Kaiser Permanente National Implant Registries2019 Annual Report

Table of ContentsLeadership Message3Inter-Regional Implant Registries Committee Members4What We Provide5By the Numbers6National and International Collaborations7Highlights of a Transformative Care ModelInnovative Tools to Support Clinical Decision Making8Remote Monitoring for Cardiac Devices9Risk Factors for Opioid Use Following Surgery10Race & Orthopedic Surgical Outcomes11Updates from our RegistriesAnterior Cruciate Ligament Reconstruction13Cardiac Device15Endovascular Stent Graft17Hip Fracture19Shoulder Arthroplasty21Spine Surgery23Total Joint Replacement25Staff29Publications302Kaiser Permanente National Implant Registries

Leadership MessageDear Colleagues,We are honored to present the 2019 Kaiser Permanente National Implant Registries Annual Report whichhighlights the critical role of the implant registries in transforming quality of care using an evidence-basedmedicine approach.The registries monitor patient characteristics, surgical approaches, implant characteristics, and clinical outcomesfor more than 3.05 million cardiac, neurosurgery, orthopedic, and vascular implants for our 12.3 million members.Using this real-world data, the registries provide feedback to our frontline clinicians and staff to enhance patientcare and safety using a variety of methods including: Research studies and quality reporting tools to identify clinical best practices Benchmarking and quality reporting to monitor and identify medical center and regional variation in clinicaloutcomes Outlier implant reports to identify implants with higher and lower than expected clinical performance Patient-centered risk calculators to identify individualized patient risk and enhance clinical decision-making at thepoint of care Confidential physician profiles to benchmark clinical practices and outcomes at the medical center, regional andnational levelThese techniques have transformed care and enhanced patient quality as evidenced in our exemplary clinicaloutcomes.The success of the National Implant Registries is the direct result of the dedication and commitment of the KaiserPermanente physicians and staff who contribute to and use this evidence on a continual basis to guide clinicalpractice decisions.Thank you all for your important contributions and continued support enhancing patient safety and quality of carefor our members and patients worldwide.Liz Paxton, PhD, MADirector, National Implant RegistriesTadashi Funahashi, MDChair, Inter-Regional Implant Registries Committee3Kaiser Permanente National Implant Registries

Inter-Regional Implant RegistriesCommittee MembersIIRC MembershipScott H. Adelman, MD, FACCChair, Cardiology Core Group of National Product CouncilChair, NCAL Cardiovascular Technology CommitteeSenior Technology Advisor-Innovation and Advanced TechnologyRalph G. Brindis, MD, MPH, MACC, FSCAIClinical Professor of MedicineDepartment of Medicine & the Philip R. Lee Institute for Health Policy StudiesUniversity of California, San FranciscoPatrick Courneya, MDExecutive Vice President and Chief Medical OfficerKaiser Foundation Hospitals and Health PlanHospital Quality and Care Delivery ExcellenceChristopher M. Grant, BAExecutive Vice President and Chief Operating OfficerThe Permanente FederationJo Carol Hiatt, MD, MBAChair, National Product CouncilChair, Inter-Regional New Technologies CommitteeAssistant Medical Director, Southern California Permanente Medical GroupMurray N. Ross, PhDVice President and Director of Institute for Health PolicyKaiser Foundation Health Plan Enhancing Patient Safety and Quality of CareRonald A. Navarro, MDRegional Coordinating Chief of Orthopedic Surgery, Southern California Permanente Medical GroupAssistant Area Medical Director, Surgical and Perioperative ServicesLead, Kaiser Permanente Shoulder Arthroplasty RegistryMember at Large, Board of Directors, American Academy of Orthopedic SurgeonsEric Cain, MD, MBAPhysician-in-Chief, Fremont Medical CenterMargaret Mentakis, MD, FACSDepartment of Surgery, South SacramentoKaiser Permanente HealthConnect Procedural and Perioperative ServicesThe Permanente Medical Group Technology Leader4Kaiser Permanente National Implant Registries

What We ProvideRegistries play a critical role in enhancing quality of care by identifying variation and clinical best practices andproviding feedback to frontline staff and clinicians using a variety of dynamic feedback mechanisms.NATIONAL IMPLANT REGISTRIESWHAT WE PROVIDEIdentifying the most effectivesurgical techniques and implantdevices for quality improvement andsafetyIntegrating researchmethodologies withfacility level reporting tohelp support the growthof transformativecare modelMonitoringpatients withrecalledimplantsAssessing patientrisk factors forcomplicationsusing riskcalculators atpoint of care forclinical decisionmakingProviding confidential feedback tosurgeons on their patients’outcomesMonitoring outcomes, includingrevisions, re-operations, andcomplicationsTracking implant usage andperformance for contractdecision-making5Providing risk-adjustedhospital outcomes andbenchmarking forquality improvementKaiser Permanente National Implant Registries

National Implant Registries: By the Numbers8 regions, 9 states representing12.3 million members75 medical centers187 publications in peer-reviewed journals17 in 2018211 posters & presentations at national &international symposia2,566 participating surgeons110,026 patients with enhanced surveillance due to95 recalls from 2000-2018690,000 procedures captured and tracked forthe patient’s lifetime3.05 million implants registered6Kaiser Permanente National Implant Registries

National and International Collaborations Full member and President of International Society ofArthroplasty Registries (ISAR) focused on enhancingarthroplasty registries’ collaboration to improve globalarthroplasty outcomes Leading along with Cornell the USA OrthopaedicCoordinated Registries network (OrthoCRN) toenhance postmarket surveillance in the USA Member of The Medical Device EpidemiologyNetwork (MDEpiNet), a global public-privatepartnership advancing the use of real-world data toimprove patient outcomes7 National Evaluation System for Health Technology(NEST) pilot project developing objective performancecriteria for arthroplasty devices in the USA Anterior Cruciate Ligament Reconstruction (ACLR)registry international collaborations with Denmark,Luxembourg, Norway, Sweden, Australia, NewZealand, and the United Kingdom Shoulder Arthroplasty Registry (SAR) internationalcollaborations with Denmark, Australia, and SwedenKaiser Permanente National Implant Registries

Highlights of a Transformative Care ModelInnovative Tools to Support Clinical Decision MakingRisk calculators, facility specific reports, andsurgeon profiles are among the innovative toolsthat use registry data to support clinical decisionmaking.Risk calculators enable implanting surgeons topredict surgical outcomes for current patients. “I nowuse the risk calculators to assess my patients prior tosurgery similar to the way I use radiographs, clinicalexams, and lab work to determine the best pathforward for each patient,” said orthopedic surgeonAdrian Hinman, MD, San Leandro Medical Center.“Risk calculators help me weigh the risks and benefitsof both operative and non-operative treatments andtailor my recommendation to each patient.”Facility specific reports clearly identify medicalcenters with outlying performance to create anopportunity for benchmarking and shared learnings.Once identified as an outlier a deep dive into theunderlying reasons as to why a variability in practiceor outcomes is occurring is reviewed. “There are veryfew other organizations that have this commitment tocollecting data on quality,” said Christopher Grimsrud,MD, PhD, Chief of Orthopedics, Kaiser East Bay8Medical Centers. Conversely, facilities demonstratingabove average performance are clearly identified aslikely sources of best practice learnings. In this wayDr. Grimsrud explains, “the registries are extremelyvaluable in improving care for our patients.”Surgeon profiles serve as confidential report cardswhich enable surgeons to identify specific areas withoutlying performance they can then target for practiceimprovement. “This gives surgeons an opportunity toreach out to their partners for advice and support,”said Dr. Grimsrud.In Dr. Grimsrud’s experience, his surgeon profileprovides an added benefit. “I was one of the firstsurgeons to start doing direct anterior approach totalhip replacement in Northern California. The reportenabled me to track my results and inform my patientsthat they could expect good outcomes from surgerywith me.”Risk calculators, medical center reports, and surgeonprofiles provide real world feedback to clinicians andstaff to enhance quality of care.Kaiser Permanente National Implant Registries

Highlights of a Transformative Care ModelRemote Monitoring for Cardiac Devices Allows for Round-the-Clock Diagnosis Ensuring DeviceFunctionality and Increased Patient CareTraditionally, patients with cardiac implantableelectronic devices (CIEDs) needed to arrangea clinic or hospital visit every three months toensure their device was performing properly. Now,through the capabilities of remote monitoring onevisit per year is sufficient for most patients.Remote monitoring is a function of KaiserPermanente’s Cardiac Device Registry whichevaluates and monitors device performance andpatient outcomes. With its ability to report patientlevel information to clinicians and front-line staff,remote monitoring enrollment rates have increasedby over 20% program-wide since 2017, allowing forthe continuous care of nearly 94% of all of KaiserPermanente’s CIED patients.“Patients get all the advantages of monitoring withouthaving to come in for routine device interrogation,”said Nigel Gupta, MD, Director, Regional CardiacElectrophysiology Services, Los Angeles MedicalCenter. “We can now tell remotely how each patient’s9device is performing on a round-the-clock basis andfrom wherever they happen to be.”Many problems that may formerly have goneundetected for weeks or longer are now being caughtin real time. “Earlier detection is the key to preventingserious complications,” said Dr. Gupta. “For example,remote monitoring enables us to quickly detect abroken lead in a device so we can get our patientinto the operating room right away and fix it. Whenwe detect an arrhythmia, we can often resolve theproblem with a medication change right over thephone and thus prevent a bad outcome like stroke oreven heart failure.”Kaiser Permanente is currently working to get everypatient with a CIED linked to a remote monitoringdevice and enrollment rates are on the rise. “Therereally isn’t a patient who should not have remotemonitoring,” said Dr. Gupta. “This is a great use oftechnology to provide better, more efficient, lifesaving care.”Kaiser Permanente National Implant Registries

Highlights of a Transformative Care ModelRisk Factors for Opioid Use After Shoulder Arthroplasty and Anterior Cruciate LigamentReconstructionOpioid misuse and abuse have contributedto a significant national crisis, yet opioidsremain an important component in relievingpain after orthopedic surgery. Studies conductedusing Kaiser Permanente registry data are helpingorthopedic surgeons identify patients at risk ofprolonged opioid use in order to help ensure the safeand proper use of these medications.As reported in the 2018 National Implant RegistriesAnnual Report, studies looking at the effects ofopioids before and after total joint replacement ledto the implementation of strategies to reduce unsafeusage.Registry studies have also been conducted toidentify the risk factors for opioid use followingshoulder arthroplasty and anterior cruciate ligamentreconstruction. “These studies have helped create anawareness of risk factors we did not have objectivelybefore,” said orthopedic surgeon, Anita Rao,10MD, Kaiser Permanente Northwest Region. “Thisawareness is affecting how we prescribe opioids topatients.”Registry study results are regarded as very importantin supporting clinicians in the opioid crisis by providingobjective data and risk factors that can be used inclinical decision-making and in setting appropriateexpectations with patients. The studies also helpcreate protocols and multi-modal treatment planswithin the Kaiser Permanente organization that canbenefit both patients and providers.“The heightening interest in what we could do assurgeons to help combat the opioid crisis were keydrivers for these studies,” said Dr. Rao. “The increasedawareness about prescription opioid usage, aidedby opioid data from the registry studies, has helpedproduce early changes in prescribing habits that weanticipate will produce appreciable reductions inopioid usage in the perioperative period.”Kaiser Permanente National Implant Registries

Highlights of a Transformative Care ModelAssociation Between Race/Ethnicity and Orthopedic Surgical Outcomes Within a UniversallyInsured PopulationUnequal access to health care is among themost commonly cited reasons for racial andethnic disparities. Prior studies have shownthat universal access may mitigate some racialdisparities in surgical outcomes.Kaiser Permanente’s universally insured care modeloffers a unique opportunity to investigate whetherracial/ethnic disparities exist within its managed healthcare system in which all patients have uniform accessto care. “We wanted to see if our Kaiser Permanentesystem fundamentally treated disparities differentlysince the access to care should be easier,” said RonaldNavarro, MD, Regional Chief of Orthopedics, SouthBay Medical Center.Kaiser Permanente conducted multiple studies acrossits orthopedic registries looking at surgical outcomesbased on race and ethnicity in a large managed healthcare system in which all patients are insured. Study11results suggest that, depending on the type of surgery,nonwhite races have better outcomes in most cases,however, “In some studies, our black patients hadnotably higher rates of ED visits and readmissions,”said Dr. Navarro. “Further investigation is warrantedto determine reasons for this disparity and identifyinterventions.”The National Implant Registries’ studies build on agrowing body of evidence showing that universalaccess to insurance, integrated health care delivery,and standardization of quality may be central ineliminating race and ethnic disparities.“By first studying if disparities exist, even in a systemthat lessens the burden to access care, we can knowif there are opportunities for improvement,” said Dr.Navarro. “We can then work to lessen disparity if itexists and increase awareness of any biases that mightget in the way of equitable care.”Kaiser Permanente National Implant Registries

Updates from our Registries12Kaiser Permanente National Implant Registries

Anterior Cruciate Ligament Reconstruction RegistryDescription:The anterior cruciate ligament reconstruction(ACLR) registry was established in 2005 andtracks implants and outcomes of ACLR cases.As of year-end 2018, there were 49,204 casesin the ACLR registry.Clinical Findings In our cohort of 19,059 patients with primary ACLR,tibial independent (TI) techniques were used for12,342 (64.8%) of the ACLRs, and the transtibial(TT) method was used for 6,717 (35.2%). Afteradjustments for covariates, the TI group had a higherrisk of aseptic revision than the TT group, and thisrisk was 1.41 times higher in patients younger than22 years specifically. No difference in risk for asepticreoperation was observed. (Tejwani et al. 2018) In our combined cohort of 101,125 primaryACLRs across six national, regional, and hospitalbased ACLR registry cohorts including Denmark,Luxembourg, Norway, Sweden, the UK, and KPpatient demographics and surgical characteristicswere observed to understand variation across13countries. In all six cohorts, males and soccer injurieswere most common. European countries mostly usedautografts while allograft was most common in theUS. Interference screw was the most frequent femoralfixation in Luxembourg and the US, and suspensoryfixation was more frequent in the other countries.Interference was the most frequent tibial fixationtype in all six cohorts. Overall adverse events wereinfrequent. (Prentice et al. 2018) In our cohort of 6,593 primary ACLRs four femoraltibial fixation groups were observed to evaluate therisk of aseptic revision and reoperation after hamstringautograft ACLR: crosspin, interference, suspensory, orcombination. After adjusting for covariates, revisionrisk was lower for the crosspin-interference andinterference-interference methods compared to thesuspensory-interference. In contrast, reoperation riskwas higher for crosspin-interference and suspensorycombination methods compared to suspensoryinterference. (Spragg et al. 2018)Registry Champions: Gregory Maletis, MD, Tadashi Funahashi,MD, Anita Rao, MD, Mark Shaieb, MD, Ron Wyatt, MD, AnneDenys, MD, Mark Davies, MDKaiser Permanente National Implant Registries

Anterior Cruciate Ligament Reconstruction RegistryAnterior Cruciate Ligament ReconstructionKP Compared To BenchmarksKaiserPermanenteDanish CruciateLigamentRegisterNorwegianNational KneeLigament RegisterSwedishNational ACLRegisterStart DateFeb-05Jul-05Jun-04Mar-05Total N49,20433,35025,62444,465Primaries43,480 (88.4)28,677 (86.3)23,337 (91.1)41,500 (93.3)Revisions5,724 (11.6)2,793 (8.4)2,287 (8.9)2,965 (6.7)30,254 (61.5)18,950 (38.5)20,047 (60.1)13,303 (39.9)13,179 (56.5)10,158 (43.5)25,380 (57.1)19,085 (42.9) 2521,916 (44.5)14,741 (44.2)10,328 (44.3)21,956 (49.4) 2527,286 (55.5)18,609 (55.8)13,009 (55.7)22,509 (50.6)Total Reoperations4,783 (11.0)Not reported1,498 (6.4)Not reportedIpsilateral KneeReoperations3,303 (7.6)Not reported769 (3.3)Not reportedContralateral KneeOperations1,480 (3.4)Not reported729 (3.1)2,006 (4.8)Revisions100 persons-yrs1,695 (3.9)Not reported1,105 (4.7)2,221 (5.4)1 year incidence0.84Not reported0.84Not Reported3 year incidence1.21Not reported1.19Not ReportedGenderMalesFemalesAge years(at time of surgery)Outcomes14Kaiser Permanente National Implant Registries

Cardiac Device RegistryDescription:The cardiac device registry was established in2000, and tracks pacemakers (PM), implantablecardioverter defibrillators (ICD) and cardiacresynchronization therapy (CRT). As of Q42018, there are 136,857 devices in the registry(98,836 initial and 38,021 replacements).Clinical Findings Battery Longevity: In 65,261 patients: CRT-D 6%,ICD 15% and PM/CRT-P 79% the 10-year incidenceof battery replacement of old generation (OG 20002007) and new generation (NG 2008-2017) wasreduced in CRT-D (46 to 39%), ICD (41 to 31%),and PM/CRT-P (29 to 18%). 10-year total mortalityof OG and NG was similar at 75% for CRT-D, 71%for ICD, and 67% for PM/CRT-P. Death before anyreplacement was increased in CRT-D (41 to 50%), ICD(45 to 55%), and PM/CRT-P (54 to 61%). With NGdevices, only 44% patients in CRT-D, 38% in ICD, and23% in PM/CRT-P get to their second device beforedeath despite stable overall mortality. Conclusions: NG device longevity and need forreplacement due to malfunction has improved withfewer consequent surgeries. Investments into batterylongevity may be better used for other endeavors thathelp prolong patient survival so they can obtain fullbenefit from these life-saving yet costly devices.15 Device Revisions: The registry tracks all devicesundergoing a procedure to explant or replace thedevice for any reason. Normal battery depletion(ERI) is an expected replacement procedure. Deviceexplant reasons other than ERI include: prematurebattery depletion, device upgrade/downgrade,mechanical complication of the pulse generator,mechanical complication of a lead, infection, devicerecall/advisory, pocket erosion/device migration,pocket pain, and other patient anatomy issues. Datais available for quality reporting, research, and medicalcenter specific requests. The overall complication ratefor devices, excluding normal ERI, implanted from2007-2018 is noted on the next page. Lead Revisions: The registry tracks all leadsundergoing a procedure to replace, reposition, orrepair the lead due to a mechanical malfunctionincluding: lead dislodgement, perforation, conductorfracture, insulation failure, high/low thresholds,oversensing, undersensing, non-capture, extracardiacstimulation, and lead noise. The overall complicationrate for leads implanted from 2007-2018 are found onthe following page.Registry Champions: Nigel Gupta, MD, Cesar Alberte-Lista,MD, Jason Rashkin, MD, Brant Liu, MD, Jitesh Vasadia, MD,Rasoul Mokabberi, MDKaiser Permanente National Implant Registries

Cardiac Device RegistryRegistry Volume By Device Type CRT-P11,2491,295—12,544CRTsOverall Complication Rate, For Devices (excluding normal ERI) (2007-2018)DeviceTotal VolumeComplication% Complication 72.58PacemakerLeadlessICDCRTOverall Complication Rate, For LeadsFunctionTotal VolumeComplication Volume% Complication Rate102,5382,0121.96Heart 2018)Kaiser Permanente National Implant Registries

Endovascular Stent Graft RegistryDescription:Established in 2010, the endovascularstent graft registry has effectively trackedthe deployment and ensured outcomessurveillance of graft devices used inendovascular aneurysm repair (EVAR)procedures for the repair of abdominal aorticaneurysm (AAA). By the end of 2018, theregistry monitored 4,499 primary and 469revision procedures.Clinical Findings Registry findings have highlighted the clinicalimportance of evaluating pre-surgical aneurysm sizewhen assessing the need for an EVAR procedure,including pre-surgical surveillance and tracking ofaneurysm size prior to an EVAR procedure. Of the4,499 EVAR cases captured in the registry, the mostcommon aneurysm size was 5.0-5.59 cm (31.8%). Inprevious years, the most common procedure groupwere those patients with 6 cm aneurysm size.17 Tracking of EVAR procedure outcomes, includingsubsequent related procedures (revisions, secondaryinterventions, and conversion to open repair),is an important role of the registry. The registryidentified endoleak as the most common reason forreintervention (14.8%). Revision of the stent graftoccurred in 5.1% of all cases. The most common hospital length of stay for EVARpatients is 0 to 1 days (60.3% of patients) with the nexthighest length of hospital stay being 2 days (17.9%).Device Recall Registry support for surgeons continued in responseto the advancement of a AAA device Safety Advisory,into a Class I medical device recall. The recall was dueto higher than anticipated type III endoleaks events.The registry promptly identified patients at risk,providing Kaiser Permanente surgeons and medicalcenters a roster of patients with affected implants,ensuring patients receive appropriate post-marketsurveillance of their device and treatment as needed.Registry Champions: Jeffrey Hsu, MD, Nicolas Nelken, MD,Thomas Rehring, MD, Homayon Hajarizadeh, MD, RobertChang, MDKaiser Permanente National Implant Registries

Endovascular Stent Graft RegistryStent GraftKP Compared To BenchmarksStudyTotal PatientVolumeabcKaiserPermanenteTotal PatientVolumeStudyMean F/UTimeKaiserPermanenteStudyMean F/UTimeEstimatedEvent Rateat 2 YearsKaiserPermanenteEstimatedEvent Rateat 2 Years (95% CI)Type 1 endoleak17,0681712.13.833.392.64 (2.18-3.2)Type 2 endoleak17,900 a1561.84 a3.8313.04 a2.35 (1.91-2.89)Type 3 endoleak16,116751.873.830.760.80 864.91 (4.27-5.65)Cumulativeendoleakexcluding type 213,6362361.883.835.673.26 (2.75-3.88)Re-interventionRate21,595 b6702.26 b3.8311.12 b10.78 (9.86-11.79)Adjusted for the proportion of male patients.Adjusted for median patient age and mean aneurysm size.A Class I medical device recall has been issued for the device contributing to increased Type 3 endoleak event rate within theKP patient population.Eur J Vasc Endovasc Surg (2018) 55, 177-18318Kaiser Permanente National Implant Registries

Hip Fracture RegistryDescription:Established in 2009, the hip fracture registrytracks surgery of the proximal femur. As ofDecember 2018, 49,853 primary hip fracturecases and 1,823 revisions are tracked.Clinical Findings: A study to assess whether racial and ethnic disparitiesin hip fracture treatment and outcomes persist withina universally insured population of patients enrolledin an integrated managed care system with equalaccess and/or standardized protocols, found thatpostoperative mortality rates were similar across racialand ethnic groups. Compared to white patients,1-year mortality was similar among black patients,and lower among Hispanic and Asian patients. Blackand Hispanic patients had fewer 90-day postoperativecomplications, compared to white patients. Asianpatients had fewer in-hospital decubitus ulcers and90-day unplanned readmissions, but black patientshad more 90-day unplanned readmissions. There wereno significant differences between racial/ethnic groupsin terms of surgical delay and no differences in 90-dayemergency department visits or revisions during thepatient’s lifetime. (Okike et al. 2018)19 Choice of anesthesia technique can affect in-hospitaloutcomes for fragility hip fracture surgeries andRegional Anesthesia (RA) may offer advantages overGeneral Anesthesia (GA). Compared to RA, GA wasassociated with higher risk of in-hospital mortalityand shorter time to in-hospital mortality. Patientswith Conversion (Cv) from RA to GA experienced thehighest in-hospital mortality and shortest time to inhospital mortality. In addition, compared to RA, GAwas associated with longer time to discharge andmore discharges to a health care facility. (Qiu et al.2018) A study of the association of anesthesia technique tomortality and complications within 90 days of surgeryfor geriatric patients with hip fractures, found that RAwas associated with an overall lower risk of mortalityand all-cause readmission when compared with GA.During the inpatient stay period, mortality was higherfor both GA and Cv from RA to GA. In the periodfrom hospital discharge to 90 days postoperatively,no differences in mortality were observed, howeverpatients undergoing GA had a higher risk for 90day all-cause readmission, while no difference wasobserved between Cv and RA 90-day all-causereadmissions. (Desai et al. 2018)Registry Champions: Christopher D Grimsrud, MD, PhD, JamesM Jackman, MD, Kanu M Okike, MD, Gary L Zohman, MDKaiser Permanente National Implant Registries

Hip Fracture RegistryHip FractureKP Compared To BenchmarksKaiser n &New ZealandSwedenNorwayPeriodHistoric: 2009-2018Current: 2018Historic: 2007-2017Current: 2017Historic: 2012-2017Current: 2017Historic: 2013-2017Current: 2016-2017Historic: 2005-2017Current: 2017Historic: 2005-2017Current: 2017CasesHistoric: 49,853Current: 5,987Historic: Not ReportedCurrent: 65,958Historic: 13,500Current: 3,497Historic: 8,697Current: 5,178Historic: 75,313Current: 6,033Historic: 104,993Current: 8,32168.3%Not Reported71%AUS: 70% / NZ: 69%Not Reported69%80AUS: Mean: 82Median: Male 83,Median: Female: 85NZ: Mean: 83Median: Male 85Median: Female: 85Male: 80Female: 82Overall: 80Female: 82Male: 77Not Reported84.8% 48 hoursMean: 23 hoursMedian: 21 hoursFemaleMeanAgeTime toSurgeryLengthof StayRevisionRateMortality20Male: 76Female:80Not ReportedMean: 24.7 hours92.6% 48 hoursMean: 33 hours70.2% 36 hours72% 48 hoursAUS:Median 29 hoursNZ:Median 24 hoursMean: 4.2 daysMean: 15.6 daysMean: 20 daysMedian: 13 daysAUSMedian 7.7 daysNZMedian: 5.8 daysNot ReportedNot Reported1.8%Not Reported1% 30 daysNot Reported4.9%Reoperation: 9.7%9.8% 90 days6.9% 30 daysNot ReportedInpatient: 5%15-20% 1 yearpost discharge90 dayMale: 15%Female: 8%Not ReportedKaiser Permanente National Implant Registries

Shoulder Arthroplasty RegistryDescription:The shoulder arthroplasty registry (SAR),established in 2005, tracks elective and urgentshoulder arthroplasty procedures including totalshoulder arthroplasty (TSA), reverse total shoulderarthroplasty (RTSA), hemiarthroplasty (HA) andhumeral head resurfacing (HHR). As of year-end2018, the SAR has captured 19,083 primaryshoulder procedures.Clinical Findings In 2015, RTSA utilization for the treatment of proximalhumerus fractures surpassed that of HA for thefirst time within Kaiser Permanente’s health caresystem. The utilization of RTSA for the treatment ofproximal humerus fractures increased from 4.5% ofarthroplasties in 2009 to 67.4% of arthroplasties in2016, an almost 1400% increase. While HA appears tobe falling out of favor in the treatment of fractures ofthe shoulder, surgeons may still be preferentially usingthe procedure in younger patients. (Dillon et al. 2019)21 In our cohort of 510 revision shoulder arthroplasty (SA)procedures 69 (13.5%) had a subsequent re-revisionSA procedure. Instability was the primary reason forfirst revision (24.1%) and re-revision (43.5%). Instabilityfor the first revision was associated with a higher risk ofre-revision within 3-months post-revision. Conversionof primary TSA or HEMI to RTSA was associatedwith a lower risk of re-revision when compared to noconversion procedure. (Dillon et al. 2019) In our cohort of 5,009 primary SA patients,bisphosphonate use more than one year prior to theindex SA procedure was associated with higher asepticand all-cause revision risks. (Budge et al. 2019)Registry Champions: Ronald Navarro, MD, Mark Dillon, MD,Mark Shaieb, MD, Matthew Budge, MD, Anita Rao, MDKaiser Permanente National Implant Registries

Shoulder Arthroplasty RegistryShoulder ArthroplastyKP Co

Remote monitoring is a function of Kaiser Permanente’s Cardiac Device Registry which evaluates and monitors device performance and patient outcomes. With its ability to report patient level information to clinicians and front-line staff, remote monitoring enrollment rates have in