University Chairs Publish Less?!; Joint Registry Wins Best Poster; New Study: Patient Selection Boosts Outcomes

Chair Candidates Beware…Your Research May Decline

New research could help those seeking the position of chair to determine the future of their research. The article, “Publication Productivity of Orthopaedic Surgery Chairs,” was published in the June 21, 2017 edition of The Journal of Bone & Joint Surgery.

Boris A. Zelle, M.D., a co-author on the study, is an orthopedic surgeon at the University of Texas Health Science Center at San Antonio. The additional authors, Michael A. Weathers, M.D., Roberto J. Fajardo, Ph.D., Varan Haghshenas, B.S. and Bhandari, Mohit MD, Ph.D., are with the Division of Orthopaedic Surgery at McMaster University, Hamilton, Ontario, Canada. Dr. Zelle told OTW, “Journal publications are the currency of scholarly activity. Orthopaedic chairs are leaders within their field. Yet it is unclear how much scholarly activity leads to the nomination of a chair. Moreover, it has remained unclear how the scholarly activity develops after the nomination to chair.”

“A large database with more than 10,000 data points was created to analyze the publication productivity of orthopaedic chairs. This included information retrieved from multiple online databases.”

The authors wrote, “During the 7 years prior to their appointment to chair, the mean number of total publications was significantly higher for university chairs than for non-university chairs. The mean number of publications per year during the 7 years leading up to the chair position was 4.66 for the university chairs, and 2.29 for the non-university group.”

“While serving as chair, the mean number of publications per year significantly decreased among the university chairs to 3.75, whereas no significant change was observed among non-university chairs. The mean percentage of first authorships was not significantly different between university and non-university chairs. Both groups showed significant declines in first authorships while serving as chair.”

Dr. Zelle commented to OTW, “Chairs of university programs have published more papers than chairs of non-university based programs. However, the university chair decreases the publication productivity after his nomination whereas the non-university chair maintains his research productivity.”

“During the data collection, we learned that several program websites did not provide any information about the department chair. It was also surprising that the university chair decreases the research productivity after becoming chair. We expected that the number of publications would increase as we assumed that the greater access to resources would stimulate increased research productivity.”

“Orthopaedic surgeons seeking a chair position should be aware that the average university candidate has published approximately 60 papers, whereas the non-university chair has published 30. Also, chair candidates should be aware that most likely administrative and managerial responsibilities may interfere with subsequent research productivity. That said, we also identified several examples of university chairs, who actually increased their research productivity after their nomination.”

American Joint Replacement Registry Wins ISAR Best Poster

At the recent International Congress of Arthroplasty Registries one poster stood out from the rest.

The American Joint Replacement Registry (AJRR) walked away with the “Best Poster Presentation,” conferred by the International Society of Arthroplasty Registries (ISAR). The poster, “Infection burden in total hip and knee arthroplasty: an international registry based perspective,” was based on an original research article published in the June 2017 issue of Arthroplasty Today.

The authors wrote, “We evaluated publicly reported data from 6 arthroplasty registries (Australian Orthopaedic Association National Joint Replacement Registry [AOANJRR], New Zealand Joint Registry, Swedish Hip Arthroplasty Register, Swedish Knee Arthroplasty Register, National Joint Registry of England, Wales, Northern Ireland, and the Isle of Man, and the American Joint Replacement Registry) for revisions performed with an infection diagnosis over the last 6 years.”

“The 2015 hip infection burden varied between registries from 0.76% (AOANJRR) to 1.24% (Swedish Hip Arthroplasty Register), and the unweighted overall average for hip infection burden was 0.97%. In 2012, 2013, and 2014, average hip infection burden held steady at 0.87%, 0.93%, and 0.94%, respectively, higher than the preceding 2 years. The 2015 knee infection burden varied from 0.88% (AOANJRR) to 1.28% (Swedish Knee Arthroplasty Register), and the unweighted average was 1.03%. In 2012, 2013, and 2014, knee infection burden was 1.04%, 1.11%, and 1.02%, respectively. These numbers were also higher than the preceding 2 years.”

Bryan Springer, M.D., orthopedic surgeon at OrthoCarolina and secretary of the AJRR, told OTW, “As AJRR continues to grow each year, we are able to do more detailed analysis of implants and in particular failures rates and etiology of failure. Understanding and recognizing why implants fail and require revision is critical to improving on the success of total joint arthroplasty.”

“AJRR now has over one million procedures in the registry and growing daily.”

“Many of the international registries cited in this study have a long and rich history with excellent captures rates (>95%). These registries also allow for detailed analyses and serve as an early warning system for implants and or procedures with higher than expected failure rates.”

“The goal of AJRR is to capture ultimately >90% of hip and knee replacements done in the U.S. We are making great strides. As our numbers continue to grow, we will be able to compare and contrast ourselves with other international registries around the world. Both this study and a similar study by McGrory et al. published last year looking at revision burden are the first to look at data from AJRR comparing to other registries.”

“Periprosthetic joint infection (PJI) remains one of the most common failure modes in total hip and knee arthroplasty. As such, much attention has been paid over the past decade to reducing the incidence of PJI. This occurs through patient optimization and protocols designed to reduce the risk of surgical site infection (SSI) across the spectrum of care. Despite these measures, this study suggest that the incidence of PJI did not decrease over the time period of the study and continued efforts need to focus on the reduction of this failure mode.”

“At the end of this year, the AJRR is expected to have 30% of the U.S. hospitals and surgery centers participating in the registry, and another 10% growth is expected through 2018. We are in the middle of a three-year platform upgrade to be able to handle the growth and to provide solutions for all of our stakeholders including medical device manufacturers and individual surgeons.”

“Our upgraded platform allows for those institutions in CMS’ Comprehensive Care for Joint Replacement (CJR) metropolitan areas to be able to pull reports from the registry to be able to meet requirements for that program. Patient-reported outcomes (PRO) continue to be high on our radar. Registry participation includes a PRO platform that can facilitate a PRO program for participants that includes implementation, collection, storing, and reporting.”

“We also plan on populating the registry with Level II data that includes comorbidity information so we can risk adjust the data, allowing for a more robust dataset. Additionally, we are releasing our first-ever patient summary of our annual report so the public can better understand the findings and what it means for their care.”

Boost TKA, THA Outcomes by Improving Patient Selection

Researchers have shed more light on the interaction between preoperative health status and outcomes. Specifically, they have found that patients with diabetes and other comorbidities are much less likely to perceive a significant benefit from a total knee arthroplasty.

The study, “The New Surgical Technique for Improving Total Knee and Hip Arthroplasty Outcomes: Patient Selection,” was published in the July 2017 edition of The Journal of Arthroplasty.

Theresa Atkinson, Ph.D. with the Department of Mechanical Engineering at Kettering University in Flint, Michigan, and coauthor on the study commented to OTW, “The McLaren Flint Orthopedics Residency and the Ortho-Michigan groups have been collecting outcome data from their patients to better understand factors driving success or challenges after total joint arthroplasty. There was a lot of discussion between the groups about how factors like obesity or smoking might be influencing outcomes, based on published studies, but no clear answer for our local patient population. The study arose from these discussions.”

“At the same time we were preparing for participation in the Medicare ‘Comprehensive Care for Joint Replacement’ bundled payment program. In that program outcome measures factor into reimbursements. It seems that understanding factors driving patient satisfaction and functional outcome scores will be increasingly important in maintaining recognition that a practice provides quality medical care.”

“The study followed typical methods. Where it was somewhat different is that it focused on identifying simple methods a surgeon might use in their practice to identify high risk patients.”

The authors wrote, “After knee arthroplasty, women and younger patients achieved a clinically significant improvement in physical function more frequently than men and older patients. The largest differences in improvement occurred between the diabetic and nondiabetic groups, where the diabetic patients with ≥2 additional comorbidities demonstrated the lowest rate of achieving a clinically significant improvement in physical function and bodily pain. In comparison, in hip patients only age had significant influence on gains in physical function, but this did not alter the rate at which patients achieved a clinically significant improvement.”

Dr. Atkinson commented to OTW, “Factors like diabetes, especially when it comes with comorbidities, can significantly reduce the likelihood of a patient’s achieving a clinically significant improvement in physical function following a total knee. This is significant because diabetes is not included in the list of risk variables required to be reported in the Medicare Comprehensive Care program. In our sample group smoking did not have a strong influence, which was a surprise.”

“This work indicated that the mix of diabetes and significant comorbidities greatly reduces the likelihood that patients will perceive a significant benefit from a total knee arthroplasty. Efforts to optimize the patient’s health prior to surgery and provide realistic expectations may improve outcomes and patient satisfaction.”