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Should high-risk patients seek out care from high-volume surgeons?
Jeremiah Thomas1, Itay Ashkenazi1,2, Kyle W Lawrence1
1Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA.
Insights
High-volume surgeons performing total hip arthroplasty (THA) on patients with high comorbidity burden (HCB) lead to fewer complications and shorter hospital stays. Referring HCB THA patients to high-volume surgeons can reduce risks and improve outcomes.
Area of Science:
- Orthopedic Surgery
- Arthroplasty Research
- Patient Outcomes
Background:
- Patients with high comorbidity burden (HCB) experience similar quality of life improvements after total hip arthroplasty (THA) but may face higher surgical risks.
- The impact of surgeon volume on THA outcomes for HCB patients remains under-investigated.
- Understanding surgeon volume's role is crucial for optimizing care for complex THA patients.
Purpose of the Study:
- To compare complication rates and implant survivorship in HCB patients undergoing THA by high-volume (HV) versus non-high-volume (non-HV) surgeons.
- To evaluate the influence of surgeon experience on postoperative outcomes in a high-risk THA population.
Main Methods:
- Retrospective review of 1,134 HCB patients (Charlson Comorbidity Index ≥ 5, ASA grade III/IV) undergoing primary elective THA between 2013-2021.
- Patients were stratified into HV (top 25% of surgeons by annual THA volume) and non-HV groups.
- Propensity-matched analysis compared 90-day readmissions, revisions, and implant survivorship using Kaplan-Meier methods.
Main Results:
- High-volume surgeons demonstrated significantly shorter surgical times and lengths of stay compared to non-HV surgeons.
- The HV group experienced significantly fewer 90-day readmissions, all-cause revisions, and septic revisions.
- Kaplan-Meier analysis revealed significantly greater freedom from all-cause and septic revision in the HV group.
Conclusions:
- Total hip arthroplasty patients with a high comorbidity burden treated by high-volume surgeons exhibit reduced 90-day readmissions, fewer revisions, and shorter hospital stays.
- Referral of HCB THA candidates to high-volume surgeons is recommended to mitigate procedural risks and enhance postoperative results.
- Surgeon volume is a significant factor in optimizing outcomes for complex THA cases.
Aims:
Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons.
Methods:
Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period.
Results:
Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group.
Conclusion:
The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.
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