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.
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.
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.
We completed Aim 1, the results of which have been accepted for publication in the Journal of Arthoplasty.
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
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.
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- 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.
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- 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.
- 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.
Aging, Older Veterans' Health and Care
Care Management Tools, Practice Patterns/Trends, Predictive Modeling, Research Tools, Risk Adjustment, Safety Measurement Development