Kaiser Permanente Total Joint Replacement Registry (TJRR)
Kaiser Permanente Total Joint Replacement Registry
What is it? The TJRR is a database that monitors the outcomes of hip and knee implants in Kaiser Permanente
members.
How long has it been in existence? Created in 2001; it has undergone continuous updates and expansions
since present day.1
Where it is located? US-based; it includes data from all seven Kaiser Permanente regions, representing 452
surgeons in 51 medical centers.2
Who oversees the registry? The TJRR is operated and managed by Kaiser Permanente staff and several
internal advisory bodies.
How does it work? The TJRR pulls information on member demographics (e.g., age, gender), implant models,
surgeries or other procedures, and health outcomes directly from patient electronic health records (EHRs).
Why is it used? To improve patients’ health outcomes by monitoring the safety of implanted devices; also aids in
Kaiser Permanente quality improvement and research studies.
What are its accomplishments? The TJRR is used within Kaiser Permanente to: improve quality of care
(often resulting in positive changes at the medical center or clinician level); achieve cost savings (the majority of
which comes from lowering the rate of revision surgeries); improve decision-making (TJRR allows clinicians and
patients to make more informed decisions around care, including device choice); expedite surveillance (TJRR
allows substandard performing devices and affected patients to be identified quickly so that appropriate care can
be administered); and, inform medical device decision-making about which devices to offer throughout the
system (often used as a resource when negotiating contracts with medical suppliers).3
Introduction to Kaiser Permanente
Founded in 1945, Kaiser Permanente is an integrated health
system with locations across the United States. Kaiser Permanente
represents a working partnership of three components:
• Kaiser Foundation Health Plan: a not-for-profit insurance plan;
includes employers, employees and individual members;
• Kaiser Foundation Hospitals: facilities providing medical care;
owned and operated by Kaiser Permanente; and,
• Permanente Medical Groups: for-profit physician-owned
organizations that provide medical care to beneficiaries of the
Health Plan.4
With 9.3 million members, Kaiser Permanente provides care
throughout seven regions in the United States: Northern California, Southern California, Colorado, Georgia, Hawaii, Mid-Atlan-
tic (District of Columbia, including Maryland and Virginia), and
Northwest (Oregon/Washington).5
As both a payer and provider of health services, Kaiser Permanente has developed a suite of tools and data resources that support
the delivery of better quality and lower cost health care. Critical
to these efforts are several implant and medical device registries,
called the National Implant Registries – one of which is the Total
Joint Replacement Registry (TJRR).
The TJRR is Kaiser Permanente’s first interregional implant
registry, meaning that all regions contribute data. Now the largest
registry database of its kind in the United States, enrollment is
expected to surpass 200,000 patients in 2014.7
2 | Kaiser Permanente Total Joint Replacement Registry (TJRR)
What is joint replacement surgery?
Joint replacement is when a surgeon removes damaged cartilage
and bone from a joint and replaces it with a machine made
device of metal and plastic. In a partial joint replacement, the
surgeon only replaces one part of a joint. In a total replacement,
all parts of a joint are removed.6 In some instances, initial replacement surgeries must be corrected or done again. These are
called revision surgeries.
Hip and knee replacements are two types of joint replacement
surgeries.
Purpose
The TJRR is used throughout Kaiser Permanente to:
• Monitor revisions, failures, and key complication rates of knee
and hip replacement surgeries (e.g., infection);
• Identify patients at risk for poor clinical outcomes;
• Identify the most effective surgical techniques and implant
devices;
• Track implant usage and costs; and,
• Monitor and support implant recalls and advisories in cooperation with the US Food and Drug Administration (FDA).8
Figure 1: Data Entry and Use of Registry Along Patient
Care Continuum
Consultation with Orthopedic
Surgeon (Pre-Operative)
Patient and surgeon discuss implant
options and potential outcomes. Risk
calculators are used to inform the
decision-making process.
Surgery (Intra-Operative)
Patient receives joint replacement surgery.
Following the procedure, information about
the procedure and the implanted device is
entered into electronic health records and
subsequently transfered into the TJRR.
Follow up visit after 30 days (Post-Operative)
Patient has a follow up visit with their orthopedic
surgeon and reports on their recovery (including
physical therapy). This information is entered
into electronic health records and
subsequently transfered into the TJRR.
History and Development
The TJRR originated in 2001 during a meeting of orthopedic surgeons who were debating ways to improve patient outcomes for
total joint replacements. Their discussion was motivated by a very
specific and pragmatic procurement question: which implants
should the Kaiser Permanente system use to optimize patient
outcomes? The answer would allow them to negotiate favorable
contracts with medical device suppliers and improve care delivery
for all total joint replacement patients.
At the time, not much was known about total joint replacement
procedures, the performance of similar devices, nor their associated outcomes for different patient populations. To answer these
and other questions, the surgeons, in conjunction with the health
system, decided to develop a total joint replacement registry for
hips and knees.
The TJRR is modeled after the Swedish Hip Arthroplasty Register,
a similar effort that has proved successful in reducing revision
rates (i.e., repeat surgeries required to adjust or replace an implanted device) among patients in Sweden.9
Follow up as needed
Additional patient visits with their orthopedic
surgeon and other physicians are captured
through electronic health records.
Figure 1 illustrates the points at which key data are captured in an EHR and then transferred to the TJRR.10
Information (Data) Included
The TJRR includes data from multiple sources. Figure 2 illustrates
the types of information captured from EHRs and other sources,
and then regularly pushed to the TJRR. The Registry contains
information on patient characteristics (e.g., age, height, weight,
health history), as well as implant-specific information (e.g., type
of medical device used, model number, manufactured date) and
surgical techniques employed.
Specific to implant surgeries, clinicians enter information into
the EHR at three points during a patient’s encounter with the
health system: pre-operative (before a procedure), intra-operative
(during a procedure), and post-operative (after a procedure).
After each encounter, data from the EHR are transferred into the
Registry’s analytic platform.
3 | Kaiser Permanente Total Joint Replacement Registry (TJRR)
Originally, the TJRR collected information using paper-based
forms completed by physicians, nurses and other medical staff.
Since moving to a fully electronic system, other sources of health
data have been integrated into the Registry. These sources include
outpatient pharmacy (e.g., prescriptions), lab (e.g., test results),
radiology/imaging data (e.g., x-rays, CT scans) and others.11,12
Figure 2: Sources of Data
Outpatient
pharmacy
Patient health
history
Lab data
surgeons. The surgeons are also assured that their participation
in the TJRR will not result in punitive repercussions; rather, all
outputs, or analyses produced from the Registry, are aimed at
quality improvement and better patient outcomes.15 Furthermore,
clinician-focused analyses are only available for clinician use and
not provided to others within the Kaiser Permanente system, including patients. These factors contribute to widespread clinician
support.
Another key component of TJRR success is that all data are validated by being cross-referenced by Kaiser Permanente staff and
with electronic health records. This means that data are thoroughly checked for accuracy (e.g., correct procedure codes, identification numbers). The validation process ensures that TJRR data are
of high quality and, as a result, stakeholders are fully confident in
its ability to report surgical outcomes information correctly.
What Is Produced, and Who Uses It?
Total Joint
Replacement
Registry
Radiology &
Imaging
Other sources
(immunization,
EKG, dictation,
cancer registry)
Medical
device
information
Patient
demographics
Legend: Green indicates data from EHR; Blue indicates
data from other sources.13
Management, Governance & Funding
The TJRR is solely funded by the Kaiser Permanente Health
Plan. The Health Plan views the Registry as a core quality
improvement activity and thus supports its operation and
long-term sustainability.
The TJRR is guided by an internal steering committee comprised
of orthopedic surgeons, hospital chiefs, regional quality improvement staff and members of the National Product Council. The
representation on the steering committee is distributed among the
different geographic regions of the Kaiser Permanente system.14
Noteworthy Attributes
A main feature of the TJRR is the vast stakeholder buy-in and
acceptance from within the Kaiser Permanente system. For example, the transition to an electronic system has eased the administrative burden that a paper-based system posed for participating
Multiple stakeholders within the Kaiser Permanente health system use, reference, and rely on data and outputs (e.g., analyses,
surgeon profiles) from the TJRR. Outputs are used for internal
purposes, including decision-making and quality improvement
activities. TJRR outputs help to identify opportunities for improvement within the Kaiser Permanente system, and generate
value for a range of stakeholders.
Outputs include:
1. Patient risk calculator for joint replacement revision: this
calculator is a web-based tool that can be used by clinicians
during patient visits. Clinicians are able to populate the calculator with real-time, easily determinable information on risk
factors associated with surgery (e.g., diabetes, body mass index
[BMI]) that can be used to help inform decision-making. For
example, a man with a body mass index of 40 may have a predicted complication risk 50 percent higher than an otherwise
comparable man who had surgery with a body mass index of
30. The high risk patient could receive additional treatment or
be referred to a weight loss treatment program prior to joint
surgery to reduce the patient’s risk of revision.
• How to use the risk calculator: First, clinicians enter patient information (e.g., gender, height, weight) into the tool.
They then select a procedure or condition on which to run
the analysis, which uses Registry data from prior patients
to draw inferences and “predict” the risk of revision surgery
for the presenting patient. During the clinical encounter,
hypothetical adjustments can then be made to patient information to see how changes – for example, in smoking status
– affect likely revision rates. This exercise helps clinicians to
illustrate the potential benefits of behavior change to their
patients, and can serve as an effective tool for improving
patient outcomes.
4 | Kaiser Permanente Total Joint Replacement Registry (TJRR)
Table 1: Revision Example18
Highlight
Risk for knee revision surgery in female patient,
52 years old, 5 feet and 1 inch
Weight
260 lbs.
130 lbs.
Osteoarthritis
no
no
Post traumatic arthritis
no
no
Rheumatoid arthritis
no
no
Inflammatory arthritis status
no
no
Osteonecrosis
no
no
Diabetes status
yes
yes
Revision risk for knee surgery
within 5 years
2.9%
1.6%
2. Patient risk calculator for deep surgical site infection: Kaiser
Permanente recently developed and implemented a deep
surgical site infection calculator. This tool is similar to the
joint replacement revision calculator, and allows clinicians
to predict the likelihood of patients acquiring infections
during or after surgery. While this tool is still being rolled out,
publications on risk factors for deep surgical site infection are
expected to be released soon.19
3. Reports (e.g., Interactive Statistical Process Control Charts): the
TJRR produces quarterly internal reports that highlight trends
and noteworthy statistics, such as devices with “poor” performance. This information is used to make decisions throughout
the Kaiser Permanente system. Each medical center within
the Kaiser Permanente system receives customized reports
which include: risk adjusted medical center reports, dynamic web-based medical center reports, and medical center
quarterly quality reports. One such medical center report uses
an Interactive Statistical Process Control Chart to show the
average medical device and outcome trends over time. Reports
also show the standard deviation and a benchmark target line,
if available. When data falls outside the statistical process control limits, showing improvement or worsening, it indicates a
possible change in process for the medical center to investigate
further. Medical chiefs then use this information to implement
an action plan.
4. Confidential Surgeon Practice Profiles: the TJRR analyzes
clinician-specific data bi-annually and produces a corresponding clinician profile. Currently, this information is provided
via hard copy reports. In the future, clinicians will receive this
information through their Kaiser Permanente employee secure
web-portal.
5. Publications and presentations: Research findings are disseminated through peer-reviewed journal publications, posters and
panel presentations at scientific meetings, such as the American Academy of Orthopaedic Surgeons.20 These TJRR outputs
are publically available and are used by both internal Kaiser
Permanente employees and external Permanente stakeholders.
The TJRR has shown a reduction in hip revisions within the Kaiser
Permanente from 15.4 percent (270 revisions/1,753 total cases)
in 2002 to 10.1 percent (769 revisions/7,641 cases) in 2010.16,17
Data users and stakeholders include:
1. Surgeons access their profiles on the Kaiser Permanente platform, which includes customized performance and patient
outcome reports derived from registry data. These outcomes
are often used for individual performance evaluation and
improvement (i.e., clinicians adjust their practices based on
performance relative to peers21), and can provide continuing
medical education credit opportunities.
2. Hospital Chiefs and Administrators receive quarterly reports
on the performance of their centers relative to other centers
in the Kaiser Permanente system with similar characteristics;
they also are benchmarked against national performance
rates. This information is used by Chiefs to help identify areas
of substandard performance within their medical center and
subsequently implement necessary improvement activities.22
3. Kaiser Permanente National Product Council and the Kaiser Permanente Procurement and Supply Team use TJRR data to analyze
device performance (i.e., identify devices with higher revision
rates) to inform their inclusion decisions for the entire Kaiser
Permanente system and allow Kaiser Permanente to negotiate
favorable device contracts with suppliers. TJRR data have also
been used to develop formularies (listings of approved devices
and medications by the health plan) for joint replacement.23
4. Other Kaiser Permanente Staff access TJRR findings and status
reports through regular newsletters and internal symposia.
This process of continually reporting registry findings contributes to a collaborative environment, allows all staff to feel
accountable for outcomes, and thus, often leads to system
improvements and practice changes.24
5. Researchers (both internal and external) use TJRR data (or
resulting analyses) to answer clinical and research questions.
Internal researchers use TJRR to support numerous research
studies, many of which result in peer reviewed publications.
Most recently, the TJRR was used in a study looking at surgical
outcomes for knee replacement by diabetes status. The study
concluded that patients with diabetes did not experience higher rates of revisions or infections than those without.25
6. Quality Group, a team that focuses on system-wide quality
improvement activities, uses registry analyses to conduct their
standard reporting activities. The widespread adoption of
registries within the Kaiser Permanente system has helped to
increase efficiency (e.g., time savings) and reduce unnecessary
or duplicative work, which yields financial savings. Prior to the
registry, the Quality Group ran individual queries in parallel
Kaiser Permanente systems which was inefficient and often
duplicative.
5 | Kaiser Permanente Total Joint Replacement Registry (TJRR)
Figure 4: Examples of practice change resulting from data
Based on the TJRR data, Kaiser Permanente has noted a change in surgeon practice for Total Knee
Arthroplasty (knee replacement).
Implanted knee replacement devices have several variations based on their mobility and material used. In 2007, TJRR findings indicated that two
variations, uncemented total knee replacement and unicompartmental knee replacement surgeries, had higher failure rates. These findings were
communicated to clinicians via TJRR reports. As a result of this activity, Kaiser Permanente noted fewer surgeons opting for these procedures.
As a result of the decreased use of these procedures, Kaiser Permanente avoided an estimated 16 revisions surgeries from these procedures,
with cost savings of more than $550,000 in the year following the communication of these findings.26
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. These findings were disseminated to clinicians through site visits
and other presentations. As a result, there was a significant reduction usage of smaller femoral heads in practice.27
The TJRR identified a three-times-higher risk of revision for hip resurfacing (a surgery where the femoral
head is trimmed and capped with a smooth metal covering), as compared with total hip replacement.
After providing feedback to surgeons, the number of surface replacements in Kaiser Permanente’s system decreased—from 261 in 2008 to 85
in 2012.28
Contributions
The TJRR has multiple value propositions that warrant its continued support and integration in the Kaiser Permanente health
system. While the value may vary by stakeholder, several TJRR
contributions are viewed as important across all stakeholder
groups:
• Quality improvement activities: As mentioned, the Kaiser
Permanente Quality Group relies heavily on registry data. The
Quality Group’s internal improvement process often results
in changes at the clinician level (e.g., changed performance
practices) and/or medical center (e.g., changes to improve
outcomes). For example, Kaiser Permanente has seen quality
improvement through identification of affected patients during
major recalls, identification of risk factors associated with
outcomes of interest such as obesity and revision surgeries,
development of risk calculators, and surveillance programs for
infections and adverse events.29 Specific examples of quality
improvement include:
– When a medical center is identified as an outlier in performance, a team is assembled (either from within the center or
from another region) to review medical charts and radiographic analyses, catalogue the reasons for each revision,
document potential for improvement in each case, and share
these findings during presentations to the medical center
surgeons. These interventions have led to changes in clinical
decision-making in medical centers identified as outliers.
◦A recent study of medical center variation for knee and hip
replacement identified four centers that had higher than
expected revision rates. In two centers with a high rate of
total hip revision surgery, surgeons were early adopters of
metal-on-metal total hip replacements, which are proven
to result in worse patient outcomes. Both centers subsequently decreased the frequency of these implants and
thus saw revision rates improve (i.e., closer to the regional
mean). In one center with higher than expected total knee
revision rates, the study identified a difference in clinical
decision making. The center was giving patients with an
erythematous wound a polyethylene exchange. The rate of
this practice was more than double that at other medical
centers, but infection rates were similar. Once this difference in clinical decision-making was identified, revision
rates reduced closer to the regional mean.32
• Cost-savings: The TJRR has enhanced patient outcomes and
reduced complication rates. Revision rates for total hip replacement have been reduced, leading to both the improvement in
patient outcomes and money saved by avoidance of another
surgery.33 According to Healthcare Bluebook, an independent
organization analyzing pricing practices nationally, the total
fair price of a knee replacement revision is $28,613 and a hip
replacement revision is $29,161; this does not include costs
for follow-up visits and physical therapy.34,35 Considering the
reduction of revisions across the Kaiser Permanente health system and the costs of these surgeries, the TJRR has significantly
reduced costs overall.
• Informed patient decisions / facilitated patient interactions:
Clinicians often use findings from the TJRR to inform shared
decision-making with the patients. The most widely cited tool
is the patient risk calculator. Clinicians noted that information from the Registry allows them to customize care for their
patients and often leads to better outcomes (e.g., fewer surgical
revisions) and cost-savings (e.g., avoidance of multiple surgery
expenses).36
• Expedited device surveillance: There have been 28 device
recalls, 21 occurring since 2008 to present.37 Once a device
advisory or recall notification is announced by the U.S. FDA
or a device manufacturer, the TJRR immediately identifies the
affected patient population and subsequently sends a notification (e.g., electronic, paper-based, phone call) to those
involved.38,39 Clinicians then consult with their patients to
determine appropriate next steps. This real-time system is often
cited as “advanced”. Other notification processes take a more
6 | Kaiser Permanente Total Joint Replacement Registry (TJRR)
passive approach and rely on surgeons to contact their patients
on their own (e.g., FDA alerts patients by contacting surgeons
and/or posting billboards messages).40 Unaided by the Kaiser
Permanente data infrastructure, external surgeons must rely on
the accuracy of their specific practice’s information. Between
surgeons retiring and patients changing health systems practices, there are gaps in this system.
Noteworthy Recalls Addressed By Kaiser
Permanente’s Tracking System
All recalls are managed by Kaiser Permanente National Product
Recall Program. The following example demonstrates the TJRR’s
ability to navigate a recall quickly and effectively to ensure a high
quality of care standards.
• 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.41,42
tries, an initiative aimed to facilitate and enhance inter-registry
collaboration through the provision of a supportive infrastructure and the development of a distributed data network that uses
innovative approaches to analyze the data.45 Kaiser Permanente
is co-leading the effort to connect data from orthopedic registries worldwide to expand the sampling power of research both
within Kaiser Permanente and external venues, furthermore,
Kaiser Permanente is also collaborating with other US orthopedic
registries (e.g., the California Joint Replacement Registry and
FORCE-TJRR) to create quality metrics to better report outcomes
on a national scale.46
Citations
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.
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. 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.
3
Future Opportunities
Kaiser Permanente is committed to enhancing its work with the
TJRR by:
1. Disseminating findings to the broader community, specifically
a consumer audience;
2. Improving internal operations and performance; and,
3. Expanding its research portfolio through collaboration.
Kaiser Permanente, History, available at: http://share.kaiserpermanente.org/article/history-of-kaiser-permanente/. Accessed on
May 1, 2014.
4
Kaiser Permanente, Fast Facts, available at: http://share.kaiserpermanente.org/article/fast-facts-about-kaiser-permanente/.
Accessed on May 1, 2014.
5
Disseminating findings
Kaiser Permanente is looking to partner with consumer and
patient groups to promote the TJRR patient risk calculator. Part
of this dissemination includes conducting validation processes to
determine whether the risk calculator can be appropriately scaled
for use by consumers outside of the Kaiser Permanente system.
Kaiser Permanente is also working to translate peer-reviewed
journal articles citing TJRR data into resources appropriate for
and relevant to consumer audiences.43
Improving internal operations and performance
Within Kaiser Permanente, further work and research are ongoing to continuously learn about and improve upon aspects of the
health system. For example, future research initiatives that use the
TJRR include improving health outcomes for high risk populations, investigating drug and device interactions, and enhancing
the electronic data capture system to monitor quality throughout
the system.44
National Institute of Arthritis and Musculoskeletal and Skin
Diseases. Joint Replacement Surgery: What Patients Should Know,
available at: http://www.niams.nih.gov/News_and_Events/Announcements/2010/joint_replace_surg.asp. Accessed on May 1,
2014.
6
Key informant interview, Spring 2014.
7
Accountable Care Choices, Accountable Care Case Studies, available at: http://www.accountablecarechoices.org/case_studies/
kaiser-permanentes-joint-replacement-registry-improves-patient-outcomes-while-reducing-costs-1. Accessed on May 1,
2014.
8
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.
9
Paxton, E. and Funahashi, T. “Kaiser Permanente Implant Registries – Patient Focus Group,” Presented at Optimizing Registries
for Patients and Consumers: Opportunities for Engagement
in Registry Design and Use. AcademyHealth. April 29, 2013,
Washington, DC.
10
Expanding its research portfolio
Kaiser Permanente has partnered with the FDA to collaborate on
international post-market surveillance activities using the TJRR
through the International Consortium of Orthopaedic Regis-
7 | Kaiser Permanente Total Joint Replacement Registry (TJRR)
Ibid.
11
Key informant interview, Spring 2014.
12
Paxton, E. and Funahashi, T. “Kaiser Permanente Implant Registries – Patient Focus Group,” Presented at Optimizing Registries
for Patients and Consumers: Opportunities for Engagement
in Registry Design and Use. AcademyHealth. April 29, 2013,
Washington, DC.
13
Key informant interview, Spring 2014.
14
Ibid.
15
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.
16
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.
Available at: http://aaos2014.conferencespot.org/55844-aaosb1.927211/t-003-1.932388/f-024-1.934580/paper543-1.934709/
paper543-1.934710. Accessed May 1, 2014.
17
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.
27
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.
28
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/.
29
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.
Available at: http://aaos2014.conferencespot.org/55844-aaosb1.927211/t-003-1.932388/f-024-1.934580/paper543-1.934709/
paper543-1.934710.
30
Key informant interview, Spring 2014.
31
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.
Barber, T. Patient risk calculator examples. E-mail to Jessica
Winkler (Jessica.winkler@academyhealth.org). April 23, 2014.
Cited May 2, 2014.
32
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.
33
18
19
Kaiser Permanente, Conference Presentations, available at: http://
www.kpimplantregistries.org/Publications/Abstracts.htm. Accessed May 1, 2014.
20
Key informant interview, Spring 2014.
21
Ibid.
22
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/.
23
Key informant interview, Spring 2014.
24
Adams, A. “Surgical Outcomes of Total Knee Replacement According to Diabetes Status and Glycemic Control, 2001 to 2009,”
The Journal of Bone and Joint Surgery. Vol. 95., 2013. pp. 1-7.
Available at: http://www.kpimplantregistries.org/Publications/
Journal_Articles/JBJS%20TKR%20Outcomes%20by%20Diabetes%202.13.pdf.
25
Paxton, E. “The Kaiser Permanente National Total Joint Replacement Registry,” The Permanente Journal, Vol. 12, No. 3,
Summer 2008. Available at: http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3037118/.
26
Paxton, E. and Funahashi, T. “Kaiser Permanente Implant Registries – Patient Focus Group.” Optimizing Registries for Patients
and Consumers: Opportunities for Engagement in Registry Design and Use. AcademyHealth. April 29, 2013, Washington, DC.
Healthcare Bluebook, Revision of Knee Replacement, available
at: https://www.healthcarebluebook.com/page_Results.aspx?id=32&dataset=md&g=Revision%20Of%20Knee%20Replacement. Accessed April 4, 2014.
34
Healthcare Bluebook, Revision of Hip Replacement, available
at: https://www.healthcarebluebook.com/page_Results.aspx?id=29&dataset=md&g=Revision%20Of%20Hip%20Replacement. Accessed April 4, 2014.
35
Key informant interview, Spring 2014.
36
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/.
37
Paxton, E. and Funahashi, T. “Kaiser Permanente Implant Registries – Patient Focus Group.” Optimizing Registries for Patients
and Consumers: Opportunities for Engagement in Registry Design and Use. AcademyHealth. April 29, 2013, Washington, DC.
38
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/.
39
8 | Kaiser Permanente Total Joint Replacement Registry (TJRR)
Funahashi, T. “Registries: Why Now? What Can It Do? How
Does It Do It? Why Must We Have It?” Presented at Practical
Applications, Challenges & Opportunities: How Registries Can
Help Support a Learning Healthcare System. AcademyHealth.
October 11, 2012, Washington, DC.
40
DePuy Synthes, Important Information About the ASR Hip System Recall, available at: http://asrrecall.depuy.com/depuy-asr-recall-usen. Accessed May 1, 2014.
41
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/.
42
Key informant interview, Spring 2014.
43
Ibid.
44
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.
International Consortium of Orthopaedic Registries, available
at: http://www.icor-initiative.org/. Accessed May 2, 2014.
45
Key informant interview, Spring 2014.
46
This document represents a synthesis of information generated by a series of key informant interviews. Any views expressed are those of the interviewees.