Alejandro Allepuz

Arthroplasty registers: A review of international experiences

OBJECTIVES Registers have proven to be a valuable instrument in the evaluation of arthroplasty procedures and the performance of implants. The aim of this study was to describe the structure, functioning, and content of arthroplasty registers in Europe and other parts of the world. METHODS A search of technical reports was carried out through the Internet and in Medline/PubMed. The exhaustiveness of the information was confirmed using the links to Web pages of other registers and contacts with key people. Aims, methods in data collection and evaluation, internal structure and organization, participants, validity of the data, and other variables were assessed for each arthroplasty register using a qualitative content analysis of the texts. RESULTS Fifteen arthroplasty registers were identified which published sufficient information to conduct a comparative analysis. Eight additional registers were identified but no information was available on the Internet or in English. Most registers were initiatives of an orthopaedic society receiving governmental funding. Data were collected using standardized clinical forms and additional information from clinical-administrative datasets or other registers (mortality, implant costs, hip fractures). The main outcome measure of these registers is survival of the prostheses. Registers use the Internet and their annual reports as the main strategy for the dissemination and feed-back of their results. CONCLUSIONS Scientific or professional societies and the public health administration should collaborate in the development of arthroplasty registers. To adequately assess the results of observational data information on the structure, the process of arthroplasty interventions and patients characteristics should be collected.

Artroplastias de cadera y rodilla en Cataluña desde 1994 a 2005

Objetivo: Las artroplastias de cadera y rodilla estan entre los procedimientos quirurgicos mas frecuentes en Cataluna. El objetivo de este estudio fue describir su evolucion y los cambios en sus caracteristicas entre 1994 y 2005. Metodos: Estudio transversal de altas por artroplastias totales primarias de cadera (ATC) o rodilla (ATR) y de revision seleccionadas del Conjunto Minimo Basico de Datos al Alta Hospitalaria: codigos 81.51, 81.53, 81.54 y 81.55 (CIE-9-MC). Se calcularon las tasas de ATC y ATR estandarizadas por edad y sexo, y la carga de revision, analizando su evolucion mediante la regresion de joinpoint. Se definieron 4 periodos y se analizaron las caracteristicas de los pacientes y de los episodios asistenciales comparando los periodos 4 y 1 a partir de modelos de regresion logistica. Resultados: Las tasas por 10.000 habitantes se incrementaron entre 1994 y 2000 en ATC, pasando de 4,1 a 6,6, y entre 1994 y 2005 en ATR, pasando de 2,6 a 15,5. La carga de revision aumento en la cadera hasta 2001 y en la rodilla durante todo el periodo de estudio. El principal motivo de artroplastia primaria fue la artrosis. Los pacientes de 75 anos o mayores y la comorbilidad aumentaron en ATC y ATR. Conclusiones: El incremento de las tasas y el cambio del perfil de los pacientes reflejan una posible ampliacion de los criterios de indicacion. El previsible aumento de la cirugia de revision se podria reducir mediante sistemas de evaluacion de la supervivencia de las protesis y el desarrollo de guias de practica clinica.

Comparison of 3 systems for assigning priority to patients on waiting lists for cataract extraction

OBJECTIVE As the demand for cataract surgery grows, patients in some health care systems are assigned to a waiting list. Several explicit priority tools have been developed. We compared 3 of these: the IRYSS-Cataract Priority Score (ICPS), Catalan Agency for Health Technology Assessment and Research cataract priority system (CCPS), and Western Canada Waiting List project for cataract surgery (WCWL). DESIGN Prospective cohort study. PARTICIPANTS A total of 1723 consecutive patients awaiting cataract surgery at 5 hospitals. METHODS The ICPS, CCPS, and WCWL were applied to these patients after the collection of data. The 3 prioritization systems were compared using correlation methods, 95% limits of agreement, and the kappa coefficient. RESULTS Means and standard deviations for the different prioritization systems were 60.9 (22.2) for the ICPS, 35.7 (20.4) for the CCPS, and 25.7 (21.5) for the WCWL. Pearsons correlation coefficients were 0.56 between the ICPS and the CCPS, 0.62 between the WCWL and CCPS, and 0.71 between the ICPS and WCWL. The kappa value among them ranged from 0.13 to 0.40, and the intraclass correlation coefficients ranged from 0.31 to 0.55. CONCLUSIONS These 3 prioritization tools showed acceptable correlations but assigned significantly different point scores to similar scenarios. This may have consequences when using these tools for managing a waiting list for cataract extraction.

Factores relacionados con la calidad de vida al año de la artroplastia total de cadera y rodilla: estudio multicéntrico en Cataluña

AIMS To assess the health related quality of life (HRQOL) and associated factors of patients before, and one year after, total knee (TKA) and hip (THA) arthroplasty. METHODS A quasi-experimental prospective study conducted in hospitals with different levels of complexity and volume in Catalonia, and on patients with an indication of a TKA or THA. Demographic and psychosocial variables were recorded, and the SF-36 and WOMAC, and a question on perception of change after surgery were administered to patients by telephone interview. The standardised differences (effect size) of perceived change using the SF-36 and WOMAC scores before and after surgery were calculated. The factors associated with HRQOL one year after surgery were analysed using adjusted general linear models. RESULTS Although there was an overall improvement in most HRQOL domains of patients (n=672), 9% saw little improvement after surgery, with their scores at baseline and follow-up being very similar (small size effect: 0.0-0.4). Women, patients with low social support, with lower scores (worse) in perceived mental health and baseline HRQOL, and who declared that their condition was more severe, perceived a poorer HRQOL one year after surgery (P<.05). CONCLUSIONS Factors associated to a worse prognosis one year after an arthroplasty have been identified and are consistent with other published studies. The assessment of HRQOL can be a key instrument for identifying possible patients without improvement, in order to assess alternatives to an intervention, or apply other interventions in order to improve the efficiency of the healthcare process.

Los registros de artroplastias como sistemas de vigilancia poscomercialización: el Registro de Artroplastias de Cataluña

OBJECTIVE The aim is to present the functioning and results of the Catalan Arthroplasty Registry (RACat). MATERIAL AND METHOD The RACat arose by the initiative of the Catalan Society of Orthopaedic Surgery and Traumatology, the Catalan Health Service (CHS) and the Catalan Agency for Health Information Assessment and Quality. Publicly funded hospitals sent information through the Internet (CHS Applications website) on knee and hip arthroplasties: patient identification, hospital, joint (hip/knee), type (primary/revision), side of operation, date of surgery and prosthesis (manufacturers name and reference number). The quality of the data is analysed regularly. We estimate the risk of replacement by the Kaplan-Meier method. RESULTS A total of 52 hospitals out of 62 send data to RACat, and information on 36,951 knee and 26,477 hip arthroplasties is available. Data quality improved between 2005 and 2010. In 2010 coverage exceeded 70%, with side of operation 97%, and prostheses identification of 80%. The risk of replacement at three years was 3.3% (95% CI:3.1-3.6) for knee, 2.9% (95% CI:2.5-3.3) for total hip, and 2.5% (95% CI:2.0-3.1) for partial hip. DISCUSSION Risk of replacement is higher than that observed in other registers, although data quality and its improvement over time should be taken into account. CONCLUSIONS The information available in the RACat will help to establish a standard that will enable hospitals to compare results.

Different hip and knee priority score systems: are they good for the same thing?

OBJECTIVE The aim of the present study was to compare two priority tools used for joint replacement for patients on waiting lists, which use two different methods. METHODS Two prioritization tools developed and validated by different methodologies were used on the same cohort of patients. The first, an IRYSS hip and knee priority score (IHKPS) developed by RAND method, was applied while patients were on the waiting list. The other, a Catalonia hip-knee priority score (CHKPS) developed by conjoint analysis, was adapted and applied retrospectively. In addition, all patients fulfilled pre-intervention the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Correlation between them was studied by Pearson correlation coefficient (r). Agreement was analysed by means of intra-class correlation coefficient (ICC), Kendall coefficient and Cohern kappa. The relationship between IHKPS, CHKPS and baseline WOMAC scores by r coefficient was studied. RESULTS The sample consisted of 774 consecutive patients. Pearson correlation coefficient between IHKPS and CHKPS was 0.79. The agreement study showed that ICC was 0.74, Kendall coefficient 0.86 and kappa 0.66. Finally, correlation between CHKPS and baseline WOMAC ranged from 0.43 to 0.64. The results according to the relationship between IHKPS and WOMAC ranged from 0.50 to 0.74. CONCLUSIONS Results support the hypothesis that if the final objective of the prioritization tools is to organize and sort patients on the waiting list, although they use different methodologies, the results are similar.

Impact of a priority system on patients in waiting lists for knee arthroplasty.

RATIONALE, AIMS AND OBJECTIVES The Agency for Health Quality and Assessment of Catalonia (AQuAS) developed a system for the prioritization of patients on non-urgent waiting lists for cataract as well as knee and hip arthroplasty. The aim was to evaluate the impact of the priority systems application for primary knee arthroplasty (PKA). METHODS A retrospective evaluative study with data from the Data Tracking and Management Registry of the CatSalut Waiting Lists for PKA of hospitals in the public hospital network in the period 2003-2009. A description of the characteristics of patients on waiting lists was made and the association between priority scoring and waiting time and the order of operation analysed. Finally, waiting times were simulated that patients would have experienced if being operated on strictly according to a first in first out system or one of priority scoring, to compare them with real waiting times. RESULTS The number of people included on waiting lists for PKA was 67403. 67% had a priority score. The distribution of the priority score was negatively skewed with an average score of 70 points. The association with the priority score for the waiting time as well as the order of the operations performed was practically null. CONCLUSIONS The study concludes that, globally, the prioritization system for PKA has been implemented but had no effect on the prioritization of patients based on their severity. Nevertheless, in some centres, a moderate correlation between the order of operations performed and the priority score was identified.

Eficiencia en la prescripción de medicamentos: impacto de un programa de intercambio terapéutico

OBJECTIVE To assess the impact of substituting proton pump inhibitors (PPI) for omeprazole. METHOD We performed a community trial of the impact of a therapeutic exchange program in the primary care teams of a region compared with non-implementation in a control region. The study included patients prescribed a PPI between May 2008 and June 2009. The intervention consisted of providing educational sessions to physicians (n=68), as well as a list of patients receiving a PPI who were suitable for therapeutic exchange. Information was gathered from medical records (PPI prescribed, primary care team) and the pharmacy database (cost of defined daily doses of the PPI). The percentage of therapeutic exchange in each region before and after the intervention was compared through relative risk (RR). The percentage of omeprazole at the end of each study period and changes in PPI costs were also calculated. RESULTS Therapeutic exchange was higher in the intervention group (RR: 4.2; 95%CI: 3.1-5.8) than in the control group (RR: 1.8; 95%CI: 1.2-2.6). The percentage of patients prescribed omeprazole increased from 86.2% to 89.3% in the intervention region and from 84.3% to 84.7% in the control region. The total cost of the PPI group decreased by 7.6% in the intervention region and increased by 2.0% in the control group. CONCLUSIONS This study demonstrates the effectiveness of the therapeutic exchange program. This is a simple intervention that is able to modify prescription and reduce its costs.

Predicting the Burden of Revision Knee Arthroplasty: Simulation of a 20-Year Horizon

OBJECTIVES To estimate future utilization scenarios for knee arthroplasty (KA) revision in the Spanish National Health System in the short- and long-term and their impact on primary KA utilization. METHODS A discrete-event simulation model was built to represent KA utilization for 20 years (2012-2031) in the Spanish National Health System. Data on KA utilization from 1997 to 2011 were obtained from the minimum data set. Three scenarios of future utilization of primary KA (1, fixed number since 2011; 2, fixed age- and sex-adjusted rates since 2011; and 3, projection using a linear regression model) were combined with two prosthesis survival functions (W [worse survival], from a study including primary KA from 1995 to 2000; and B [better survival], from the Catalan Registry of Arthroplasty, including primary KA from 2005 to 2013). The simulation results were analyzed in the short-term (2015) and the long-term (2030). RESULTS Variations in the number of revisions depended on both the primary utilization rate and the survival function applied, ranging from increases of 8.3% to 31.6% in the short- term and from 38.3% to 176.9% in the long-term, corresponding to scenarios 1-B and 3-W, respectively. The prediction of increases in overall surgeries ranged from 0.1% to 22.3% in the short-term and from 3.7% to 98.2% in the long-term. CONCLUSIONS Projections of the burden of KA provide a quantitative basis for future policy decisions on the concentration of high-complexity procedures, the number of orthopedic surgeons required to perform these procedures, and the resources needed.