K. I. Suchman, Icahn School of Medicine at Mount Sinai, New York, NY, USA J. Poeran, H.-H. Huang, M. Mazumdar, Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA M. Bronson, Mount Sinai West, Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA J. Poeran, H.-H. Huang, L. M. Galatz, C. S. Moucha, Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Clin Orthop Relat Res. 2019 Aug;477(8):1815-1824. doi: 10.1097/CORR.0000000000000635.
It is currently unknown to what extent routine histological examination of joint arthroplasty specimens occurs across hospitals nationwide. Although this practice is neither supported nor refuted by the available evidence, given the increasing demand for joint arthroplasties, it is crucial to study overall utilization as well as its main drivers.
QUESTIONS/PURPOSES: Using national data on joint replacements, we aimed to evaluate: (1) What is the current use of routine histological examination of joint arthroplasty specimens? (2) Does the use vary by geographic location and hospital characteristics? (3) Has use changed over time?
From the Premier Healthcare database (2006-2016) we included claims data from 87,667 shoulder (595 hospitals, median age 70 years, 16% nonwhite), 564,577 hip (629 hospitals, median age 65 years, 21% nonwhite), and 1,131,323 (630 hospitals, median age 66 years, 24% nonwhite) knee arthroplasties (all elective). Our study group has extensive experience with this data set, which contains information on 20% to 25% of all US hospitalizations. Included hospitals are mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). Moreover, the Premier data set has detailed billing information, which allows for evaluations of real-world clinical practice. There was no missing information on the main variables of interest for this specific study. We assessed frequency of histology examination (defined by Current Procedural Terminology codes) overall as well as by hospital characteristics (urban/rural, bed size, teaching status, arthroplasty volume), geographic region (Northeast, South, Midwest, West), and year. Given the large sample size, instead of p values, standardized differences were applied in assessing group differences where a standardized difference of > 0.1 (or 10%) was assumed to represent a meaningful difference between groups. For significance of trends, p values were applied. Percentages provided represent proportions of individual procedures.
In most hospitals, histology testing was either rare (1%-10%, used in 187 of 595, 189 of 629, and 254 of 630 hospitals) or ubiquitous (91%-100%, used in 121 of 595, 220 of 629, and 195 of 630 hospitals) for shoulder, hip, and knee arthroplasties, respectively. Overall, histology testing occurred more often in smaller hospitals (37%-53% compared with 26%-45% in larger hospitals) and those located in the Northeast (59%-68% compared with 22%-44% in other regions) and urban areas (32%-49% compared with 20%-31% in rural areas), all with standardized differences > 10%. Histologic examination is slowly decreasing over time: from 2006 to 2016, it decreased from 34% to 30% for shoulder arthroplasty, from 50% to 45% for THAs, and from 43% to 38% for TKAs (all p < 0.001).
Although overall use is decreasing, a substantial number of hospitals still routinely perform histology testing of arthroplasty specimens. Moreover, variation between regions and hospital types suggests that this practice is driven by a variety of factors. This is the first study addressing national utilization, which will be helpful for individual hospitals to assess how they compare with national utilization patterns. Moreover, the findings have clear implications for followup studies, which may be necessary given the exponentially growing demand for arthroplasties.
Level III, therapeutic study.
目前尚不清楚全国范围内有多少家医院会例行对关节置换手术标本进行组织学检查。尽管现有证据既不支持也不反对这种做法，但鉴于关节置换手术需求不断增加，研究其整体应用情况及其主要驱动因素至关重要。
问题/目的：我们利用全国范围内的关节置换数据，旨在评估：（1）目前对关节置换手术标本进行常规组织学检查的使用情况如何？（2）这种使用情况是否因地理位置和医院特征而有所不同？（3）使用情况是否随时间发生了变化？
从 Premier Healthcare 数据库（2006-2016 年）中，我们纳入了 595 家医院的 87667 例肩部（中位年龄 70 岁，16%为非白人）、629 家医院的 564577 例髋关节（中位年龄 65 岁，21%为非白人）和 630 家医院的 1131323 例膝关节（中位年龄 66 岁，24%为非白人）全膝关节置换术（均为择期手术）的理赔数据。我们的研究小组在使用这个数据集方面拥有丰富的经验，该数据集包含了 20%至 25%的美国住院患者信息。纳入的医院主要集中在南部（约 40%），东北部、西部和中西部的分布大致相同（各占约 20%）。此外，Premier 数据集具有详细的计费信息，这允许对真实世界的临床实践进行评估。对于本研究特定的主要变量，没有缺失信息。我们评估了组织学检查的频率（通过当前程序术语代码定义），包括整体情况以及医院特征（城市/农村、床位数、教学地位、关节置换量）、地理位置（东北部、南部、中西部、西部）和年份。由于样本量较大，在评估组间差异时，我们应用了标准化差异，当标准化差异>0.1（或 10%）时，认为组间存在有意义的差异。对于趋势的显著性，应用了 p 值。提供的百分比表示各个手术的比例。
在大多数医院，组织学检测要么很少（1%-10%，在 595 家医院中的 187 家、629 家医院中的 189 家和 630 家医院中的 254 家医院中使用），要么非常普遍（91%-100%，在 595 家医院中的 121 家、629 家医院中的 220 家和 630 家医院中的 195 家医院中使用），分别用于肩部、髋关节和膝关节置换术。总体而言，在较小的医院（37%-53%，而较大的医院为 26%-45%）和位于东北部（59%-68%，而其他地区为 22%-44%）和城市地区（32%-49%，而农村地区为 20%-31%）的医院中，组织学检测更常见，所有这些差异的标准化差异均>10%。组织学检查的频率正在缓慢下降：从 2006 年到 2016 年，肩部关节置换术从 34%下降到 30%，全髋关节置换术从 50%下降到 45%，全膝关节置换术从 43%下降到 38%（均 p<0.001）。
尽管总体使用率正在下降，但仍有相当数量的医院经常对关节置换手术标本进行组织学检查。此外，区域和医院类型之间的差异表明，这种做法是由多种因素驱动的。这是第一项针对全国范围内使用率的研究，这将有助于每家医院评估自己与全国使用率模式的比较。此外，这些发现对后续研究具有明确的意义，鉴于关节置换手术的需求呈指数级增长，可能需要进行这些研究。
III 级，治疗性研究。
