Marina Torre

International survey of primary and revision total knee replacement.

PurposeTotal knee arthroplasty (TKA) is currently the international standard of care for treating degenerative and rheumatologic knee joint disease, as well as certain knee joint fractures. We sought to answer the following three research questions: (1) What is the international variance in primary and revision TKA rates around the world? (2) How do patient demographics (e.g., age, gender) vary internationally? (3) How have the rates of TKA utilization changed over time?MethodsThe survey included 18 countries with a total population of 755 million, and an estimated 1,324,000 annual primary and revision total knee procedures. Ten national inpatient databases were queried for this study from Canada, the United States, Finland, France, Germany, Italy, the Netherlands, Portugal, Spain, and Switzerland. Inpatient data were also compared with published registry data for eight countries with operating arthroplasty registers (Denmark, England & Wales, Norway, Romania, Scotland, Sweden, Australia, and New Zealand).ResultsThe average and median rate of primary and revision (combined) total knee replacement was 175 and 149 procedures/100,000 population, respectively, and ranged between 8.8 and 234 procedures/100,000 population. We observed that the procedure rate significantly increased over time for the countries in which historical data were available. The compound annual growth in the incidence of TKA ranged by country from 5.3% (France) to 17% (Portugal). We observed a nearly 27-fold range of TKA utilization rates between the 18 different countries included in the survey.ConclusionIt is apparent from the results of this study that the demand for TKA has risen substantially over the past decade in countries around the world.

International differences in acute coronary syndrome patients’ baseline characteristics, clinical management and outcomes in Western Europe: the EURHOBOP study

Objective We aimed to describe current characteristics of patients admitted for acute coronary syndrome (ACS) in Western Europe and to analyse whether international in-hospital mortality variations are explained by differences in patients’ baseline characteristics and in clinical management. Methods We studied a population-based longitudinal cohort conducted in Finland, France, Germany, Greece, Portugal and Spain, and comprising 12 231 consecutive ACS patients admitted in 53 hospitals between 2008 and 2010. Baseline characteristics, clinical management and inhospital outcomes were recorded. Contextual effect of country on death was analysed through multilevel analysis. Results Of all patients included, 8221 (67.2%) had NSTEMI (non-ST-elevation myocardial infarction), and 4010 (32.8%) had STEMI (ST-elevation myocardial infarction). Inhospital mortality ranged from 15.1% to 4.9% for German and Spanish STEMI patients, and from 6.8% to 1.9% for Finnish and French NSTEMI patients (p<0.001 for both). These international variations were explained by differences in patients’ baseline characteristics (older patients more likely to have cardiogenic shock in Germany) and in clinical management, with differences in rates of thrombolysis (less performed in Germany) and primary percutaneous coronary intervention (high in Germany, low in Greece). A remaining contextual effect of country was identified after extensive adjustment. Conclusions Inhospital mortality rates of STEMI and NSTEMI patients were two to three times higher in Finland, Germany and Portugal than in Greece and Spain, with intermediate values for France. Differences in baseline characteristics and clinical management partly explain differences in outcome. Our data also suggest an impact of the healthcare system organisation.

A European benchmarking system to evaluate in-hospital mortality rates in acute coronary syndrome: the EURHOBOP project.

BACKGROUND Hospital performance models in acute myocardial infarction (AMI) are useful to assess patient management. While models are available for individual countries, mainly US, cross-European performance models are lacking. Thus, we aimed to develop a system to benchmark European hospitals in AMI and percutaneous coronary intervention (PCI), based on predicted in-hospital mortality. METHODS AND RESULTS We used the EURopean HOspital Benchmarking by Outcomes in ACS Processes (EURHOBOP) cohort to develop the models, which included 11,631 AMI patients and 8276 acute coronary syndrome (ACS) patients who underwent PCI. Models were validated with a cohort of 55,955 European ACS patients. Multilevel logistic regression was used to predict in-hospital mortality in European hospitals for AMI and PCI. Administrative and clinical models were constructed with patient- and hospital-level covariates, as well as hospital- and country-based random effects. Internal cross-validation and external validation showed good discrimination at the patient level and good calibration at the hospital level, based on the C-index (0.736-0.819) and the concordance correlation coefficient (55.4%-80.3%). Mortality ratios (MRs) showed excellent concordance between administrative and clinical models (97.5% for AMI and 91.6% for PCI). Exclusion of transfers and hospital stays ≤1day did not affect in-hospital mortality prediction in sensitivity analyses, as shown by MR concordance (80.9%-85.4%). Models were used to develop a benchmarking system to compare in-hospital mortality rates of European hospitals with similar characteristics. CONCLUSIONS The developed system, based on the EURHOBOP models, is a simple and reliable tool to compare in-hospital mortality rates between European hospitals in AMI and PCI.

Heart rate at admission is a predictor of in-hospital mortality in patients with acute coronary syndromes: Results from 58 European hospitals: The European Hospital Benchmarking by Outcomes in acute coronary syndrome Processes study

Aims: The purpose of this study was to investigate the relationship between heart rate at admission and in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Methods: Consecutive ACS patients admitted in 2008–2010 across 58 hospitals in six participant countries of the European Hospital Benchmarking by Outcomes in ACS Processes (EURHOBOP) project (Finland, France, Germany, Greece, Portugal and Spain). Cardiogenic shock patients were excluded. Associations between heart rate at admission in categories of 10 beats per min (bpm) and in-hospital mortality were estimated by logistic regression in crude models and adjusting for age, sex, obesity, smoking, hypertension, diabetes, known heart failure, renal failure, previous stroke and ischaemic heart disease. In total 10,374 patients were included. Results: In both STEMI and NSTE-ACS patients, a U-shaped relationship between admission heart rate and in-hospital mortality was found. The lowest risk was observed for heart rates between 70–79 bpm in STEMI and 60–69 bpm in NSTE-ACS; risk of mortality progressively increased with lower or higher heart rates. In multivariable models, the relationship persisted but was significant only for heart rates >80 bpm. A similar relationship was present in both patients with or without diabetes, above or below age 75 years, and irrespective of the presence of atrial fibrillation or use of beta-blockers. Conclusion: Heart rate at admission is significantly associated with in-hospital mortality in patients with both STEMI and NSTE-ACS. ACS patients with admission heart rate above 80 bpm are at highest risk of in-hospital mortality.

Percutaneous coronary intervention reduces mortality in myocardial infarction patients with comorbidities: Implications for elderly patients with diabetes or kidney disease

BACKGROUND Percutaneous coronary intervention (PCI) reduces mortality in most myocardial infarction (MI) patients but the effect on elderly patients with comorbidities is unclear. Our aim was to analyse the effect of PCI on in-hospital mortality of MI patients, by age, sex, ST elevation on presentation, diabetes mellitus (DM) and chronic kidney disease (CKD). METHODS Cohort study of 79,791 MI patients admitted at European hospitals during 2000-2014. The effect of PCI on in-hospital mortality was analysed by age group (18-74, ≥75years), sex, presence of ST elevation, DM and CKD, using propensity score matching. The number needed to treat (NNT) to prevent a fatal event was calculated. Sensitivity analyses were conducted. RESULTS PCI was associated with lower in-hospital mortality in ST and non-ST elevation MI (STEMI and NSTEMI) patients. The effect was stronger in men [Odds ratio (95% confidence interval) 0.30 (0.25-0.35)] than in women [0.46 (0.39-0.54)] aged ≥75years, and in NSTEMI [0.22 (0.17-0.28)] than in STEMI patients [0.40 (0.31-0.5)] aged <75years. PCI reduced in-hospital mortality risk in patients with and without DM or CKD (54-72% and 52-73% reduction in DM and CKD patients, respectively). NNT was lower in patients with than without CKD [≥75years: STEMI=6(5-8) vs 9(8-10); NSTEMI=10(8-13) vs 16(14-20)]. Sensitivity analyses such as exclusion of hospital stays <2days yielded similar results. CONCLUSIONS PCI decreased in-hospital mortality in MI patients regardless of age, sex, and presence of ST elevation, DM and CKD. This supports the recommendation for PCI in elderly patients with DM or CKD.

The validity of hospital administrative data for outcome measurement after hip replacement

Background : Because of the increasing availability of clinical information on the basis of electronically processed data obtained through the hospital discharge records in the HIS, large databases are being set up to develop risk adjustment models for outcome assessment. This study is aimed at assessing the validity of hospital discharge data from the Hospital Information System (HIS) of patients with hip arthroplasty. Methods : 677 records were extracted from the database of the pilot project “Lazio Region Hip Arthroplasty Register (Ripa-L)” and were compared to the corresponding HIS discharge records. The Ripa-L dataset was used as a reference to evaluate the completeness and accuracy of the socio-demographic and clinical HIS data. Results : Data such as the patients’ age and sex, principal diagnosis, and surgical procedures, showed a very high level of agreement. By contrast, clinical information about comorbidities on admission and in-hospital complications mostly showed unacceptable variances in the datasets. The sensitivity of hospital data reporting was generally very low for almost all conditions, with the highest value being observed for diabetes (58%) and the lowest for endocrine and peripheral venous diseases (4%). Conclusions : Gaps in clinical information may compromise the ability to carry out high quality appraisals. In particular, the underreporting of comorbidities in hospital administrative data may lead to misestimation of the providers’ skill and quality of care, as a consequence of imperfect risk-adjustment. Stakeholders should highlight the potentialities related to the use of high quality administrative datasets also in clinical evaluations by stimulating health professionals to further improve the quality of the collected data.

Hospital admission for rheumatoid arthritis dwindled in Italy between 2001 and 2008

SIR, Recent advances in the management of RA have resulted in more effective control of inflammation. On the one hand, RA patients are diagnosed earlier so that treatment can be instituted during the so-called window of opportunity [1], and on the other, new and potent biological modulators of the inflammatory response have become available [2]. These advances have yielded a notable clear positive effect for patients, but are difficult to pinpoint for the whole society and the health services. To test the hypothesis that RA is now being better controlled, we analysed the trend of hospital RA admissions in Italy. The nationwide database of Hospital Discharge Records (HDRs), routinely collected by the Italian National Health Service for every admission to both public and private institutions for inpatients and day-patients, has been searched for all the hospitalizations with primary diagnosis of RA during the period 2001 08. Age-adjusted discharge rates per 10 000 population were calculated. The data on hospital discharges are retrieved by the Ministry of Health and then referred to Unit of Statistics of the National Institute of Health (Istituto Superiore di Sanità). HDRs contain information such as demographics, primary and additional diagnoses (maximum of five), types of medical interventions, including surgery and length of hospital stay. The primary diagnosis was defined as the principal reason for hospitalization, entailing expenditure of most resources. A diagnosis of RA was considered if code 714 of the International Classification of Diseases, Ninth Revision, Clinical Modifications (ICD-9-CM) was recorded. For comparison, discharges with a primary diagnosis of OA (ICD-9-CM 715) and all other musculoskeletal conditions excluding osteoporosis (ICD-9-CM 710 739, excluding 714, 715 and 733.0) were also recorded. Since the focus of our analysis was the evaluation of discharges, multiple hospitalizations for the same patient were counted as different items. During the period 2001 08, 184 137 discharges with the primary diagnosis of RA were recorded in Italy. There was an overall decrease (Fig. 1), both in the number of discharges ( 17.1%) and in the age-adjusted discharge rate ( 22%). The decrease was steady for inpatient hospitalization, but was appreciable only as from 2005 for day-care hospitalization. Discharges with medical disease-related groups (DRGs) accounted for 96% of the total; for them the decrease was 16.6% in absolute figures and 21.6% in age-adjusted rates. The figures for discharges with surgical DRGs, which represented 4% of the total, were 26.3 and 30.5%, respectively. These data indicate that hospital admissions for RA considerably decreased over an 8-year period, especially for surgical procedures. The system used for recording hospital discharges did not change in this time interval. In addition, data from the 1950s [3], 1998 [4] and 2005 [5] suggest that the prevalence of RA has remained stable in Italy, with figures between 0.33 and 0.46%. The possibility that pressure for savings in sanitary expenditure was the cause of this reduction in hospital admissions is inconsistent because, in the same period, the number of discharges and the age-standardized rates for OA increased by 33.6 and 22.1%, respectively, and they were unchanged for all the remaining musculoskeletal conditions. For RA, there was most probably a shift from inpatient to day-care hospitalization up to 2005. Subsequently, however, both inpatient and daycare admissions decreased. The lower need of hospital admissions for RA patients may be either due to RA becoming milder [6], or to diagnostic misclassification. However, there is no reason why misclassification should have worked differently in the different periods of the study. Alternatively, the better utilization of traditional and new biological therapies administered to early-diagnosis patients could represent the major cause of the decrease in hospitalization number. This view is supported by the timing of availability of anti-TNF agents in Italy, where infliximab, the first TNF-a inhibitor, was marketed in 2000, etanercept in 2001 and adalimumab in 2004. In conclusion, we have observed a decrease in the number of hospitalizations for RA in Italy apparently not due to changes in health policy. Therefore, it is possible that RA is better managed as a result of earlier diagnosis and intervention, and of the availability of more effective treatments.

ACL reconstruction by bone-patellar tendon-bone graft: mechanical evaluation of the elastic modulus and failure modes

The aim of this study was to apply an engineering approach to study the biomechanical behaviour of both native and reconstructed anterior cruciate ligaments (ACL) under tensile test, simulating the primary stability of the reconstructed ACL in the immediate postoperative period, when the bone callus has not formed yet. We used the bovine bone-patellar tendon-bone grafts to reconstruct ACL in bovine knees. The grafts were fixed by means of titanium interference screws and titanium transverse compressive screws. We tested 18 native and 18 reconstructed ligaments (7 with interference screws and 11 with transverse compressive screws). We applied mechanical tension at a 500 mm/min strain rate, and observed the mode of failure. The data analysis confirmed the different behaviour recorded in load elongation curves, a difference enhanced in stress-strain curves for both fixation methods. The stress-strain patterns for the interference screw and for the native ligament were quite similar.