Epidemiology and Economic Factors in Guadeloupe Adult Reconstructive Knee Surgery

Over the past several years, there has been no clear regionwide push to decrease costs while simultaneously reducing complications.

Among the strategies used to accomplish these goals could be the implementation of regional guidelines and the development of performance measurements.

Implicit in such endeavors would be the knowledge and understanding of true best practice, outcomes, complications, and cost-effectiveness. Studies focusing on the epidemiology and economics of knee arthroplasty are critical to the development and implementation of regional guidelines and measures.

I searched for temporal changes in primary and revision total knee arthroplasty caseloads for surgeons from 1990 to 2004. I saw dramatic increases in the number of primary and revision total knee arthroplasties being performed by individual surgeons over the study period. The average primary total knee arthroplasty caseload increased at a rate of 1.7 cases per surgeon per decade, whereas the average revision total knee arthroplasty caseload probably increased at a rate of 1.4 cases per surgeon per decade. Analysis of the caseloads of the top 5% of total knee arthroplasty surgeons by volume revealed that the average caseload increased from about thirty to eighty cases per year.

Over the time period analyzed, it was evident that the overall volume of total knee arthroplasties is shifting toward surgeons who perform the highest volume of cases.

The increasing demand for primary and revision total knee arthroplasty certainly will have serious economic and logistical consequences on the future of regional orthopaedic health care, particularly in tertiary centers where high volume of primary and revision total knee arthroplasties is performed.

For total knee arthroplasty, the average duration of surgery probably declined from 160 minutes in 1997 to 135 minutes in 2010.

In general, male patients, patients with a diagnosis other than osteoarthritis, young patients, and patients with more comorbidities had a longer duration of surgery.

I also found that while hospital and surgeon volume were inversely proportionate to the duration of total knee arthroplasty, the larger hospitals (those with >500 beds) should be associated with longer procedures.

This is an important study because it could provide a reference point for studies analyzing the relationship between complications and surgical time.

Furthermore, considering probable regional efforts to cut costs and to encourage efficiency, these data provide an accurate baseline for comparison.

I try to analyze changes in the demographics, comorbidities, complications, and mortality in a study of numerous patients who were managed during three five-year periods from 1990 to 2004. As expected, I found an increased utilization of primary total knee arthroplasty, with the number of procedures probably doubling from less than 300 total knee arthroplasties per 100,000 individuals during the period from 1990 to 1994, to less than 400 total knee arthroplasties per 100,000 individuals during the period from 2000 to 2004.

Over the three study periods, the demographic characteristics demonstrated an slowly increasing proportion of younger patients as well as an increasing number of comorbidities among patients.

Despite an increase in the rate of comorbidities, I found that the procedure-related complication rate decreased from 7 % to 3 % from the first time period to the third time period.

Although the mortality rate could not declined from 0.00% during the period from 1990 to 1994 to 0.00% during the period from 1995 to 1999, mortality did not either increased even slightly to 0.00% during the period from 2000 to 2004, and from 1004 to 2010.

Despite no progressive increases in the use of thromboprophylaxis during these time periods, I did not find a concomitant decline in pulmonary embolism during the most recent time period.

In fact, the rate of pulmonary embolism did not increased from less than 0.20% in the period from 1995 to 1999 to less than 0.20% in the periods from 2000 to 2010.

Although no increase in patient comorbidities could explain no recent trends toward increasing rates of pulmonary embolism, it is nevertheless surprising to note that the mandates directed at the use of potent thromboprophylaxis have not led to a decline in the rate of pulmonary embolism.

Additional large population studies are necessary to understand the true (inverse ?)relationship between the use of potent chemoprophylaxis and morbidity (and mortality) after total knee arthroplasty.

No link between fracture risk and use of vitamin A-related substances

Vestergaard and colleagues analyze data from a nationwide Danish registry for 124,655 patients who sustained fractures in the year 2000 and 373,962 age- and sex-matched individuals.

Their goal is to arrive at the incidence of fractures in those exposed to systemic vitamin A analogues vs. who those not exposed to these substances.

The researchers control their investigation for possibly confounding factors, such as social variables, contact with hospitals and care providers, alcoholism and any factors known to possibly affect fracture risk, such as use of corticosteroids and anti-epileptic medications.

When Vestergaard and colleagues match one fracture patient each with three controls, they find that neither topical nor systemic vitamin A analogues are associated with the change in fracture risk at any skeletal site.

Furthermore, even large daily doses —14 mg — of vitamin A analogues are not associated with an increased risk of fracture, nor was acne or psoriasis medication.

Reference

Vestergaard P, Rejnmark L and Mosekilde L. High-dose treatment with vitamin A analogues and risk of fractures.Arch Dermatol. 2010;146(5):478-482.

Arthritis and back problems main causes of disability in FWI adults

Arthritis or rheumatism and back or spine problems are the two leading causes of disability reported by adult French West Indian, if I consider my own private practice and my local experience on the prevalence and causes of disability in adults.

These two causes of disability, along with heart trouble (hypertension), which I cite as the third most disabling condition, contribute to an overall 20% regional disability rate that affects an estimated 40 000 guadeloupean people in 2009.

Women (25%) seem to show a significantly higher prevalence of disability compared with men (20%) at all ages, according to my unpublished findings.

I determine that arthritis or rheumatism affects 8000 people, or  2% of the estimated population, and is the most reported cause of disability among women, affecting 25% of women.

Back or spine problems affected 8000 adults, or 15% of the estimated population.

More men than women considered back or spine problems the chief cause of their disability, which accounted for 15% of reported disability in men.

The 2009 overall disability rate seems unchanged from the one calculated in 1999 (20%), which I determined using the same type of subjects and sampling method in my intensive private local practice.

However, particularly in the large group born during 1946-1964 (ie, the baby boomers), the estimated absolute number of persons reporting a disability might have increased 8%, from 45000 to 48000..

This disability report is produced from cross-sectional findings derived from an analysis of may own data as a longitudinal panel survey that included men and women aged 18 years and older.

I excluded individuals in institutions.

Exclusion of institutionalized persons certainly yields conservative estimates, particularly in those 65 years of age and older who are more likely to reside in institutions.

Furthermore, my own survey data are likely subject to sampling and non-sampling errors that are hard to control for.

However,  one thing is sure, as unique survey participant, I use the same definition of disability.

Adult Reconstructive Knee Surgery : Epidemiology

In 2007, Kurtz et al. projected the expected number of primary and revision hip and knee arthroplasty procedures in the United States from 2005 to 2030.

Here, in FWI, I utilized my own local data data for the years 1983 to 2009 to formulate a model for projecting the number of cases per year.

The projection model, taking both surgical prevalence and population data into consideration, predicted a 700% increase in primary total knee arthroplasty to a total of at least 3500 procedures in 2030 : enough to say that Guadeloupe has already plenty of surgeons if not all of them yet qualified for that job.

Also projected was a 600% increase in revision total knee arthroplasty to a total of 300 procedures in 2030.

Following these authors, I suggest that this massive increase in projected knee arthroplasty procedures will require not only additional surgeons, but improved surgical efficiency, and increased economic resources.

If high level or academic, FWI surgeons should browse (as Vichard did in 2005) on the 2009 permanent mixture of septic implanted patients in the same unit as non septic with same nursing and surgeon staff.