Download PDF
J Knee Surg 2022; 35(04): 384-392
DOI: 10.1055/s-0040-1715097
Original Article

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

Giancarlo Buitrago 
1   Department of Surgery, Clinical Research Institute, Universidad Nacional de Colombia, Bogota, DC, Colombia
2   Department of Surgery, Hospital Universitario Nacional de Colombia, Bogotá, DC, Colombia
,
Jorge R. Ortiz
2   Department of Surgery, Hospital Universitario Nacional de Colombia, Bogotá, DC, Colombia
3   Orthopedics and Traumatology Unit, Department of Surgery, Universidad Nacional de Colombia, Bogota, DC, Colombia
,
Felipe Camacho
2   Department of Surgery, Hospital Universitario Nacional de Colombia, Bogotá, DC, Colombia
3   Orthopedics and Traumatology Unit, Department of Surgery, Universidad Nacional de Colombia, Bogota, DC, Colombia
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

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


Publication History

Received: 25 February 2020

Accepted: 25 June 2020

Article published online:
24 August 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 6 Pabinger C, Lothaller H, Geissler A. Utilization rates of knee-arthroplasty in OECD countries. Osteoarthritis Cartilage 2015; 23 (10) 1664-1673
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 11 OECD. OECD Reviews of Health Systems: Colombia 2016. Paris: OECD Publishing; 2015
    Google Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 20 Austin PC, Goel V, van Walraven C. An introduction to multilevel regression models. Can J Public Health 2001; 92 (02) 150-154
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 29 Barros PP. Cream-skimming, incentives for efficiency and payment system. J Health Econ 2003; 22 (03) 419-443
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 39 Ward MM. Risk of total knee arthroplasty in young and middle-aged adults with ankylosing spondylitis. Clin Rheumatol 2018; 37 (12) 3431-3433
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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 (08) 1037-1046
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar