Abstract
Objective: To pilot a provincial joint replacement registry using electronic point-of-care data collection.
Design: Data collection study.
Setting: Southwestern Ontario, which has a population base of 3.5 million people.
Participants: Eighteen orthopedic surgeons.
Method: Information on total hip and knee replacements was obtained by the orthopedic surgeons over a 6-month period. Information was obtained in paper form and electronically on hand-held computers.
Main outcome measures: Patient demographics, waiting times from referral to operation, patient satisfaction and relevance and value of electronic records compared with paper records.
Main results: Data were collected on 815 total hip and knee arthroplasties. A slightly greater number of hips required revision than knees. The majority of patients were in the 60 to 90-year age range. With respect to the waiting time from referral to operation 10% of patients waited less than 5 weeks, 50% waited less than 30 weeks, and 90% waited less than 59 weeks. There was a high level of patient satisfaction with the operation and with hospital care received. Most surgeons found that the gathering and use of data electronically was relevant and easy. The electronic data were more timely, accurate and complete than paper records.
Conclusion: Electronic point-of-care data collection is appropriate, particularly in high-volume, high-cost surgical interventions such as total joint replacements.
Canadians expect high-quality, accessible, cost-effective health care, and it is becoming increasingly obvious that we need better information to achieve these goals.1
Total hip and knee replacement surgery illustrates our current dilemma. These joint arthroplasties are high-volume (2.5% of the population over 60 years of age), efficacious, durable procedures that are not only cost-effective but also cost-saving.2–6 In this country the demand for total hip and knee replacement exceeds available resources, resulting in rationing of services and long waiting lists. Also a perception exists among orthopedic surgeons that waiting lists are too long and that revision surgery rates are higher than necessary. There is no mechanism to identify patient, surgical and implant factors that might affect the quality of the result and implant durability.7 Poor information exists for even obvious questions, such as what are our Canadian joint arthroplasty revision rates, because our information databases have not separated primary from revision joint replacements or side of the procedure. In addition, countries such as Sweden and Norway who have national joint replacement registries have demonstrated a stepwise reduction in the need for revision surgery and rates that are much lower than in Canada and the United States. These improvements have been made possible by evidence-based practice guidelines, gleaned from the information in these national arthroplasty registries.7–10
In Ontario, a cooperative effort by the Ontario Ministry of Health and Long Term Care and the Ontario Orthopaedic Association was undertaken to pilot a provincial joint replacement registry.11 Southwestern Ontario was selected as the site for this pilot study because of its well-defined geography, population base (3.5 million people) and perceived high utilization rates. Funding was provided by the Ontario Ministry of Health and Long Term Care for 1 year. Three months were allotted to infrastructure set-up, 6 months to data collection and 3 months to data analysis. A computer company (Hewlett-Packard) agreed to supply hand-held computers (HP #650) to each participating surgeon, so that electronic and paper data collection might be compared for validation purposes. In this article we outline the methodology and results of the Southwestern Ontario Joint Replacement Pilot Project.
Materials and methods
The first steps were to develop a work plan and recruit orthopedic surgeon participants. A roll-out meeting was held, involving the pilot project leaders, participating surgeons, Ontario Ministry of Health and Long Term Care officials and hospital executives. Surgeons and allied health professionals were briefed on data collection, the use of the hand-held computers, electronic data transmission, the use of the secure custom-designed Web site and of add-on benefits (chat room, MEDLINE, electronic journals and “case of the week” continuing medical education). A field coordinator played a critical role in instructing and coaching surgeons on how to get immediate real-time feedback on data they submitted. The information collected is outlined in Fig. 1. Waiting time data, and referral to consult, consult to surgery and total waiting times were also collected and were available for viewing on the secure Web site. Individual surgeons could compare their performance to the aggregate performance of the study group.
Data collected electronically and in paper form by orthopedic surgeons, participants in the Southwestern Ontario Joint Replacement Pilot Project.
When data collection was concluded, data validation was performed comparing the paper records. Satisfaction surveys were mailed to all surgeons and to 100 randomly selected patients. The participating surgeons were surveyed concerning the relevance of the data collected and ease of using the hand-held computers. Patients were surveyed at 3 months as to their satisfaction with their joint replacement and care. Patients were also surveyed as to their preparedness to go home and their desire to be more involved with post-discharge planning. A final report was prepared, presented to the stakeholders and used to propose a province-wide registry.
Results
Eighteen out of 26 eligible surgeons participated. Reasons for non-participation included impending retirement (2 surgeons), a disabling health problem (1 surgeon) and concern about the time required for participation (3 surgeons).
The duration of data collection varied from 3 to 6 months for each surgeon. Winter weather and limited surgeon availability for training were the main impediments. Information was obtained on 815 arthroplasties (408 knees, 407 hips) (Table 1). Fig. 2 demonstrates the age distribution of the patient population.
The age distribution of the 815 patients assessed in the study. There is a wide range in age, but most patients are in the 60 to 90-year age group.
The Number of Total Hip and Knee Replacements Captured During the Study
Waiting time data (Fig. 3) were more complex than originally anticipated. In patients having primary hip or knee replacement, the times from referral to consult, consult to surgery and total waiting time were clear. But patients who were already part of an orthopedic surgeon’s practice (i.e., had already been seen and treated conservatively or by another joint replacement) were difficult to compare to new patients’ waiting times. Therefore, only the time from final consult to surgery could be determined in this subset of patients. Ten percent of patients waited under 5 weeks, 50% waited under 30 weeks and 90% waited under 59 weeks.
Total waiting times from referral to total hip or knee replacement surgery. There were 598 patients in this sample.
Concerning the relevance of the data collected and ease of using the hand-held computers, 17 of the 18 surgeons felt that the data were relevant and that the hand-held computers were easy to use.
Patients surveyed at 3 months concerning their degree of satisfaction with joint replacement and hospital care indicated a high level of satisfaction with both (Figs. 4 and 5). Ninety-eight percent indicated satisfaction with the results of their surgery. With respect to patients’ preparedness to go home and their desire to be involved with post-discharge planning, overall, they were happy with their discharge planning and expected this planning to be done for them.
Patient satisfaction with total hip or knee replacement. The survey response rate was 85%.
Patient satisfaction with hospital care for total hip or knee replacement. The survey response rate was 85%.
Comparison of electronic and paper data collection indicated that electronic data were substantially more timely, complete and accurate than paper records.
Discussion
The Southwestern Ontario Joint Replacement Pilot Project has demonstrated that a cooperative venture between a health care provider (the Ontario Ministry of Health and Long Term Care) and orthopedic surgeons under the umbrella of a provincial orthopedic association (the Ontario Orthopaedic Association) is possible. Patients benefit from evidence-based improvements in the quality of the results and a reduced need for revision surgery. Orthopedic surgeons benefit from comparing their practice patterns with their peers in terms of surgical technique, implant selection and outcomes. Health care providers benefit from improved total joint replacement quality, reduced revision surgery, help with waiting list management and guidance with regard to resource allocation. A business plan has revealed that if a provincial registry could reduce revision surgery by 10%, then funding of a province-wide joint replacement registry in Ontario would pay for itself. Indeed, if revision surgery rates were reduced by 50%, then a cost avoidance of $4.5 million would be achieved in Ontario alone.
Health care is not only a provincial concern but a national issue. Any provincial joint replacement registry should be part of a national endeavour. Health Canada has provided funding for a Canadian Joint Replacement Registry (CJRR) through the Canadian Institute of Health Information in cooperation with orthopedic surgeons, the Canadian Orthopaedic Association and the 7 provincial/regional orthopedic associations.11,12 The CJRR will present a high level overview of patient, surgical and implant data, using revision as an end-point. Provincial comparisons of patient access, surgery rates and revision will be possible. In addition, Health Canada will be able to identify which total hip or knee replacement is in which patient and be able to assure the safety of new technologies in the area of total joint replacement. The provincial registries will allow more timely, detailed analyses of the needs of an evergrowing arthritic population, especially in terms of patient prioritization, waiting list management, satisfaction, quality of life and resource allocation. Point-of-care electronic data collection and transmission should be encouraged. High level data should be transferred to the national CJRR, and more detailed information retained for timely evidence-based provincial decision-making. Provider and patient satisfaction surveys should be an integral part of any provincial initiative.
Important interactions with other databases (i.e., mortality registers and billing databases) and federally or provincially funded research groups (i.e., the Canadian Institute of Health Information and the Institute for Clinical Evaluative Studies) will greatly enhance such initiatives.
The time has come for electronic point-of-care data collection, particularly in high-volume, high-cost medical interventions such as total joint replacement. Such efforts should represent a partnership between the health care provider and practitioners. and will benefit the patients, practitioners and health care providers. The application of national registries to other medical and surgical conditions should be encouraged.
Acknowledgements
We wish to thank the Ontario Orthopaedic Association, Hewlett-Packard Company and the Southwestern Ontario Study Group. Members of this group include: Drs. James Allen and John Turnbull, Chatham; Drs. Robert Bourne, David Chess, Steve MacDonald, Richard McCalden, and Cec Rorabeck, London; Drs. Robert Kutcy, Robert Miller and Paul Moroz, Owen Sound; Drs. Pran Mehta, Peter Southcott and Ralph Pototschnik, Stratford; Drs. Garth Annisette, Stephen Bartol, Dana Fleming and George Koppert, Windsor; and Drs. Gordon Krueger and Robert Reid, Woodstock.
- Accepted May 15, 2000.
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