criteria (Expect TO work and ACTIVE) from 15 hospitals/clinics received care-as-usual. The primary outcomes were the time to first day of RTW and time to full RTW within 12 months. Inverse Probability of Treatment Weighting was used with known prognostic factors as covariates to account for possible differences in baseline characteristics. Results: A total of 457 patients were included (BAAS n = 145; Expect TO work n = 179; ACTIVE n = 133). The median time to first day of RTW was 16–25 days shorter in the BAAS cohort (27 days) compared to Expect TO work (52 days; hazard ratio [HR] 2.7; 95% confidence interval [CI]:2.1–3.4) and ACTIVE cohort (43 days; HR:1.95; CI:1.5–2.6). At three months, 90% of BAAS patients had started RTW versus 63% and 77% in the control cohorts. BAAS patients also achieved full RTW earlier, with a median time reduced by 27 days compared to the ACTIVE cohort (HR:1.4; CI:1.1–1.8). The odds of full RTW at 12 months were higher in the BAAS cohort compared to Expect TO work, namely odds ratio (OR) 5.0 (CI:1.3–18.5) and ACTIVE OR 9.3 (CI:2.5–34.8). Conclusion: The BAAS work-integrated care pathway was more effective than care-as-usual in improving RTW after KA in the Netherlands. Trail Registration: This study was retrospectively registered at clinicaltrails.gov ( https://clinicaltrials.gov/ct2/show/NCT05690347 , date of first registration: 19-01-2023).

In recent decades, the number of cases of knee arthroplasty among people of working age has increased. The integrated clinical pathway ‘back at work after surgery’ is an initiative to reduce the possible cost of sick leave. The evaluation of this pathway, like many clinical studies, faces the challenge of small data sets with a relatively high number of features. In this study, we investigate the possibility of identifying features that are important in determining the duration of rehabilitation, expressed in the return-to-work period, by using feature selection tools. Several models are used to classify the patient’s data into two classes, and the results are evaluated based on the accuracy and the quality of the ordering of the features, for which we introduce a ranking score. A selection of estimators are used in an optimization step, reorganizing the feature ranking. The results show that for some models, the proposed optimization results in a better ordering of the features. The ordering of the features is evaluated visually and identified by the ranking score. Furthermore, for all models, higher accuracy, with a maximum of 91%, is achieved by applying the optimization process. The features that are identified as relevant for the duration of the return-to-work period are discussed and provide input for further research.

Optimizing return to work (RTW) after knee arthroplasty (KA) is becoming increasingly important due to a growing incidence of KA and poor RTW outcomes after KA. We developed the Back At work After Surgery (BAAS) clinical pathway for optimized RTW after KA. Since the effectiveness and cost analysis of the BAAS clinical pathway are still unknown, analysis on effectiveness and costs of BAAS is imperative. This protocol paper has been written in line with the standards of Standard Protocol Items: Recommendations for Interventional Trails. To assess the effectiveness and cost-effectiveness for RTW, we will perform a multicenter prospective cohort study with patients who decided to receive a total KA (TKA) or an unicompartmental KA (UKA). To evaluate the effectiveness of BAAS regarding RTW, a comparison to usual care will be made using individual patient data on RTW from prospectively performed cohort studies in the Netherlands. One of the strengths of this study is that the feasibility for the BAAS clinical pathway was tested at first hand. Also, we will use validated questionnaires and functional tests to assess the patient’s recovery using robust outcomes. Moreover, the intervention was performed in two hospitals serving the targeted patient group and to reduce selection bias and improve generalizability. The limitations of this study protocol are that the lead author has an active role as a medical case manager (MCM) in one of the hospitals. Additionally, we will use the data from other prospective Dutch cohort studies to compare our findings regarding RTW to usual care. Since we will not perform an RCT, we will use propensity analysis to reduce the bias due to possible differences between these cohorts. This study was retrospectively registered at clinicaltrails.gov (https://clinicaltrials.gov/ct2/show/NCT05690347, date of first registration: 19–01-2023).

Purpose: The Back At work After Surgery (BAAS) care pathway integrates medical and occupational care to enhance return to work (RTW) after knee arthroplasty (KA). BAAS has shown effectiveness in improving RTW outcomes, but its economic impact is unknown. This study evaluates the costs and return on investment (ROI) of BAAS compared with care-as-usual. Methods: This multicenter, prospective cohort study involved 270 employed patients having KA, comparing the BAAS pathway ( n = 137) to care-as-usual (ACTIVE trial, n = 133). The ROI was evaluated from societal and employer’s perspectives. Productivity (absenteeism and presenteeism) and healthcare (primary and secondary) costs were assessed using cost questionnaires administered at 3, 6, 9, and 12 months post-surgery. Propensity score matching and multiple imputation addressed non-randomization and missing data, respectively. ROI was calculated by dividing the netto benefits—defined as reductions in productivity and healthcare costs, or productivity costs alone minus costs of the BAAS intervention—by the intervention costs multiplied by 100%. Results: Propensity score-matched analyses included 102 patients per cohort. The total netto benefits from employers and societal perspective were of €4,493 and €4,982, respectively. Intervention costs were €845/patient. This resulted in a ROI of 590% (95% CI 67–1112%) and 532% (95% CI 27–1037%) from the societal and employer’s perspective, respectively, per Euro invested. Conclusions: The BAAS care pathway demonstrates a favorable economic impact through significant 12 month downstream reductions in absenteeism and healthcare costs, and a positive ROI from both the societal and employer perspective. Trail registration : This study was retrospectively registered at clinicaltrails.gov ( https://clinicaltrials.gov/ct2/show/NCT05690347 , date of first registration: 19-01-2023).

Aims: To investigate the impact of consecutive perioperative care transitions on in-hospital recovery of patients who had primary total knee arthroplasty (TKA) over an 11-year period.Methods: This observational cohort study used electronic health record data from all patients undergoing preoperative screening for primary TKA at a Northern Netherlands hospital between 2009 and 2020. In this timeframe, three perioperative care transitions were divided into four periods: Baseline care (Joint Care, n = 171; May 2009 to August 2010), Function-tailored (n = 404; September 2010 to October 2013), Fast-track (n = 721; November 2013 to May 2018), and Prehabilitation (n = 601; June 2018 to December 2020). In-hospital recovery was measured using inpatient recovery of activities (IROA), length of stay (LOS), and discharge to preoperative living situation (PLS). Multivariable regression models were used to analyze the impact of each perioperative care transition on in-hospital recovery.Results: The four periods analyzed involved 1,853 patients (65.9% female (1,221/1,853); mean age 70.1 years (SD 9.0)). IROA improved significantly with each transition: Function-tailored (0.9 days; p < 0.001 (95% confidence interval (CI) -0.32 to -0.15)), Fast-track (0.6 days; p < 0.001 (95% CI -0.25 to -0.16)), and Prehabilitation (0.4 days; p < 0.001 (95% CI -0.18 to -0.10)). LOS decreased significantly in Function-tailored (1.1 days; p = 0.001 (95% CI -0.30 to -0.06)), Fast-track (0.6 days; p < 0.001 (95% CI -0.21 to -0.05)), and Prehabilitation (0.6 days; p < 0.001 (95%CI -0.27 to -0.11)). Discharge to PLS increased in Function-tailored (77%), Fast-track (91.6%), and Prehabilitation (92.6%). Post-hoc analysis indicated a significant increase after the transition to the Fast-track period (p < 0.001 (95% CI 3.19 to 8.00)).Conclusion: This study highlights the positive impact of different perioperative care procedures on in-hospital recovery of patients undergoing primary TKA. Assessing functional recovery, LOS, and discharge towards PLS consistently, provides hospitals with valuable insights into postoperative recovery. This can potentially aid planning and identifying areas for targeted improvements to optimize patient outcomes.Cite this article: Bone Joint J 2024;106-B(6):573–581.