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

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200 Volume Outcome KCE reports 113 7.2.7.3 Comparative analysis of literature and Belgian data DEFINITION OF VOLUME As shown in Table 7.23, Belgian hospitals had a mean annual elective TKR volume of 97 in 2004; median is 78; 75 th Percentile is 120. Table 7.24 shows that Belgian orthopaedic surgeons performed on average 23 elective TKR in 2004; median is 12; 75 th Percentile is 30 TKR per year. These summary measures are very similar to those for elective total hip replacement (see page 49). When we compare the highest volume hospitals for elective THR (Figure 5.1) with those for elective TKR (Figure 6.2), the same hospital IDs turn up on the horizontal axis. This means that Belgian hospitals with a high annual volume of THR, often also have a high volume of elective TKR. In the selected primary studies and the systematic review, we did not find any information on the annual TKR volume of hospitals or surgeons in other countries. OUTCOME Again we have to acknowledge the fact that the Belgian MCD do not capture clinically relevant outcome measures such as loss of dependence, loss of mobility or residual pain. Table 7.34: Total knee arthroplasty: complication rate: comparison of Volume-Outcome KCE study with scientific literature IN-HOSPITAL KCE study Hervey Coyte Kreder Katz COMPLICATIONS Volume outcome 2003 1999 2003 2004 Complications during index admission Death 0.15% 0.21% 0.4% Deep venous thrombosis 0.41% 0.48% Pulmonary embolism 0.46% 0.37% Deep wound infection 0.06% 0.25% Complications within 90 days from index admission Death 0.5% 0.6% Deep venous thrombosis 0.42% Pulmonary embolism 0.63% 0.8% Deep wound infection 0.31% 0.4% AMI 0.20% 0.8% Pneumonia 0.56% 1.4% Complications within 1 year (or more) after index admission Revision within 1 year 0.98% 0.8% Revisions within 500 days (1.36 0.2% (*) year) 1.6% (*) (*) Coyte et al used two methods to estimate the revision rate: based on a group of patients with the longest time to revision and based on a group with the shortest time. In-hospital outcome after total knee replacement In-hospital outcome in the KCE study was first compared with the study by Hervey on 1997 data. 328 See Table 7.34. Hervey’s complication rates were very similar to the ones that were found in the MCD data except for deep wound infection. This difference can probably be explained by the use of different codes. Hervey et al. identified the infections by means of ICD-9-CM codes 998.59 “Postoperative wound infection” and 686.9 “Postoperative wound infection knee (skin)” while we used 996.66 “Infection and inflammatory reaction due to internal joint prosthesis”. The latter code was an exclusion criterion in the Hervey study. Kreder et al. reported an in-hospital mortality of 0.4%, but this is perhaps related to the fact that it concerns older data i.e. TKR performed between 1993 and 1996. 329
KCE Reports 113 Volume Outcome 201 90-day complication rate after total knee replacement In Table 7.34 we compare the KCE study’s 90-day complication rates with those published by Katz et al. on elective TKR performed in 2000. 325 The rates for pulmonary embolism and deep wound infection are very similar. For AMI and pneumonia, on the other hand, Katz obtained substantially higher rates. The explanation for these differences is again related to the use of different codes. For pneumonia, the KCE study used the ICD-9-CM codes 480 to 486 while Katz selected a larger range of codes (according to the AHRQ algorithms). For AMI, the KCE used code 410.xx while Katz’s AHRQ algorithm identified only the stays with 410.x1. On the other hand, the KCE only considered the principal diagnosis of re-admissions while Katz also considered the secondary diagnoses of AMI. Revision rate at 12 months after total knee replacement Table 7.34 shows that the 1-year revision rate observed in our study (0.98%) is very similar to the one found by Kreder (0.80%). 329 Coyte and colleagues found a 500-days revision rate between 1.6% and 2.0% (according to the method used). 331 Nevertheless, the reader has to take into account the fact that Coyte used data on TKR performed between 1984 and 1991. PATIENT CASE MIX Table 7.28 and Table 7.31 showed that low-volume (
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