Case mix and outcomes of total knee replacement in orthopaedic specialty hospitals.
ABSTRACT To examine patient characteristics and outcomes of total knee replacement (TKR) in orthopaedic specialty hospitals.
We performed a retrospective cohort study in the US Medicare population. We defined specialty hospitals for TKR as centers: (1) that performed >75 TKRs in Medicare recipients in 2000; (2) in which TKR accounted for >7% of all Medicare discharges; and (3) that had <300 beds. We divided specialty hospitals into those with <or=100 beds and those with 101-299 beds. We compared preoperative characteristics and complications among patients undergoing TKR in specialty and nonspecialty centers. We stratified patients according to risk of complications and performed stratum-specific analyses.
A total of 2,417 patients received TKA in 19 specialty hospitals, accounting for 3% of all TKRs in 2000. The specialty hospitals had fewer patients with poverty level income. The smaller "boutique" specialty hospitals had lower complication rates than the larger specialty hospitals and the nonspecialty centers (P value for trend = 0.001). In analyses that adjusted for patient age and sex, low-risk patients had similar outcomes across all hospital categories. However, high-risk patients had statistically significantly greater benefit from treatment in smaller specialty hospitals, with the risk of any adverse event ranging from 1.4% (95% CI, 0%-3.5%) in smaller specialty hospitals to 4.9% (95% CI, 4.4%-5.5%) in low-volume centers.
Smaller specialty hospitals have low complication rates and are especially beneficial for high-risk patients. Further work should address functional outcomes, costs, and satisfaction in these specialty centers, and evaluate strategies to manage more high-risk patients in specialty centers.
- Journal of Clinical Epidemiology 11/1993; 46(10):1075-9; discussion 1081-90. · 5.33 Impact Factor
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ABSTRACT: 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. 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. 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. 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.The Journal of Bone and Joint Surgery 10/2004; 86-A(9):1909-16. · 3.23 Impact Factor
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ABSTRACT: Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed. Using information from the national Medicare claims data base and the Nationwide Inpatient Sample, we examined the mortality associated with six different types of cardiovascular procedures and eight types of major cancer resections between 1994 and 1999 (total number of procedures, 2.5 million). Regression techniques were used to describe relations between hospital volume (total number of procedures performed per year) and mortality (in-hospital or within 30 days), with adjustment for characteristics of the patients. Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure. Absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals ranged from over 12 percent (for pancreatic resection, 16.3 percent vs. 3.8 percent) to only 0.2 percent (for carotid endarterectomy, 1.7 percent vs. 1.5 percent). The absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals were greater than 5 percent for esophagectomy and pneumonectomy, 2 to 5 percent for gastrectomy, cystectomy, repair of a nonruptured abdominal aneurysm, and replacement of an aortic or mitral valve, and less than 2 percent for coronary-artery bypass grafting, lower-extremity bypass, colectomy, lobectomy, and nephrectomy. In the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.New England Journal of Medicine 05/2002; 346(15):1128-37. · 51.66 Impact Factor