Kaiser Permanente Total Joint Replacement Registry:
The Surgeon’s Perspective
What is the TJRR?
Surgeons within Kaiser Permanente, an integrated health system currently serving 9.3 million members, rely on data
from the Total Joint Replacement Registry (TJRR), a database that tracks the outcomes of artificial hip and knee
implants, to evaluate the safety and effectiveness of these medical devices and make informed decisions regarding
care, with the ultimate goal of improving patient health outcomes.1,2
As described in the following perspective and informed by stakeholder interviews, surgeons both contribute data to
and benefit from findings generated by the TJRR.
Monitoring Device Safety
The TJRR is an integral part of Kaiser Permanente’s work to
ensure the safety of its patients. By tracking outcomes for devices used in total hip and knee replacement procedures, surgeons
can see which hip and knee implants result in high performance,
and which are associated with improved patient outcomes. In the
event of a medical device safety alert or recall, the Registry can
also be used to identify which patients are affected and thus need
follow up surgery.
The widely publicized DePuy ASR (i.e., metal-on-metal
hip implants) recall is one example of the value of the TJRR.
While many patients across the United States only realized
they were affected by viewing television ads or billboards, the
Kaiser Permanente recall manager and his team were able to
identify the approximately 650 affected patients immediately
using the TJRR and then communicated a plan of action to
surgeons and patients that week.
–Kaiser Permanente Regional Medical Director
Improve Patient-Provider Decision-Making
One of TJRR’s features is its risk calculator for joint replacement
revision that surgeons can use during patient visits. A web-based
tool that includes information on some of the risks associated
with surgery (e.g., infection, blood clots, and revision surgery),
the calculator allows surgeons to communicate possible risks and
anticipated outcomes with their patients. First, clinicians enter
patient information (e.g., gender, height, weight) into the tool.
Over the past several years, the [calculator] has helped
me choose prosthetics, counsel high-risk patients, and
show evidence of diminishing revision rates across the
organization.
–Kaiser Permanente Orthopedic Surgeon, Southern California region
They then select a candidate medical procedure or condition on
which to run the analysis. The calculator uses data from prior patients to draw inferences and “predict” surgical outcomes for the
presenting patient. During the clinical encounter, hypothetical
adjustments can be made to patient information to see how certain behavioral changes, such as weight loss or smoking cessation,
might lessen the risk of revision surgery. For surgeons, the value
of the patient risk calculator is its ability to assist in the identification and selection of the most appropriate medical device for each
patient. Being able to choose the correct type of medical device
often results in the best patient outcomes and avoids unnecessary,
and often costly, revision surgeries.
Assess Individual Provider Performance
The TJRR and its outputs allow surgeons to benchmark or compare their professional performance against others within Kaiser
Permanente. Analyses on clinician-specific data are run bi-annually and produce a corresponding clinician profile report. The
profile illustrates a surgeon’s performance through indicators such
as number of initial surgeries performed, number of revision surgeries required, types of hip and knee implants used (e.g., make,
model, year), patient satisfaction, etc. The profile also includes
Kaiser Permanente Total Joint Replacement Registry: The Surgeon’s Perspective
comparison figures using indicators from surgeons within the
same Kaiser Permanente region, and surgeons within the entire
Kaiser Permanente system. This information allows surgeons to
analyze their own performance relative to peers and, if needed,
adjust their practices to improve.
Kaiser Permanente surgeons give the TJRR profile reports high
marks, noting that analyses are impartial and provide a fair review
of the data.
Future Considerations
Looking forward, surgeons suggested two areas for enhancing the
TJRR. The first is to integrate new data types, such as physical
therapy data and patient-reported outcomes. This would allow
for more robust analyses, which would support better and more
customized patient care. In addition, surgeons are interested in
investigating how to leverage the TJRR to automate and streamline patient follow-up.
Citations
Kaiser Permanente, Fast Facts, available at http://share.kaiserpermanente.org/article/fast-facts-about-kaiser-permanente/.
Accessed on May 1, 2014.
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I am in the debt for all that the TJRR registry has done for
our quality of care and my maturation as a surgeon.
–Kaiser Permanente Neuromusculoskeletal Medicine Specialist,
Southern California region
Facilitate Research
The TJRR facilitates the conduct of robust research. Research
findings from the TJRR inform surgeons’ understanding of variations in outcomes for different implants, procedures and patient
populations.
Within the US, we are the largest (joint replacement)
registry, and because of our integration within other databases
at our organization, we’re able to ask questions that many
national registries cannot. We can investigate a lot of variables
related to outcomes, such as medications that patients are
taking.
–Kaiser Permanente Orthopedic Surgeon, Southern California region
Many surgeons within the Kaiser Permanente system lead studies
that rely on data from the TJRR. Surgeons note that the TJRR allows them to contribute to science, expand their knowledge-base,
and improve care for their patients.
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.
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About the Authors
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.
Acknowledgements
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.