Rates Of Knee Replacement Research Articles

Surgical Outcomes and Analysis of Quality of Life Following Knee Arthroplasty in Very Elderly Patients.

In an aging population, the incidence of severe knee osteoarthritis in very elderly patients increases, leading to functional impairment and loss of independence. Knee replacement could be an effective treatment but is often denied due to fear of increased complication rate with advanced age. The objective of this study was to investigate complication rate, mortality, clinical outcome, and quality-adjusted life years (QALYs) of primary knee replacement in very elderly patients, defined as 83 years or older. Medical records of 85 cases, receiving a primary total (total knee arthroplasty [TKA]) or unicompartmental (unicompartmental knee arthroplasty [UKA]) knee replacement, aged 83 years or older at the time of surgery, were retrospectively reviewed for surgical and medical complications as well as survivorship. Functional outcome was obtained by Oxford Knee Score (OKS) and QALY. At a mean follow-up of 21 months (TKA) and 24 months (UKA), surgical and medical complication rates were 9.7 and 8.1% for TKA and 4.3 and 4.3% for UKA, respectively. One-year survival rate was 98.4% in TKA and 98.8% in UKA, the 5-year survival rate was 83.1 and 86.6%, respectively. OKS improved from 19 to 41 points in TKA and 23 to 40 points in UKA. Mean QALYs were 4.1 years for TKA and 3.9 years for UKA. TKA and UKA are safe and reliable surgical procedures in treating end-stage osteoarthritis in very elderly patients. Patients might benefit from improved pain, function, and quality of life. The mortality rate and overall complication rate were low, although slightly higher than reported in cohorts with younger patients. If the patient is suitable, UKA might be preferred over TKA, as the complication rate was significantly lower. Patients should not be excluded from knee replacement based on their age alone, but careful patient selection, peri- and postoperative optimization, and awareness for complications are quintessential for successful treatment.

Hip and Knee Replacements in Ghana: A 2-Year Prospective Assessment of Outcomes

Objective: Our objective was to assess the outcomes of hip and knee replacements among patients at the Komfo Anokye Teaching Hospital in Ghana.Methodology: We recruited consenting patients who underwent a hip or knee replacement at the KATH over a 3-year period and followed up each study participant for 2 years. Prosthetic joint function was evaluated at 2 years following joint replacement. Complications of surgery were recorded for each patient during the follow-up period.Results: A total of 87 hip and knee replacements were performed in 78 patients over the 3-year period. Of the 78 patients enrolled in the study, 67.9% (53) were females and 32.1% (25) were males. Most, 47.2% (37), of the patients were aged between 61 and 80 years, with those less than 40 years constituting 7.7%. At 2 years follow-up, good to excellent outcome was reported in 95.5% THA, 91.2% hiphemiarthroplasty, and 90% TKA patients. The satisfaction rates were 95.5% THA, 97.0% hip hemiarthroplasty and 90% TKA participants.Conclusion: Women have a higher hip or knee replacement rate (67.9%) than men (32.1%) and the rate of hip or knee replacement increases with age for both men and women. Osteonecrosis of the femoral head is the most common indication for total hip arthroplasty in patients younger than 60 years. The presence of diabetes mellitus and sickle cell disease predicts less favourable patient reported outcomes following a hip or knee replacement. Arthroplasty of the knee or hip provides pain relief and improvement in function with a low complication rate and high patient satisfaction rate.

Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias

Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare's mandatory bundled payment reform-the Comprehensive Care for Joint Replacement (CJR) model-was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Implementation of the CJR model in 2016. Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, -0.13 to -0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, -0.12 to -0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, -0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: -0.03, 95% CI, -0.09 to 0.02; P = .27). In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.

Intervention strategies on knee pain to reduce the risk of a knee replacement

Purpose: While the development of new osteoarthritis (OA) treatments target pain improvement, it is unclear how much pain reduction is needed to decrease rates of knee replacement (KR). This is, in part, because trials are not sustained long enough to capture effects on KR. Quantifying the long-term effect of pain reduction on KR rates is hampered by biases induced by informative censoring due to loss to follow-up or death, time-varying nature of pain interventions, and the influence of time-dependent confounding factors and evolving patient comorbidities on both pain interventions and receiving a KR.

Association of Medicare Mandatory Bundled Payment Program With the Receipt of Elective Hip and Knee Replacement in White, Black, and Hispanic Beneficiaries

The Comprehensive Care for Joint Replacement (CJR) model was designed to reduce the cost and improve the quality of hip or knee replacement among Medicare beneficiaries. Yet whether this model may exacerbate existing racial/ethnic disparities in access to the surgery is unclear. To examine the association of the CJR model with the receipt of elective hip or knee replacement across White, Black, and Hispanic Medicare beneficiaries. Retrospective cohort study of Medicare claims from 2013 through 2017 among White, Black, and Hispanic Medicare beneficiaries undergoing elective joint replacement in 65 treatment (selected for CJR participation) and 101 control metropolitan statistical areas (MSAs). Starting in April 2016, hospitals in the treatment MSAs were required to participate in the CJR model and were accountable for expenditures occurring during patients' hospitalization for hip or knee replacement and 90 days after the hospital discharge. Beneficiary-level elective hip or knee replacement receipt in a given year. Among 17 243 304 patients, 9 839 996 (57%) were women; 2 107 425 (12%) were age 85 years or older. Of the final sample, 14 632 434 (85%) were White beneficiaries, 1 518 629 (9%) were Black beneficiaries, and 1 092 241 (6%) were Hispanic beneficiaries. The CJR model was associated with an increase of 1.6 elective hip or knee replacements per 1000 beneficiary-years for Hispanic beneficiaries (95% CI, 0.06-2.05) and a decrease of 0.64 replacements for Black beneficiaries (95% CI, -1.25 to -0.02). No evidence was found for any changes for White beneficiaries per 1000 beneficiary-years (0.04 replacements, 95% CI, -0.35 to 0.42 replacements). The Black-White difference in the rate of elective hip or knee replacement per 1000 beneficiary-years further widened by 0.68 replacements (-0.68, 95% CI, -1.20 to -0.15). In this cohort study, the CJR model was associated with increased receipt of elective hip or knee replacement among Hispanic beneficiaries, decreased receipt among Black beneficiaries, and no change in receipt among White beneficiaries. The decreased receipt of elective hip or knee replacement among Black beneficiaries may suggest that value-based payment models, including the CJR model, could be monitored for unintended consequences. However, the lack of similar findings among Hispanic beneficiaries suggests that payment models may have differential impacts across racial/ethnic groups.

Persistent Racial Disparities in Joint Replacement Use: Commentary on an article by Caroline P. Thirukumaran, MBBS, MHA, PhD, et al.: "Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017".

Persistent Racial Disparities in Joint Replacement Use: Commentary on an article by Caroline P. Thirukumaran, MBBS, MHA, PhD, et al.: "Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017".

Geographic Variation and Disparities in Total Joint Replacement Use for Medicare Beneficiaries: 2009 to 2017.

Little is known about how the geographic variation and disparities in use of elective primary total hip and knee replacements for Medicare beneficiaries have evolved in recent years. The study objectives are to determine these variations and disparities, whether Black Medicare beneficiaries have continued to undergo fewer total hip replacements and total knee replacements across regions, and whether disparities affected all Black beneficiaries or mainly affected socioeconomically disadvantaged Black beneficiaries. We used 2009 to 2017 Medicare enrollment and claims data to examine Hospital Referral Region (HRR)-level variation and disparities by race (non-Hispanic White and Black) and socioeconomic status (Medicare-only and dual eligibility for both Medicare and Medicaid). The outcomes were HRR-level age and sex-standardized total hip replacement and total knee replacement utilization rates for White Medicare-only beneficiaries, White dual-eligible beneficiaries, Black Medicare-only beneficiaries, and Black dual-eligible beneficiaries, and the differences in rates between these groups as a representation of disparities. The key exposure variables were race-socioeconomic group and year. We constructed multilevel mixed-effects linear regression models to estimate trends in total hip replacement and total knee replacement rates and to examine whether rates were lower in HRRs with high percentages of Black beneficiaries or dual-eligible beneficiaries. The study included 924,844 total hip replacements and 2,075,968 total knee replacements. In 2017, the mean HRR-level total hip replacement rate was 4.64 surgical procedures per 1,000 beneficiaries, and the mean HRR-level total knee replacement rate was 9.66 surgical procedures per 1,000 beneficiaries, with a threefold variation across HRRs. In 2017, the total hip replacement rate was 32% higher for White Medicare-only beneficiaries and 48% higher for Black Medicare-only beneficiaries than in 2009 (p < 0.001). However, because the surgical rates for White and Black dual-eligible beneficiaries remained unchanged over the study period, the 2017 Medicare-only and dual-eligible disparity for White beneficiaries increased by 0.75 surgical procedures per 1,000 from 2009 (40.98% increase; p = 0.03), and the disparity for Black beneficiaries by 1.13 surgical procedures per 1,000 beneficiaries (297.37% increase; p < 0.001). The total knee replacement disparities remained unchanged. Notably, the rates for White dual-eligible beneficiaries were significantly lower than those for Black Medicare-only beneficiaries (p < 0.001 for both total hip replacements and total knee replacements), and fewer surgical procedures were conducted in HRRs with a higher density of Black or dual-eligible beneficiaries. Although the total hip replacement use for Medicare-only beneficiaries of both races increased, disparities for White and Black dual-eligible beneficiaries (compared with their Medicare-only counterparts) are increasing. Efforts to improve equity must identify and address both racial and socioeconomic barriers and focus on regions with high concentrations of disadvantaged beneficiaries. Although total hip replacements and total knee replacements are highly successful surgical procedures for end-stage osteoarthritis, our findings show that, as recently as 2017, Black beneficiaries and those dual eligible for Medicaid (a proxy for socioeconomic status) are less likely to undergo these surgical procedures and that there is profound geographic variation in the use of these surgical procedures. This evidence is essential for the design and implementation of disparity-reduction strategies focused on patients, providers, and geographic areas that can potentially improve the equity in joint replacement care.

Increases in the rates of primary and revision knee replacement are reducing: a 15-year registry study across 3 continents

Background and purpose — Rates of knee replacement (KR) are increasing worldwide. Based on population and practice changes, there are forecasts of a further exponential increase in primary knee replacement through to 2030, and a corresponding increase in revision knee replacement. We used registry data to document changes in KR over the past 15 years, comparing practice changes across Sweden, Australia, and the United States. This may improve accuracy of future predictions.Patients and methods — Aggregated data from the Swedish Knee Arthroplasty Register (SKAR), the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), and the Kaiser Permanente Joint Replacement Registry (KPJRR) were used to compare surgical volume of primary and revision KR from 2003 to 2017. Incidence was calculated using population census statistics from Statistics Sweden and the Australian Bureau of Statistics, as well as the yearly active membership numbers from Kaiser Permanente. Further analysis of KR by age < 65 and ≥ 65 years was carried out.Results — All registries recorded an increase in primary and revision KR, with a greater increase seen in the KPJRR. The rate of increase slowed during the study period. In Sweden and Australia, there was a smaller increase in revision surgery compared with primary procedures. There was consistency in the mean age at surgery, with a steady small decrease in the proportion of women having primary KR. The incidence of KR in the younger age group remained low in all 3 registries, but the proportional increases were greater than those seen in the ≥ 65 years of age group.Interpretation — There has been a generalized deceleration in the rate of increase of primary and revision KR. While there are regional differences in KR incidence, and rates of change, the rate of increase does not seem to be as great as previously predicted.

New surgical instrumentation reduces the revision rate of unicompartmental knee replacement: A propensity score matched comparison of 15,906 knees from the National Joint Registry

BackgroundUnicompartmental knee replacement (UKR) offers advantages over total knee replacement but has higher revision rates. New instrumentation known as Microplasty was introduced to address this. The aim was to compare the revision rates of UKRs implanted with Microplasty and traditional instrumentation (Non-Microplasty). MethodsNational Joint Registry (NJR) data was used to propensity score match 15,906 UKRs (7953 Microplasty and 7953 Non-Microplasty) for important patient, implant and surgical factors. Implant survival rates were determined using the Kaplan–Meier method and compared using Cox regression models in a multilevel model. ResultsThe five-year implant survival for Microplasty and Non-Microplasty UKRs were 96.7% (95% CI: 96.0%–97.2%) and 94.5% (CI: 93.8–95.1%), respectively. The revision rate for Microplasty UKR was significantly lower than that of Non-Microplasty UKRs (hazard ratio [HR] = 0.77, p = 0.008). Compared with Non-Microplasty UKRs, the revision rate of Microplasty UKRs implanted during the year after the introduction of Microplasty was lower, but the difference was not significant (HR: 0.86, CI: 0.67–1.10, p = 0.23), whereas for those implanted more than a year after introduction, the difference was significant (HR: 0.69, CI: 0.54–0.89, p = 0.004). ConclusionThe use of Microplasty instrumentation has resulted in an improved five-year UKR survival. Microplasty UKR implanted during the first year after introduction had a small, non-significant decrease in revision rate. As the revision rate did not increase, this suggests that there is no adverse learning curve effect. Microplasty UKRs implanted after this transition period had a revision rate 31% lower than the Non-Microplasty group. Level of evidenceII.

Most unicompartmental knee replacement revisions could be avoided: a radiographic evaluation of revised Oxford knees in the National Joint Registry

PurposeThe purpose of this study was to understand why the revision rate of unicompartmental knee replacement (UKR) in the National Joint Registry (NJR) is so high. Using radiographs, the appropriateness of patient selection for primary surgery, surgical technique, and indications for revision were determined. In addition, the alignment of the radiographs was assessed.MethodsOxford UKR registered with the NJR between 2006 and 2010 and subsequently revised were identified by the NJR. A blinded review was undertaken of pre-primary, post-primary, and pre-revision anteroposterior and lateral radiographs of a sample of 107 cases from multiple centres.ResultsThe recommended indications were satisfied in 70%, with 29% not demonstrating bone-on-bone arthritis. Major technical errors, likely leading to revision, were seen in 6%. Pre-revision radiographs were malaligned and, therefore, difficult to interpret in 53%. No reason for revision was seen in 67%. Reasons for revision included lateral compartment arthritis (10%), tibial loosening (7%), bearing dislocation (7%), infection (6%), femoral loosening (3%), and peri-prosthetic fracture (2%, one femoral, one tibial).ConclusionsOnly 20% of the revised UKR were implanted for the recommended indications, using appropriate surgical technique and had a mechanical problem necessitating revision. One-third of primary surgeries were undertaken in patients with early arthritis, which is contraindicated. Two-thirds were presumably revised for unexplained pain, which is not advised as it tends not to help the pain. This study suggests that variable and inappropriate indications for primary and revision surgery are responsible for the high rates of revision seen in registries.Level of evidenceIII, Therapeutic study.

Geographical variation in musculoskeletal surgical care in public hospitals in Ireland: a repeated cross-sectional study

ObjectiveTo examine the extent of geographical variation across musculoskeletal surgical procedures and associated factors in Ireland.DesignRepeated cross-sectional study.Setting36 public hospitals in Ireland.ParticipantsAdult admissions for hip fracture, hip and knee replacement,...

Meniscus Root Repair vs Meniscectomy or Nonoperative Management to Prevent Knee Osteoarthritis After Medial Meniscus Root Tears: Clinical and Economic Effectiveness

Background: Medial meniscus root tears are a common knee injury and can lead to accelerated osteoarthritis, which might ultimately result in a total knee replacement. Purpose: To compare meniscus repair, meniscectomy, and nonoperative treatment approaches among middle-aged patients in terms of osteoarthritis development, total knee replacement rates (clinical effectiveness), and cost-effectiveness. Study Design: Meta-analysis and cost-effectiveness analysis. Methods: A systematic literature search was conducted. Progression to osteoarthritis was pooled and meta-analyzed. A Markov model projected strategy-specific costs and disutilities in a cohort of 55-year-old patients presenting with a meniscus root tear without osteoarthritis at baseline. Failure rates of repair and meniscectomy procedures and disutilities associated with osteoarthritis, total knee replacement, and revision total knee replacement were accounted for. Utilities, costs, and event rates were based on literature and public databases. Analyses considered a time frame between 5 years and lifetime and explored the effects of parameter uncertainty. Results: Over 10 years, meniscus repair, meniscectomy, and nonoperative treatment led to 53.0%, 99.3%, and 95.1% rates of osteoarthritis and 33.5%, 51.5%, and 45.5% rates of total knee replacement, respectively. Meta-analysis confirmed lower osteoarthritis and total knee replacement rates for meniscus repair versus meniscectomy and nonoperative treatment. Discounted 10-year costs were $22,590 for meniscus repair, as opposed to $31,528 and $25,006 for meniscectomy and nonoperative treatment, respectively; projected quality-adjusted life years were 6.892, 6.533, and 6.693, respectively, yielding meniscus repair to be an economically dominant strategy. Repair was either cost-effective or dominant when compared with meniscectomy and nonoperative treatment across a broad range of assumptions starting from 5 years after surgery. Conclusion: Repair of medial meniscus root tears, as compared with total meniscectomy and nonsurgical treatment, leads to less osteoarthritis and is a cost-saving intervention. While small confirmatory randomized clinical head-to-head trials are warranted, the presented evidence seems to point relatively clearly toward adopting meniscus repair as the preferred initial intervention for medial meniscus root tears.

Association between NICE guidance on biologic therapies with rates of hip and knee replacement among rheumatoid arthritis patients in England and Wales: An interrupted time-series analysis.

To estimate the impact of NICE approval of tumor necrosis factor inhibitor (TNFi) therapies on the incidence of total hip replacement (THR) and total knee replacement (TKR) among rheumatoid arthritis (RA) patients in England and Wales. Primary care data [Clinical Practice Research Datalink (CPRD)] for the study period (1995-2014) were used to identify incident adult RA patients. The age and sex-standardised 5-year incidence of THR and TKR was calculated separately for RA patients diagnosed in each six-months between 1995-2009. We took a natural experimental approach, using segmented linear regression to estimate changes in level and trend following the publication of NICE TA 36 in March 2002, incorporating a 1-year lag. Regression coefficients were used to calculate average change in rates, adjusted for prior level and trend. We identified 17,505 incident RA patients of whom 465 and 650 underwent THR and TKR surgery, respectively. The modeled average incidence of THR and TKR over the biologic-era was 6.57/1000 person years (PYs) and 8.51/1000 PYs, respectively, with projected (had pre-NICE TA 36 level and trend continued uninterrupted) figures of 5.63/1000 PYs and 12.92 PYs, respectively. NICE guidance was associated with a significant average decrease in TKR incidence of -4.41/1000 PYs (95% C.I. -6.88 to -1.94), equating to a relative 34% reduction. Overall, no effect was seen on THR rates. Among incident RA patients in England and Wales, NICE guidance on TNFi therapies for RA management was temporally associated with reduced rates of TKR but not THR.

Racial/ethnic variations in knee and hip elective joint replacement in the UK

Racial/ethnic variations in knee and hip elective joint replacement in the UK

Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data.

Despite a health care system that is free at the point of delivery, ethnic minorities may not always get care equitable to that of White patients in England. We examined whether ethnic differences exist in joint replacement rates and surgical practice in England. 373,613 hip and 428,936 knee National Joint Registry (NJR) primary replacement patients had coded ethnicity in Hospital Episode Statistics (HES). Age and gender adjusted observed/expected ratios of hip and knee replacements amongst ethnic groups were compared using indirect standardisation. Associations between ethnic group and type of procedure were explored and effects of demographic, clinical and hospital-related factors examined using multivariable logistic regression. Adjusted standardised observed/expected ratios were substantially lower in Blacks and Asians than Whites for hip replacement (Blacks 0.33 [95% CI, 0.31-0.35], Asians 0.20 [CI, 0.19-0.21]) and knee replacement (Blacks 0.64 [CI, 0.61-0.67], Asians 0.86 % [CI, 0.84-0.88]). Blacks were more likely to receive uncemented hip replacements (Blacks 52%, Whites 37%, Asians 44%; P<0.001). Black men and women aged <70 years were less likely to receive unicondylar or patellofemoral knee replacements than Whites (men 10% vs 15%, P=0.001; women 6% vs 14%, P<0.001). After adjustment for demographic, clinical and hospital-related factors, Blacks were more likely to receive uncemented hip replacement (OR 1.43 [CI, 1.11-1.84]). In England, hip and knee replacement rates and prosthesis type given differ amongst ethnic groups. Whether these reflect differences in clinical need or differential access to treatment requires urgent investigation.

Geographic variation in selected hospital procedures and services in the Israeli health care system

BackgroundMedical practice variation refers to differences in health service utilization among regions in the same country. It is used as a tool for studying health inequities.In 2011, the OECD launched a Medical Practice Variation Project which examines regional differences within countries and explores the sources of the inter-regional differences. The aim of this study is to examine the patterns and trends in geographic variation for selected health services in Israel.MethodsThe analysis is based on data from the National Hospital Discharges Database (NHDD) of the Israeli Ministry of Health. The eight procedures and services studied were: medical admissions (i.e. admissions without surgical procedures); hip fractures; caesarian sections; diagnostic cardiac catheterization; cardiac angioplasty (PTCA); cardiac bypass surgery (CABG); hysterectomy; and knee replacement surgery. The data are presented for the 7 districts in Israel, determined by address of residence.ResultsThe procedures and services with the lowest variation across the seven districts were medical admissions (RR between regions-maximum/minimum 1.3) and hip fractures (RR 1.44), while the one with the highest variation was CABG (RR 1.98). The Israeli periphery, and the northern district in particular, had higher rates of medical admissions, knee replacement and cardiac procedures. When studying the trend over time, we found a decrease in use rates for most procedures, such as coronary bypass (R. 04) and CABG (R 0.8). Medical admissions decreased by 8%, with the highest decline (16%) observed in the central districts.ConclusionsThis study provides Israeli policy makers with information which is vital for the strategic planning of service development, such as strengthening preventive medical services in the community, reducing cardiovascular risk factors in the periphery and expanding the national publication of clinical quality scores.

The rate of joint replacement in osteoarthritis depends on the patient’s socioeconomic status

Background and purpose — Assessment of potential disparities in access to care is a vital part of achieving equity in health and healthcare. We have therefore studied the effect of socioeconomic status (SES) on the rates of knee and hip replacement due to osteoarthritis.Methods — This was a cohort study in Skåne, Sweden. We included all residents aged ≥ 35 years with consultations between 2004 and 2013 for hip or knee osteoarthritis. We retrieved individual information on income, education, and occupation and evaluated the rates of knee and hip replacement according to SES, with adjustment for age and sex. Professionals, legislators, senior officials, and managers, and individuals with the longest education, served as the reference group.Results — We followed 50,498 knee osteoarthritis patients (59% women) and 20,882 hip osteoarthritis patients (58% women). The mutually adjusted rate of knee replacement was lower in those with an elementary occupation (hazard ratio (HR) = 0.81, 95% CI: 0.72–0.92), in craft workers and those with related trades (HR = 0.88, CI: 0.79–0.98), and in skilled agricultural/fishery workers (HR = 0.83, CI: 0.72–0.96), but higher in the 2 least educated groups (HR = 1.2 in both). The rate of hip replacement was lower in those with an elementary occupation (HR = 0.77, 95% CI: 0.68–0.87), in plant and machine operators/assemblers (HR = 0.83, CI: 0.75–0.93), and service workers/shop assistants (HR = 0.88, CI: 0.80–0.96). The rate of hip replacement was higher in the highest income group (HR = 1.1, 95% CI: 1.0–1.2).Interpretation — There was a lower rate of joint replacement in osteoarthritis patients working in professions often associated with lower socioeconomic status, suggesting inequity in access to care. However, the results are not unanimous, as the rate of knee replacement was higher in the least educated groups.

Electronic health databases for epidemiological research on joint replacements: considerations when making cross-national comparisons

PurposeThe purpose of this study was to examine the rate of primary knee, hip, or shoulder replacement among persons with osteoarthritis (OA) of the knee by gender and age comparing two nations in similar periods using electronic health records, but with different health-care systems. MethodsTwo electronic health care databases of anonymized information were used to construct cohorts of adults with OA of the knee from the United Kingdom (UK) and the United States. Patients were required to have activity in the database at least 6 months before the first diagnosis of knee OA (“index diagnosis”) in the study period to ensure that the patient samples were eligible for medical evaluation. The outcomes (numerator) measured were primary knee, hip, or shoulder replacement or the composite of primary knee, hip, or shoulder replacement. The denominator was the person-time at risk computed from time from the date of the index diagnosis to the date of each outcome separately or to the end of the database period if no outcome was documented. ResultsThere were 93,146 subjects in the UK and 1,468,217 in the United States who were aged 18+ years and met the study eligibility criteria. The composite joint replacement rate (hip, knee, or shoulder) ranged from 11.89 per 100 person-years (PY) in the Unites States to 4.13 per 100 PY in the UK Primary knee replacements rates ranged from 10.38 per 100 PY in the Unites States to 3.40 per 100 PY in the UK and occurred at a somewhat higher rate in males than females in both countries. Both primary hip and shoulder replacement rates were higher in the Unites States than in the UK (hip: 1.19 per 100 PY and 0.76 per 100 PY; shoulder: 0.19 per 100 PY and 0.03 per 100 PY, respectively). The median time to a primary hip or knee replacement in the UK was approximately twice as long as in the Unites States. ConclusionsKnee replacements are not an uncommon event in persons with knee OA occurring throughout the adult life span, with the rate steeply rising in both sexes until aged 75 years. Although the pattern of the age-specific joint replacement rates was similar between sexes, the magnitude of the rates was markedly lower in the UK.

Cost‐Effectiveness of Total Knee Replacement: A Prospective Cohort Study

Total knee replacement (TKR) rates have significantly increased in the past decade. While the procedure itself might be costly, the cost-effectiveness and potential offset costs from patient and societal benefits have not been clearly established. The objective of this study was to perform an economic evaluation of TKR in patients with knee osteoarthritis (OA). We conducted a 6-month prospective cohort study of 212 patients with knee OA who underwent TKR at a single hospital in Houston, Texas. We included patient-level data from hospital billing databases and the patients' self-reported direct and indirect costs. The clinical outcome measure was pain and function measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire; we used the minimum clinically important difference (MCID; ≥20-point change) and the WOMAC 20% (WOMAC20), 50% (WOMAC50), and 70% (WOMAC70) relative improvement criteria. Incremental cost-effectiveness ratios were estimated using direct and indirect costs and WOMAC improvement. A societal perspective was used and multiple sensitivity analyses were performed to assess the robustness of the principal analysis. The total incremental cost per TKR was $20,133. The incremental cost-effectiveness ratios (ICERs) for improvement at 6 months were $33,345, $25,255, $35,274, and $56,908 for the MCID, WOMAC20, WOMAC50, and WOMAC70, respectively. Best- and worst-case scenario sensitivity analyses did not have a significant impact on the ICERs. Patient time lost was the most influential variable in the multiway sensitivity analysis. TKR is an effective intervention in reducing pain and improving functional status among patients with knee OA and is cost effective at both low and high levels of improvement.

(487) Knee and hip replacements: prevalence and healthcare utilization and costs pre- and post-surgery for Medicare Advantage members

During the last decade, knee and hip replacement rates in the US rose dramatically. While joint replacement may result in improvement in pain and functionality, the rise in prevalence and associated high cost call for better selecting appropriate candidates to ensure successful outcomes. This study examined the prevalence of knee and hip replacements in Humana’s Medicare Advantage population, 2007–2012. Knee and hip replacement cohorts were also followed longitudinally to determine changes in osteoarthritis (OA)–related healthcare utilization and costs from 180 days pre-surgery until 360 days post-surgery, relative to members with OA and steroid or viscosupplementation injection(s) into the knee or hip. The rate of knee replacements rose from 6.0 to 6.6 and the rate of hip replacements rose from 4.6 to 4.8 per 1,000 members enrolled during 2007-2012. Demographic characteristics were age: 70.7 years for knee, 71.7 years for hip, and 71.1 years for comparison cohort (P<.0001); RxRisk-V comorbidity score: 4.7 knee, 4.4 hip, 4.8 comparison cohort (P<.0001). Mean pre-index healthcare costs were $610 knee, $523 hip, and $717 comparison cohort (P<.0001). A difference-in-difference (DID) analysis comparing 180 days pre-index to days 181-360 post-index indicated that the decrease in OA-related costs post-surgery was greater in members with joint replacements than the comparison cohort (coefficient for knee replacement*time: -0.165; hip replacement*time: -0.438; P<.001 for both). A subgroup of knee replacement members diagnosed with depression had higher healthcare costs (coefficient: 0.167, P=0.05), implying need to address comorbid conditions and relationship to joint pain. Rates of venous thromboembolic events were greater post-surgery than pre-surgery, and only 55.9% of knee replacement and 56.6% of hip replacement cohorts received anti-coagulants post-surgery. While the overall DID results implied better outcomes among members with joint replacements, their high surgical costs may warrant the provider and patient explore all options prior to undergoing surgery. This study was sponsored by Humana Inc. and Pfizer Inc. During the last decade, knee and hip replacement rates in the US rose dramatically. While joint replacement may result in improvement in pain and functionality, the rise in prevalence and associated high cost call for better selecting appropriate candidates to ensure successful outcomes. This study examined the prevalence of knee and hip replacements in Humana’s Medicare Advantage population, 2007–2012. Knee and hip replacement cohorts were also followed longitudinally to determine changes in osteoarthritis (OA)–related healthcare utilization and costs from 180 days pre-surgery until 360 days post-surgery, relative to members with OA and steroid or viscosupplementation injection(s) into the knee or hip. The rate of knee replacements rose from 6.0 to 6.6 and the rate of hip replacements rose from 4.6 to 4.8 per 1,000 members enrolled during 2007-2012. Demographic characteristics were age: 70.7 years for knee, 71.7 years for hip, and 71.1 years for comparison cohort (P<.0001); RxRisk-V comorbidity score: 4.7 knee, 4.4 hip, 4.8 comparison cohort (P<.0001). Mean pre-index healthcare costs were $610 knee, $523 hip, and $717 comparison cohort (P<.0001). A difference-in-difference (DID) analysis comparing 180 days pre-index to days 181-360 post-index indicated that the decrease in OA-related costs post-surgery was greater in members with joint replacements than the comparison cohort (coefficient for knee replacement*time: -0.165; hip replacement*time: -0.438; P<.001 for both). A subgroup of knee replacement members diagnosed with depression had higher healthcare costs (coefficient: 0.167, P=0.05), implying need to address comorbid conditions and relationship to joint pain. Rates of venous thromboembolic events were greater post-surgery than pre-surgery, and only 55.9% of knee replacement and 56.6% of hip replacement cohorts received anti-coagulants post-surgery. While the overall DID results implied better outcomes among members with joint replacements, their high surgical costs may warrant the provider and patient explore all options prior to undergoing surgery. This study was sponsored by Humana Inc. and Pfizer Inc.