Kaiser Permanente. National Total Joint Replacement Registry. Liz Paxton Director of Surgical Outcomes & Analysis
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1 Kaiser Permanente National Total Joint Replacement Registry Liz Paxton Director of Surgical Outcomes & Analysis
2 Overview Background Total Joint Replacement (TJR) Importance of establishing a TJR post-market surveillance system Kaiser Permanente National Total Joint Registry Development/Implementation Clinical quality improvement Clinical effectiveness Patient safety Risk management Resource stewardship Service quality Expansion within & beyond orthopedics
3 Background Total Joint Replacement in the United States Current Volume 600,000 TJRs each year (Hip & Knees) 14,000 program-wide in KP Projected Volume 2030 (Kurtz et al., 2006) TKA 3.48 million per year THA 572,000 per year Projected Costs Annual Hospital Charges by 2015 (Ong et al.,2007) Primary THA $17.4 billion, TKA $40.8 billion Revision THA $3.8 billion, TKA $4.1 billion
4 Importance of a TJR System Identify TJR revision/failure rates Identify patients at risk for failures/revisions Assess post-market implant performance Immediately identify/notify patients w/recalled implants Hip Stem Failure (late 90 s) - Silent failures until reach catastrophic level - Still presenting Hip Cup Recall (2000) - 17,500 patients with recalled implant - Traces of machine oil on the cup
5 KP National Total Joint Registry Initiated 2001 by Orthopedic Surgeons Funded via savings w/ Nat purchasing contracts Standardized TJA documentation Database of all Total Joint procedures 95% voluntary participation 300 surgeons 38 KP centers 5 Regions Outcomes data helps guide purchasing decisions Value Clinical effectiveness Cost efficiency Patient safety/quality Risk management Pre-operative Operative Follow-up 65,000 total joints registered Demographics Surgical Techniques Implant Characteristics
6 Pre-op Form Intra-op Form Post-op Form Total Joint Registry Database Total Joint Registry Database Data Sources and Flow KP HealthConnect Clarity database KASIS Claims MIA Mortality database MIA Membership database Participating Regions: Colorado, Southern CA, Northern CA, Hawaii, Northwest MIA: Management and Information Analysis Dept KASIS: Kaiser Anesthesia and Surgery Information System
7 KPHC Smart Phrases Pre-op Physician/PA Section
8 KPHC Smart Phrases
9 Patient Safety/Risk Management Implant Recalls & Advisories Timely, efficient patient identification S&N calaxo screws MTF allografts S&N TC plus knee implants Stryker Trident hip cups
10 Clinical Effectiveness: THA Survival
11 TJR Registry - THA Reasons for Revision Top Reasons for Revision Instability Infection Aseptic Loosening Other Periprosthetic Fracture Femoral Fracture Pain LLI Polyliner Wear Osteolysis Registry THAs 161(54%) 59 (20%) 32 (11%) 29 (10%) 18 (6%) 15 (5%) 13 (4%) 12 (4%) 8 (3%) 4 (1.3%)
12 THA Revision Risk Factors Higher ASA score Younger Age Region Cemented technique Conventional insert
13 Clinical & Cost Effectiveness: THA Implants
14 Clinical Effectiveness: TKA Survival
15 TJR Registry TKA Reasons for Revision Top Reasons for Revision Infection Instability Other Aseptic Loosening Pain Arthrofibrosis Femoral Fracture Wound Dehiscence Osteolysis Registry TKAs 202 (49%) 78 (16%) 69 (14%) 64 (13%) 64 (13%) 47 (10%) 13 (3%) 9 (2%) 9 (2%)
16 TKA Revision Risk Factors Higher ASA score Younger Age Region Uncemented technique Femoral Component
17 Clinical & Cost Effectiveness: Testing Industry claims Gender Specific Knee $1,000 extra Registry data indicated men and women similar ROM, satisfaction, pain, and revision rates Why needed?
18 Clinical Effectiveness: Changes in Practice
19 Clinical Effectiveness: Changes in Practice
20 Clinical Effectiveness: Changes in Practice Significantly higher pain in Minimally Invasive (MIS) TKA TKA MIS 6 # of Mini TKAs Pain (3 weeks post-op) Pain (4 weeks-8 months)
21 Clinical Effectiveness: Changes in Practice Significant decrease in MIS TKAs after providing feedback 20 # of Mini TKAs Site Site Site Site Site Site
22 Future of National Implant Registries Predictive Modeling Apply advanced statistical techniques to predict risk for post op infection, DVT and other complications Automated postmarket surveillance system Evolution of the KP Total Joint Registry Interactive web site Dynamic/customized reports for surgeons Risk Calculators Clinical decision support tools Leverage TJR Infrastructure Use TJR registry model to expand to other areas (e.g. cardiology) Collaboration National and International KP HealthConnect Migrate data capture from forms to 100% electronic
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