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: 7938721
• 负责人: STEPHEN L LYMAN
• 金额: $ 34.26万
• 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 2011-11-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7938721
• 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）：此申请解决挑战区域（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。修订髋关节或膝关节的总关节置换术（RTJA）是一个复杂，昂贵的手术。每年在美国（2006年估计）每年进行约83,000。这些修订程序的频率仅有望随着预计在未来几年进行的大量原发性总关节置换术（PTJA）程序的频率增加（估计到2030年每年超过400万）。鉴于RTJA程序的结果比PTJA差，包括更高的并发症风险，更高的死亡率和更频繁的进一步修订手术，因此既需要减少对这些程序的需求，又需要优化这些修订结果。这项研究的目的是：1）评估患者的影响，以及制度因素对PTJA后早期RTJA的需求； 2）确定第一个PTJA后RTJA的转介模式以及这些模式的预测指标； 3）确定转介模式对RTJA后并发症的影响。这些目标将通过确定纽约和加利福尼亚州的州居民在2006年1月1日至12月31日之间经历了他们的第一个PTJA。这些患者将被遵循，直到RTJA在同一关节上的RTJA研究期结束为止。那些与其他外科医生和另一家医院进行手术的人将被视为“转诊”。将通过纽约和加利福尼亚的现有医院出院数据库来确定患者。将评估患者和机构（外科医生和医院）因素的影响。为了解决这三个特定目标，将评估这些效果的时间，用于RTJA，转介的可能性以及RTJA后的并发症。这将使用三个目标中的每个模型对此进行分析。 COX回归模型将用于分析到RTJA的时间1。 AIM 2的模型将评估转介的预测指标。 AIM 3模型将确定推荐是否改善短期结局，尤其是手术并发症发生率，90天的再入院，90天的院内死亡率以及随后的修订手术。这些将在被转诊的患者和未参考的患者之间进行比较，并调整潜在的其他混杂因素。目前尚不清楚哪些患者从美国的人群角度来看，特别是在患者和制度因素的结合方面，有最大的RTJA风险。早期RTJA的转介模式也未知。对于RTJA，是否存在地理差异也未知。最后，尚不清楚早期RTJA转诊的患者是否比与较低体积外科医生或中心进行手术的患者更好。所有这些问题将在本研究中探讨。迅速确定最有可能出现早期RTJA风险的患者将有助于开发未来的研究，并希望采取临床干预措施，以防止这些早期失败。 RTJA的推荐模式和趋势对分配医疗资源有直接影响，尤其是与培训和招募受过研究金培训的关节置换术外科医生有关的情况。此外，外科医生或医院对早期RTJA后结果的影响与提高护理质量并降低与这些复杂且已经昂贵的程序相关的成本直接相关。该项目解决了我们对RTJA的理解中一个极为重要的问题。获得的知识将使我们能够前进，以减少修订性关节置换术的需求，并通过减少并发症和优化资源分配来确定改善结果后改善结果的方法。强大的调查团队和主要的学术环境将在其中进行这项研究，确保将产生高质量的研究。对管理数据的分析代表了使用这些数据来评估与策略相关问题的前进一步。虽然先前在骨科结局的研究集中在关节置换后的体积结果关系，并发症或死亡率上，但该分析在检查转介模式的转介模式以及这些转介模式的含义时转向了新领域。这代表了先前用于此类大型数据库分析的方法的实质性完善，并将为将来的这种分析提供模板。修订性关节置换术通常是一个复杂，昂贵的程序，其结果比原发性促进术更差。修订程序被认为更常见于三级护理中心和大型外科医生，但转诊模式实际上是未知的。这项研究建议在1996年至2007年间鉴定纽约和加利福尼亚州修订性关节置换术的转诊模式，并确定早期修订的危险因素（在初次手术后的10年内）和修订手术后并发症的危险因素。