Oral anticoagulation in heart failure complicated by atrial fibrillation: A nationwide routine data study

BACKGROUND

This nationwide routine data analysis evaluates if oral anticoagulant (OAC) use in patients with heart failure (HF) and atrial fibrillation (AF) leads to a lower mortality and reduced readmission rate. Superiority of new oral anticoagulants (NOACs), compared to vitamin K antagonists (VKA), was analyzed for these endpoints.

METHODS

Anonymous data of patients with a health insurance at the Allgemeine Ortskrankenkasse and a claims record for hospitalization with the main diagnosis of HF and secondary diagnosis of AF (2017-2019) were included. A hospital stay in the previous year was an exclusion criterion. Mortality and readmission for all-cause and stroke/intracranial bleeding (ICB) were analyzed 91-365 days after the index hospitalization. Kaplan-Meier survival curves and multivariable Cox regression models were used to evaluate the impact of medication on outcome.

RESULTS

180,316 cases were included [81 years (IQR 76-86), 55.6% female, CHA2DS2-VASc score ≥ 2 (96.81%)]. In 80.6%, OACs were prescribed (VKA: 21.7%; direct factor Xa inhibitors (FXaI): 60.0%; direct thrombin inhibitors (DTI): 3.4%; with multiple prescriptions per patient included). Mortality rate was 19.1%, readmission rate was 29.9% and stroke/ICB occurred in 1.9%. Risk of death was lower with any OAC (HR 0.77, 95% CI [0.75-0.79]) but without significant differences in OAC type (VKA: HR 0.73, [0.71-0.76]; FXaI: HR 0.77, [0.75-0.78]; DTI: HR 0.71, [0.66-0.77]). The total readmission rate (HR 0.97, [0.94 to 0.99]) and readmission for stroke/ICB (HR 0.71, [0.65-0.77]) was lower with OAC.

CONCLUSIONS

Nationwide data confirm a reduction in mortality and readmission rate in HF-AF patients taking OACs, without NOAC superiority.

Risk-related short-term clinical outcomes after transcatheter aortic valve implantation and their impact on early mortality: an analysis of claims-based data from Germany

Objectives

We aimed to define and assess risk-specific adverse outcomes after transcatheter aortic valve implantation (TAVI) in an all-comers patient population based on German administrative claims data.

Methods

Administrative claims data of patients undergoing transvascular TAVI between 2017 and 2019 derived from the largest provider of statutory health-care insurance in Germany were used. Patients’ risk profile was assessed using the established Hospital Frailty Risk (HFR) score and 30-day adverse events were evaluated. Multivariable logistic regression models were applied to investigate the relation of patients’ risk factors to clinical outcomes and, subsequently, of clinical outcomes to mortality.

Results

A total of 21,430 patients were included in the analysis. Of those, 51% were categorized as low-, 37% as intermediate-, and 12% as high-risk TAVI patients according to HFR score. Whereas low-risk TAVI patients showed low rates of periprocedural adverse events, TAVI patients at intermediate or high risk suffered from worse outcomes. An increase in HFR score was associated with an increased risk for all adverse outcome measures. The strongest association of patients’ risk profile and outcome was present for cerebrovascular events and acute renal failure after TAVI. Independent of patients’ risk, the latter showed the strongest relation with early mortality after TAVI.

Conclusions

Differentiated outcomes after TAVI can be assessed using claims-based data and are highly dependent on patients’ risk profile. The present study might be of use to define risk-adjusted outcome margins for TAVI patients in Germany on the basis of health-insurance data.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-022-02009-y.

Blood transfusion and venous thromboembolism trends and risk factors in primary and aseptic revision total hip and knee arthroplasties: A nationwide investigation of 736,061 cases

BACKGROUND

Over the last years, new transfusion guidelines and pharmaceuticals have been introduced in primary and revision total hip and knee arthroplasty (P-THA, P-TKA, R-THA, R-TKA). In the US, a substantial decrease in transfusions has been observed in recent years. Little data exists on the subject in Europe. In this context we aimed to analyze: (1) Is there also a significant decrease in blood transfusion for these procedures in Germany? (2) Which patient and hospital related factors are associated with the risk of blood transfusion? (3) Is there a trend in complications, especially venous thromboembolism and stroke events that can be linked to tranexamic acid use?

HYPOTHESIS

There is a significant trend in decreasing blood transfusions in hip and knee arthroplasty.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 736,061 cases treated between January 2011 and December 2017 were included (318,997 P-THAs, 43,780 R-THAs, 338,641 P-TKAs, 34,643 R-TKAs). Multivariable logistic regression was used to model the odds of transfusion as a function of the year of surgery. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

In each cohort the odds of transfusion decreased over time (2017 vs. 2011 (reference): P-THA: OR 0.42 (95%CI: 0.39-0.45), P-TKA: OR 0.41 (95%CI: 0.37-0.46), R-THA: OR 0.52 (95%CI: 0.47-0.58), R-TKA: OR 0.53 (95%CI: 0.46-0.61). Patient-related risk factors for blood transfusion included older age, female gender, lower Body Mass Index, comorbidities such as renal failure, cardiac arrhythmia, congestive heart failure, valvular disease, coagulopathy, depression, and antithrombotic medication prior to surgery. Venous thromboembolism or stroke events did not increase over the study period.

DISCUSSION

The incidence of blood transfusions in primary and revision TKA and THA decreased over the study period. This may be due to new transfusion guidelines and the introduction of novel pharmaceuticals such as tranexamic acid. A further improved patient blood management and a focus on vulnerable patient groups might lead to a further future reduction of transfusions, especially in R-THA.

LEVEL OF EVIDENCE

III; comparative observational study.

Prevalence and Infant Mortality of Major Congenital Malformations Stratified by Birthweight

BACKGROUND

Low birthweight and major congenital malformations (MCMs) are key causes of infant mortality.

OBJECTIVES

The aim of this study was to explore the prevalence of MCMs in infants with low and very low birthweight and analyze the impact of MCMs and birthweight on infant mortality.

METHODS

We determined prevalence and infant mortality of 28 life-threatening MCMs in very-low-birthweight (<1,500 g, VLBW), low-birthweight (1,500-2,499 g, LBW), or normal-birthweight (≥2,500 g, NBW) infants in a cohort of 2,727,002 infants born in Germany in 2006-2017, using de-identified administrative data of the largest statutory public health insurance system in Germany.

RESULTS

The rates of VLBW, LBW, and NBW infants studied were 1.3% (34,401), 4.0% (109,558), and 94.7% (2,583,043). MCMs affected 0.5% (13,563) infants, of whom >75% (10,316) had severe congenital heart disease. The prevalence (per 10,000) of any/cardiac MCM was increased in VLBW (286/176) and LBW (244/143), as compared to NBW infants (38/32). Infant mortality rates were significantly higher in infants with an MCM, as opposed to infants without an MCM, in each birthweight group (VLBW 28.5% vs. 11.5%, LBW 16.7% vs. 0.9%, and NBW 8.6% vs. 0.1%). For most MCMs, observed survival rates in VLBW and LBW infants were lower than expected, as calculated from survival rates of VLBW or LBW infants without an MCM, and NBW infants with an MCM.

CONCLUSIONS

Infants with an MCM are more often born with LBW or VLBW, as opposed to infants without an MCM. Many MCMs carry significant excess mortality when occurring in VLBW or LBW infants.

Time to Surgery and Outcome in the Treatment of Proximal Femoral Fractures

BACKGROUND

It has not been conclusively established whether, or to what extent, the time to surgery affects mortality and the risk of complications after the surgical treatment of proximal femoral fractures.

METHODS

Data on 106 187 hospitalizations over the period 2015-2017 involving insurees of the German AOK health insurance company aged 20 and above were drawn from pseudonymized billing data and stratified in three subgroups: osteosynthesis for pertrochanteric fracture (PTF-OS: N = 52 358), osteosynthesis for femoral neck fracture (FNF-OS: N = 7970), and endoprosthesis for femoral neck fracture (FNF-EP: N = 45 859). Multivariate regression models were used to analyze the relation between preoperative in-hospital stay (time to surgery, TTS: 0 days [reference category], 1, 2, 3, 4-7 days) and mortality and general complications within 90 days, with risk adjustment for fracture site, operative method, age, sex, accompanying illnesses, and antithrombotic medication in the preceding year.

RESULTS

Mortality was significantly elevated only with PTF-OS, and only with a TTS of 2 days (odds ratio: 1.12 [95% confidence interval: (1.02; 1.23)]). General complications in relation to TTS were significantly elevated in the following situations: PTF-OS: 2 days: OR 1.24 [1.13; 1.37], 3 days: OR 1.33 [1.11; 1.60], 4-7 days: OR 1.47 [1.21; 1.78]; FNF-EP: 3 days: OR 1.21 [1.06; 1.37], 4-7 days: OR 1.42 [1.25; 1.62]; FNF-OS: 4-7 days: OR 1.86 [1.26; 2.73].

CONCLUSION

A prolonged time to surgery is associated with an elevated general complication risk depending on the site of the fracture and the type of surgical procedure used.

Are birth outcomes in low risk birth cohorts related to hospital birth volumes? A systematic review

Background

There is convincing evidence that birth in hospitals with high birth volumes increases the chance of healthy survival in high-risk infants. However, it is unclear whether this is true also for low risk infants. The aim of this systematic review was to analyze effects of hospital’s birth volume on mortality, mode of delivery, readmissions, complications and subsequent developmental delays in all births or predefined low risk birth cohorts. The search strategy included EMBASE and Medline supplemented by citing and cited literature of included studies and expert panel highlighting additional literature, published between January/2000 and February/2020. We included studies which were published in English or German language reporting effects of birth volumes on mortality in term or all births in countries with neonatal mortality < 5/1000. We undertook a double-independent title-abstract- and full-text screening and extraction of study characteristics, critical appraisal and outcomes in a qualitative evidence synthesis.

Results

13 retrospective studies with mostly acceptable quality were included. Heterogeneous volume-thresholds, risk adjustments, outcomes and populations hindered a meta-analysis. Qualitatively, four of six studies reported significantly higher perinatal mortality in lower birth volume hospitals. Volume-outcome effects on neonatal mortality (n = 7), stillbirths (n = 3), maternal mortality (n = 1), caesarean sections (n = 2), maternal (n = 1) and neonatal complications (n = 1) were inconclusive.

Conclusion

Analyzed studies indicate higher rates of perinatal mortality for low risk birth in hospitals with low birth volumes. Due to heterogeneity of studies, data synthesis was complicated and a meta-analysis was not possible. Therefore international core outcome sets should be defined and implemented in perinatal registries.

Systematic review registration

PROSPERO: CRD42018095289

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03988-y.

[Structure of hospital care for COVID-19 patients up to July 2020 in Germany]

Hintergrund

Hospitalisierte COVID-19-Patienten weisen eine hohe Morbidität und Mortalität auf und sind häufig auf eine intensivstationäre Behandlung und hier vor allem auf eine Beatmungstherapie angewiesen. Bisher ist wenig über die Patientenallokation bekannt.

Ziel der Arbeit

Die Darstellung der Strukturen der Krankenhausversorgung der COVID-19-Patienten zwischen dem 26. Februar bis zum 31. Juli 2020

Daten und Methoden

Für die Analyse der Versorgungsstrukturen wurden die Abrechnungsdaten der Allgemeinen Ortskrankenkassen (AOK) ausgewertet. Es wurden ausschließlich abgeschlossene somatische COVID-19-Fälle ausgewertet, bei denen das Virus durch einen Labortest nachgewiesen wurde. Die Stichprobe umfasst 17.094 COVID-19-Fälle, deren Behandlung in 1082 Krankenhäusern erfolgte.

Ergebnisse

An der Versorgung der COVID-19-Fälle waren 77 % aller Krankenhäuser beteiligt, an der intensivmedizinischen Behandlung 48 % aller Krankenhäuser. Von den Krankenhäusern, die COVID-19-Fälle behandelt haben, versorgte eine Hälfte 88 % aller Fälle. Das deutet zwar auf einen Zentrierungseffekt der COVID-19-Fälle auf bestimmte Krankenhäuser hin, jedoch verteilten sich die übrigen 12 % der Fälle auf viele Krankenhäuser mit oftmals sehr kleinen Fallzahlen. Des Weiteren wurde knapp ein Viertel der beatmeten COVID-19-Fälle in Krankenhäusern behandelt, die eine unterdurchschnittliche Beatmungserfahrung aufweisen.

Diskussion

Im Rahmen steigender Infektionszahlen ist es sowohl notwendig die Versorgungsstrukturen von COVID-19-Fällen durch klar definierte und zentral gesteuerte Stufenkonzepte zu verbessern als auch die Versorgung der Patienten ohne COVID-19 weiterhin aufrechtzuerhalten. Ein umfassendes Stufenkonzept mit stärkerer Konzentration erscheint für die Versorgung dieser komplex erkrankten Patienten sinnvoll.

Zusatzmaterial online

Die Onlineversion dieses Beitrags (10.1007/s00063-021-00776-6) enthält die Tabelle S1 und die Abbildungen S1 bis S3. Beitrag und Zusatzmaterial stehen Ihnen auf www.springermedizin.de zur Verfügung. Bitte geben Sie dort den Beitragstitel in die Suche ein, das Zusatzmaterial finden Sie beim Beitrag unter „Ergänzende Inhalte“.

Impact of regionalisation and case-volume on neonatal and perinatal mortality: an umbrella review

OBJECTIVE

This umbrella review summarises and critically appraises the evidence on the effects of regulated or high-volume perinatal care on outcome among very low birth weight/very preterm infants born in countries with neonatal mortality <5/1000 births.

INTERVENTION/EXPOSITION

Perinatal regionalisation, centralisation, case-volume.

PRIMARY OUTCOMES

Death.

SECONDARY OUTCOMES

Disability, discomfort, disease, dissatisfaction.

METHODS

On 29 November 2019 a systematic search in MEDLINE and Embase was performed and supplemented by hand search. Relevant systematic reviews (SRs) were critically appraised with A MeaSurement Tool to Assess systematic Reviews 2.

RESULTS

The literature search revealed 508 hits and three SRs were included. Effects of perinatal regionalisation were assessed in three (34 studies) and case-volume in one SR (6 studies). Centralisation has not been evaluated. The included SRs reported effects on 'death' (eg, neonatal), 'disability' (eg, mental status), 'discomfort' (eg, maternal sensitivity) and 'disease' (eg, intraventricular haemorrhages). 'Dissatisfactions' were not reported. The critical appraisal showed a heterogeneous quality ranging from moderate to critically low. A pooled effect estimate was reported once and showed a significant favour of perinatal regionalisation in terms of neonatal mortality (OR 1.60, 95% CI 1.33-1.92). The qualitative evidence synthesis of the two SRs without pooled estimate suggests superiority of perinatal regionalisation in terms of different mortality and non-mortality outcomes. In one SR, contradictory results of lower neonatal mortality rates were reported in hospitals with higher birth volumes.

CONCLUSIONS

Regionalised perinatal care seems to be a crucial care strategy to improve the survival of very low birth weight and preterm births. To overcome the low and critically low methodological quality and to consider additional clinical and patient-reported results that were not addressed by the SRs included, we recommend an updated SR. In the long term, an international, uniformly conceived and defined perinatal database could help to provide evidence-based recommendations on optimal strategies to regionalise perinatal care.

PROSPERO REGISTRATION NUMBER

CRD42018094835.

Case characteristics, resource use, and outcomes of 10 021 patients with COVID-19 admitted to 920 German hospitals: an observational study

Background Nationwide, unbiased, and unselected data of hospitalised patients with COVID-19 are scarce. Our aim was to provide a detailed account of case characteristics, resource use, and outcomes of hospitalised patients with COVID-19 in Germany, where the health-care system has not been overwhelmed by the pandemic.

METHODS

In this observational study, adult patients with a confirmed COVID-19 diagnosis, who were admitted to hospital in Germany between Feb 26 and April 19, 2020, and for whom a complete hospital course was available (ie, the patient was discharged or died in hospital) were included in the study cohort. Claims data from the German Local Health Care Funds were analysed. The data set included detailed information on patient characteristics, duration of hospital stay, type and duration of ventilation, and survival status. Patients with adjacent completed hospital stays were grouped into one case. Patients were grouped according to whether or not they had received any form of mechanical ventilation. To account for comorbidities, we used the Charlson comorbidity index.

FINDINGS

Of 10 021 hospitalised patients being treated in 920 different hospitals, 1727 (17%) received mechanical ventilation (of whom 422 [24%] were aged 18-59 years, 382 [22%] were aged 60-69 years, 535 [31%] were aged 70-79 years, and 388 [23%] were aged ≥80 years). The median age was 72 years (IQR 57-82). Men and women were equally represented in the non-ventilated group, whereas twice as many men than women were in the ventilated group. The likelihood of being ventilated was 12% for women (580 of 4822) and 22% for men (1147 of 5199). The most common comorbidities were hypertension (5575 [56%] of 10 021), diabetes (2791 [28%]), cardiac arrhythmia (2699 [27%]), renal failure (2287 [23%]), heart failure (1963 [20%]), and chronic pulmonary disease (1358 [14%]). Dialysis was required in 599 (6%) of all patients and in 469 (27%) of 1727 ventilated patients. The Charlson comorbidity index was 0 for 3237 (39%) of 8294 patients without ventilation, but only 374 (22%) of 1727 ventilated patients. The mean duration of ventilation was 13·5 days (SD 12·1). In-hospital mortality was 22% overall (2229 of 10 021), with wide variation between patients without ventilation (1323 [16%] of 8294) and with ventilation (906 [53%] of 1727; 65 [45%] of 145 for non-invasive ventilation only, 70 [50%] of 141 for non-invasive ventilation failure, and 696 [53%] of 1318 for invasive mechanical ventilation). In-hospital mortality in ventilated patients requiring dialysis was 73% (342 of 469). In-hospital mortality for patients with ventilation by age ranged from 28% (117 of 422) in patients aged 18-59 years to 72% (280 of 388) in patients aged 80 years or older.

INTERPRETATION

In the German health-care system, in which hospital capacities have not been overwhelmed by the COVID-19 pandemic, mortality has been high for patients receiving mechanical ventilation, particularly for patients aged 80 years or older and those requiring dialysis, and has been considerably lower for patients younger than 60 years.

FUNDING

None.

Low Hospital Volume Increases Re-Revision Rate Following Aseptic Revision Total Knee Arthroplasty: An Analysis of 23,644 Cases

BACKGROUND

Along with rising numbers of primary total knee arthroplasty (TKA), the number of revision total knee arthroplasties (R-TKAs) has been increasing. R-TKA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals with more R-TKAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study is to evaluate the relationship between hospital volume and re-revision rate following R-TKA.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 23,644 aseptic R-TKAs in 21,573 patients treated between January 2013 and December 2017 were analyzed. Outcomes were 90-day mortality, 1-year re-revision rate, and in-house adverse events. The effect of hospital volumes on outcomes were analyzed by means of multivariate logistic regression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Hospital volume had a significant effect on 1-year re-revision rate (≤12 R-TKA/a: OR 1.44, CI 1.20-1.72; 13-24 R-TKA/a: OR 1.43, CI 1.20-1.71; 25-52 R-TKA/a: OR 1.13, CI 0.94-1.35; ≥53 R-TKA/a: reference). Ninety-day mortality and major in-house adverse events decreased with increasing volume per year, but after risk adjustment this was not statistically significant.

CONCLUSION

We found evidence of higher risk for re-revision surgery in hospitals with fewer than 25 R-TKA per year. It might contribute to improved patient care if complex elective procedures like R-TKA which require experience and a specific logistic background were performed in specialized centers.

Low Hospital Volume Increases Revision Rate and Mortality Following Revision Total Hip Arthroplasty: An Analysis of 17,773 Cases

BACKGROUND

With the number of primary total hip arthroplasty (THA), the amount of revision THA (R-THA) increases. R-THA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals performing a higher number of R-THAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study was to evaluate the relationship between hospital volume and risk of postoperative complications following R-THA.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 17,773 aseptic R-THAs in 16,376 patients treated between January 2014 and December 2016 were included. Outcomes were 90-day mortality, 1-year revision procedures, and in-house adverse events. The effect of hospital volume on outcome was analyzed by means of multivariate logistic regression. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Hospital volume had a significant effect on 90-day mortality (≤12 cases per year: OR 2.13, CI 1.53-2.96; 13-24: OR 1.79, CI 1.29-2.50; 25-52: OR 1.53, CI 1.11-2.10; ≥53: reference) and 1-year revision procedures (≤12: OR 1.26, CI 1.09-1.47; 13-24: OR 1.18, CI 1.02-1.37; 25-52: OR 1.03, CI 0.90-1.19; ≥53: reference). There was no significant effect on risk-adjusted major in-house adverse events.

CONCLUSION

We found evidence of higher risk for revision surgery and mortality in hospitals with fewer than 25 and 53 R-THA per year, respectively. To improve patient care, complex elective procedures like R-THA which require experience and a specific logistic background should be performed in specialized centers.

Obesity Increases the Risk of Postoperative Complications and Revision Rates Following Primary Total Hip Arthroplasty: An Analysis of 131,576 Total Hip Arthroplasty Cases

BACKGROUND

The aim of our study is to evaluate the association of body mass index (BMI) and the risk of postoperative complications, mortality, and revision rates following primary total hip arthroplasty given other potentially confounding patient characteristics in a large cohort study.

METHODS

Using nationwide billing data for inpatient hospital treatment of the biggest German healthcare insurance, 131,576 total hip arthroplasties in 124,368 patients between January 2012 and December 2014 were included. Outcomes were 90-day mortality, 1-year revision procedures (with and without removal or exchange of implants), 90-day surgical complications, 90-day femoral fractures, and overall complications. The effect of BMI on outcome was analyzed using multivariable logistic regression. Risk-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

BMI had a significant effect on overall complications (30-34 in kg/m²: OR 1.1, CI 1.0-1.2, P = .014; 35-39: OR 1.5, CI 1.3-1.6, P < .001; ≥40: OR 2.1, CI 1.9-2.3, P < .001; <30: reference). The OR for 1-year revision procedures (30-34: OR 1.2, CI 1.1-1.4, P = .001; 35-39: OR 1.6, CI 1.4-1.8, P < .001; ≥40: OR 2.4, CI 2.1-2.7, P < .001; <30: reference) and 90-day surgical complications increased with every BMI category. For mortality and periprosthetic fractures there was a higher risk only for patients with BMI ≥40.

CONCLUSION

BMI increases the risk of revision rates in a liner trend. Therefore, the authors believe that patients with a BMI >40 kg/m² should be sent to obesity medicine physicians in order to decrease the body weight prior elective surgery.

Are TKAs Performed in High-volume Hospitals Less Likely to Undergo Revision Than TKAs Performed in Low-volume Hospitals?

BACKGROUND

High-volume hospitals have achieved better outcomes for THAs and unicompartmental knee arthroplasties (UKAs). However, few studies have analyzed implant survival after primary TKA in high-volume centers.

QUESTIONS/PURPOSES

Is the risk of revision surgery higher when receiving a TKA in a low-volume hospital than in a high-volume hospital?

METHODS

Using nationwide billing data of the largest German healthcare insurer for inpatient hospital treatment, we identified 45,165 TKAs in 44,465 patients insured by Allgemeine Ortskrankenkasse who had undergone knee replacement surgery between January 2012 and December 2012. Revision rates were calculated at 1 and 2 years in all knees. The hospital volume was calculated using volume quintiles of the number of all knee arthroplasties performed in each center. We used multiple logistic regression to model the odds of revision surgery as a function of hospital volume. Age, sex, 31 comorbidities, and variables for socioeconomic status were included as independent variables in the model.

RESULTS

After controlling for socioeconomic factors, patient age, sex, and comorbidities, we found that having surgery in a high-volume hospital was associated with a decreased risk of having revision TKA within 2 years of the index procedure. The odds ratio for the 2-year revision was 1.6 (95% CI, 1.4-2.0; p < 0.001) for an annual hospital volume of 56 or fewer cases, 1.5 (95% CI, 1.3-1.7; p < 0.001) for 57 to 93 cases, 1.2 (95% CI, 1.0-1.3; p = 0.039) for 94 to 144 cases, and 1.1 (95% CI, 0.9-1.2; p = 0.319) for 145 to 251 cases compared with a hospital volume of 252 or more cases.

CONCLUSIONS

We found a clear association of higher risk for revision surgery when undergoing a TKA in a hospital where less than 145 arthroplasties per year were performed. The study results could help practitioners to guide potential patients in hospitals that perform more TKAs to reduce the overall revision and complication rates. Furthermore, this study underscores the importance of a minimum hospital threshold of arthroplasty cases per year to get permission to perform an arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Indication Criteria for Total Knee Arthroplasty in Patients with Osteoarthritis - A Multi-perspective Consensus Study

Background and Objectives Knee osteoarthritis (OA) is a significant public health burden. Rates of total knee arthroplasty (TKA) in OA vary substantially between geographical regions, most likely due to the lack of standardised indication criteria. We set out to define indication criteria for the German healthcare system for TKA in patients with knee OA, on the basis of best evidence and transparent multi-stakeholder consensus. Methods We undertook a complex mixed methods study, including an iterative process of systematic appraisal of existing evidence, Delphi consensus methods and stakeholder conferences. We established a consensus panel representing key German national societies of healthcare providers (orthopaedic surgeons, rheumatologists, pain physicians, psychologists, physiotherapists), payers, and patient representatives. A priori defined consensus criteria were at least 70% agreement and less than 20% disagreement among the consensus panel. Agreement was sought for (1) core indication criteria defined as criteria that must be met to consider TKA in a normal patient with knee OA, (2) additional (not obligatory) indication criteria, (3) absolute contraindication criteria that generally prohibit TKA, and (4) risk factors that do not prohibit TKA, but usually do not lead to a recommendation for TKA. Results The following 5 core indication criteria were agreed within the panel: 1. intermittent (several times per week) or constant knee pain for at least 3 - 6 months; 2. radiological confirmation of structural knee damage (osteoarthritis, osteonecrosis); 3. inadequate response to conservative treatment, including pharmacological and non-pharmacological treatment for at least 3 - 6 months; 4. adverse impact of knee disease on patient's quality of life for at least 3 - 6 months; 5. patient-reported suffering/impairment due to knee disease. Additional indication criteria, contraindication criteria, and risk factors for adverse outcome were also agreed by a large majority within the multi-perspective stakeholder panel. Conclusion The defined indication criteria constitute a prerequisite for appropriate provision of TKA in patients with knee OA in Germany. In eligible patients, shared-decision making should eventually determine if TKA is performed or not. The next important steps are the implementation of the defined indication criteria, and the prospective investigation of predictors of success or failure of TKA in the context of routine care provision in Germany.

[Impact of Case Numbers on the 5-Year Survival Rate of Unicondylar Knee Replacements in Germany]

BACKGROUND

Reported survival rates of unicondylar knee arthroplasty (UKA) vary considerably. The influences of patient characteristics and the type of implant have already been examined. This analysis investigated the influence of hospital volume on 5-year-survival rate, using administrative claims data of Germany's largest health insurance provider.

METHODS

We analysed administrative claims data for 20,946 UKAs covered by the German local healthcare funds (Allgemeine Ortskrankenkasse, AOK) between 2006 and 2012. Survival rates were estimated using Kaplan-Meier analysis. The influence of hospital case numbers on 5-year survival was analysed by means of multivariable Cox regression adjusted for patient characteristics. We estimated hazard ratios (HR) with 95% confidence intervals for five hospital volume categories: < 12 cases, 13 - 24 cases, 25 - 52 cases, 53 - 104 cases, > 104 cases (per hospital and year).

RESULTS

The overall 5-year Kaplan-Meier survival rate was 87.8% (95%-CI: 87.3 - 88.3%). This increased with hospital volume (< 12 cases: 84.1% vs. > 104 cases: 93.2%). The analysis identified low hospital volume as an independent risk factor for surgical revision (< 12 cases: HR = 2.13 [95%-CI 1.83 - 2.48]; 13 - 24 cases: HR = 1.94 [95%-CI: 1.67 - 2.25]; 25 - 52 cases: HR = 1.66 [95%-CI: 1.41 - 1.96]; 53 - 104 cases: HR = 1.51 [95%-CI: 1.28 - 1.77]; > 104 cases: reference category).

DISCUSSION

Our analysis revealed a significant relationship between hospital case numbers and 5-year survival rate, which increases with hospital volume. The risk of surgical revision within 5 years in hospitals with fewer than 25 UKAs per year is approximately twice as high as in hospitals with more than 104 cases.

Drug-eluting stents in clinical routine: a 1-year follow-up analysis based on German health insurance administrative data from 2008 to 2014

OBJECTIVES

To describe the use of drug-eluting stents (DESs) in the largest population of statutory health insurance members in Germany, including newly developed bio-resorbable vascular scaffolds (BVSs), and to evaluate 1-year complication rates of DES as compared with bare metal stents (BMSs) in this cohort.

DESIGN

Routine data analysis of statutory health insurance claims data from the years 2008 to 2014.

SETTING

The German healthcare insurance Allgemeine Ortskrankenkasse covers approximately 30% of the German population and is the largest nationwide provider of statutory healthcare insurance in Germany.

PARTICIPANTS AND INTERVENTIONS

We included all patients with a claims record for a percutaneous coronary intervention (PCI) with either DES or BMS and additionally, from 2013, BVS. Patients with acute myocardial infarction (AMI) were excluded.

MAIN OUTCOME MEASURE

major adverse cerebrovascular and cardiovascular event (MACCE, defined as mortality, AMI, stroke and transient ischaemic attack), bypass surgery, PCI and coronary angiography) at 1 year after the intervention.

RESULTS

A total of 243 581 PCI cases were included (DES excluding BVS: 143 765; BVS: 1440; BMS: 98 376). The 1-year MACCE rate was 7.42% in the DES subgroup excluding BVS and 11.29% in the BMS subgroup. The adjusted OR for MACCE was 0.72 (95% CI 0.70 to 0.75) in patients with DES excluding BVS as compared with patients with BMS. In the BVS group, the proportion of 1-year MACCE was 5.0%.

CONCLUSION

The analyses demonstrate a lower MACCE rate for PCI with DES. BVSs are used in clinical routine in selected cases and seem to provide a high degree of safety, but data are still sparse.

Five-Year Survival of 20,946 Unicondylar Knee Replacements and Patient Risk Factors for Failure: An Analysis of German Insurance Data

BACKGROUND

Improvements in implant design and surgical technique of unicondylar knee arthroplasty have led to reduced revision rates, but patient selection seems to be crucial for success of such arthroplasties. The purpose of the present study was to analyze the 5-year implant survival rate of unicondylar knee replacements in Germany and to identify patient factors associated with an increased risk of revision, including >30 comorbid conditions.

METHODS

Using nationwide billing data of the largest German health-care insurance for inpatient hospital treatment, we identified patients who underwent unicondylar knee arthroplasty between 2006 and 2012. Kaplan-Meier survival curves with revision as the end point and log-rank tests were used to evaluate 5-year implant survival. A multivariable Cox regression model was used to determine factors associated with revision. The risk factors of age, sex, diagnosis, comorbidities, type of implant fixation, and hospital volume were analyzed. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were calculated.

RESULTS

During the study period, a total of 20,946 unicondylar knee arthroplasties were included. The number of unicondylar knee arthroplasties per year increased during the study period from 2,527 in 2006 to 4,036 in 2012. The median patient age was 64 years (interquartile range, 56 to 72 years), and 60.4% of patients were female. During the time evaluated, the 1-year revision rate decreased from 14.3% in 2006 to 8.7% in 2011. The 5-year survival rate was 87.8% (95% CI, 87.3% to 88.3%). Significant risk factors (p < 0.05) for unicondylar knee arthroplasty revision were younger age (the HR was 2.93 [95% CI, 2.48 to 3.46] for patient age of <55 years, 1.86 [95% CI, 1.58 to 2.19] for 55 to 64 years, and 1.52 [95% CI, 1.29 to 1.79] for 65 to 74 years; patient age of >74 years was used as the reference); female sex (HR, 1.18 [95% CI, 1.07 to 1.29]); complicated diabetes (HR, 1.47 [95% CI, 1.03 to 2.12]); depression (HR, 1.29 [95% CI, 1.06 to 1.57]); obesity, defined as a body mass index of ≥30 kg/m² (HR, 1.13 [95% CI, 1.02 to 1.26]); and low-volume hospitals, denoted as an annual hospital volume of ≤10 cases (HR, 1.60 [95% CI, 1.39 to 1.84]), 11 to 20 cases (HR, 1.47 [95% CI, 1.27 to 1.70]), and 21 to 40 cases (HR, 1.31 [95% CI, 1.14 to 1.51]) (>40 cases was used as the reference).

CONCLUSIONS

Apart from known risk factors, this study showed a significant negative influence of obesity, depression, and complicated diabetes on the 5-year unicondylar knee replacement survival rate. Surgical indications and preoperative patient counseling should consider these findings.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Revascularisation of patients with end-stage renal disease on chronic haemodialysis: bypass surgery versus PCI-analysis of routine statutory health insurance data

Objectives

We aimed to analyse the short-term and long-term outcome of patients with end-stage renal disease (ESRD) undergoing percutaneous intervention (PCI) as compared to coronary artery bypass surgery (CABG) to evaluate the optimal coronary revascularisation strategy.

Design

Retrospective analysis of routine statutory health insurance data between 2010 and 2012.

Main outcome measures

Primary outcome was adjusted all-cause mortality after 30 days and major adverse cardiovascular and cerebrovascular events at 1 year. Secondary outcomes were repeat revascularisation at 30 days and 1 year and bleeding events within 7 days.

Results

The total number of cases was n=4123 (PCI; n=3417), median age was 71 (IQR 62–77), 30.4% were women. The adjusted OR for death within 30 days was 0.59 (95% CI 0.43 to 0.81) for patients undergoing PCI versus CABG. At 1 year, the adjusted OR for major adverse cardiac and cerebrovascular events (MACCE) was 1.58 (1.32 to 1.89) for PCI versus CABG and 1.47 (1.23 to 1.75) for all-cause death. In the subgroup of patients with acute myocardial infarction (AMI), adjusted all-cause mortality at 30 days did not differ significantly between both groups (OR 0.75 (0.47 to 1.20)), whereas in patients without AMI the OR for 30-day mortality was 0.44 (0.28 to 0.68) for PCI versus CABG. At 1 year, the adjusted OR for MACCE in patients with AMI was 1.40 (1.06 to 1.85) for PCI versus CABG and 1.47 (1.08 to 1.99) for mortality.

Conclusions

In this cohort of unselected patients with ESRD undergoing revascularisation, the 1-year outcome was better for CABG in patients with and without AMI. The 30-day mortality was higher in non-AMI patients with CABG reflecting an early hazard with surgery. In cases where the patient's characteristics and risk profile make it difficult to decide on a revascularisation strategy, CABG could be the preferred option.

[Influence of surgeon experience in total hip arthroplasty. Dependence on operating time and complication risk]

BACKGROUND

As a consequence of limited personnel and financial resources, the increase in total hip arthroplasties places higher demands on orthopedic surgeons.

OBJECTIVES

In order to maintain high quality treatment, the correlation between surgical experience, duration of surgery and risk of complications was examined.

MATERIAL AND METHODS

The surgery time and, if applicable, complications (until discharge from hospital) of 1129 total hip arthroplasties over a period of 4 years were evaluated retrospectively.

RESULTS

The group of most experienced surgeons needed an average time of 53.2 ± 17.6 min for each implantation, followed by moderately experienced surgeons (74.5 ± 25.5 min) and less experienced surgeons (80.8 ± 21.9 min). Of all included cases, a total of 41 complications until discharge from hospital occurred. The number of complications increased with duration of surgery, whereby the risk of complications was significantly lower for shorter surgery times conducted by the most experienced surgeons as well as moderately experienced surgeons. The complication risk of less experienced surgeons remained constant independent of surgery duration.

CONCLUSION

These results underline the recommendations of the German Endocert system, which determine a minimum number of total joint arthroplasties as a quality indicator not only for hospitals but also for individual surgeons.

[Conservative and operative treatment of working age patients with gonarthritis. Economic considerations]

BACKGROUND

The development of the overall achievements for hospital performance since the introduction in Germany of the diagnosis-related groups (DRG) system in 2003 is the subject of healthcare political discussion. The field of prosthetics is often at the center of considerations.

PROBLEM

After consideration of the development of achievements with international and regional earnings, the question was investigated how the average expenditure for patients with gonarthritis developed in a time period of 1 year before and after implantation of total knee prostheses.

MATERIAL AND METHODS

The study was based on individual patient data from the accounting data of the AOK (General Regional Healthcare Insurance) from the categories, inpatient care, panel physician treatment, pharmaceuticals and medicines as well as disability leave periods. The data include the average expenditure and disability times calculated by the AOK for individual patients 12 months before and 12 months after implantation of a total knee prosthesis. The methods were selected because the international classification of diseases (ICD) coding does not allow a differentiation in the degree of severity and, therefore, a comparison of patients who were only conservatively treated within the scope of panel physicians which would have led to problems in risk adjustment. Due to a lack of coding guidelines for treatment by panel physicians, the accuracy of the diagnosis is also limited in comparison to inpatient treatment data.

RESULTS

The expenditure and the average disability leave for gonarthritis patients were higher in the year following implantation of total knee prostheses than in the year prior to implantation.

DISCUSSION

No conclusions can be drawn from the provision of service data with respect to the quality of life of the patients. Investigations over a longer time period seem to be necessary.

[Re-evaluation of the AOK hospital navigator with a focus on total knee replacement]

BACKGROUND

One of the biggest health insurance companies in Germany (AOK, Allgemeine Ortskrankenkasse) has published new results focussing on process quality of total knee replacement in 2010. These results were published in the online portal "Weiße Liste", which is based on health insurance routine data. The German Association of Orthopeadic Surgery questions the credibility of the rating system of the "Weiße Liste". To prove the system an interdisciplinary task force was created.

MATERIAL AND METHODS

The task force identified patient-specific parameters, which influence the outcome of total knee replacement based on the literature and expert opinions. Out of 907 orthopaedic departments, 4 above average and four below average were identified. The AOK was asked to provide 80 data sets for each department. These anonymised data sets could be converted into patient-specific data sets in the identified departments. Statistical analysis was performed to answer the question of whether there are differences between the below and the above average groups.

RESULTS

625 cases could be investigated. We found an increased rate of postoperative complications in the below average group. There are differences between both groups in terms of factors influencing the procedure. In the below average group an increased rate of patients with one or more comorbidities and a preoperative extension lag of over 10° was found. The above average group has a higher rate of operations before the knee replacement.

CONCLUSION

The results need to be proven on a larger scale. Further, prospective investigations are planned.

[Complication rates and secondary interventions after coronary procedures in clinical routine: 1-year follow-up based on routine data of a German health insurance company]

BACKGROUND

Data on 1-year complication and follow-up intervention rates after coronary angiography (CA) and percutaneous coronary intervention (PCI) in German clinical routine are sparse. This analysis aims to determine these rates.

METHODS

The analysis uses 2009 AOK claims data. Patients were divided into 3 groups (CA, without cardiac surgery and without acute myocardial infarction (AMI) n=116.071; PCI with stenting, without AMI: n=36.685; PCI with stenting and with AMI: n=32.707). The frequency of the endpoints MACCE (mortality, AMI, stroke, TIA), CABG, PCI and CA was recorded for up to one year.

RESULTS

1-year MACCE rates were 8.1 % (CA), 9.9 % (PCI without AMI) and 17.9 % (PCI with AMI). Quality-relevant follow-up intervention rates in the CA group were 2.5 % for CABG (after 31-365 days), 1.7 % for PCI within 90 days and 3.5 % for follow-up CA within 1 year. In the PCI groups, the frequencies were 1.6 % (without AMI) and 2.7 % (with AMI) for CABG (after 31-365 days), and 10.2 % (without AMI) and 10.1 % (with AMI) for PCI after 91-365 days.

CONCLUSION

This is the first cross-sectoral routine analysis of cardiac catheters and sequential events up to one year in Germany. The actual medical care situation revealed information particularly with regard to the second and follow-up inventions, which cannot be derived directly from medical guidelines. Beyond clinical trials, knowledge can be gained which is important both for medicine as well as the politics of health services.