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IIR 13-051 – HSR&D Study

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IIR 13-051
Development and Validation of a Risk Calculator for Total Joint Replacement
Alfred C Kuo
San Francisco VA Medical Center, San Francisco, CA
San Francisco, CA
Funding Period: February 2015 - September 2020

BACKGROUND/RATIONALE:
Advanced osteoarthritis of the hip and knee is treated with total joint arthroplasty (TJA). Among the most common orthopedic procedures performed in VHA, roughly 11,000 total hip and knee arthroplasty surgeries were conducted in fiscal year 2011. Although complications during and following total joint arthroplasty are overall relatively rare (about 5% nationally), dramatic variation exists in the likelihood of complications based on patient demographic and clinical factors (e.g., diabetes, alcohol misuse, smoking, body mass index). Currently, VHA orthopedic surgeons have no systematic and validated way of using a TJA candidate's demographic and clinical profile to estimate his or her risk of complications or death related to the procedure, satisfaction with results, or likelihood of improvement.

OBJECTIVE(S):
This study aims to develop and validate a tool to improve informed consent and help prevent complications from TJA: a risk, benefit, and satisfaction calculator that will allow for easy, accurate estimation of the personalized risks and benefits for each candidate.

METHODS:
To develop the TJA risk calculator, we will use the most recent three years of VHA Corporate Date Warehouse (CDW) and VA Surgical Quality Improvement Project (VASQIP) data to merge data on outcomes, especially death and major complications, and many known and candidate predictors of outcomes. For the TJA benefit calculator, 1200 patients scheduled to undergo TJA at three VA medical centers (Palo Alto, San Francisco, Minneapolis) will be recruited to provide pre-operative symptom, functioning, expectation, and quality of life data and then reassessed one year later. The results from these pre- and post-operative questionnaires will be linked with VASQIP and CDW data in order to develop predictive benefit models, especially changes in functioning and pain, based on pre-operative, demographic, and clinical data. We will create the patient satisfaction calculator using data from the 1200 recruited patients.

We will then develop and pilot test a CDW-integrated risk/benefit calculator and decision support system. This decision-support tool can be used by surgeons and patients within a shared-decision making process to weigh the patient-tailored risks and probable benefits of a TJA. The calculator will also help identify factors such as smoking or diabetic control that might be addressed prior to surgery in order to minimize risks and maximize potential benefits of the procedure.

FINDINGS/RESULTS:
We completed Aim 1, the results of which have been accepted for publication in the Journal of Arthoplasty.

http://www.arthroplastyjournal.org/article/S0883-5403(17)31091-4/fulltext

Results: 70,569 patients diagnosed with OA who received primary TJA were included. C-Statistics and bootstrapped confidence intervals for the cross validation of the boosted regression models were highest for cardiac complications (0.75: 0.71 to 0.79) and 30-day mortality (0.73: 0.66 to 0.79), and lowest for deep vein thrombosis (0.59: 0.55 to 0.64 and return to the operating room (0.60: 0.57 to 0.63).

Conclusions: Moderately accurate predictive models of 30-day mortality and cardiac complications following TJA in VHA patients were developed and internally cross-validated. By reporting model coefficients and performance metrics, other model developers can test these models on new samples, and have a procedure and indication-specific benchmark to surpass.


Data collection for Aim 2 is almost complete



IMPACT:
This project will develop and validate a unique risk and benefit calculator for Veterans anticipating a total joint replacement. It will improve shared decision making and increase the value of informed consent for Veterans undergoing TJA. It will also help identify factors such as smoking or diabetic control that might be addressed prior to surgery in order to minimize risks and maximize potential benefits for Veterans undergoing TJA.

This project is also poised to further thinking on methods and standards for surgical prediction models. For example, using VA data, we conducted a cross-validation of the American Joint Replacement Risk Calculator and found it to have poor accuracy.

PUBLICATIONS:

Journal Articles

  1. Wong JK, Kim TE, Mudumbai SC, Memtsoudis SG, Giori NJ, Howard SK, Oka RK, King R, Mariano ER. Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System?. Clinical orthopaedics and related research. 2019 Jan 1; 477(1):177-190.
  2. Harris AHS, Kuo AC, Bozic KJ, Lau E, Bowe T, Gupta S, Giori NJ. American Joint Replacement Registry Risk Calculator Does Not Predict 90-day Mortality in Veterans Undergoing Total Joint Replacement. Clinical orthopaedics and related research. 2018 Sep 1; 476(9):1869-1875.
  3. Giori NJ. CORR Insights®: Do Stem Design and Surgical Approach Influence Early Aseptic Loosening in Cementless THA?. Clinical orthopaedics and related research. 2018 Jun 1; 476(6):1221-1222.
  4. Giori NJ, Amanatullah DF, Gupta S, Bowe T, Harris AHS. Risk Reduction Compared with Access to Care: Quantifying the Trade-Off of Enforcing a Body Mass Index Eligibility Criterion for Joint Replacement. The Journal of Bone and Joint Surgery. American volume. 2018 Apr 4; 100(7):539-545.
  5. Borg LK, Kumar G, Funck N, Tamm-Daniels I, Giori NJ, Mariano ER. Six Month Follow-Up of a Patient With a Retained Fascia Iliaca Catheter: A Case Report. A&A practice. 2018 Mar 1; 10(5):107-109.
  6. Arsoy D, Giori NJ, Woolson ST. Mobile Compression Reduces Bleeding-related Readmissions and Wound Complications After THA and TKA. Clinical orthopaedics and related research. 2018 Feb 1; 476(2):381-387.
  7. Harris AH, Kuo AC, Bowe T, Gupta S, Nordin D, Giori NJ. Prediction Models for 30-Day Mortality and Complications After Total Knee and Hip Arthroplasties for Veteran Health Administration Patients With Osteoarthritis. The Journal of arthroplasty. 2018 May 1; 33(5):1539-1545.
  8. Campbell ST, Goodnough LH, Bennett CG, Giori NJ. Antiseptics Commonly Used in Total Joint Arthroplasty Interact and May Form Toxic Products. The Journal of arthroplasty. 2018 Mar 1; 33(3):844-846.
  9. Arsoy D, Huddleston JI, Amanatullah DF, Giori NJ, Maloney WJ, Goodman SB. Femoral Nerve Catheters Improve Home Disposition and Pain in Hip Fracture Patients Treated With Total Hip Arthroplasty. The Journal of arthroplasty. 2017 Nov 1; 32(11):3434-3437.
  10. Bennett CG, Lu LY, Thomas KA, Giori NJ. Joint replacement surgery in homeless veterans. Arthroplasty today. 2017 Dec 1; 3(4):253-256.
  11. Raghu H, Lepus CM, Wang Q, Wong HH, Lingampalli N, Oliviero F, Punzi L, Giori NJ, Goodman SB, Chu CR, Sokolove JB, Robinson WH. CCL2/CCR2, but not CCL5/CCR5, mediates monocyte recruitment, inflammation and cartilage destruction in osteoarthritis. Annals of The Rheumatic Diseases. 2017 May 1; 76(5):914-922.
  12. Steckelberg RC, Funck N, Kim TE, Walters TL, Lochbaum GM, Memtsoudis SG, Giori NJ, Indelli PF, Graham LJ, Mariano ER. Adherence to a Multimodal Analgesic Clinical Pathway: A Within-Group Comparison of Staged Bilateral Knee Arthroplasty Patients. Regional Anesthesia and Pain Medicine. 2017 May 1; 42(3):368-371.
  13. Chan JY, Giori NJ. Uncemented Metal-Backed Tantalum Patellar Components in Total Knee Arthroplasty Have a High Fracture Rate at Midterm Follow-Up. Journal of Arthroplasty. 2017 Aug 1; 32(8):2427-2430.
  14. Mudumbai SC, Kim TE, Howard SK, Giori NJ, Woolson S, Ganaway T, Kou A, King R, Mariano ER. An ultrasound-guided fascia iliaca catheter technique does not impair ambulatory ability within a clinical pathway for total hip arthroplasty. Korean journal of anesthesiology. 2016 Aug 1; 69(4):368-75.
  15. Mudumbai SC, Ganaway T, Kim TE, Howard SK, Giori NJ, Shum C, Mariano ER. Can bedside patient-reported numbness predict postoperative ambulation ability for total knee arthroplasty patients with nerve block catheters? Korean journal of anesthesiology. 2016 Feb 1; 69(1):32-6.
  16. Urish KL, Giori NJ, AAOS Biomedical Engineering Committee. Biofilm: A unique factor in orthopedic infection. AAOS Now. 2016 Feb 1; http://www.aaos.org/AAOSNow/2016/Feb/Research/research2/?ssopc=1.
  17. Anderson PA, Giori NJ, Lavernia CJ, Villa JM, Greenwald AS. Update on Biomaterials. Instructional course lectures. 2016 Jan 1; 65:449-65.
Journal Other

  1. Giori NJ, Harris AHS. Letter to the Editor on "Implementation of Preoperative Screening Criteria Lowers Infection and Complication Rates Following Elective Total Hip Arthroplasty and Total Knee Arthroplasty in a Veteran Population". [Letter to the Editor]. The Journal of arthroplasty. 2018 Jun 1; 33(6):1983-1984.
  2. Giori NJ. Should Only the Highest-Volume Surgeons and Centers Be Doing Primary Total Knee Arthroplasty? Commentary on an article by Sean Wilson, BA, et al.: "Meaningful Thresholds for the Volume-Outcome Relationship in Total Knee Arthroplasty". The Journal of Bone and Joint Surgery. 2016 Oct 19; 98(20):e92.


DRA: Aging, Older Veterans' Health and Care
DRE: Prognosis
Keywords: Care Management Tools, Practice Patterns/Trends, Predictive Modeling, Research Tools, Risk Adjustment, Safety Measurement Development
MeSH Terms: none