Maria Shepherd, President and Founder, Medi-Vantage02.18.20
The more things change, the more they stay the same. Since 2012, the American Joint Replacement Registry (AJRR) Annual Report1 has published registry results. The goal is to inform surgeons, hospital administrators, medical device manufacturers, ambulatory surgical centers (ASCs), patients, and payers about the 1,525,435 primary and revision hip and knee arthroplasty procedures the organization has tracked that were implanted between 2012 and 2018 (Table 1). And the momentum continues. In 2019, the AJRR Annual Report reported aggregate procedural growth of 28.5 percent over 2018.
Why This Is Important
These numbers are astonishing when one thinks of the overall impact this collected data has had and will have on patient lives. Primary knee (54.4 percent) and primary hip (32.7 percent) procedures were the bulk of the procedures (Table 2). By gender, 59 percent of the patients were female and 41 percent were male (Table 3). The mean age of the patients having knee procedures was 66.7 years old, and 67.4 years old for hip arthroplasty patients.
Most of the data in the AJRR covering surgeons performing hip procedures were for elective primary total hip arthroplasties and hemiarthroplasty for fracture at 93,122 and 6,884 procedures respectively. Surgeons performing elective primary total hip arthroplasty procedures had a mean annual procedure total of 32. Length of stay declined by greater than 0.5/day when analyzing total hip arthroplasties from 2012 to 2018. In elective primary total hip arthroplasty procedures, the use of ceramic heads continued to increase, with a corresponding decrease in the use of cobalt chromium heads.
For the first time ever in the 2019 AJRR Annual Report, the data was assessed to determine the association of patient comorbidities and survivorship following total hip arthroplasty. For the comorbidity of smoking (current or former), the data reported a decline in survivorship in patients >65 years old after an elective primary total hip arthroplasty. Further, after adjusting the data for age and sex, it was found patients who were current smokers were associated with a rate of revision 1.42 times greater than those patients who had never smoked. This highlights smoking as an important risk factor to code and track for the purposes of future guidelines development. Finally, based on the Hip disability and Osteoarthritis Outcome Score (HOOS, JR), 92.7 percent of patients saw a meaningful improvement after elective primary total hip arthroplasty.
Knee Procedures
We all know surgeon experience and procedure volume make a difference when measuring outcomes. In the AJRR in 2018, the mean number of total knee arthroplasty procedures per surgeon was 44.8. Mean length of stay declined by greater than 0.9/day when analyzing total knee arthroplasties from 2012 to 2018. The AJRR is also useful in detecting practice trends in the U.S. that are different from other counties. In 2018, the AJRR total knee arthroplasty procedures underwent patellar resurfacing at a rate of 90.6 percent. Not so in the Australian Orthopaedic Association National Joint Replacement Registry or the Swedish Knee Arthroplasty Register, each reporting patellar resurfacing rates of 66.6 percent and 2.4 percent in 2017 respectively.
As in the data assessed for hips, identifying correlations between patient comorbidities and survivorship is an important area of analysis for AJRR and in the initial assessment, patient smoking was considered. The data pointed to current or former smokers as having a decline in total knee arthroplasty survivorship in patients >65 years old. Adjusting for age and sex, patients who were current smokers saw a rate of revision 1.30 times greater than those patients who had never smoked. The AJRR report notes the AJRR is an observational database, and these findings do not prove causation.
The number of healthcare institutions enrolled in the registry is impressive. By June 30, 2019, 1,133 hospitals, 104 ASCs, and 65 private practices had signed up to submit data to AJRR from across the United States. California leads the pack with the most facilities contracted (135), trailed by Florida (84) and Texas (83). Five additional states had more than 50 facilities contracted (Illinois, Wisconsin, Ohio, Pennsylvania, and New York).
The number of ASCs in the AJRR grew to 104 from 75 from 2018; an impressive growth of 38.7 percent. The participation of ASCs in the AJRR is important since these facilities keep raising the bar for outpatient care. This also means the AJRR can capture data during the shift from performing arthroplasty in hospitals to the presumably lower cost environment of the ASC while giving ASCs (and private practices) access to quality data, analysis, and benchmarking.
Among the many types of information tracked is the size of the healthcare organization. Most arthroplasty procedures submitted to the AJRR were conducted in medium-sized hospitals (43.7 percent) and small teaching institutions (40.9 percent). Non-teaching institutions trailed closely behind small teaching institutions at 36.9 percent. Large and small teaching hospitals combined accounted for 53.1 percent of all hospitals submitting data to the AJRR.
Participating facilities have substantial opportunity to immediately use and analyze their own data for the purposes of quality improvement programs. In the beginning of 2019, an improved RegistryInsights program was introduced. This program has provided a new user interface, benchmarking resources, and analytics. Surgeons working in the institutions part of the Registry benefit from a personalized dashboard and summaries of their procedures. Facility-wide data is also available to aggregate data for benchmarking purposes. This allows orthopedic surgeons and administrators to compare their aggregate data to national AJRR data for procedural, post-op, and patient-reported outcome measures. Benchmarking is a critical tool in increasing quality in patient care. It is also useful for qualifying for payer incentive programs.
One surgeon—Kieran Cody, M.D., an orthopedic surgeon at Doylestown Hospital in Doylestown, Pa.—was quoted as saying, “Surgeon Dashboards add value to quality improvement efforts in my practice. Specifically, it allows me to review my cases with a growing list of statistics and analytics. Through the dashboards, I have access to national benchmarks and averages for the procedures I am performing. It allows me to apply the platform’s interactive abilities to filter by patient and case type, and identify important practice changes that will benefit my patients going forward.”
The Medi-Vantage Perspective
What a wealth of information for orthopedic medical device companies! Are your surgeons registered in the AJRR? Think of what you could learn; for example, in 2017, AJRR expanded the data collected to include procedural information, patient comorbidities and risk factors, and complication rates. Interestingly, the AJRR data reports that only 3.3 percent of its procedures are robot-assisted and 3.4 percent are computer navigated. We expect these percentages to grow over the coming decade.
Reference
Maria Shepherd has more than 20 years of experience in medical device marketing in small startups and top-tier companies. After her industry career, including her role as VP of marketing for Oridion Medical, where she boosted the company valuation prior to its acquisition, director of marketing for Philips Medical, and senior management roles at Boston Scientific Corp., she founded Medi-Vantage. Medi-Vantage provides marketing, business strategy, and innovation research for the medical device, diagnostic, and digital health industries. The firm quantitatively and qualitatively sizes and segments opportunities, evaluates new technologies, provides marketing services, and assesses prospective acquisitions. Shepherd has taught marketing and product development courses and is a member of the Aligo Medtech Investment Committee (www.aligo.com). She can be reached at 855-343-3100. Visit her website at www.medi-vantage.com.
Why This Is Important
These numbers are astonishing when one thinks of the overall impact this collected data has had and will have on patient lives. Primary knee (54.4 percent) and primary hip (32.7 percent) procedures were the bulk of the procedures (Table 2). By gender, 59 percent of the patients were female and 41 percent were male (Table 3). The mean age of the patients having knee procedures was 66.7 years old, and 67.4 years old for hip arthroplasty patients.
Most of the data in the AJRR covering surgeons performing hip procedures were for elective primary total hip arthroplasties and hemiarthroplasty for fracture at 93,122 and 6,884 procedures respectively. Surgeons performing elective primary total hip arthroplasty procedures had a mean annual procedure total of 32. Length of stay declined by greater than 0.5/day when analyzing total hip arthroplasties from 2012 to 2018. In elective primary total hip arthroplasty procedures, the use of ceramic heads continued to increase, with a corresponding decrease in the use of cobalt chromium heads.
For the first time ever in the 2019 AJRR Annual Report, the data was assessed to determine the association of patient comorbidities and survivorship following total hip arthroplasty. For the comorbidity of smoking (current or former), the data reported a decline in survivorship in patients >65 years old after an elective primary total hip arthroplasty. Further, after adjusting the data for age and sex, it was found patients who were current smokers were associated with a rate of revision 1.42 times greater than those patients who had never smoked. This highlights smoking as an important risk factor to code and track for the purposes of future guidelines development. Finally, based on the Hip disability and Osteoarthritis Outcome Score (HOOS, JR), 92.7 percent of patients saw a meaningful improvement after elective primary total hip arthroplasty.
Knee Procedures
We all know surgeon experience and procedure volume make a difference when measuring outcomes. In the AJRR in 2018, the mean number of total knee arthroplasty procedures per surgeon was 44.8. Mean length of stay declined by greater than 0.9/day when analyzing total knee arthroplasties from 2012 to 2018. The AJRR is also useful in detecting practice trends in the U.S. that are different from other counties. In 2018, the AJRR total knee arthroplasty procedures underwent patellar resurfacing at a rate of 90.6 percent. Not so in the Australian Orthopaedic Association National Joint Replacement Registry or the Swedish Knee Arthroplasty Register, each reporting patellar resurfacing rates of 66.6 percent and 2.4 percent in 2017 respectively.
As in the data assessed for hips, identifying correlations between patient comorbidities and survivorship is an important area of analysis for AJRR and in the initial assessment, patient smoking was considered. The data pointed to current or former smokers as having a decline in total knee arthroplasty survivorship in patients >65 years old. Adjusting for age and sex, patients who were current smokers saw a rate of revision 1.30 times greater than those patients who had never smoked. The AJRR report notes the AJRR is an observational database, and these findings do not prove causation.
The number of healthcare institutions enrolled in the registry is impressive. By June 30, 2019, 1,133 hospitals, 104 ASCs, and 65 private practices had signed up to submit data to AJRR from across the United States. California leads the pack with the most facilities contracted (135), trailed by Florida (84) and Texas (83). Five additional states had more than 50 facilities contracted (Illinois, Wisconsin, Ohio, Pennsylvania, and New York).
The number of ASCs in the AJRR grew to 104 from 75 from 2018; an impressive growth of 38.7 percent. The participation of ASCs in the AJRR is important since these facilities keep raising the bar for outpatient care. This also means the AJRR can capture data during the shift from performing arthroplasty in hospitals to the presumably lower cost environment of the ASC while giving ASCs (and private practices) access to quality data, analysis, and benchmarking.
Among the many types of information tracked is the size of the healthcare organization. Most arthroplasty procedures submitted to the AJRR were conducted in medium-sized hospitals (43.7 percent) and small teaching institutions (40.9 percent). Non-teaching institutions trailed closely behind small teaching institutions at 36.9 percent. Large and small teaching hospitals combined accounted for 53.1 percent of all hospitals submitting data to the AJRR.
Participating facilities have substantial opportunity to immediately use and analyze their own data for the purposes of quality improvement programs. In the beginning of 2019, an improved RegistryInsights program was introduced. This program has provided a new user interface, benchmarking resources, and analytics. Surgeons working in the institutions part of the Registry benefit from a personalized dashboard and summaries of their procedures. Facility-wide data is also available to aggregate data for benchmarking purposes. This allows orthopedic surgeons and administrators to compare their aggregate data to national AJRR data for procedural, post-op, and patient-reported outcome measures. Benchmarking is a critical tool in increasing quality in patient care. It is also useful for qualifying for payer incentive programs.
One surgeon—Kieran Cody, M.D., an orthopedic surgeon at Doylestown Hospital in Doylestown, Pa.—was quoted as saying, “Surgeon Dashboards add value to quality improvement efforts in my practice. Specifically, it allows me to review my cases with a growing list of statistics and analytics. Through the dashboards, I have access to national benchmarks and averages for the procedures I am performing. It allows me to apply the platform’s interactive abilities to filter by patient and case type, and identify important practice changes that will benefit my patients going forward.”
The Medi-Vantage Perspective
What a wealth of information for orthopedic medical device companies! Are your surgeons registered in the AJRR? Think of what you could learn; for example, in 2017, AJRR expanded the data collected to include procedural information, patient comorbidities and risk factors, and complication rates. Interestingly, the AJRR data reports that only 3.3 percent of its procedures are robot-assisted and 3.4 percent are computer navigated. We expect these percentages to grow over the coming decade.
Reference
Maria Shepherd has more than 20 years of experience in medical device marketing in small startups and top-tier companies. After her industry career, including her role as VP of marketing for Oridion Medical, where she boosted the company valuation prior to its acquisition, director of marketing for Philips Medical, and senior management roles at Boston Scientific Corp., she founded Medi-Vantage. Medi-Vantage provides marketing, business strategy, and innovation research for the medical device, diagnostic, and digital health industries. The firm quantitatively and qualitatively sizes and segments opportunities, evaluates new technologies, provides marketing services, and assesses prospective acquisitions. Shepherd has taught marketing and product development courses and is a member of the Aligo Medtech Investment Committee (www.aligo.com). She can be reached at 855-343-3100. Visit her website at www.medi-vantage.com.