Early Identification of Poorly Performing Joint Replacements

关节置换手术是退伍军人健康中心最常见的住院手术 管理(VHA)。2015年，VHA进行了14,349例初次关节置换术。关于 5%的患者因失败或感染而在10年内再次手术。不良植入物的再手术率要高得多。 (例如，对于DePuy ASR XL，5年为17%-25%)。失败或不满意的关节置换费用高昂， 导致退伍军人患者的个人和经济困难。此外，失败的关节更换会造成 医疗保健系统每集约3.8万美元。随着植入物设计和技术的发展，一些变化 可能会对植入物的存活率产生负面影响，并伤害患者。一个最好的例子就是金属对金属 髋关节置换术，最近导致召回几个常用的植入物。 为了减少对病人的伤害和医疗保健系统的成本，我们必须提高我们的监测能力。 植入物的性能和识别不良的植入物比现在更早。病历 是一个潜在的丰富的信息来源，可以及早识别性能不佳的植入物 甚至在它们最终不得不修改之前，就有可能避免新患者接受它们。 VHA是美国最大的综合医疗保健系统，也是最早采用该系统的人之一 电子健康记录(EHR)。VHA EHR可用于创建VA关节植入物注册表。这 可以为未来在退伍军人医疗保健系统中选择植入物以改善退伍军人的决策提供信息 并将再次手术或并发症降至最低。此外，退伍军人关节置换登记处 可以通过计算提取和聚合来支持国家植入物监控系统 供FDA使用的个人假体数据。 我们提出了一个试点项目，以提取和评估关节置换假体植入和 来自退伍军人事务部数据仓库(CDW)的种植信息。《公约》的具体目标 拟进行的试验工作包括： 目标1：确定全国关节置换植入物使用的趋势和VA的地区差异 从2000年到2016年。为我们发展邮政市场监管的总体目标奠定基础 对于关节置换系统，从CDW检索特定于植入物的信息将是必不可少的 VHA随时间的变化，包括手术日期、站点、CPT代码、假体供应商、假体 型号、假体大小和假体名称。在评估了这些记录的完整性之后 随着时间的推移，我们将使用这些记录来描述每个站点和 每一历年。这将通过量化全国关节置换的趋势来支持进一步的研究。 植入物的使用和洞察整个VA系统在植入物选择方面的区域差异。 目标2：在VA系统中建立关节置换植入物的一级登记。1级注册表是 由患者人口统计、医院、外科医生和与手术相关的数据组成，包括偏侧性 手术、手术日期和使用的植入物。并非所有这些信息都在结构化记录中可用。 例如，由于操作的偏侧性不是直接在结构化字段中找到的，我们将需要 分析非结构化字段以确定索引操作的命运。这一目标的(A)部分将侧重于 从非结构化数据中提取用于索引手术和任何后续再操作的偏侧性信息 菲尔兹。这将告诉我们关节假体在需要重新手术之前持续了多长时间。第(二)部分 这一目标将需要对非结构化数据进行更具挑战性的分析，以确定 关节置换是有问题的，并被移除。通过实现这一目标，我们将生成关于 使用的每个植入物无需再次手术或取出即可存活 弗吉尼亚州医疗保健系统。

Joint replacement surgery is the most common inpatient surgery in the Veterans Health Administration (VHA). 14,349 primary joint replacement cases were performed in the VHA in 2015. About 5% are reoperated by 10 years for failure or infection. Poor implants have a much higher reoperation rate (e.g. 17-25% by 5 years for the DePuy ASR XL). Failed or unsatisfactory joint replacements are costly and result in personal and financial hardship for veteran patients. In addition, failed joint replacements cost the health care system about $38,000 per episode. As implant designs and techniques evolve, some changes can have a negative effect on implant survival and harm patients. A prime example of this is metal on metal hip arthroplasty, which recently resulted in recall of several commonly used implants. To limit harm to patients and costs for the health care system, we must improve our ability to monitor implant performance and identify poorly performing implants earlier than is now possible. Medical records are a potentially rich source of information that may allow early identification of poorly performing implants even before they end up having to be revised, and potentially sparing new patients from receiving them. The VHA is the nation's largest integrated health care system and was among the earliest adopters of the electronic health record (EHR). VHA EHRs may be used to create a VA joint implant registry. This could inform future decisions on implant selection across the VA health care system to improve veteran patient outcomes and minimize reoperations or complications. In addition, a VA joint replacement registry could act to support a national implant surveillance system by computationally extracting and aggregating individual prosthetic data for use by the FDA. We propose a pilot project to extract and evaluate joint replacement prosthesis implantation and explantation information from the VA Corporate Data Warehouse (CDW). The specific aims of the proposed pilot work are: Aim 1: Determine trends in national joint replacement implant use and regional variation in the VA from 2000 to 2016. To establish a foundation for our overall goal of developing a post market surveillance system for joint replacement, it will be essential to retrieve implant-specific information from the CDW across the VHA over time, including Operative Date, Station, CPT code, Prosthesis Vendor, Prosthesis Model, Prosthesis Size, and Prosthesis Name. After evaluating the completeness of these records across the VHA over time, we will use these records to characterize implantation practices for each station and each calendar year. This will support further study by quantifying trends in national joint replacement implant use and provide insight into regional variation in implant selection across the VA system. Aim 2: Build a level 1 registry of joint replacement implants in the VA system. A level 1 registry is made up of patient demographics, hospital, surgeon, and procedure-related data including the laterality of surgery, date of surgery and implant utilized. Not all of this information is available in structured records. For example since laterality of the operation is not directly found in a structured field, we will need to analyze unstructured fields to determine the fate of the index operation. Part (a) of this aim will focus on extracting laterality information for both index surgery and any subsequent reoperations from unstructured fields. This will tell us how long the joint prosthesis lasted before it needed to be reoperated on. Part (b) of the aim will require a more challenging analysis of unstructured data to determine which component of the joint replacement was problematic and removed. By completing this aim, we will generate reports on the individual component survivorship free of reoperation or removal for each of the implants used across the VA health care system.