Association between hospital and surgeon procedure volume and the outcomes of total knee replacement
Related Experiment Videos
Jeffrey N Katz1, Jane Barrett, Nizar N Mahomed
1Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA 02115, USA. jnkatz@partners.org
Insights
Higher hospital and surgeon volume for total knee replacement is linked to fewer patient complications and lower mortality rates. Choosing high-volume providers can improve outcomes for patients undergoing this procedure.
Area of Science:
- Orthopedic Surgery
- Health Services Research
- Patient Outcomes
Background:
- Previous studies show inverse association between procedure volume and mortality/complications in cardiovascular and oncologic surgery.
- The impact of hospital and surgeon volume on total knee replacement (TKR) outcomes is less understood.
Purpose of the Study:
- To investigate the association between annual hospital and surgeon volume and perioperative outcomes following primary total knee replacement (TKR).
Main Methods:
- Analysis of Medicare claims data for elective primary TKR between January 1 and August 31, 2000.
- Hospital and surgeon volumes defined by the number of primary and revision TKRs performed annually.
- Examined associations between volume and 90-day postoperative mortality and complication rates (infection, pulmonary embolism, myocardial infarction, pneumonia).
- Adjusted analyses for patient demographics, comorbidities, and socioeconomic factors; also adjusted for the other volume measure (hospital for surgeon, surgeon for hospital).
Main Results:
- Hospitals with >200 annual TKRs had lower risks of pneumonia (OR, 0.65) and any adverse outcome (OR, 0.74) compared to those with ≤25 annual TKRs.
- Surgeons performing >50 annual TKRs had lower risks of pneumonia (OR, 0.72) and any adverse outcome (OR, 0.81) compared to those performing ≤12 annual TKRs.
- Low-volume providers (hospitals ≤25 TKRs/year, surgeons ≤12 TKRs/year) accounted for 11% and 25% of procedures, respectively.
Conclusions:
- Higher hospital and surgeon volume in total knee replacement is associated with reduced perioperative adverse events.
- Patients and clinicians should consider procedure volume when selecting surgeons and hospitals for TKR.
- Findings support policy discussions on regionalizing total joint replacement to high-volume centers.
Background:
The annual volume of major cardiovascular and oncologic procedures performed in hospitals and by surgeons has been inversely associated with the rates of perioperative mortality and complications. The relationship between hospital and surgeon volume and perioperative outcomes following total knee replacement has received little study.
Methods:
We analyzed claims data for Medicare patients who had elective primary total knee replacement between January 1 and August 31, 2000. Hospital and surgeon volumes were defined as the number of primary and revision total knee replacements performed in the hospital or by the surgeon in Medicare recipients in 2000. We examined the associations between the annual volumes of total knee replacement performed in the hospitals and by the surgeons and the rates of mortality and complications (infection, pulmonary embolus, myocardial infarction, or pneumonia) in the first ninety days postoperatively. The analyses were adjusted for age, gender, comorbid conditions, Medicaid eligibility (a marker of low income), and arthritis diagnosis. Analyses of hospital volume were adjusted for surgeon volume and vice versa.
Results:
Twenty-five percent of the primary total knee replacements were done by surgeons who performed twelve of these procedures or fewer in the Medicare population annually, and 11% were done in hospitals with an annual volume of twenty-five of these procedures or fewer. Compared with the patients who had a primary total knee replacement in hospitals with an annual volume of twenty-five procedures or fewer, those managed in hospitals with an annual volume exceeding 200 procedures had a lower risk of pneumonia (odds ratio, 0.65; 99% confidence interval, 0.47 to 0.90) and any of the adverse outcomes examined (death, pneumonia, pulmonary embolus, acute myocardial infarction, or deep infection) (odds ratio, 0.74; 99% confidence interval, 0.60 to 0.90). Similarly, patients who had a primary total knee replacement done by surgeons who performed more than fifty such procedures in Medicare recipients annually had a lower risk of pneumonia (odds ratio, 0.72; 99% confidence interval, 0.54 to 0.95) and any adverse outcome (odds ratio, 0.81; 99% confidence interval, 0.68 to 0.98) compared with patients of surgeons with an annual volume of twelve procedures or fewer.
Conclusions:
Patients managed at hospitals and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events following primary total knee replacement. Patients and clinicians should incorporate these findings into discussions about selecting a surgeon and a hospital for total knee replacement. These data should also be integrated into the policy debate about the advantages and drawbacks of regionalizing total joint replacement to high-volume centers.