Centralization and the relationship between volume and outcome in knee arthroplasty procedures

Australian Safety and Efficacy Register of New Interventional Procedures-Surgical, Royal Australasian College of Surgeons, Adelaide, Australia.
ANZ Journal of Surgery (Impact Factor: 1.12). 04/2010; 80(4):234-41. DOI: 10.1111/j.1445-2197.2010.05243.x
Source: PubMed


Centralization aims to reduce adverse patient outcomes by concentrating complex surgical procedures in specified hospitals.
This review assessed the efficacy of centralization for knee arthroplasty by examining the relationship between hospital and surgeon volume and patient outcomes.
The systematic review identified studies using multiple databases, including Medline and Embase. Two independent researchers ensured studies met the inclusion criteria. Morbidity, mortality, length of stay, financial outcomes and statistical rigour were examined. Correlations between volume and outcome were reported.
Twelve primary knee arthroplasty studies examined hospital volume, which was significantly associated with decreased morbidity (five of seven studies), mortality (two of five studies) and length of stay (two of three studies). Three primary knee arthroplasty studies examined surgeon volume, which was significantly associated with decreased morbidity (two of three studies), mortality (zero of two studies) and length of stay (one of one study). Two revision knee arthroplasty studies examined hospital volume. One study examined but did not test for significance between hospital volume and patient morbidity; both studies examined volume and patient mortality reporting inconclusive results; and one study reported no significant association between volume and length of stay. None of the revision knee arthroplasty studies examined surgeon volume.
Significant associations between increased hospital and surgeon volume and improved patient outcomes were reported. However, when these results were separated by arthroplasty type, the association appeared tenuous. Judgements regarding centralization of knee arthroplasty should be made with caution until further evidence is published.

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    • "Understanding the relationship between provider volume and outcomes for TKA is critical to informing discussions concerning ‘centralization’ or ‘regionalization’ [24] and overall efforts to improve quality and outcomes of care in TKA. The principle behind centralization or regionalization is that improved patient outcomes can be achieved by concentrating complex surgical procedures in regional centers, or “centers of excellence”. "
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    ABSTRACT: Background A number of factors have been identified as influencing total knee arthroplasty outcomes, including patient factors such as gender and medical comorbidity, technical factors such as alignment of the prosthesis, and provider factors such as hospital and surgeon procedure volumes. Recently, strategies aimed at optimizing provider factors have been proposed, including regionalization of total joint arthroplasty to higher volume centers, and adoption of volume standards. To contribute to the discussions concerning the optimization of provider factors and proposals to regionalize total knee arthroplasty practices, we undertook a systematic review to investigate the association between surgeon volume and primary total knee arthroplasty outcomes. Methods We performed a systematic review examining the association between surgeon volume and primary knee arthroplasty outcomes. To be included in the review, the study population had to include patients undergoing primary total knee arthroplasty. Studies had to report on the association between surgeon volume and primary total knee arthroplasty outcomes, including perioperative mortality and morbidity, patient-reported outcomes, or total knee arthroplasty implant survivorship. There were no restrictions placed on study design or language. Results Studies were variable in defining surgeon volume (‘low’: <3 to <52 total knee arthroplasty per year; ‘high’: >5 to >70 total knee arthroplasty per year). Mortality rate, survivorship and thromboembolic events were not found to be associated with surgeon volume. We found a significant association between low surgeon volume and higher rate of infection (0.26% - 2.8% higher), procedure time (165 min versus 135 min), longer length of stay (0.4 - 2.13 days longer), transfusion rate (13% versus 4%), and worse patient reported outcomes. Conclusions Findings suggest a trend towards better outcomes for higher volume surgeons, but results must be interpreted with caution.
    BMC Musculoskeletal Disorders 12/2012; 13(1):250. DOI:10.1186/1471-2474-13-250 · 1.72 Impact Factor
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    • "Why this association was apparent only for treatment injuries but not for infection injuries could possibly be explained by the lower rate of infections, by the assumption that hospital volume has a less important effect on infections, or by the assumption that infections are affected only by very large volumes—volumes that did not occur in this study. Irrespective of the underlying reasons, the result supports the view that TKAs should take place at hospitals with a higher volume of such procedures, in order to both reduce adverse events and to improve quality (Losina et al. 2009, Marlow et al. 2010). "
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    ABSTRACT: Factors associated with malpractice claims are poorly understood. Knowledge of these factors could help to improve patient safety. We investigated whether patient characteristics and hospital volume affect claims and compensations following total hip arthroplasty (THA) and knee arthroplasty (TKA) in a no-fault scheme. A retrospective registry-based study was done on 16,646 THAs and 17,535 TKAs performed in Finland from 1998 through 2003. First, the association between patient characteristics-e.g., age, sex, comorbidity, prosthesis type-and annual hospital volume with filing of a claim was analyzed by logistic regression. Then, multinomial logistic regression was applied to analyze the association between these same factors and receipt of compensation. For THA and TKA, patients over 65 years of age were less likely to file a claim than patients under 65 (OR = 0.57, 95% CI: 0.46-0.72 and OR = 0.65, CI: 0.53-0.80, respectively), while patients with increased comorbidity were more likely to file a claim (OR = 1.17, CI: 1.04-1.31 and OR = 1.14, CI: 1.03-1.26, respectively). Following THA, male sex and cemented prosthesis reduced the odds of a claim (OR = 0.74, CI: 0.60-0.91 and OR = 0.77, CI: 0.60-0.99, respectively) and volume of between 200 and 300 operations increased the odds of a claim (OR = 1.29, CI: 1.01-1.64). Following TKA, a volume of over 300 operations reduced the probability of compensation for certain injury types (RRR = 0.24, CI: 0.08-0.72). Centralization of TKA to hospitals with higher volume may reduce the rate of compensable patient injuries. Furthermore, more attention should be paid to equal opportunities for patients to file a claim and obtain compensation.
    Acta Orthopaedica 03/2012; 83(2):190-6. DOI:10.3109/17453674.2012.672089 · 2.77 Impact Factor
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    ABSTRACT: This systematic review assessed if outcomes in adult intensive care units (ICUs) are related to hospital and ICU patient volume. A systematic search strategy was used to identify studies reporting on volume-outcome relationship in adult ICU patients till November 2010. Inclusion of articles was established through a predetermined protocol. Two reviewers assessed studies independently and data extraction was performed using standardized data extraction forms. A total of 254 articles were screened. Of these 25 were relevant to this study. After further evaluation a total of 13 studies including 596,259 patients across 1,068 ICUs met the inclusion criteria and were reviewed. All were observational cohort studies. Four of the studies included all admissions to ICU, five included mechanically ventilated patients, two reported on patients admitted with sepsis and one study each reported on patients admitted with medical diagnoses and post cardiac arrest patients admitted to ICU, respectively. There was a wide variability in the quantitative definition of volume and classification of hospitals and ICUs on this basis. Methodological heterogeneity amongst the studies precluded a formal meta-analysis. A trend towards favourable outcomes for high volume centres was observed in all studies. Risk-adjusted mortality rates revealed a survival advantage for a specific group of patients in high volume centres in ten studies but no significant difference in outcomes was evident in three studies. The results indicate that outcomes of certain subsets of ICU patients--especially those on mechanical ventilation, high-risk patients, and patients with severe sepsis--are better in high volume centres within the constraints of risk adjustments.
    Intensive Care Medicine 04/2012; 38(5):741-51. DOI:10.1007/s00134-012-2519-y · 7.21 Impact Factor
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