Clinical Outcomes, Health Care Costs and Prognostic Factors for Total Knee Arthroplasty: A Multilevel Analysis of a National Cohort Study Using Administrative Claims Data

Abstract

Total knee arthroplasty (TKA) is one of the most frequent orthopaedic surgeries. The purpose of this study was to determine the 30-day postoperative mortality rate, total episode-of-care costs, and prognostic factors associated with these outcomes, for adult patients who underwent TKA in Colombia's contributory health care system. A retrospective cohort study of all adult patients enrolled in Colombia's contributory health system, who underwent TKA between January 1, 2012 and November 30, 2015 was performed. Thirty-day postoperative mortality rates, 30-day ICU admissions rates, 30-day hospital readmission rates, 1-year arthroplasty revision rates, and total episode-of-care costs were estimated. Multilevel, generalized linear models were generated, to determine the prognostic factors associated with outcomes presented. A total of 12,453 patients were included. The 30-day mortality rate was 0.13 per 100 surgeries and the ICU admissions rate at 30 days postoperative was 4.44 per 100 surgeries. The 30-day hospital readmission rate was 4.28 per 100 surgeries and the 1-year arthroplasty revision rate was 1.22 per 100 surgeries. The prognostic factors associated with mortality were age, Charlson Index, and type of insurer. The prognostic factors associated with hospital readmission were age category, Charlson Index, and geographic region; younger age and higher Charlson Index were found to be associated with a higher 1-year arthroplasty revision rate. The median of total episode-of-care costs was USD$ 6,190.07 (interquartile range: 2,299–7,282). The multivariate model found that age, the Charlson Index, the Atlantic region, and type of insurer were associated with the costs incurred by the health system. For patients undergoing TKA in Colombia, age, the Charlson Index, insurers, and geographic region are associated with mortality, ICU admissions, 30-day hospital readmissions, 1-year arthroplasty revisions, and total costs incurred by the health system.

Keywords

total knee arthroplasty - costs - developing country - Charlson Index - Likelihood rate

• References

• 1 Ethgen O, Bruyère O, Richy F, Dardennes C, Reginster JY. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systematic review of the literature. J Bone Joint Surg Am 2004; 86 (05) 963-974
• 2 Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The functional outcomes of total knee arthroplasty. J Bone Joint Surg Am 2005; 87 (08) 1719-1724
• 3 Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States—an alternative projection model. Osteoarthritis Cartilage 2017; 25 (11) 1797-1803
• 4 Koh IJ, Kim TK, Chang CB, Cho HJ, In Y. Trends in use of total knee arthroplasty in Korea from 2001 to 2010. Clin Orthop Relat Res 2013; 471 (05) 1441-1450
• 5 Leitner L, Türk S, Heidinger M. et al. Trends and economic impact of hip and knee arthroplasty in Central Europe: findings from the Austrian National Database. Sci Rep 2018; 8 (01) 4707
• 6 Pabinger C, Lothaller H, Geissler A. Utilization rates of knee-arthroplasty in OECD countries. Osteoarthritis Cartilage 2015; 23 (10) 1664-1673
• 7 Smith MC, Ben-Shlomo Y, Dieppe P. et al; National Joint Registry for England, Wales and Northern Ireland. Rates of hip and knee joint replacement amongst different ethnic groups in England: an analysis of National Joint Registry data. Osteoarthritis Cartilage 2017; 25 (04) 448-454
• 8 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (04) 780-785
• 9 Inacio MCS, Graves SE, Pratt NL, Roughead EE, Nemes S. Increase in total joint arthroplasty projected from 2014 to 2046 in Australia: a conservative local model with international implications. Clin Orthop Relat Res 2017; 475 (08) 2130-2137
• 10 Berstock JR, Beswick AD, López-López JA, Whitehouse MR, Blom AW. Mortality after total knee arthroplasty: a systematic review of incidence, temporal trends, and risk factors. J Bone Joint Surg Am 2018; 100 (12) 1064-1070
• 11 OECD. OECD Reviews of Health Systems: Colombia 2016. Paris: OECD Publishing; 2015
• 12 Lin KJ, Schneeweiss S. Considerations for the analysis of longitudinal electronic health records linked to claims data to study the effectiveness and safety of drugs. Clin Pharmacol Ther 2016; 100 (02) 147-159
• 13 Rassen JA, Bartels DB, Schneeweiss S, Patrick AR, Murk W. Measuring prevalence and incidence of chronic conditions in claims and electronic health record databases. Clin Epidemiol 2018; 11: 1-15
• 14 Buitrago G, Junca E, Eslava-Schmalbach J, Caycedo R, Pinillos P, Leal LC. Clinical outcomes and healthcare costs associated with laparoscopic appendectomy in a middle-income country with Universal Health Coverage. World J Surg 2019; 43 (01) 67-74
• 15 Bardey D, Buitrago G. Supplemental health insurance in the Colombian managed care system: adverse or advantageous selection?. J Health Econ 2017; 56: 317-329
• 16 El-Galaly A, Haldrup S, Pedersen AB, Kappel A, Jensen MU, Nielsen PT. Increased risk of early and medium-term revision after post-fracture total knee arthroplasty. Acta Orthop 2017; 88 (03) 263-268
• 17 Charlson M, Wells MT, Ullman R, King F, Shmukler C. The Charlson comorbidity index can be used prospectively to identify patients who will incur high future costs. PLoS One 2014; 9 (12) e112479
• 18 Sundararajan V, Henderson T, Perry C, Muggivan A, Quan H, Ghali WA. New ICD-10 version of the Charlson comorbidity index predicted in-hospital mortality. J Clin Epidemiol 2004; 57 (12) 1288-1294
• 19 Zhang JX, Iwashyna TJ, Christakis NA. The performance of different lookback periods and sources of information for Charlson comorbidity adjustment in Medicare claims. Med Care 1999; 37 (11) 1128-1139
• 20 Austin PC, Goel V, van Walraven C. An introduction to multilevel regression models. Can J Public Health 2001; 92 (02) 150-154
• 21 Meara JG, Leather AJ, Hagander L. et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015; 386 (9993): 569-624
• 22 Stundner O, Danninger T, Chiu YL. et al. Rheumatoid arthritis vs osteoarthritis in patients receiving total knee arthroplasty: perioperative outcomes. J Arthroplasty 2014; 29 (02) 308-313
• 23 Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996; 49 (12) 1373-1379
• 24 Glassou EN, Pedersen AB, Hansen TB. Is decreasing mortality in total hip and knee arthroplasty patients dependent on patients' comorbidity?. Acta Orthop 2017; 88 (03) 288-293
• 25 Higuera CA, Elsharkawy K, Klika AK, Brocone M, Barsoum WK. 2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clin Orthop Relat Res 2011; 469 (05) 1391-1400
• 26 Inacio MCS, Pratt NL, Roughead EE, Graves SE. Evaluation of three co-morbidity measures to predict mortality in patients undergoing total joint arthroplasty. Osteoarthritis Cartilage 2016; 24 (10) 1718-1726
• 27 Marya SK, Amit P, Singh C. Impact of Charlson indices and comorbid conditions on complication risk in bilateral simultaneous total knee arthroplasty. Knee 2016; 23 (06) 955-959
• 28 Shahi A, Bradbury TL, Guild III GN, Saleh UH, Ghanem E, Oliashirazi A. What are the incidence and risk factors of in-hospital mortality after venous thromboembolism events in total hip and knee arthroplasty patients?. Arthroplast Today 2018; 4 (03) 343-347
• 29 Barros PP. Cream-skimming, incentives for efficiency and payment system. J Health Econ 2003; 22 (03) 419-443
• 30 van de Ven WP, Beck K, Buchner F. et al. Risk adjustment and risk selection on the sickness fund insurance market in five European countries. Health Policy 2003; 65 (01) 75-98
• 31 AbdelSalam H, Restrepo C, Tarity TD, Sangster W, Parvizi J. Predictors of intensive care unit admission after total joint arthroplasty. J Arthroplasty 2012; 27 (05) 720-725
• 32 Courtney PM, Melnic CM, Gutsche J, Hume EL, Lee GC. Which patients need critical care intervention after total joint arthroplasty? A prospective study of factors associated with the need for intensive care following surgery. Bone Joint J 2015; 97-B (11) 1512-1518
• 33 Oviedo Baena AM, Moeschler SM, Smith HM, Duncan CM, Schroeder DR, Kopp SL. Perioperative comorbidities and complications among patients undergoing primary total knee arthroplasty: a retrospective analysis and prospective survey. J Clin Anesth 2015; 27 (07) 558-565
• 34 Courtney PM, Whitaker CM, Gutsche JT, Hume EL, Lee GC. Predictors of the need for critical care after total joint arthroplasty: an update of our institutional risk stratification model. J Arthroplasty 2014; 29 (07) 1350-1354
• 35 Klasan A, Dworschak P, Heyse TJ. et al. COPD as a risk factor of the complications in lower limb arthroplasty: a patient-matched study. Int J Chron Obstruct Pulmon Dis 2018; 13: 2495-2499
• 36 Patterson JT, Tillinghast K, Ward D. Dialysis dependence predicts complications, intensive care unit care, length of stay, and skilled nursing needs in elective primary total knee and hip arthroplasty. J Arthroplasty 2018; 33 (07) 2263-2267
• 37 Mont MA, Gwam C, Newman JM. et al. Outcomes of a newer-generation cementless total knee arthroplasty design in patients less than 50 years of age. Ann Transl Med 2017; 5 (Suppl. 03) S24
• 38 Niinimäki TT, Ohtonen P, Harila-Saari AH, Niinimäki RA. Young patients with hematologic and lymphatic malignancies have an increased risk of hip and knee arthroplasty. Acta Oncol 2016; 55 (05) 567-571
• 39 Ward MM. Risk of total knee arthroplasty in young and middle-aged adults with ankylosing spondylitis. Clin Rheumatol 2018; 37 (12) 3431-3433
• 40 Zhu W, He X, Xia Z, Zhai J, Weng X. Hemophilic arthropathy in a patient with multi-joint replacement: a case report and literature review. Medicine (Baltimore) 2018; 97 (29) e11163
• 41 Varacallo MA, Herzog L, Toossi N, Johanson NA. Ten-year trends and independent risk factors for unplanned readmission following elective total joint arthroplasty at a large urban academic hospital. J Arthroplasty 2017; 32 (06) 1739-1746
• 42 George J, Chughtai M, Khlopas A. et al. Readmission, reoperation, and complications: total hip vs total knee arthroplasty. J Arthroplasty 2018; 33 (03) 655-660
• 43 Lehtonen EJ, Hess MC, McGwin Jr G, Shah A, Godoy-Santos AL, Naranje S. Risk factors for early hospital readmission following total knee arthroplasty. Acta Ortop Bras 2018; 26 (05) 309-313
• 44 Ali AM, Loeffler MD, Aylin P, Bottle A. Predictors of 30-day readmission after total knee arthroplasty: analysis of 566,323 procedures in the United Kingdom. J Arthroplasty 2019; 34 (02) 242-248.e1
• 45 Cancienne JM, Werner BC, Browne JA. Complications of primary total knee arthroplasty among patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and osteoarthritis. J Am Acad Orthop Surg 2016; 24 (08) 567-574
• 46 Ponzio DY, Chiu Y-F, Salvatore A, Lee Y-Y, Lyman S, Windsor RE. An analysis of the influence of physical activity level on total knee arthroplasty expectations, satisfaction, and outcomes: increased revision in active patients at five to ten years. J Bone Joint Surg Am 2018; 100 (18) 1539-1548
• 47 Scott CEH, Turnbull GS, MacDonald D, Breusch SJ. Activity levels and return to work following total knee arthroplasty in patients under 65 years of age. Bone Joint J 2017; 99-B [phone]
• 48 Finkelstein A, Ji Y, Mahoney N, Skinner J. Mandatory medicare bundled payment program for lower extremity joint replacement and discharge to institutional postacute care: interim analysis of the first year of a 5-year randomized trial. JAMA 2018; 320 (09) 892-900
• 49 Ilfeld BM, Mariano ER, Williams BA, Woodard JN, Macario A. Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: a retrospective, case-control, cost-minimization analysis. Reg Anesth Pain Med 2007; 32 (01) 46-54
• 50 Navathe AS, Troxel AB, Liao JM. et al. Cost of joint replacement using bundled payment models. JAMA Intern Med 2017; 177 (02) 214-222
• 51 Padegimas EM, Verma K, Zmistowski B, Rothman RH, Purtill JJ, Howley M. Medicare reimbursement for total joint arthroplasty: the driving forces. J Bone Joint Surg Am 2016; 98 (12) 1007-1013
• 52 Weeks WB, Schoellkopf WJ, Ballard DJ, Kaplan GS, James B, Weinstein JN. Episode-of-care characteristics and costs for hip and knee replacement surgery in hospitals belonging to the high value healthcare collaborative compared with similar hospitals in the same health care markets. Med Care 2017; 55 (06) 583-589
• 53 Weeks WB, Schoellkopf WJ, Sorensen LS, Masica AL, Nesse RE, Weinstein JN. . The High Value Healthcare Collaborative. The high value healthcare collaborative: observational analyses of care episodes for hip and knee arthroplasty surgery. J Arthroplasty 2017; 32 (03) 702-708
• 54 Ariyaratnam R, Palmqvist CL, Hider P. et al. Toward a standard approach to measurement and reporting of perioperative mortality rate as a global indicator for surgery. Surgery 2015; 158 (01) 17-26
• 55 Ng-Kamstra JS, Arya S, Greenberg SLM. et al. Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Glob Health 2018; 3 (03) e000810