Het volume van chirurgische ingrepen en de impact ervan op ... - KCE
Het volume van chirurgische ingrepen en de impact ervan op ... - KCE
Het volume van chirurgische ingrepen en de impact ervan op ... - KCE
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<strong>KCE</strong> Reports 113 Volume Outcome 183<br />
There are several possible explanations for these differ<strong>en</strong>ces.<br />
First, <strong>de</strong>ep wound infection was <strong>de</strong>fined differ<strong>en</strong>tly by Katz and Solomon. They only<br />
inclu<strong>de</strong>d <strong>de</strong>ep wound infections that required either surgical <strong>de</strong>bri<strong>de</strong>m<strong>en</strong>t or removal of<br />
the prosthesis, while the <strong>KCE</strong> study searched for the diagnostic co<strong>de</strong> 996.66 “Infection<br />
and inflammatory reaction due to internal joint prosthesis”.<br />
Second, the low 90-day complication rates are probably related to the fact that<br />
complications are not well co<strong>de</strong>d in the MCD. As it happ<strong>en</strong>s, a previous <strong>KCE</strong> study<br />
assessed the accuracy of Belgian MCD for <strong>de</strong>tecting adverse ev<strong>en</strong>ts. Gillet et al. 111<br />
conclu<strong>de</strong>d that <strong>de</strong>ep v<strong>en</strong>ous thrombosis or pulmonary embolism and post<strong>op</strong>erative<br />
wound infection were no valid indicators for an a<strong>de</strong>quate <strong>de</strong>tection of these adverse<br />
ev<strong>en</strong>ts. In case of pulmonary embolism and <strong>de</strong>ep v<strong>en</strong>ous thrombosis, these results are<br />
surprising since the diagnostic co<strong>de</strong>s 415.1 and 451.1x have an initial level of severity of,<br />
respectively, 3 and 4. Omitting to co<strong>de</strong> them is not in the interest of the hospital since<br />
the Belgian hospital financing system is based on the hospital case-mix. The diagnostic<br />
co<strong>de</strong> for <strong>de</strong>ep wound infection (996.66), on the other hand, has an initial level of<br />
severity that equals 1, which means that coding it cannot modify the stays global level of<br />
severity. On the basis of these practical implications, one would expect that hospitals<br />
would be financially motivated to <strong>en</strong>co<strong>de</strong> DVT and pulmonary embolism. The report by<br />
Gillet et al. proved this assumption to be wrong. 111<br />
Third, Katz and Solomon used both inpati<strong>en</strong>t as outpati<strong>en</strong>t claims data.<br />
Fourth, Katz and Solomon took into account secondary diagnoses co<strong>de</strong>d during<br />
readmissions to calculate the complication rate, whereas the <strong>KCE</strong> study did not inclu<strong>de</strong><br />
the secondary diagnoses. As the p<strong>op</strong>ulation might have nee<strong>de</strong>d orth<strong>op</strong>aedic care for<br />
other joints than the <strong>op</strong>erated hip due to their <strong>de</strong>g<strong>en</strong>erative disease or arthritis, we<br />
chose not to select complication co<strong>de</strong>s pres<strong>en</strong>t as secondary diagnoses in posterior<br />
stays. Consequ<strong>en</strong>tly, the reliability of the link to the hip placem<strong>en</strong>t was preferred to the<br />
<strong>de</strong>trim<strong>en</strong>t of a possible un<strong>de</strong>restimation of the rate.<br />
Fifth, the selection process applied in our study focused on single total hip arthr<strong>op</strong>lasty,<br />
excluding bilateral procedures and pati<strong>en</strong>ts with more than one procedure during 2004-<br />
2005. These pati<strong>en</strong>ts stayed inclu<strong>de</strong>d in the US studies.<br />
Finally, Katz and Solomon, on the other hand, exclu<strong>de</strong>d pati<strong>en</strong>ts who were less than 65<br />
years old.<br />
Revision rate at 18 months after total hip replacem<strong>en</strong>t<br />
Table 7.18 shows similar revision rates at 18 months in differ<strong>en</strong>t studies. The 1.84%<br />
revision rate in the 2004 Belgian MCD (see Table 7.10) is very comparable to the +/-<br />
2% which was observed by Losina et al. in the Medicare claims data for 1995-1996. 314 In<br />
2000, Diels et al. calculated an 18 month revision rate of approximately 1.5% among all<br />
members of the Belgian Christian Sickness Funds who un<strong>de</strong>rw<strong>en</strong>t a total hip<br />
replacem<strong>en</strong>t betwe<strong>en</strong> 1990 and 1999. 312<br />
Table 7.18: Total hip arthr<strong>op</strong>lasty: revision rate at 18 months: comparison of<br />
Volume-Outcome <strong>KCE</strong> study with other studies<br />
COMPLICATION WITHIN 18 MONTHS<br />
<strong>KCE</strong> study<br />
Volume outcome<br />
Losina<br />
2004 USA<br />
Diels<br />
2000 Belgium<br />
Revision rate at 18 months 1.84% +/- 2% +/- 1.5%<br />
PATIENT CASE MIX<br />
Table 7.11 and Table 7.14 showed that low-<strong>volume</strong> hospitals (