Tad Funahashi, MD Chair, Kaiser Permanente Implant Registries

Evidence Based Medicine Driven by Registry Findings

May 20, 2016, California Orthopaedic Association

Disclosures

None

Integrated health care delivery system

32 hospitals and medical centers

9 million members

140,000+ employees

7 regions serving 8 states and D.C.

12,000+ physicians

Nation’s largest nonprofit health plan

Hawaii

Northern California

Southern California

Washington

Georgia

Oregon

Colorado

Mid-Atlantic 430+ medical offices

3 | © Kaiser Permanente 2010-2011. All Rights Reserved.May 16, 2016

About Kaiser Permanente

Kaiser Permanente Registries Developed in 2001

Modeled after Swedish Hip Register

Methods

– Standardized documentation

– Leveraging existing EHR data

Patient information

Procedures/diagnoses

Implant data and clinical attributes library

Labs

Medications

– Adverse event electronic screening methods

– Stringent quality control processes

– Chart review validation of outcomes

4

NATIONAL IMPLANT REGISTRIES

6

Orthopedic

Registries

Total Joint 250,000

Hip Fracture 28,000

ACLR 30,300

Spine 19,500

Shoulder 9,400

Cardiac/Vascular

ICDS 30,900

Pacemakers 69,000

Leads 140,120

Heart Valve 24,500

EVAR 3,260

KP Tools for Enhancing Quality & Patient care

Medical center reports

Individualized surgeon profiles

Quarterly quality reports

Patient risk calculators

Outlier implant reports

Recall/advisory identification/tracking

Newsletters/meetings/conferences

Publications

7

Identification of Variation

Patient

• Individual risk

• Subgroups at risk

Implant

• Outliers (best/worst)

Surgeon

• Individual performance

• Clinical best practices

Medical Center

• Medical center performance

Outlier Implants

9

10

Age and Gender Adjusted Hazard Ratios by Time Period

Time Period HR 95% LB 95% UB P

<3 months 1.44 1.07 1.95 0.017

3 months-1.5 years 1.47 0.96 2.25 0.075

>1.5 years 1.08 0.34 3.40 0.894

Outlier Implants

Medical Center Variation

11

Method:

– Observed vs expected risk adjusted revision rate for THR and TKR

– Limited to facilities performing 500 total joints per year

Medical Centers Identified

– 4 facilities (out of 35) were identified as outliers (2 in SCAL)

Facility Review

– Independent, outside orthopedic surgeons invited to review (2 for each site)

– Radiologic and chart review of ALL revisions was done

Results Presentation & Intervention

– All total joint surgeons present for presentation

Medical Center Variation and Improvement

12

Risk Factors for Revisions and Complications

13 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.May 16, 2016

Identification of Clinical Best Practices

14 May 16, 2016

Pulmonary Embolism Prophylaxis in More Than

30, 000 Total Knee Arthroplasty Patients:

Is There a Best Choice?

Monti Khatod, MD,* Maria C.S. Inacio, MS, Stefano A., MD,

and Elizabeth W. Paxton, MA

Acta Orthopaedica

2014; 85 (1): x–x

Can total knee arthroplasty be safely performed in patients with chronic renal disease?

An evaluation of perioperative morbidity in 2,686 procedures from a Total Joint Replacement Registry

Alexander Miric, Maria CS Inacio, and Robert S Namba

Device Comparative Effectiveness

15 May 16, 2016

Acta Orthopaedica

2013; 84 (2): x–x

Alternative bearings in total knee arthroplasty: risk of early

revision compared to traditional bearings An analysis of 62,177 primary

cases Maria C S Inacio, Guy Cafri, Elizabeth W Paxton, Steven M Kurts, and Robert

S Namba

ORIGINAL ARTICLE

Evaluation of total hip arthroplasty devices using a total

joint replacement registryElizabeth W. Paxton1*, Christopher F. Ake1, Maria C.S. Inacio1, Monti

Khatod2, Danica Marinac-Dabic3 and Art Sedrakyan3,4

Changes in Practice

16

Registry findings:Hip resurfacing had a higher risk of revision than THA (HR=3.51,

2.02-6.10, p<.001

0

100

200

300

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

Reduction in Hip Resurfacing Cases

Percent

Use of GSF High-Flex TKA

0%2%4%6%8%

10%12%

20

10

20

11

20

12

20

13

20

14

20

15

Q1

20

15

Q2

20

15

Q3

Percent of Primary TKA Cases withZimmer GSF High-Flex

NATIONAL IMPLANT REGISTRIES

ACLR Allograft Use

18

42 43 45 4540 36 34

26 23 22 20 23 23 2531 31 31 33 34 36 32

1 2 2 2 3 5 61 1 0 0 0 0

30

10

20

30

40

50

2008 2009 2010 2011 2012 2013 2014

Percent of Graft Type, Primary ACLRs, Program-Wide

Allografts (all) Patellar tendon autograft

Hamstring autograft Other

Missing

Shoulder Hemiarthroplasty

19

Study Findings: increased risk of revision after hemiarthroplasty (HA) in patients <=59 years supports the use of total shoulder arthroplasty(TSA) in that population

0%

20%

40%

60%

80%

100%

2005 2006 2007 2008 2009 2010 2011 2012 2013

Primary Elective Procedures by Type in Patients =<59 years, by Year (NCAL and SCAL)

TSA

HA

BMP in Spine Surgery

Total Knee Arthroplasty LCS Implant

21

0%

1%

2%

3%

4%

5%

6%

Percent of Primary TKR Cases with LCS Implant

Longitudinal Tracking of Procedures/Devices

22 May 16, 2016

Total Joint Replacement 10-year Survival % (CI)

Registry Hip Knee

KP (2001-2013) 95.4 (95.1-95.7) 95.4 (95.2-95.6)

Australia (1999-2013) 93.2 (93.1-93.4) 94.4 (94.3-94.6)

Sweden (2003-2012) 94.6 (94.3-94.9) 94.6 (94.3-94.9)

New Zealand (1999-2013) 93.10% 95.7

NJR (2002-2013) 94.25 (94.09-94.45) 96.7 (96.6-96.8)

uncemented

Thank You