Het volume van chirurgische ingrepen en de impact ervan op ... - KCE

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186 Volume Outcome KCE reports 113 Key points on volume outcome association for elective total hip replacement/arthroplasty (THR) • A total of 11 856 patients were hospitalized in 2004 for a total hip arthroplasty. Partial arthroplasties, revisions of hip replacement, bilateral procedures and procedures for trauma were not included in this selection. • These interventions were performed in 115 centres by 522 surgeons. Annual mean number of THR was approximately 100 per centre, and 23 per surgeon. These volumes are much higher than US data (44% of centres less than 11 elective THR). • In-hospital mortality is virtually inexistent after elective THR, and in-hospital complications are also very rare (or under reported in the MCD). Following outcomes were analysed: complications requiring a hospitalisation within 90 days of intervention (3.3% of all patients), and revision of the prosthesis at 18 months (1.8% of all patients). Logistic and Cox regression models were fitted to assess the association between these outcomes and hospital or surgeon volume. Factors included in the models were: age, sex, Charlson score and principal diagnosis (ostheoarthrosis, other disorders of bone or cartilage, or other). • The literature review did not succeed in identifying good quality systematic reviews that studied revision rate and 90-day complication rate after THR. • Complication rate at 90 days was 4.1% for hospitals with less than 110 THR/year, and 2.9 % for other centres. Results from logistic regression without adjustment for case mix showed a statistically significant effect of hospital volume on the probability of complication rate (increase of 10% of volume associated with decrease of 2.6% in odds of death). After adjustment for case mix, this effect was reduced (1.6% decrease) and was only borderline statistically significant. • The association between surgeon volume and likelihood of complication at 90 days was more robust: 5.0% for surgeons with ≤ 6 THR/year, 4.5% for surgeons between 6 and 20 THR/yr, and 3.0% for surgeons with more than 20 THR/year. This association remained statistically significant after adjustment for case mix. • Revision rates at 18 months were lowest in high volume centres (1.7% in centres with more than 110 THR/year), highest (2.9%) in medium volume centres (between 60 and 110 THR) and 1.9% in low volume centres (less than 60 THR/year). Increases in volume were thus not consistently associated with decreases in revision rate. • A small decrease was observed in revision rates at 18 months from small or medium volume surgeons (≤ 20 THR/year, 2.0%) in comparison with high volume surgeons (> 20 THR/year, 1.8%), but effects are too small to draw conclusions. • Unfortunately, the MCD do not provide information on the outcomes of greatest interest to patients such as loss of independence, loss of mobility or residual pain. • POSSUM (Physiological and Operative Severity Score for enUmeration of Mortality and morbidity) would be better for risk adjustment in orthopaedic surgery than the applied Charlson score. However, these clinical parameters are not encoded in the MCD.
KCE Reports 113 Volume Outcome 187 7.2 ELECTIVE TOTAL KNEE REPLACEMENT/ARTHROPLASTY (TKR) 7.2.1 General description of procedure Total knee replacement or arthroplasty is a procedure in which damaged or diseased parts of the knee joint are removed and replaced with an artificial joint, called prosthesis. The thigh bone (or femur) abuts the large bone of the lower leg (tibia) at the knee joint. During a total knee replacement, the end of the thigh bone (femur) is removed and replaced with a metal shell. The end of the lower leg bone (tibia) is also removed and replaced with a channelled plastic piece with a metal stem. Depending on the condition of the kneecap, a plastic "button" may also be added under the kneecap surface. Revision knee replacement is performed when the original primary total knee replacement has worn out or loosened in the bone, or when the primary TKR fails due to, for example, recurrent dislocation, infection or fracture. This report only studies the volume-outcome relationship for the primary total knee replacement. 7.2.2 Primary data selection in MCD 2004 First selection of data was based on ICD-9-CM procedure and NIHDI procedure codes as proposed by Taylor et al., and by Jacques et al. This selection resulted in a total of 246, 309 14 105 stays. Table 7.19: Total knee arthroplasty: Primary data selection in MCD 2004 SELECTION 1 SELECTION 2 ICD-9-CM procedure code NIHDI procedure code 8154 TOTAL KNEE REPLACEMENT 8155 REVISE KNEE REPLACEMENT 290264 Femoro-tibial arthroplasty with simple prosthesis 290286 Femoro-tibial arthroplasty with articulated prosthesis 293462 Removal of a total knee prosthesis and placement of a new total prosthesis STAYS SELECTED =13 856 STAYS SELECTED =13 762 7.2.3 Definition of procedure TOTAL STAYS SELECTED= 14 105 (selection 1 OR selection 2) Table 7.20 shows that both ICD-9-CM and NIHDI procedures codes were recorded for almost 96% of the stays. There was thus a good correspondence between both classification systems. Table 7.20: Total knee arthroplasty: Cross table ICD-9 and NIHDI procedures codes Cumulative Cumulative Number Percent Freq Percent ICD-9 only 343 2.43 343 2.43 NIHDI only 249 1.77 592 4.20 Both 13 513 95.80 14 105 100.00 Among the 13 513 stays with both an ICD-9 and a NIHDI code, there were 926 which related to a revision of the hip arthroplasty. These stays were not withheld. Subsequently, we identified 12 752 stays with one total knee arthroplasty in which both the NIHDI procedure code 290286 as well as the ICD-9-CM procedure code 8151 were encoded. Stays with more than one TKR billed were then discarded (number=109) together with 190 stays with abnormalities in the data. After withdrawing the remaining 84 stays with a simple prosthesis (NIHDI code 290264), in order to obtain a homogeneous population, 12 369 stays could be further examined.
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