Association Between Hospital and Surgeon Procedure Volume and Outcomes of Total Hip Replacement in the United States Medicare Population*

190

Background Lack of consensus continues regarding the benefit of anteriorly based surgical approaches for primary total hip arthroplasty (THA). The purpose of this study was to evaluate the risk of aseptic revision, septic revision, and dislocations for various approaches used in primary THAs from a community-based healthcare organization. Questions/purposes (1) What is the incidence of aseptic revision, septic revision, and dislocation for primary THA in a large community-based healthcare organization? (2) Does the risk of aseptic revision, septic revision, and dislocation vary by THA surgical approach? Methods The Kaiser Permanente Total Joint Replacement Registry was used to identify primary THAs performed between April 1, 2001 and December 31, 2011. Endpoints were septic revisions, aseptic revisions, and dislocations. The exposure of interest was surgical approach (posterior, anterolateral, direct lateral, direct anterior). Patient, implant, surgeon, and hospital factors were evaluated as possible confounders. Survival analysis was performed with marginal multivariate Cox models. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. A total of 42,438 primary THAs were available for analysis of revision outcomes and 22,237 for dislocation. Median followup was 3 years (interquartile range, 1-5 years). The registry's voluntary participation is 95%. The most commonly used approach was posterior (75%, N = 31,747) followed by anterolateral (10%, N = 4226), direct anterior (4%, N = 1851), and direct lateral (2%, N = 667). Results During the study period 785 hips (2%) were revised for aseptic reasons, 213 (0.5%) for septic reasons, and 276 (1%) experienced a dislocation. The revision rate per 100 years of observation was 0.54 for aseptic revisions, 0.15 for septic revisions, and 0.58 for dislocations. There were no differences in adjusted risk of revision (either septic or aseptic) across the different THA approaches. However, the anterolateral approach (adjusted HR, 0.29; 95% CI, 0.13-0.63, p = 0.002) and direct anterior approach (adjusted HR, 0.44; 95% CI, 0.22-0.87, p = 0.017) had a lower risk of dislocation relative to the posterior approach. There were no differences in any of the outcomes when comparing the direct anterior approach with the anterolateral approach. Conclusions Anterior and anterolateral surgical approaches had the advantage of a lower risk of dislocation without increasing the risk of early revision. Level of Evidence Level III, therapeutic study.

Section: Discussionmentioning

confidence: 99%

Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk

Sheth

Cafri

Inacio

et al. 2015

190

“…Each year, this data set includes the healthcare records in inpatient, outpatient, Part B carrier, skilled nursing facility, hospice care, home health, and durable medical equipment analytic data files. To limit the study to the elective cohort, we excluded patients undergoing primary TKA who received their implant as a result of bone cancer, joint infection, or fracture using criteria identical to those used previously by Katz, Mahomed, and coworkers [9,12]. Patients younger than 65 years old or health maintenance organization (HMO) enrollees were also excluded.…”

Section: Patients and Materialsmentioning

confidence: 99%

“…Because of its comprehensive nationwide coverage, Medicare claims data have the potential to serve as a framework for longitudinal analysis of infections for the United States. Thus far, assessments of PJI risk using Medicare data have been limited to 3-to 6-month postoperative assessment and suggest procedure duration and volume may be important risk factors [8,9,12,15].…”

Section: Introductionmentioning

confidence: 99%

Prosthetic Joint Infection Risk after TKA in the Medicare Population

Kurtz

Ong

Lau

et al. 2010

612

341

“…Furthermore, previous studies have reported the risk of rerevision for patients undergoing TKA to range from 11% to 19.8% at 5 years and those for patients undergoing THA to be as much as 16.1% at 3 years and 19.4% at 5 years [1,11,[30][31][32][33]. However, these data were obtained from patient cohorts at single institutions [31][32][33] or by international registries [1,11,30], but not for a large, nationally representative patient sample in the United States in which the patient profile or experience of the surgeon/hospital may differ [12,13]. In the absence of a national joint replacement registry in the United States, national administrative claims databases such as the Medicare claims data set offer very large population-based samples for evaluating the epidemiology and outcomes of TJA [16,19].…”

Section: Introductionmentioning

confidence: 99%

Risk of Subsequent Revision after Primary and Revision Total Joint Arthroplasty

Ong

Lau

Suggs

et al. 2010

246

155

Background Revision is technically more demanding than primary total joint arthroplasty (TJA) and requires more extensive use of resources. Understanding the relative risk of rerevision and risk factors can help identify patients at high risk who may require closer postsurgical care. Objectives/purposes We therefore evaluated the risk of subsequent revision after primary and revision TJA in the elderly (65 years or older) patient population and identified corresponding patient risk factors. Patients and Methods Using the 5% Medicare claims data set (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006), we identified a total of 35,746 patients undergoing primary THA and 72,913 undergoing primary TKA; of these, 1205 who had THAs and 1599 who had TKAs underwent initial revision surgery. The rerevision rate after primary and revision TJAs was analyzed by the Kaplan-Meier method. The relative risk of revision surgery for primary and revision TJAs was compared using hazard ratio analysis. ResultsThe 5-year survival probabilities were 95.9%, 97.2%, 81.0%, and 87.4% for primary THA and TKA and revision THA and TKA, respectively. Patients with revision arthroplasty were five to six times more likely to undergo rerevision (adjusted relative risk, 4.89 for THA; 5.71 for TKA) compared with patients with primary arthroplasty. Age and comorbidities were associated with initial revision after primary THA and TKA. Conclusions Patients should undergo stringent preoperative screening for preexisting health conditions and careful patient management and followup postoperatively so as to minimize the risk of an initial revision, which otherwise could lead to a significantly greater likelihood of subsequent rerevisions.