Mikko Peltola

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.

A methodological approach for register-based evaluation of cost and outcomes in health care.

Abstract Introduction. In health care, measures of performance are needed at producer level for improving the treatment processes and at system level for steering purposes. In addition, measures that enable reliable comparisons of producers with respect to each other should encourage them to develop their treatment processes to attain better positioning in benchmarking. Methods. The main innovation of the Performance, Effectiveness, and Costs of Treatment episodes (PERFECT) project is to measure performance using existing linkable information available from registers within well-defined care episodes in a whole population. Finnish health care and related registers are used for constructing the disease-specific databases, with rich content on treatment processes and complete follow-up data. Results. The PERFECT project has developed numerous performance indicators that can be used to evaluate health policy actions as well as to create regional and hospital-level benchmarking data. In PERFECT, the idea is to eliminate individual-level variation from the performance indicators by using individual-level data and proper risk adjustment methods. The focus of our interest is in the variation at the producer or regional level. Conclusions. Our experience shows that the utilization of population-level health care registers with an episode-of-care approach enables a continual system and producer-level performance measurement.

Comorbid diseases as predictors of survival of primary total hip and knee replacements: a nationwide register-based study of 96 754 operations on patients with primary osteoarthritis

Objectives To examine how comorbid diseases (cardiovascular diseases, hypertension, diabetes, cancer, pulmonary diseases, depression, psychotic disorders and neurodegenerative diseases) affect survival of hip and knee replacements. Methods Data for this register-based study were collected by combining data from five nationwide health registers. 43 747 primary total hip and 53 007 primary total knee replacements performed for osteoarthritis were included. The independent effects of comorbid diseases on prosthesis survival were analysed using multivariate Cox regression analysis. Results Occurrence of one or more of the diseases analysed was associated with poorer survival of hip (HR for revision 1.16, 95% CI 1.08 to 1.23) and knee replacements (1.23, 1.16 to 1.30). Cardiovascular diseases and psychotic disorders were associated with increased risk of revision after both hip (1.19, 1.06 to 1.34 and 1.41, 1.04 to 1.91, respectively) and knee replacement (1.29, 1.14 to 1.45 and 1.41, 1.07 to 1.86, respectively). Hypertension and diabetes were associated with early revision (0–5 years after primary operation) after knee replacements (1.14, 1.01 to 1.29 and 1.27, 1.08 to 1.50, respectively). Cancer was associated with poorer survival of hip replacements (1.27, 1.05 to 1.54) and late revision (>5 years) of knee replacements (2.21, 1.31 to 3.74). Depression affected the risk of early revision after hip replacement (1.50, 1.02 to 2.21). Neurodegenerative and pulmonary diseases did not affect prosthesis survival. Conclusions Comorbid diseases may play an important role in predicting survival of primary hip and knee replacements. The mechanisms underlying these findings and their effect on cost-effectiveness of joint replacements, merit further research.

Health care performance comparison using a disease-based approach: The EuroHOPE project

This article describes the methodological challenges associated with disease-based international comparison of health system performance and how they have been addressed in the EuroHOPE (European Health Care Outcomes, Performance and Efficiency) project. The project uses linkable patient-level data available from national sources of Finland, Hungary, Italy, The Netherlands, Norway, Scotland and Sweden. The data allow measuring the outcome and the use of resources in uniformly-defined patient groups using standardized risk adjustment procedures in the participating countries. The project concentrates on five important disease groups: acute myocardial infarction (AMI), ischemic stroke, hip fracture, breast cancer and very low birth weight and preterm infants (VLBWI). The essentials of data gathering, the definition of the episode of care, the developed indicators concerning baseline statistics, treatment process, cost and outcomes are described. The preliminary results indicate that the disease-based approach is attractive for international performance analyses, because it produces various measures not only at country level but also at regional and hospital level across countries. The possibility of linking hospital discharge register to other databases and the availability of comprehensive register data will determine whether the approach can be expanded to other diseases and countries.

The incidence of late prosthetic joint infections: A registry-based study of 112,708 primary hip and knee replacements

Background and purpose — Late prosthetic joint infections (PJIs) are a growing medical challenge as more and more joint replacements are being performed and the expected lifespan of patients is increasing. We analyzed the incidence rate of late PJI and its temporal trends in a nationwide population. Patients and methods — 112,708 primary hip and knee replacements performed due to primary osteoarthritis (OA) between 1998 and 2009 were followed for a median time of 5 (1–13) years, using data from nationwide Finnish health registries. Late PJI was detected > 2 years postoperatively, and very late PJI was detected > 5 years postoperatively. Results — During the follow-up, involving 619,299 prosthesis-years, 1,345 PJIs were registered: cumulative incidence 1.20% (95% CI: 1.13–1.26) (for knees, 1.41%; for hips, 0.92%). The incidence rate of late PJI was 0.069% per prosthesis-year (CI: 0.061–0.078), and it was greater after knee replacement than after hip replacement (0.080% vs. 0.057%, p = 0.006). The incidence rate of very late PJI was 0.051% per prosthesis-year (CI: 0.042–0.063), 0.058% for knees and 0.044% for hips (p = 0.2). The incidence rate of late PJI varied between 0.041% and 0.107% during the years of observation without any temporal trend (incidence rate ratio (IRR) = 0.98, 95% CI: 0.93–1.03). Very late PJI increased from 0.026% in 2004 to 0.056% in 2010 (IRR = 1.11, 95% CI: 1.02–1.20). Interpretation — In our nationwide study, the incidence rate of late PJI after hip or knee arthroplasty was approximately 0.07% per prosthesis-year. The incidence of very late PJI appeared to increase.

The incidence of late prosthetic joint infections A registry-based study of 112,708 primary hip and knee replacements

Background and purpose — Late prosthetic joint infections (PJIs) are a growing medical challenge as more and more joint replacements are being performed and the expected lifespan of patients is increasing. We analyzed the incidence rate of late PJI and its temporal trends in a nationwide population. Patients and methods — 112,708 primary hip and knee replacements performed due to primary osteoarthritis (OA) between 1998 and 2009 were followed for a median time of 5 (1–13) years, using data from nationwide Finnish health registries. Late PJI was detected > 2 years postoperatively, and very late PJI was detected > 5 years postoperatively. Results — During the follow-up, involving 619,299 prosthesis-years, 1,345 PJIs were registered: cumulative incidence 1.20% (95% CI: 1.13–1.26) (for knees, 1.41%; for hips, 0.92%). The incidence rate of late PJI was 0.069% per prosthesis-year (CI: 0.061–0.078), and it was greater after knee replacement than after hip replacement (0.080% vs. 0.057%, p = 0.006). The incidence rate of very late PJI was 0.051% per prosthesis-year (CI: 0.042–0.063), 0.058% for knees and 0.044% for hips (p = 0.2). The incidence rate of late PJI varied between 0.041% and 0.107% during the years of observation without any temporal trend (incidence rate ratio (IRR) = 0.98, 95% CI: 0.93–1.03). Very late PJI increased from 0.026% in 2004 to 0.056% in 2010 (IRR = 1.11, 95% CI: 1.02–1.20). Interpretation — In our nationwide study, the incidence rate of late PJI after hip or knee arthroplasty was approximately 0.07% per prosthesis-year. The incidence of very late PJI appeared to increase.

Comparing ischaemic stroke in six European countries. The EuroHOPE register study.

The incidence of hospitalizations, treatment and case fatality of ischaemic stroke were assessed utilizing a comprehensive multinational database to attempt to compare the healthcare systems in six European countries, aiming also to identify the limitations and make suggestions for future improvements in the between‐country comparisons.

Health-Related Quality of Life in 5-Year-Old Very Low Birth Weight Infants

OBJECTIVE To investigate the effect of preterm birth, the time of birth, and birth hospital level and district on health-related quality of life (HRQoL) and quality-adjusted life years (QALYs). STUDY DESIGN This national study included all very low birth weight infants (VLBWIs; birth weight <or= 1500 g or gestational age < 32 weeks) born in Finland between 2000 and 2003 (n = 1169; live-born, n = 900) and full-term controls (n = 368). Register data and parental questionnaires were used. The relationships among HRQoL and QALYs at age 5 years and preterm birth, time of birth, and the level and district of the birth hospital were studied. RESULTS HRQoL at age 5 years was lower and 1.3 QALYs were lost in VLBWIs compared with controls. Regional differences in the QALYs of VLBWIs were found among the 5 university hospital districts. Birth hospital level or birth outside office hours had no effect on the QALYs of live-born VLBWIs. The adjusted HRQoL total score was not affected by birth outside office hours or by the birth hospital level or district. CONCLUSIONS Differences in QALYs related to hospital district suggest variation in the care of VLBWIs that needs to be addressed.

Regional and hospital variance in performance of total hip and knee replacements: a national population-based study.

Abstract Introduction. This article in the supplement on the Performance, Effectiveness, and Costs of Treatment episodes (PERFECT)-project describes the PERFECT Hip and Knee Replacement Database and its possibilities by evaluating regional and hospital-level differences in length of stay (LOS), costs and complication rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Finland. Material and methods. All hip and knee arthroplasties are recorded in the Finnish Hospital Discharge Register (FHDR) and Finnish Arthroplasty Register (FAR). LOS, length of uninterrupted institutional care (LUIC), complication rates and other parameters of treatment were determined by region and hospital during 1998–2008 based on these. Results. LOS and LUIC following THA and TKA diminished during the follow-up period. In 1998 average LOS after THA and TKA was 9.9 and 10 days. In 2008, these had shortened to 5.2 and 5.3 days, respectively. There was a 5.0 and 7.5 percentage point difference in revision rate between regions in THAs and TKAs, respectively, performed during 2005–2007 and followed to the end of 2009. Discussion. The Finnish health care registers provide a monitoring system for evaluating hospital- and regional-level differences in THA and TKA. The differences in LOS, LUIC and revision rates between hospitals and regions are considerable.

The effect of hospital volume on length of stay, re-admissions, and complications of total hip arthroplasty

Background and purpose Hospital volume has been suggested to be one of the best indicators of adverse orthopedic events in patients undergoing THR surgery. We therefore evaluated the effect of hospital volume on the length of stay, re-admissions, and complications of THR at the population level in Finland. Methods 30,266 THRs performed for primary osteoarthritis were identified from the Hospital Discharge Register. Hospitals were classified into 4 groups according to the number of THRs performed on an annual basis over the whole study period: 1–50 (group 1), 51–150 (group 2), 151–300 (group 3), and > 300 (group 4). Results In 2005, the length of the period of surgical treatment was 5.5 days in group 4 and 6.8 days in group 1 (the reference group). During the whole study period (1998–2005), the length of surgical treatment period was shorter in group 4 than in group 1 (p < 0.001). The odds ratio for dislocations (0.7, 95% CI: 0.6–0.9) was lower in group 3 than in group 1. Interpretation Hip replacements performed in high-volume hospitals reduce costs by shortening the length of stay, and they may reduce the dislocation rate.