The TJRR is a database that monitors the safety of hip and knee implants in Kaiser Permanente patients. First created in 2001, it has undergone continuous updates and expansions. The TJRR is now the largest orthopedic registry in the United States with data from all seven Kaiser Permanente regions, which includes 452 surgeons in 51 medical centers. Enrollment is expected to surpass 200,000 patients in 2014.
1
The TJRR is used within Kaiser Permanente to:
Improve quality of care and decision-making by enabling both clinician and patient access to data that allows more informed and enhanced implant selection;
Achieve cost savings by reducing revision surgeries that often result from failed implants or complications;
Expedite surveillance of all implants which allows for consistent monitoring and thus quick identification of substandard performing devices; and,
Inform medical device offerings by studying all implanted devices and using verified data to make decisions on which devices are to be continuously offered or removed from the health system.
The TJRR has shown a reduction in hip revisions within the Kaiser Permanente from 15.4 percent (270 revisions out of 1,753 total cases) in 2002 to 10.1 percent (769 revisions out of 7,641 cases) in 2010.
2
The TJRR pulls information on patient demographics (e.g., age, gender), implant models, surgeries or other procedures, and health outcomes directly from patient electronic health records
(EHRs).
In addition, a web-based patient risk calculator for joint replacement revision can be used by clinicians during patient consultations. Clinicians are able to populate the calculator with real-time, easily determinable information on risk factors associated with hip and knee implants (e.g., diabetes, high Body Mass Index
[BMI]) that can be used to help inform decision-making. Hypothetical adjustments can then be made to patient information to see how changes – for example lowering weight (BMI) or addressing other co-morbidities – are likely to affect revision rates.
This exercise helps clinicians to illustrate the potential benefits of behavior modifications to patients, and serves as an effective tool for choosing appropriate medical devices and improving patient outcomes.
3
The TJRR is widely recognized in the United States and internationally as a high-performing registry that improves care at Kaiser Permanente and informs the field of orthopedic surgery. In 2012, Kaiser Permanente National Implant
Registries – including the TJRR – was awarded the prestigious
National Eisenberg Quality Award, which recognizes major achievements of individuals and organizations in improving patient safety and health care quality.
4
TJRR analyses identify differences in the performance of medical devices used for total joint replacement. This information is communicated throughout the health system, particularly to surgeons, and this knowledge diffusion often leads to practice change. For example, the TJRR was able to identify variation in device performance between hip implants with different sized femoral heads.
Larger femoral head size was found to reduce the risk of revision surgery. As a result, fewer small femoral heads are now used in practice.
5

Kaiser Permanente Total Joint Replacement Registry (TJRR)
Since implementation, there have been 28 device recalls, with 21 occurring from 2008 to present. Once a device advisory or recall notification is announced, the TJRR immediately identifies the affected patient population and subsequently sends a notification to those involved.
6 Clinicians then consult with their patients to determine appropriate next steps. This real-time notification system is often cited as “advanced” relative to other communication methods for medical device alerts used in the U.S.
7
In August 2010, DePuy Orthopaedics issued a voluntary recall of its ASR XL Acetabular Hip System and DePuy ASR Hip Resurfacing System. Kaiser Permanente was able to identify all 645 patients with that device and subsequently appointed a national case manager to monitor these patients. To date, 133 patients have needed revision surgery.
8,9
The frequency of hip and knee replacement surgery is rapidly expanding with the aging baby boomer population. As such, the need for accurate and detailed information on these surgeries are real world outcomes is increasingly important. The TJRR assists in this process and is a helpful decision-making resource that helps clinicians and patients make informed decisions about their health and healthcare.
4 Kaiser Permanente Implant Registries, Recognitions , available at: http://www.kpimplantregistries.org/Highlights.htm
. Accessed on May 9, 2014.
5 Paxton, E. “Kaiser Permanente National Total Joint Replacement
Registry: aligning operations with information technology,”
Clinical Orthopaedics and Related Research. Vol. 468, No. 10, pp. 2646-63. October 2010. Available at: http://www.ncbi.nlm.
nih.gov/pubmed/20652461 .
6 Ibid.
7 Funahashi, T. “Registries: Why Now? What Can It Do? How
Does It Do It? Why Must We Have It?” Practical Applications,
Challenges & Opportunities: How Registries Can Help Support a Learning Healthcare System. AcademyHealth. October 11,
2012, Washington, DC.
8 DePuy Synthes, Important Information About the ASR Hip
System Recall , available at: http://asrrecall.depuy.com/depuy-asrrecall-usen . Accessed May 1, 2014.
9 Paxton, E. et al. “The Kaiser Permanente Implant Registries: Effect on Patient Safety, Quality Improvement, Cost Effectiveness, and Research Opportunities,” Permanente Journal, Vol. 16, No.
2, Spring 2012, pp. 36-44. Available at: http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC3383159/ . Accessed May 1, 2014.
Visit http://www.kpimplantregistries.org/ for more information about Kaiser Permanente’s Total Joint Replacement Registry.
Jessica Winkler, M.P.H. is a Senior Associate at AcademyHealth.
She can be reached at Jessica.winkler@academyhealth.org
.
Emily Moore is a Research Assistant at AcademyHealth.
1 Barber, T. “The Utility of a Total Joint Registry in Quality Improvement,” Presented at the American Academy of Orthopaedic Surgeons Annual Meeting, March 24, 2014.
2 Paxton, E. “2012 John M. Eisenberg Patient Safety and Quality
Awards: Kaiser Permanente Implant Registries Benefit Patient
Safety, Quality Improvement, Cost-Effectiveness,” The Joint
Commission Journal on Quality and Patient Safety. Vol. 39, No.
6, June 2013. Available at: http://www.kpimplantregistries.org/
Publications/Journal_Articles/JCJQPS_Eseinbergaward_5.13.
pdf .
3 Paxton, E. et al. “The Kaiser Permanente Implant Registries: Effect on Patient Safety, Quality Improvement, Cost Effectiveness, and Research Opportunities,” Permanente Journal, Vol. 16, No.
2, Spring 2012, pp. 36-44. Available at: http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC3383159/ . Accessed May 1, 2014.
Sponsorship for this project was provided by The Pew Charitable
Trusts. We thank our partners at Kaiser Permanente Institute for Health Policy and all those interviewed for their contributions to these resources. A special thank you to Liz Paxton, Tad
Funahashi, MD, Thomas Barber, MD and Rebecca Love for their review and assistance.
This document represents a synthesis of information generated by a series of key informant interviews. Any views expressed are those of the interviewees.