Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
William J. Maloney, MD*,
Stanford University, Stanford, California
Posted August 2007
In this investigation, the authors reviewed a cohort of Medicare
beneficiaries who underwent total hip or total knee replacement in "specialty
orthopaedic" or general hospitals. An orthopaedic specialty hospital was
defined by the ratio of orthopaedic admissions to total admissions; a higher ratio
denoted a greater level of orthopaedic specialization. From a list of 100
hospitals with a high ratio, the authors then chose thirty-eight for study by
excluding hospitals in which obstetrics and gynecologic procedures were performed
as well as hospitals in which pediatric care was offered. In addition,
hospitals with formal medical school affiliations were also excluded from the specialty
group.
The authors then used Medicare claims data to compare
demographics, comorbidity, socioeconomic status, and the odds of adverse
outcomes in these two different hospital settings. Outcomes of interest
included sepsis, hemorrhage, pulmonary embolus, deep venous thrombosis, wound
infection requiring readmission, and death. In addition, the authors evaluated
length of stay and the proportion of patients who required transfer from the
hospital at which they underwent the initial joint replacement to another acute-care
hospital.
Their findings are interesting, but somewhat predictable. Patients
who received care in specialty hospitals generally had fewer comorbidities and
tended to reside in more affluent zip codes. Orthopaedic specialty hospitals
had greater mean procedural volumes for hip replacement and knee replacement
when compared with those in the general hospital setting. Specialty hospitals
had a lower rate of adverse outcomes even when adjusted for volume and comorbidities.
With use of the Medicare administrative data, the authors concluded that patient
outcomes were better in specialty orthopaedic hospitals than in general
hospitals.
There are several important issues that are addressed in
this article, but it is important to note that this retrospective study of
claims data has limitations. From the standpoint of outcomes that were measurable,
the data strongly suggest that specialty hospitals did better than general
hospitals. Volume has been previously shown to affect outcome in multiple studies,
including hip replacement studies. The experience of the surgeon is not the
only variable that matters. The entire team has an impact on outcome. This
includes the operating-room team, the rehabilitation team, and the nurses on
the ward. In settings in which there is high volume, it is more likely than not
that standardized protocols have been established. Standardization, whether it
is in manufacturing or in health care, leads to fewer errors and, I believe,
more predicable outcomes.
The orthopaedic specialty hospitals tended to have patients
from more affluent zip codes. This finding obviously has political implications.
Specialty hospitals, whether they are orthopaedic specialty hospitals or
hospitals that specialize in other areas, such as cardiovascular surgery, tend
to be built in more affluent communities and tend to be somewhat more restrictive
in terms of the patients that they will accept. There are concerns at the
national and regional levels that this could jeopardize the financial viability
of general hospitals. If the more profitable procedures are performed at
specialty hospitals where patients have a higher ability to pay their health-care
bills, general hospitals in those regions could be left without sufficient
resources to provide a broad level of services, including services for patients
who do not have the ability to pay. This issue is unlikely to go away in the
near future and will be the impetus for ongoing legislation.
It is also important to point out that although the adverse
outcomes that were measurable on the basis of the claims data were higher in
the general hospitals, those patients also had a higher level of comorbidities.
Although it is true that the study adjusted for the demographics and
comorbidity with use of tools currently available to do that, there is always a
question as to whether the adjustment is valid. Comorbidities tend to be more
complex than can be easily measured. Issues like poor nutrition, diminished
cognitive status, generalized reconditioning, and poor support systems are hard
to adjust for in these types of evaluations, but they can definitely impact
outcome.
The bottom line, however is that volume matters. The more we
do, the better we are. Whether we are at high-volume or low-volume centers, it
is important that we establish evidence-based protocols to minimize complications
and optimize outcomes.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
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