Outcome assessment of total hip arthroplasty in The Netherlands and Sweden

From the studies described in this thesis, investigating different aspects of outcome assessment in total hip arthroplasty, the following conclusions and recommendations can be made: To ensure good quality of life and adequate mobility for future elderly generations, adequate measures need to be taken to respond adequately to the increasing demand for THA, for instance with regard to future budgets for THA, the use of cost-effective prosthesis systems and training of surgeons and other medical personnel. The revision burden of THA (Total Hip Arthroplasty) in the Netherlands is relatively high compared to the Scandinavian countries. Apart from figures from a discharge registry and an implant registry with compliance less than 60% and no possibilities for follow-up, there is no registration system for THA in the Netherlands. In spite of problems with liability, compliance, cost and confidentiality with the introduction of a register, new efforts should be undertaken within the Dutch orthopaedic community to start nation-wide orthopaedic registries. Such registries should serve both as a database to study outcome after surgery and as a benchmarking tool for all participating clinics. The moderate to good compliance to existing recommendations for the indication for THA found in our survey of Dutch and Swedish orthopaedic surgeons shows the applicability of these recommendations in clinical practice. However, we found that patients in a later phase of the disease process did not improve to the level achieved by patients with a better preoperative function. Therefore, traditional orthopaedic practice, to delay surgery as long as possible, might need to be re-evaluated, especially for elderly patients. Clinical guidelines on THA, based on review of clinical evidence and involving cost-effectiveness and patient preference, should be established in both The Netherlands and Sweden. Apart from consensus statements, no such guidelines exist in either country. Because of the multiple risk factors found for re-revision for both septic and aseptic loosening, and the relatively low annual number of revisions for infection, the findings of our study on revisions for infection from the Swedish National Hip Registry might be a reason to centralize these difficult treatment procedures in specialized clinics. This would also improve adequate monitoring of the type and resistance patterns of bacteria found in these infections. Development of resistant bacteria is a worrisome trend in medicine in general and especially in the vulnerable group of patients with an artificial joint. Future research in prevention and treatment of this devastating complication is needed to maintain the high percentages of patients with excellent outcome after THA. Long waits for THA cause considerable loss in quality-adjusted life years for patients involved and thus impose an avertable burden of disability. With regard to the waiting list problem that still exists in orthopaedic surgery in The Netherlands and Sweden, especially for joint replacements, new approaches for managing waiting lists should be followed. These include reducing demand for the procedure by audits of waiting lists and reassessment of patients on the lists. Further, prioritization of patients on the waiting list based on clinical urgency is a strategy used in other countries. Lastly, reorganization of care patterns such as redirection of referrals to clinicians with shorter waiting lists, reduction of missed appointments and reduction of specialist physician follow-up visits are possibilities to improve access to a medical procedure like THA. In this thesis, several aspects of outcome assessment in total hip arthroplasty were investigated. We should strive for continuous quality improvement of the procedure, by following and adapting practice guidelines based on patient oriented outcome measures and population studies, to use available health care resources in an optimal way and to guarantee best quality care to our patients