Case Mix and Outcomes of Total Knee Replacement in Orthopaedic Specialty Hospitals

Immunology, and Allergy, Orthopaedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
Medical Care (Impact Factor: 3.23). 05/2008; 46(5):476-80. DOI: 10.1097/MLR.0b013e31816c43c8
Source: PubMed


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.

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    • "Following the full-length reviews, 20 articles were excluded. Sixteen were excluded because they did not compare low volume surgeons to high volume surgeons [11,15-17,29,33,35-44], two studies were excluded because TKA data was mixed with THA data [23,34], one study was excluded because primary TKA data was reported with revision TKA data [10], and one study was found to be a review article and thus, not eligible for inclusion [24]. Eleven studies met our inclusion/exclusion criteria and were retained for this review [8,9,18,21,22,25-28,30,32] (Figure 1). "
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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.
    Full-text · Article · Dec 2012 · BMC Musculoskeletal Disorders

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    ABSTRACT: Published studies of physician-owned specialty hospitals have typically examined the impact of these hospitals on disparities, quality, and utilization at a national level. Our objective was to examine the impact of newly opened physician-owned specialty orthopaedic hospitals on individual competing general hospitals. We used Medicare Part A administrative data to identify all physician-owned specialty orthopaedic hospitals performing total hip arthroplasty (THA) and total knee arthroplasty (TKA) between 1991 and 2005. We identified newly opened specialty hospitals in three representative markets (Durham, NC, Kansas City, and Oklahoma City) and assessed their impact on surgical volume and patient case complexity for the five competing general hospitals located closest to each specialty hospital. The average general hospital maintained THA and TKA volume following the opening of the specialty hospitals. The average general hospital also did not experience an increase in patient case complexity. Thus, based on these three markets, we found no clear evidence that entry of physician-owned specialty orthopaedic hospitals resulted in declines in THA or TKA volume or increases in patient case complexity for the average competing general hospital.
    Full-text · Article · Jun 2009 · Clinical Orthopaedics and Related Research
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