Relative impact of hospital and surgeon procedure volumes on primary total hip arthroplasty revision: a nationwide cohort study in France

Surgeon and Facility Volumes Are Associated With Social Disparities and Post-Operative Complications After Total Hip Arthroplasty

BACKGROUND

The purpose of this study is to further characterize the volume dependence of facilities and surgeons on morbidity and mortality after total hip arthroplasty (THA).

METHODS

Adults who underwent THA from 2009 to 2014 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification and Procedural codes in the New York Statewide Planning and Research Cooperative System database. Complication rates were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression controlling for factors such as the Social Deprivation Index. Surgeon and facility volumes were compared between the low and high volume using cutoffs established by prior research.

RESULTS

In total, 99,832 patients were included. Low volume facilities had higher rates of readmission, urinary tract infection (UTI), acute renal failure, pneumonia, surgical site infection (SSI), cellulitis, wound complications, deep vein thrombosis (DVT), in-hospital mortality, and revision. Low volume surgeons had higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, acute respiratory failure, pulmonary embolism, cellulitis, wound complications, in-hospital mortality, cardiorespiratory arrest, DVT, and revision. African Americans, Hispanics, and those with federal insurance had increased rates of readmission. Those with ≥1 Charlson comorbidities or from areas of higher social deprivation had increased incidence of treatment by low volume surgeons and facilities.

CONCLUSION

Both low volume facilities and surgeons performing primary THA have higher rates of readmission, UTI, acute renal failure, pneumonia, SSI, cellulitis, wound complications, DVT, in-hospital mortality, and revision. Demographic disparities exist between who is treated at low vs high volume surgeons and facilities placing those groups at higher risks for complications.

Kyphoplasty and Vertebroplasty Performed by Surgeons versus Nonsurgeons: Trends in Procedure Rates, Complications, and Revisions

BACKGROUND

Vertebral compression fractures are the most common fragility fractures affecting osteoporotic patients. This study evaluated volume trends and outcomes across specialties performing cement augmentation procedures.

METHODS

Patients were identified using Current Procedural Terminology codes for vertebroplasty or kyphoplasty from 2010 to 2019. Patients were grouped by surgical providers (orthopedic surgery and neurological surgery) or nonsurgical providers (anesthesia, pain medicine, radiology, and physical medicine and rehabilitation). Outcomes recorded included reoperation rates and postoperative complications occurring within 30 days. Logistic regression was employed to account for potential confounding variables, and odds ratios were obtained.

RESULTS

Inclusion criteria were met by 80,864 patients who received cement augmentation. Surgeon specialists performed 51.7% of all procedures. Of procedures carried out by nonsurgeon specialists, radiologists performed the most. Despite a stable number of procedures performed over the period, the percentage of procedures performed by surgeons decreased from 58.8% to 49.9% (P < 0.001). Patients with procedures performed by surgeons experienced lower odds of reoperation at 30 days (P < 0.001) and 1 year (P < 0.001), but 5-year and overall rates were not significant (P > 0.05). Surgical patients had lower odds of acute kidney injury (P < 0.004) and pulmonary embolism (odds ratio = 0.62, P < 0.001), yet increased odds of surgical site infection (P < 0.001).

CONCLUSIONS

Kyphoplasties and vertebroplasties are increasingly performed by nonsurgeon specialists. Although early reoperation rates are higher for nonsurgeon specialists, 5-year and overall reoperation rates were similar. Differing complication rates may relate to patient selection rather than operative technique and can be investigated with future studies.

The Association Between Surgeon Age and Early Surgical Complications of Elective Total Hip Arthroplasty: Propensity-Matched Cohort Study (122,043 Patients)

BACKGROUND

The aim of this study was to examine the relationship between surgeon age and early surgical complications following primary total hip arthroplasty (THA), within a year, in Ontario, Canada.

METHODS

In a propensity-matched cohort, we defined consecutive adults who received their first primary THA for osteoarthritis (2002-2018). We obtained hospital discharge abstracts, patient's demographics and physician claims. Age of the primary surgeon was determined for each procedure and used as a continuous variable for spline analysis, and as a categorical variable for subsequent matching (young <45; middle-age 45-55; older >55). The primary outcome was early surgical complications (revision, dislocation, infection). Secondary analyses included high-volume vs low-volume surgeons (≤35 THA per year).

RESULTS

We identified 122,043 THA recipients, 298 surgeons with median age 49 years. Younger, middle-aged, and older surgeons performed 39%, 29%, and 32% THAs, respectively. Middle-aged surgeons had the lowest rate of complications. Younger surgeons had a higher risk of composite complications (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.09-1.44, P = .002), revision (OR 1.28, 95% CI 1.07-1.54, P = .007), and infection (OR 1.39, 95% CI 1.12-1.71, P = .003). Older surgeons also had higher risk for composite complications (OR 1.18, 95% CI 1.03-1.36, P = .019), revision (OR 1.33, 95% CI 1.10-1.62, P = .004), and dislocation (OR 1.37, 95% CI 1.08-1.73, P = .009). However, when excluding low-volume surgeons, older high-volume surgeons had similar complications to middle-aged surgeons.

CONCLUSION

Younger surgeons (<45 years) had the highest recorded complications rate while the lowest rate was for surgeons aged 45-55. Volume rather than age was more important in determining rate of complications of older surgeons.

LEVEL OF EVIDENCE

IV.

Dislocation is a Leading Cause of Decreased Survival Rate in Primary Total Hip Arthroplasty Performed by Low-Volume Surgeons: Long-Term Retrospective Cohort Study

BACKGROUND

This study aimed to evaluate the complications and long-term survival of primary total hip arthroplasty (THA) performed by low-volume (LV) surgeons at a LV hospital. We also determined the relationship between complications and revisions.

METHODS

This retrospective cohort study included 220 THAs in 194 patients treated at our institution between 1998 and 2008, who received a minimum of a 10-year follow-up. The median annual THA volume at this hospital was 23 procedures (range, 11-32), and the annual volume per surgeon ranged from 1 to 19. We investigated the 90-day mortality and rates of periprosthetic joint infections, dislocations, and periprosthetic fractures up to the last visit (median follow-up, 11.8 years). Kaplan-Meier survival was calculated with revision as the end point.

RESULTS

Postoperative infections, dislocations, and fractures at any time during the follow-up period were reported for 1 hip (0.5%), 23 hips (9.8%), and 4 hips (1.8%), respectively. One death occurred within the first 90 days postoperatively. Fifteen hips required revision surgery, and the survival rate was 95.5% at 5 years and 94.1% at 10 years. Of 10 hips that required early revision surgery within 5 years after the index surgery, 9 were revisions to address recurrent dislocation.

CONCLUSION

The risk of dislocation was high. A high number of patients who underwent THA by LV surgeons required early revision because of dislocation. To achieve optimal long-term survivorship, LV surgeons should consider measures to reduce the risk of dislocation.

Evidence-Based Hospital Procedural Volumes as Predictors of Outcomes After Revision Hip Arthroplasty

BACKGROUND

The aim of this study is to define the evidence-based institutional volume-outcome relationship in revision hip arthroplasty. We hypothesized that high-volume centers would be associated with superior outcomes, and that stratum-specific likelihood ratio (SSLR) analysis would delineate concrete volume thresholds for optimizing outcomes.

METHODS

The Nationwide Readmission Database was queried from 2011 to 2016 for patients undergoing revision hip arthroplasty. SSLR analysis was used to determine hospital volume cutoffs specific for outcomes of interest. Volume categories were confirmed with multivariate regression.

RESULTS

SSLR analysis produced distinct hospital volume cutoffs for all outcomes. Each subsequent volume threshold diminished patients' risk for adverse outcomes. Tertiles were identified for 90-day infection (≤6, 7-51, ≥52 cases per year). Quartiles were found for 90-day readmission (≤5, 6-15, 16-79, ≥80), 90-day prosthesis-related complication (≤5, 6-16, 17-65, ≥66), 90-day dislocation (≤5, 6-19, 20-79, ≥80), and non-home discharge (≤5, 6-15, 16-40, and ≥41). Quintiles were generated for extended length of stay >2 days (≤2, 3-10, 11-20, 21-30, ≥31). Heptiles were produced for medical complications within 90 days (≤2, 3-8, 9-16, 17-51, 52-89, ≥90).

CONCLUSION

This is the first known study to define evidence-based thresholds for the impact of hospital volume on revision joint arthroplasty. This supports the notion that institutional volume functions as a surrogate for protocolized interdisciplinary coordination of care and surgical experience, and that high-volume centers offer enhanced outcomes for complex cases. Additional studies should investigate the potential role for incentivization of such institutions, as they offer optimal outcomes for revision hip arthroplasty.

Surgeon-stratified cohort analysis of 1976 cementless Zweymüller total hip arthroplasties from a single hospital with 23,255 component years of follow-up

INTRODUCTION

The third-generation Zweymüller hip endoprosthesis has been used for decades with excellent results in arthroplasty registries, but surgeon-stratified reports on this implant are still scarce. The aim of the presented single-hospital cohort analysis of the third-generation Endoplus-Zweymüller primary total hip arthroplasty was to determine implant survival rates until the first revision/removal at 10/15/20/25 years after implantation and to find out whether implant survival depended on the operating surgeon, patient's age and gender, operated side (right/left), season of the year and the set of implanted components (SL-PLUS femur, BICON-PLUS acetabulum or both components).

MATERIALS AND METHODS

The retrospective observational cohort study included 1976 consecutive patients with primary BICON/SL-PLUS Zweymüller hip endoprosthesis implanted at the same operating theater block of the University Medical Centre Ljubljana, Department of Orthopaedic Surgery (Ljubljana, Slovenia) between January 1, 1993 and May 1, 2014. Survival analyses were performed with the Kaplan-Meier method and the Cox regression analysis after minimum 5 and maximum 26 years of follow-up.

RESULTS

At 10/15/20/25 years after implantation, the cumulative proportion of revision-free surviving Zweymüller total hip endoprostheses was 92/90/85/81% and the cumulative proportion with unremoved immobile components was 93/91/87/84%, respectively. After adjustment for age, gender and operated side, less experienced surgeons (odds ratios 2.34-5.00), season of the year at primary implantation (spring vs. winter odds ratio 1.74) and the use of BICON-PLUS acetabulum with femoral stem from another manufacturer (odds ratio 2.23) were significant risk factors of worse implant survival.

CONCLUSIONS

The study presents the largest published third-generation Zweymüller BICON/SL-PLUS total hip arthroplasty cohort from a single non-developmental hospital with 23,255 component years of observation. Study findings indicate the impact of environmental factors at primary implantation and variability between different surgeons on the long-term implant survival.

Total Hip Arthroplasty for Developmental Dysplasia of Hip vs Osteoarthritis: A Propensity Matched Pair Analysis

Background

The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program to compare the perioperative and postoperative outcomes after total hip arthroplasty (THA) for DDH and primary OA via a propensity-matched pair analysis and the valuation of THA between both groups.

Material and Methods

All patients who underwent THA between 2008 and 2016 were identified from National Surgical Quality Improvement Program database via the current procedural terminology (CPT) code. Patients were further identified and stratified based on International Statistical Classification of Diseases and Related Health Problems-9/International Statistical Classification of Diseases and Related Health Problems-10 diagnosis codes for primary OA (n = 115,166) and DDH (n = 603), which included codes for congenital hip dislocation, hip dysplasia, or juvenile osteochondrosis. Demographic variables were used to create 557 propensity-matched pairs.

Results

The DDH group was associated with a significantly longer operative time (120.3 vs 95.9 min), higher postoperative transfusion rate (12% vs 6.6%), and longer hospital length of stay (2.8 vs 2.5 days) compared with the primary OA group (P < .001, P < .001, and P = .002, respectively). There were no statistically significant differences found between the two groups with respect to inpatient complications, discharge disposition (P = .123), readmissions (P = .615), or reoperations (P = .404).

Conclusions

Health policy makers should be cognizant of the higher complexity of THA for DDH when determining whether DDH and primary OA should be in the same bundle. Owing to the limitations of our data set, all the observed associations are likely an underestimate of the true risk posed to patients with severe DDH, as these patients were unable to be stratified in the present analysis.

Low Hospital Volume Increases Re-Revision Rate Following Aseptic Revision Total Knee Arthroplasty: An Analysis of 23,644 Cases

BACKGROUND

Along with rising numbers of primary total knee arthroplasty (TKA), the number of revision total knee arthroplasties (R-TKAs) has been increasing. R-TKA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals with more R-TKAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study is to evaluate the relationship between hospital volume and re-revision rate following R-TKA.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 23,644 aseptic R-TKAs in 21,573 patients treated between January 2013 and December 2017 were analyzed. Outcomes were 90-day mortality, 1-year re-revision rate, and in-house adverse events. The effect of hospital volumes on outcomes were analyzed by means of multivariate logistic regression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Hospital volume had a significant effect on 1-year re-revision rate (≤12 R-TKA/a: OR 1.44, CI 1.20-1.72; 13-24 R-TKA/a: OR 1.43, CI 1.20-1.71; 25-52 R-TKA/a: OR 1.13, CI 0.94-1.35; ≥53 R-TKA/a: reference). Ninety-day mortality and major in-house adverse events decreased with increasing volume per year, but after risk adjustment this was not statistically significant.

CONCLUSION

We found evidence of higher risk for re-revision surgery in hospitals with fewer than 25 R-TKA per year. It might contribute to improved patient care if complex elective procedures like R-TKA which require experience and a specific logistic background were performed in specialized centers.

Effect of hospital volume on outcomes of total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

A shift in the healthcare system towards the centralization of common yet costly surgeries, such as total hip arthroplasty (THA), to high-volume centers of excellence, is an attempt to control the economic burden while simultaneously enhancing patient outcomes. The "volume-outcome" relationship suggests that hospitals performing more treatment of a given type exhibit better outcomes than hospitals performing fewer. This theory has surfaced as an important factor in determining patient outcomes following THA. We performed a systematic review with meta-analyses to review the available evidence on the impact of hospital volume on outcomes of THA.

MATERIALS AND METHODS

We conducted a review of PubMed (MEDLINE), OVID MEDLINE, Google Scholar, and Cochrane library of studies reporting the impact of hospital volume on THA. The studies were evaluated as per the inclusion and exclusion criteria. A total of 44 studies were included in the review. We accessed pooled data using random-effect meta-analysis.

RESULTS

Results of the meta-analyses show that low-volume hospitals were associated with a higher rate of surgical site infections (1.25 [1.01, 1.55]), longer length of stay (RR, 0.83[0.48-1.18]), increased cost of surgery (3.44, [2.57, 4.30]), 90-day complications (RR, 1.80[1.50-2.17]) and 30-day (RR, 2.33[1.27-4.28]), 90-day (RR, 1.26[1.05-1.51]), and 1-year mortality rates (RR, 2.26[1.32-3.88]) when compared to high-volume hospitals following THA. Except for two prospective studies, all were retrospective observational studies.

CONCLUSIONS

These findings demonstrate superior outcomes following THA in high-volume hospitals. Together with the reduced cost of the surgical procedure, fewer complications may contribute to saving considerable opportunity costs annually. However, a need to define objective volume-thresholds with stronger evidence would be required.

TRIAL REGISTRATION

PROSPERO CRD42019123776.

Low Hospital Volume Increases Revision Rate and Mortality Following Revision Total Hip Arthroplasty: An Analysis of 17,773 Cases

BACKGROUND

With the number of primary total hip arthroplasty (THA), the amount of revision THA (R-THA) increases. R-THA is a complex procedure requiring special instruments, implants, and surgical skills. Therefore it is likely that hospitals performing a higher number of R-THAs have more experience with this type of surgery and therefore fewer complications. The purpose of this study was to evaluate the relationship between hospital volume and risk of postoperative complications following R-THA.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 17,773 aseptic R-THAs in 16,376 patients treated between January 2014 and December 2016 were included. Outcomes were 90-day mortality, 1-year revision procedures, and in-house adverse events. The effect of hospital volume on outcome was analyzed by means of multivariate logistic regression. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Hospital volume had a significant effect on 90-day mortality (≤12 cases per year: OR 2.13, CI 1.53-2.96; 13-24: OR 1.79, CI 1.29-2.50; 25-52: OR 1.53, CI 1.11-2.10; ≥53: reference) and 1-year revision procedures (≤12: OR 1.26, CI 1.09-1.47; 13-24: OR 1.18, CI 1.02-1.37; 25-52: OR 1.03, CI 0.90-1.19; ≥53: reference). There was no significant effect on risk-adjusted major in-house adverse events.

CONCLUSION

We found evidence of higher risk for revision surgery and mortality in hospitals with fewer than 25 and 53 R-THA per year, respectively. To improve patient care, complex elective procedures like R-THA which require experience and a specific logistic background should be performed in specialized centers.

Influence of Hospital Volume of Procedures by Year on the Risk of Revision of Total Hip and Knee Arthroplasties: A Propensity Score-Matched Cohort Study

The volume of total hip (THA) and knee arthroplasties (TKA) performed in a hospital per year could be an influential factor on the revision of these procedures. The aims of this study were: To obtain comparable cohorts in higher- and lower-volume hospitals; and to assess the association between the hospital volume and the incidence of revision. Data from patients undergoing THA and TKA caused by osteoarthritis and recorded in the Catalan Arthroplasty Register (RACat) between January 2005 and December 2016 were used. The main explanatory variable was hospital volume by year (higher/lower). The cut-off point was fixed, based on previous research, at 50 THA and 125 TKA procedures/year. To obtain comparable populations, a propensity-score matching method (1:1) was used. Patient characteristics prior to and after matching were compared. To assess differences by volume, subhazard ratios (SHRs) from competing risks models were obtained. After matching, 13,772 THA and 36,316 TKA patients remained in the study. Prior to matching, in both joints, significant differences in all confounders were observed between volume groups. After matching, none of them remained significant. Both in THA and TKA, a higher risk of revision in higher-volume hospitals was observed (THA SHR: 1.25, 95%CI: 1.02–1.53; and TKA SHR: 1.29, 95%CI: 1.16–1.44). Unlike other contexts, currently in Catalonia, higher-volume hospitals have a greater risk of revision than lower-volume hospitals. Further research could be valuable to define context-dependent measures to reduce the incidence of revision.

A Clinico-Microbiological Study of Prosthetic Joint Infections in an Indian Tertiary Care Hospital: Role of Universal 16S rRNA Gene Polymerase Chain Reaction and Sequencing in Diagnosis

BACKGROUND

We determined the magnitude and clinico-microbiological profile of prosthetic joint infection (PJI) at a tertiary hospital. The diagnostic potential of 16S rRNA gene polymerase chain reaction (PCR) and sequencing on periprosthetic tissue samples was evaluated for the diagnosis of PJI.

MATERIALS AND METHODS

This ambispective cohort study consisted of patients who underwent primary or revision hip or knee arthroplasty from June 2013 to June 2017. The patients were classified as either infected or noninfected according to criteria set out by the musculoskeletal infection society (MSIS). Three to five periprosthetic tissue samples were collected from each patient for culture and 16S rRNA gene PCR sequencing.

RESULTS

Hundred and six patients were diagnosed to have PJI as per the MSIS Criteria. The cumulative incidence of PJI at our Institute at the end of 36 months was 1.1% (95% confidence interval [CI]: 0.59-2.91). Microorganisms were isolated by periprosthetic tissue culture (PTC) in 84 patients (sensitivity: 79% and specificity: 100%). Gram-negative aerobes were most frequently isolated (61%). Polymicrobial infections were present in 8.3% of cases. The most common infecting microorganism was Staphylococcus aureus (19.5%). Multidrug resistance and methicillin resistance were noted in 54% and 34% of bacterial isolates, respectively. The sensitivity and specificity of 16S rRNA PCR of periprosthetic tissue was 86% (95% CI: 74.9-89.9) and 100% (95% CI: 94.7-100), respectively. Periprosthetic tissue 16S rRNA PCR was more sensitive than PTC (P = 0.008), although both were 100% specific (P = 0.99).

CONCLUSIONS

The incidence of PJI at our Institute compares well with other published reports. Contrary to previous reports, a predominance of Gram-negative PJI's was found. The preponderance of multidrug-resistant organisms in PJI's is worrisome. The high sensitivity and specificity of the 16S PCR assay used in our study support its use in culture-negative PJI suspected cases.

Does Surgeon Volume Affect Outcomes Following Primary Total Hip Arthroplasty? A Systematic Review

BACKGROUND

Surgeon volume has been identified as an important factor impacting postoperative outcome in patients undergoing orthopedic surgeries. With an absence of a detailed systematic review, we sought to collate evidence on the impact of surgeon volume on postoperative outcomes in patients undergoing primary total hip arthroplasty.

METHODS

PubMed (MEDLINE) and Google Scholar databases were queried for articles using the following search criteria: ("Surgeon Volume" OR "Provider Volume" OR "Volume Outcome") AND ("THA" OR "Total hip replacement" OR "THR" OR "Total hip arthroplasty"). Studies investigating total hip arthroplasty being performed for malignancy or hip fractures were excluded from the review. Twenty-eight studies were included in the final review. All studies underwent a quality appraisal using the GRADE tool. The systematic review was performed in accordance with the PRISMA guidelines.

RESULTS

Increasing surgeon volume was associated with a shorter length of stay, lower costs, and lower dislocation rates. Studies showed a significant association between an increasing surgeon volume and higher odds of early-term and midterm survivorship, but not long-term survivorships. Although complications were reported and recorded differently in studies, there was a general trend toward a lower postoperative morbidity with regard to complications following surgeries by a high-volume surgeon.

CONCLUSION

This systematic review shows evidence of a trend toward better postoperative outcomes with high-volume surgeons. Future prospective studies are needed to better determine long-term postoperative outcomes such as survivorship before healthcare policies such as regionalization and/or equal-access healthcare systems can be considered.