SWEDISH HIP ARTHROPLASTY REGISTER – ANNUAL REPORT 2 REPORT ANNUAL – REGISTER ARTHROPLASTY HIP SWEDISH
Address Register Associates Swedish Hip Arthroplasty Register Professor emeritus Peter Herberts, MD, PhD Swedish Hip Arthroplasty Register Registercentrum VGR E-mail: [email protected] S-413 45 Göteborg Sweden Assistant Professor Hans Lindahl, MD, PhD Annual Report 2007 E-mail: [email protected] Telephone: at each contact below Fax: +46 31 69 17 77 Thomas Eisler, MD, PhD 007 www.jru.orthop.gu.se, www.shpr.se E-post: [email protected]
Project Leaders PhD Students TOTAL ARTHROPLASTY Alingsås Kungälv SU/Östra Professor Johan Kärrholm, MD, PhD Ola Rolfson Arvika Köping Sunderby Telephone: +46 31 342 82 47 Olof Leonardsson 284 630 Bollnäs Lidköping Sundsvall E-mail: [email protected] Ferid Krupic PRIMARIES Borås Lindesberg Södersjukhuset Oskar Ström 1979-2007 Carlanderska Linköping Södertälje Total Hip Arthroplasty Danderyd Ljungby Torsby Assistant Professor Göran Garellick, MD, PhD Executive Commitee 34 192 Eksjö Lund Trelleborg Telephone: +46 31 69 39 61 Professor Johan Kärrholm, Göteborg REOPERATIONS Elisabeth- Lycksele Uddevalla E-mail: [email protected] Assistant Professor Göran Garellick, Göteborg 1979-2007 sjukhuset Malmö Umeå Professor Peter Herberts, Göteborg (closed reduction excl.) Enköping Mora Uppsala Hemi Hip Arthroplasty Assistant Professor Cecilia Rogmark, Malmö Eskilstuna Motala Varberg Assistant Professor Cecilia Rogmark, MD, PhD Professor André Stark, Stockholm Falköping Movement Visby Telefon: 040 – 33 61 23 Professor Leif Dahlberg, Malmö 27 690 Falun Nacka Närsjukhus Värnamo E-post: [email protected] Assistant Professor Uldis Kesteris, Lund REVISIONS Frölunda Specialist- Proxima Västervik Assistant Professor Krister Djerf, Motala 1979-2007 Other contact persons Hospital CEO Margaretha Rödén, Sundsvall sjukhus Norrköping Västerås Register Coordinator Kajsa Erikson Gothenburg Medical Norrtälje Växjö Telephone: +46 31 69 39 30 2 233 Center Nyköping Ystad E-mail: [email protected] ENV./TECH. PROFILES Gällivare OrthoCenter Örebro 1979-2007 Gävle Ortopediska Örnsköldsvik Register Coordinator Karin Lindborg Halmstad Huset Östersund Telephone: +46 31 69 39 90 Swedish Hip 55 799 Helsingborg Oskarshamn E-mail: [email protected] Arthroplasty Register PATIENT OUTCOME Hudiksvall Piteå 2002-2007 Hässleholm- S:t Göran Register Coordinator Karin Pettersson Kristianstad Skellefteå Telephone: +46 31 69 39 33 HEMI ARTHROPLASTY Jönköping Skene E-mail: [email protected] Kalmar Skövde Swedish 12 245 Karlshamn Sollefteå System Manager Ramin Namitabar PRIMARIES Karlskoga Sophiahemmet Telephone: +46 31 342 82 42 Orthopaedic Association 2005-2007 Karlskrona Spenshult E-mail: [email protected] Karlstad Stockholms Specialist- System Developer Roger Salomonsson 577 Katrineholm vård Telephone: +46 302 379 50 REOPERATIONS KS/Huddinge SU/Mölndal E-mail: [email protected] 2005-2007 KS/Solna SU/Sahlgrenska
Department of Ortopaedics Sahlgrenska University Hospital ISBN 978-91-977112-3-4 September 2008 ISSN 1654-5982
Copyright© 2008 Swedish Hip Arthroplasty Register www.jru.orthop.gu.se Swedish Hip Arthroplasty Register Annual Report 2007
Johan Kärrholm Göran Garellick Cecilia Rogmark Peter Herberts ISBN 978 91 977112 3 4 ISSN 1654 5982 Contents
Introduction ...... 4
Register data ...... 6 Degree of coverage ...... 6 The new home page ...... 10 Primary total hip replacement ...... 11 Resurfacing implant ...... 27 Uncemented fixation...... 28 Reoperation ...... 32 Short-term complications – reoperation within 2 years ...... 35 Readmission within 30 days ...... 38 Revision ...... 39 Implant survival as a quality indicator ...... 42 Implant survival per type ...... 62 Implant survival per hospital ...... 65 Follow-up model for patient-reported outcome ...... 67 Follow-up of activities after total hip replacement surgery ...... 71 Value Compasses ...... 72 Case-mix-profiles ...... 73 Cost and cost-utility effect ...... 77 Clinical improvement projects ...... 82 Environmental and technical profile ...... 85 Follow-up of the ‘free choice of care’ scheme ...... 87 Mortality following total hip arthroplasty ...... 89 Gender perspective ...... 92 Hip fracture and prosthesis surgery, part 1 ...... 93 Hip fracture and prosthesis surgery, part 2 ...... 94 Hemi-arthroplasty ...... 95 The BOA project ...... 100 Regions – process and result measurements ...... 102 National quality indicators ...... 117 Reoperation within 2 years per county ...... 118 Implant survival after 10 years by county ...... 120 Gain in EQ-5D index after 1 year per county ...... 122 Summary ...... 124 New this year ...... 124 This year’s in-depth analyses ...... 124 Work for clinical improvement ...... 126 Achievement of goals ...... 126 Problem areas ...... 126 Current trends ...... 127 Conclusion ...... 127 Current research projects ...... 128
Publications ...... 130 4 SWEDISH HIP ARTHROPLASTY REGISTER 2007 Introduction
The Swedish Hip Arthroplasty Register is in its thirtieth year of New this year operation. During its first twenty years the registry focused on re- sults – measured as revision frequency – for different prosthesis Nordic co-operation has been deepened during the year. A common types, fixation methods and surgical techniques. The registry’s ongo- database (Denmark, Norway and Sweden) for hip arthroplasty from ing feedback to the profession has brought national adaptation to 1995 onwards has been created. Preliminary results of a first analysis optimal technique and the use of few and well-documented im- are going to be presented at international meetings in 2009. plants. This has resulted in continually improved prosthesis survival. This important work is not over, but will continue. During the year, the registry also intensified its co-operation with the Centre for Epidemiology (EpC, National Board of Health and During the past ten years, the registry has increased its interest in Welfare). Co-processing with the National Patient Register (PAR) at the whole course of events for patients with hip disease – from individual level has been used for analysing the degree of coverage at symptom debut with hip pain to the effects on the patient experi- hospital level. ences after the operation. This in turn has afforded opportunities for health-economic analyses involving greater focus on efficiency in- For the first time we report costs of the intervention at department stead of productivity. This type of analysis should meet with greater or clinic level. Unfortunately it has been impossible to create na- interest from decision-makers, who still concentrate overmuch on tionally a standardised way of measuring costs, and that the CPP productivity without quality assurance. The structural change in (cost per patient) system has still not been implemented throughout Swedish orthopaedics with the development of few but large elective the country. units and the care guarantee has contributed to the continued inter- est in budget-steered productivity thinking with its focus on avail- In-depth analyses ability measured as time-to-treatment regardless of where the treat- ment is offered or what result it has. These process measures say The registry’s continuous recording and regular reporting of stan- nothing of the results as experienced by patients, long-term quality dard results is important for maintaining the high quality of hip and prosthesis function; or about the cost-effectiveness of the treat- arthroplasty. We have also for many years conducted and reported ment. For these reasons, the work of the Swedish Hip Arthroplasty in-depth analyses of different issues. These analyses not only have Register with both early and late measures of results is of great sig- clinical improvement as their goal but are important for develop- nificance for the future quality of Swedish hip arthroplasty surgery. ment and may lead to the publication of scientific reports.
1. This year we analysed the significance of prosthesis fixation, pri- Public Reporting marily the result of uncemented fixation. Historically, uncemented The Swedish Hip Arthroplasty Register reports openly eight outcome prosthesis types have shown poor results in Sweden. Internationally variables at unit and aggregated county-council levels. Three of these speaking, we remain conservative; and cemented fixation entirely variables, patient-reported health gain (EQ-5D index gain after one dominates. However, there has for some years been a clear but slow year), short-term complications at two years, and ten-year prosthesis trend towards the increased used of uncemented fixation with the survival) are included as national quality indicators in the report employment of more modern implants. ‘Regional Comparisons’, published by the Swedish Association of Local Authorities and Regions (SALAR) and the National Board of 2. Throughout the world, surface replacement prostheses have been Health and Welfare (SoS), which now includes over one hundred indi- marketed and are used to an increasing extent. Their introduction in cators. Two new indicators refer to hip arthroplasty: ‘readmission Sweden has been slow, some 1,000 patients having received them. within thirty days’ and ‘cervical hip fractures and arthroplasty’. The result of an analysis with a short follow-up time is disquieting, with a clearly increased revision frequency compared to conven- Open reporting of the departments’ results is important as a motor tional prostheses. for operational development. However, interpretation of the re- sults is sometimes difficult and may lead to oversimplified and un- 3. The treatment model for cervical hip fracture has changed during scientific debate. Since quality-registry reporting is increasingly the past six-to-seven years in Sweden. Dislocated cervical hip frac- being used for control and planning in the care services, decision- tures are now increasingly being treated with total or hemi- makers desire easily-accessible ways of summarising intractable arthroplasty. An analysis covering more than 10,000 cases receiving results in the form of indexing (of several variables) and the rank- total hip replacement owing to fracture shows no difference in revi- ing of hospitals. This in turn is meant for use in ‘accrediting’ hospi- sion frequency in the comparison between primary and secondary tals and in a ‘free-choice-of-care perspective’ for the patient. Lead- (following fracture treatment failure) hip replacement operations. ing biostatisticians have demonstrated serious statistical methodo- logical problems (primarily dropouts, patient demography and co- 4. In a study of the now-three-year-old hemi-arthroplasty database morbidity) associated with ranking and indexing and issue warn- we found significantly increased reoperation frequency for bipolar ings against drawing hasty conclusions from these methods. The hemi-arthroplasty compared to unipolar. Swedish Hip Arthroplasty Register avoids ranking outcomes but encourages all departments to analyse their own results as a step in 5. In a health-economic study of 2,700 patients, we calculated the the process of continual improvement. social costs of waiting times for total hip replacement surgery.
SWEDISH HIP ARTHROPLASTY REGISTER 2007 5
Primary total hip replacement in Sweden Degree of coverage 16,000
All units (79 hospitals) public and private, that carry out hip arthro- 14,000 plasty are included in the Register. All 62 hospitals that conduct hemi-arthroplasty report to the registry. The Hip Arthroplasty Reg- 12,000 ister thus enjoys 100% coverage of hospitals. The degree of coverage for primary arthroplasties at individual level has this year been checked via co-processing with the PAR and is reported in detail on 10,000 page 6. Coverage at national level was 96% for total arthroplasties and 95.8% for hemi-arthroplasties. Unfortunately a few departments 8,000 show faulty reporting (tables, pages 8-9).
The degree of coverage for reoperations has not yet been checked, 6,000 but the result of this co-processing will be reported later. One rea- son for the delay in co-processing is that members of the profession 4,000 are showing very mixed quality in their use of ICD-10 regarding diagnosis and measure codes. Just as in the previous Annual Report, we wish to urge all colleagues to improve in this area. The utility of 2,000 high-quality registration cannot be exaggerated.
,0 Swedish Copyright©Hip Register 2008 Arthroplasty Patient-reported outcome measure (PROM) was reported during 67 70 73 76 79 82 85 88 91 94 97 00 03 06 2007 from 73 of 79 hospitals (92%), and we have high hopes that all Numbers of primary total hip arthroplasties performed in Sweden units will join the follow-up routine before the end of 2008. between 1967 (6 operations) and 2007 (14,105 operations), inclusive.
The number of reoperations reported during 2007 increased some- what (2.7%). No hospital notes any big lag in their reporting of re- posals for extension of activities. In cooperation with the Swedish operations (except Lund). It is primarily the more severe complica- Knee Arthroplasty Register, the Swedish Hip Arthroplasty Register tions deep infection and dislocation that have occasioned the rise. is inviting all departments to an annual users’ meeting at Arlanda. The trend from earlier years has been a successive decline in reopera- tions and this trend has now also been broken. The complication Thanks to the Västra Götaland Region. Like many national qual- rates, however, are so low that a random variability may be present. ity registers, the Hip Arthroplasty Register is under-financed. De- spite increasing grants from SALAR the funds allocated have been Receiving reports insufficient during the past three years of activity. The Western Götaland region, which is the formal principal for the registry, has Most departments report via our web application. Some hospitals in generously contributed funds during this time. In autumn 2008, a the Skåne Region, however, have chosen their own IT system, register centre will be established at the Nordic School of Public which has caused problems for the registry with extra work and a Health (NHV) in Göteborg, with ongoing support from the Region. poorer degree of coverage from some hospitals. Copies of medical The centre will be formed of the National Diabetes Register the records from reoperations are sent over the year with varying de- Centre for Oncology and the Swedish Hip Arthroplasty Register. lays. Study of copies and systematised data collection are necessary By using joint IT resources, biostatisticians and premises, we hope for the register analyses. to achieve major synergy effects and increased and long-term finan- cial stability. Reporting Thanks to all co-workers! The Hip Arthroplasty Register is based All publications, annual reports and scientific exhibitions are re- on decentralised data capture, for which reason the contributions of ported on our website. The Annual Report this year has grown fur- the contact secretaries and contact physicians are invaluable for the ther in extent due to the inclusion of more in-depth analyses and Register’s function. Very many thanks for all your excellent help above all the expansion of the register with the hemi-arthroplasty during the past year. database. Under discussion is possible publication of most of the tables via the home page, focusing the printed Report on current in- depth analyses, for example work for clinical improvement and pro- Göteborg, September 2008
Johan Kärrholm Göran Garellick Cecilia Rogmark Peter Herberts Professor Emeritus, MD, PhD Professor, MD, PhD Assistant Professor, MD, PhD Assistant Professor, MD, PhD 6 SWEDISH HIP ARTHROPLASTY REGISTER 2007 Degree of coverage
The Swedish Hip Arthroplasty Register has for many years 1. Matching of individuals, i.e. patients registered in both had 100% coverage of hospitals that perform hip arthro- registers plasty. However, this does not mean that we know for cer- 2. Individuals registered only in the Hip Arthroplasty Reg- tain whether every hospital reports all patients undergoing ister surgery there. Before every annual report and before the 3. Individuals registered only in the PAR. database in question is analysed, every hospital department or clinic receives a request for local validation of the number The degree of coverage of the Hip Arthroplasty Register is of primary operations and reoperations. This type of valida- given in the following table as the sum of outcomes 1+2, tion should nowadays be fairly simple since most hospitals and that of the PAR as the sum of 1+3. We do not know today have digital ‘operation rosters’. The response fre- whether these results reflect the true coverage since patients quency for the present Report was only 75%. In 1998, co- may have received hip implants without the respective care processing was undertaken between the In-patient Care Reg- units registering the measure in either register. The number ister (now the National Patient Register (PAR)) and the of such cases should be low in Sweden for 2006. The cover- Swedish Hip Arthroplasty Register. This analysis was in- age given in the table is thus a ‘best-case scenario’ – the true cluded in a doctoral dissertation (Peter Södermann, 2000). figure may be a percent lower. The method also has a num- The degree of coverage for revisions was given there as 94% ber of weak points: for the period 1986-1994. Laterality. In most cases the PAR lacks laterality, i.e. right In February 2008 the steering and working group for or left is not given as a unique variable, which it is in the ‘Regional Comparisons’ initiated co-processing of various Swedish Hip Arthroplasty Register. Patients treated bilater- national quality registers and the Patient Register (Centre ally in one session and patients treated in both hips during for Epidemiology/National Board of Health and Welfare) as 2006 may ‘disappear’ from the PAR with the selection crite- a measure to achieve better quality assurance for the forth- ria chosen for the co- processing. Most national and local coming publication of ‘Regional Comparisons’ 2008 (6/10 care registers lack laterality; this should be altered so as to 2008). Operational year 2006 was analysed. The Swedish improve the quality in these registers if one wishes to ana- Hip Arthroplasty Register was one of ten selected for this lyse diseases/operations involving pair organs. type of quality assurance. The registry supplied four data- bases to the National Board: Time-lag in registration. How the various care units report to the medical quality registers and the Patient Register var-