Referral Patterns and Risk of Early Revision after Primary Total Joint Arthroplas

原发性全关节置换术后的转诊模式和早期翻修的风险

• 批准号: 7817854
• 负责人: STEPHEN L LYMAN
• 金额: $ 37.29万
• 依托单位: HOSPITAL FOR SPECIAL SURGERY
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-09-23 至 2011-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7817854
• 关键词: Accounting; Address; Age; Area; Arthroplasty; Beds; California; Case Mixes; Characteristics; Clinical; Complex; Complication; Data; Databases; Degenerative polyarthritis; Development; Diagnosis; Environment; Failure; Fellowship; Frequencies; Funding; Future; Healthcare Systems; Hip region structure; Hospital Mortality; Hospitals; Implant; Intervention; Joint Revision; Joints; Knee joint; Knowledge; Life; Measures; Medical; Methodology; Methods; Modeling; Modification; New Territories; New York; Operative Surgical Procedures; Orthopedics; Outcome; Patients; Pattern; Policies; Population; Prevention; Procedures; Public Health; Quality of Care; Replacement Arthroplasty; Research; Resource Allocation; Resources; Risk; Risk Factors; Surgeon; Surgical complication; Time; Training; United States; Variant; base; bone loss; cohort; comparative effectiveness; cost; effectiveness research; follow-up; geographic difference; high risk; improved; knee replacement arthroplasty; medical implant; mortality; premature; prevent; primary outcome; tertiary care; trend

DESCRIPTION (provided by applicant): This application addresses Challenge Area (05) Comparative Effectiveness Research (CER) and High Priority Topic (05-EB-105) Comparative Effectiveness of Medical Implants. Revision total joint arthroplasty (rTJA) for the hip or knee joint is a complex, costly procedure. Approximately 83,000 are performed annually in the US (2006 estimate). The frequency of these revision procedures is only expected to increase with the large number of primary total joint arthroplasty (pTJA) procedures that are expected to be performed in the coming years (estimated at over 4 million annually by 2030). Given that rTJA procedures have worse outcomes than pTJA including higher risk of complication, higher mortality, and more frequent need for further revision surgery, there is a need to both decrease the need for these procedures, but also to optimize outcomes for these revisions. The aims of this research are to: 1) evaluate the effect of patient, and institutional factors on the need for early rTJA after pTJA; 2) identify the referral patterns for rTJA following first pTJA and predictors of these patterns; and 3) identify the effect of referral patterns on complications after rTJA. These aims will be accomplished by identifying state residents in New York and California undergoing their first pTJA between January 1, 1997 and December 31, 2006. These patients will be followed until the end of the study period for rTJA on the same joint. Those who have surgery with a different surgeon and at a different hospital will be considered "referrals". Patients will be identified through existing hospital discharge databases for New York and California. The effects of patient and institutional (surgeon and hospital) factors will be evaluated. In order to address the 3 specific aims, these effects will be evaluated for time to rTJA, likelihood of referral, and complications following rTJA. This will be analyzed using various multivariable models for each of the 3 aims. A Cox Regression model will be used to analyze time to rTJA for Aim 1. Aims 2 and 3 will be evaluated using a multivariable repeated measures models including methods that account for the correlation of procedures performed by the same surgeon or within the same hospital. The model for Aim 2 will evaluate the predictors of referral. The model for Aim 3 will determine whether referral improves short-term outcomes, particularly rates of surgical complication, 90 day readmission, 90 day in-hospital mortality, and subsequent revision surgery. These will be compared between patients who are referred and those who are not, adjusting for potential other confounders. It is currently unknown which patients are most at risk of early rTJA from a population perspective in the US, particularly with regard to the combination of patient and institutional factors. It is also unknown what the referral patterns are for early rTJA. It is also unknown whether geographic variation exists with regard to rTJA. Finally, it is unknown whether patients who are referred for early rTJA have better outcomes than those who have their surgery with lower volume surgeons or centers. All of these questions will be explored in this study. Quickly identifying patients most at risk for early rTJA will assist in development of future research and hopefully clinical interventions to prevent these early failures. Referral patterns and trends for rTJA have direct implications for allocation of medical resources, particularly as it pertains to training and recruitment of fellowship trained arthroplasty surgeons. Furthermore, the effect of surgeon or hospital on outcomes after early rTJA are directly relevant to improving the quality of care and reducing costs associated with these complex and already costly procedures. This project addresses an extremely important problem in our understanding of rTJA. The knowledge gained will allow us to move forward to reduce need for revision arthroplasty and to identify ways to improve outcomes following revision surgery by reducing complications and optimizing resource allocation. The strong investigative team and premier academic environment in which this study will take place assures that a high quality research will result. This analysis of administrative data represents a step forward in the use of these data to evaluate policy related questions. While previous studies in orthopedic outcomes have focused on volume outcome relationships and complications or mortality following joint replacement, this analysis moves into new territory in examining the referral patterns for revision surgery and the implications of these patterns of referral. This represents a substantial refinement in the methodology previously used for these kinds of large database analyses and will provide a template for future analyses of this kind. Revision arthroplasty is often a complex, costly procedure with worse outcomes than primary arthroplasty. Revision procedures are thought to be more commonly performed at tertiary care centers and by higher volume surgeons, but referral patterns are actually unknown. This study proposes to identify patterns for referral for revision arthroplasty in New York and California between 1996 and 2007 and to identify risk factors for early revision (within 10 years of primary surgery) and risk factors for complication following revision surgery.

描述（由申请人提供）：本申请涉及挑战领域（05）比较有效性研究（CER）和高优先级主题（05-EB-105）医疗植入物的比较有效性。髋关节或膝关节的翻修全关节置换术（rTJA）是一种复杂、昂贵的手术。在美国，每年大约进行83，000例手术（2006年估计）。预计这些翻修手术的频率只会随着预计在未来几年进行的大量初次全关节置换术（pTJA）手术而增加（估计到2030年每年超过400万例）。鉴于rTJA手术的结局比pTJA差，包括并发症风险更高、死亡率更高以及更频繁地需要进一步翻修手术，因此需要减少这些手术的需求，同时优化这些翻修手术的结局。本研究的目的是：1）评估患者和机构因素对pTJA后早期rTJA需求的影响; 2）确定首次pTJA后rTJA的转诊模式和这些模式的预测因素; 3）确定转诊模式对rTJA后并发症的影响。这些目标将通过确定1997年1月1日至2006年12月31日期间在纽约和加州进行首次pTJA的州居民来实现。将对这些患者进行随访，直至同一关节的rTJA研究期结束。那些在不同医院接受不同外科医生手术的人将被视为“转诊”。将通过纽约和加州的现有出院数据库识别患者。将评价患者和机构（外科医生和医院）因素的影响。为了实现这3个具体目标，将对这些影响进行rTJA时间、转诊可能性和rTJA后并发症的评价。这将使用3个目标中每个目标的各种多变量模型进行分析。将使用考克斯回归模型分析目标1至rTJA的时间。将使用多变量重复测量模型评价目标2和3，包括说明由同一外科医生或同一医院内进行的手术相关性的方法。目标2的模型将评估转诊的预测因素。目标3的模型将确定转诊是否改善了短期结局，特别是手术并发症率、90天再入院率、90天住院死亡率和随后的翻修手术率。这些将在转诊患者和未转诊患者之间进行比较，调整潜在的其他混杂因素。从美国人群的角度来看，目前尚不清楚哪些患者最有可能发生早期rTJA，特别是在患者和机构因素的组合方面。也不清楚早期rTJA的转诊模式是什么。也不清楚rTJA是否存在地理差异。最后，目前尚不清楚早期rTJA的患者是否比那些在低手术量的外科医生或中心接受手术的患者有更好的结局。所有这些问题都将在本研究中进行探讨。快速识别早期rTJA风险最高的患者将有助于未来研究的发展，并有望通过临床干预来预防这些早期失败。rTJA的转诊模式和趋势对医疗资源的分配有直接影响，特别是当它涉及到培训和招募经过培训的关节成形术外科医生时。此外，外科医生或医院对早期rTJA后结局的影响与提高护理质量和降低与这些复杂且已经昂贵的手术相关的成本直接相关。这个项目解决了我们对rTJA的理解中一个非常重要的问题。所获得的知识将使我们能够向前迈进，以减少翻修关节置换术的需求，并确定通过减少并发症和优化资源分配来改善翻修手术后结局的方法。强大的调查团队和一流的学术环境，这项研究将确保高质量的研究将产生。对行政数据的这种分析表明，在利用这些数据评价与政策有关的问题方面向前迈进了一步。虽然以前的骨科结局研究集中在关节置换术后的体积结局关系和并发症或死亡率，但本分析进入了新的领域，检查了翻修手术的转诊模式以及这些转诊模式的影响。这是对以前用于这类大型数据库分析的方法的重大改进，并将为今后的这类分析提供一个模板。翻修型关节置换术通常是一种复杂、昂贵的手术，其结局比初次关节置换术差。翻修手术被认为更常见于三级医疗中心和高容量外科医生，但转诊模式实际上是未知的。本研究旨在确定1996年至2007年期间纽约和加州翻修关节置换术的转诊模式，并确定早期翻修（初次手术后10年内）的风险因素和翻修手术后并发症的风险因素。