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

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190 Volume Outcome KCE reports 113 Volume treated 350 300 250 200 150 100 50 0 Figure 7.9: Total knee arthroplasty: volume per surgeon 7.2.5 Definition of outcomes Common outcome measures are mortality, loss of independence, loss of mobility and residual pain. Unfortunately, the latter three are not registered in the MCD. Complications associated with TKR can be divided in three kinds. Those associated with the risk of anaesthesia includes acute myocardial infarction. Those associated with immobilization include development of deep vein thrombosis, pulmonary embolism, pneumonia, and muscular atrophy; those associated with the surgical procedure include postoperative infection, mechanical malfunctions of the prosthesis and dislocation of the knee joint. These complications can give cause for a re-intervention, i.e. a revision knee replacement. Finally, in the long term, there is the problem of knee replacements progressively wearing out over the years. Patients who wear out their prosthesis will require a revision knee replacement surgery. The literature review (see Table 2.1 on page 16) identified the following outcome measures for TKR: in-hospital mortality, in-hospital complication rate, 90-day complication rate and the 90-day revision rate. The revision rate was also studied at 36 months, but since MCD data were only available for 2004 and 2005, this long-term outcome measure was not retained in our analyses. 62 7.2.5.1 In-hospital outcome In-hospital outcome includes in-hospital mortality as well as complications after total knee arthroplasty. Information on in-hospital complications was retrieved from the MCD, on the basis of the following ICD-9-CM secondary diagnosis codes during index admission: 310 • Deep wound infection (SSI): 996.66 “Infection and inflammatory reaction due to internal joint prosthesis” • Pulmonary embolism: 415.1 “Pulmonary embolism and infarction” • Deep venous thrombosis (DVT): 451.1x “Phlebitis and thrombophlebitis of deep vessels of lower extremities”. Table 7.25 shows that these four outcome measures are rare events. During the 11 017 elective TKR stays, 17 patients deceased during their hospitalization. The most frequent in-hospital complication was pulmonary embolism with 0.46% (0.34%, 0.61%). Similarly to what was done for total hip arthroplasty, no further analysis in terms of VOA was performed on in-hospital outcomes. Instead, all our attention was focused on events occurring within 90 days after the first index stay, and on the revision rate at 12 months.
KCE Reports 113 Volume Outcome 191 Table 7.25: Total knee arthroplasty: In-hospital outcome (during index stay) Number total number outcome % outcome Death 11017 17 0.15 Deep venous thrombosis 11017 45 0.41 Pulmonary embolism 11017 51 0.46 Deep wound infection 11017 7 0.06 7.2.5.2 Complications within 90 days Among the 11 017 patients who underwent a total knee replacement in 2004, 6 633 patients (60.7%) were hospitalized at least once again in 2004 or 2005. For 1 875 patients (17%), the second admission took place within 90 days following the index admission. The 90 days interval starts with the total knee replacement index admission. This period of time was chosen previously by Katz. et al. 325 The outcome measures are very similar to those for THR. Information on the 90-day complication rate is retrieved from two sources: 1. the index admission: on the basis of the secondary diagnosis; 2. consecutive readmissions that occurred within 90 days from index admission: on the basis of the principal diagnosis or procedure. The following ICD-9-CM diagnosis (as primary or secondary diagnosis) or procedure codes are used: • Pulmonary embolism: 415.1 “Pulmonary embolism and infarction as principal diagnosis” • Deep venous thrombosis (DVT): 451.1x “Phlebitis and thrombophlebitis of deep vessels of lower extremities” • Deep wound infection: 996.66 “Infection and inflammatory reaction due to internal joint prosthesis” • Mechanical complication: 996.4 “Mechanical complication of internal orthopaedic device, implant, & graft” • Other complications: at least one ICD-9-CM diagnosis code indicating “Other complications of internal prosthetic device, implant, & graft”: o 996.77 “Due to internal joint prosthesis” o or 996.78 “Due to other internal orthopaedic device, implant, & graft” o or 996.79 “Due to other internal prosthetic device, implant, & graft” • Dislocation of knee within 90 days from initial admission: at least one of the following codes: o diagnosis 836.x “Dislocation of knee” o or procedure 79.76 “Closed reduction of dislocation of knee” o or procedure 79.86 “Open reduction of dislocation of knee” • Acute myocardial infarction: 410 “Acute myocardial infarction” • Pneumonia: at least one of the following ICD-9-CM diagnosis codes: o 480.x “Viral pneumonia” o 481.x “Pneumococcal pneumonia” o 482.x “Other bacterial pneumonia” o 483.x “Pneumonia due to other specified organism” o 485.x “Bronchopneumonia, organism unspecified” o 486.x “Pneumonia, organism unspecified”
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73. Financiering van het zorgprogra
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