This Article Full Text Full Text (PDF) [Supplementary Material] Letters to the Editor: Submit a response Letters to the Editor: View responses Alert me when this article is cited Alert me when Letters to the Editor are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Reprints and Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Katz, J. N. Articles by Baron, J. A. Search for Related Content PubMed PubMed Citation Articles by Katz, J. N. Articles by Baron, J. A. Social Bookmarking             What's this?

Association Between Hospital and Surgeon Procedure Volume and Outcomes of Total Hip Replacement in the United States Medicare Population*

Jeffrey N. Katz, MD, MS
Charlotte B. Phillips, RN, MPH
Robert A. Lew, PhD
Robert Poss, MD
Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center (J.N.K., C.B.P., and R.A.L.), Division of Rheumatology, Immunology and Allergy (J.N.K. and R.A.L.), and Department of Orthopedic Surgery (R.P.), Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail address for J.N. Katz: jnkatz{at}partners.org

Elena Losina, PhD
Department of Epidemiology and Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118

Nizar N. Mahomed, MD, ScD
Musculoskeletal Health and Arthritis Program, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON M5T 2S8 Canada

William H. Harris, MD
Department of Orthopaedics, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114

Edward Guadagnoli, PhD
Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115

John A. Baron, MD, MPH
Jane Barrett, MSc
Departments of Medicine (J.A.B.) and Family and Community Medicine (J.A.B. and J.B.), Dartmouth Medical School, Hanover, NH 03755

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from National Institutes of Health Grants P01 AR36308 and K24 AR 02123, Agency for Healthcare Research and Quality Grant 1R01 HS09775-01, and a Clinical Science Grant from the Arthritis Foundation. None of the authors 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, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

*The topic discussed in this article is also addressed in the Editorial and in a Letter to The Editor in this issue of The Journal.

Background: The mortality and complication rates of many surgical procedures are inversely related to hospital procedure volume. The objective of this study was to determine whether the volumes of primary and revision total hip replacements performed at hospitals and by surgeons are associated with rates of mortality and complications.

Methods: We analyzed claims data of Medicare recipients who underwent elective primary total hip replacement (58,521 procedures) or revision total hip replacement (12,956 procedures) between July 1995 and June 1996. We assessed the relationship between surgeon and hospital procedure volume and mortality, dislocation, deep infection, and pulmonary embolus in the first ninety days postoperatively. Analyses were adjusted for age, gender, arthritis diagnosis, comorbid conditions, and income. Analyses of hospital volume were adjusted for surgeon volume, and analyses of surgeon volume were adjusted for hospital volume.

Results: Twelve percent of all primary total hip replacements and 49% of all revisions were performed in centers in which ten or fewer of these procedures were carried out in the Medicare population annually. In addition, 52% of the primary total hip replacements and 77% of the revisions were performed by surgeons who carried out ten or fewer of these procedures annually. Patients treated with primary total hip replacement in hospitals in which more than 100 of the procedures were performed per year had a lower risk of death than those treated with primary replacement in hospitals in which ten or fewer procedures were performed per year (mortality rate, 0.7% compared with 1.3%; adjusted odds ratio, 0.58; 95% confidence interval, 0.38, 0.89). Patients treated with primary total hip replacement by surgeons who performed more than fifty of those procedures in Medicare beneficiaries per year had a lower risk of dislocation than those who were treated by surgeons who performed five or fewer of the procedures per year (dislocation rate, 1.5% compared with 4.2%; adjusted odds ratio, 0.49; 95% confidence interval, 0.34, 0.69). Patients who had revision total hip replacement done by surgeons who performed more than ten such procedures per year had a lower rate of mortality than patients who were treated by surgeons who performed three or fewer of the procedures per year (mortality rate, 1.5% compared with 3.1%; adjusted odds ratio, 0.65; 95% confidence interval, 0.44, 0.96).

Conclusions: Patients treated at hospitals and by surgeons with higher annual caseloads of primary and revision total hip replacement had lower rates of mortality and of selected complications. These analyses of Medicare claims are limited by a lack of key clinical information such as operative details and preoperative functional status.

CiteULike    Connotea    Del.icio.us    Technorati    What's this?

This article has been cited by other articles:

				J. D. Slover, A. N.A. Tosteson, K. J. Bozic, H. E. Rubash, and H. Malchau Impact of Hospital Volume on the Economic Value of Computer Navigation for Total Knee Replacement J. Bone Joint Surg. Am., July 1, 2008; 90(7): 1492 - 1500. [Abstract] [Full Text] [PDF]

				R. Iorio, W. J. Robb, W. L. Healy, D. J. Berry, W. J. Hozack, R. F. Kyle, D. G. Lewallen, R. T. Trousdale, W. A. Jiranek, V. P. Stamos, et al. Orthopaedic Surgeon Workforce and Volume Assessment for Total Hip and Knee Replacement in the United States: Preparing for an Epidemic J. Bone Joint Surg. Am., July 1, 2008; 90(7): 1598 - 1605. [Full Text] [PDF]

				M. L. Forte, B. A. Virnig, R. L. Kane, S. Durham, M. Bhandari, R. Feldman, and M. F. Swiontkowski Geographic Variation in Device Use for Intertrochanteric Hip Fractures J. Bone Joint Surg. Am., April 1, 2008; 90(4): 691 - 699. [Abstract] [Full Text] [PDF]

				A. P. Sah and D. M. Estok II Dislocation Rate After Conversion from Hip Hemiarthroplasty to Total Hip Arthroplasty J. Bone Joint Surg. Am., March 1, 2008; 90(3): 506 - 516. [Abstract] [Full Text] [PDF]

				C. A. Jacobs, C. P. Christensen, A. S. Greenwald, and H. McKellop Clinical Performance of Highly Cross-Linked Polyethylenes in Total Hip Arthroplasty J. Bone Joint Surg. Am., December 1, 2007; 89(12): 2779 - 2786. [Abstract] [Full Text] [PDF]

				N. E. Lane Osteoarthritis of the Hip N. Engl. J. Med., October 4, 2007; 357(14): 1413 - 1421. [Full Text] [PDF]

				S. A. Ibrahim Racial and Ethnic Disparities in Hip and Knee Joint Replacement:A Review of Research in the Veterans Affairs Health Care System J. Am. Acad. Ortho. Surg., September 1, 2007; 15(suppl_1): S87 - S94. [Abstract] [Full Text] [PDF]

				P. Cram, M. S. Vaughan-Sarrazin, B. Wolf, J. N. Katz, and G. E. Rosenthal A Comparison of Total Hip and Knee Replacement in Specialty and General Hospitals J. Bone Joint Surg. Am., August 1, 2007; 89(8): 1675 - 1684. [Abstract] [Full Text] [PDF]

				C. Zhan, R. Kaczmarek, N. Loyo-Berrios, J. Sangl, and R. A. Bright Incidence and Short-Term Outcomes of Primary and Revision Hip Replacement in the United States J. Bone Joint Surg. Am., March 1, 2007; 89(3): 526 - 533. [Abstract] [Full Text] [PDF]

				W. P. Weber, U. Guller, N. B. Jain, R. Pietrobon, and D. Oertli Impact of Surgeon and Hospital Caseload on the Likelihood of Performing Laparoscopic vs Open Sigmoid Resection for Diverticular Disease: A Study Based on 55 949 Patients Arch Surg, March 1, 2007; 142(3): 253 - 259. [Abstract] [Full Text] [PDF]

				T. Bhattacharyya and D. C. Hooper Antibiotic Dosing Before Primary Hip and Knee Replacement as a Pay-for-Performance Measure J. Bone Joint Surg. Am., February 1, 2007; 89(2): 287 - 291. [Abstract] [Full Text] [PDF]

				N. Agabiti, S. Picciotto, G. Cesaroni, L. Bisanti, F. Forastiere, R. Onorati, B. Pacelli, P. Pandolfi, A. Russo, T. Spadea, et al. The influence of socioeconomic status on utilization and outcomes of elective total hip replacement: a multicity population-based longitudinal study Int. J. Qual. Health Care, February 1, 2007; 19(1): 37 - 44. [Abstract] [Full Text] [PDF]

				B Bridgewater, T Hooper, C Munsch, S Hunter, U von Oppell, S Livesey, B Keogh, F Wells, M Patrick, J Kneeshaw, et al. Mitral repair best practice: proposed standards Heart, July 1, 2006; 92(7): 939 - 944. [Abstract] [Full Text] [PDF]

				W. R. Dunn, B. R. Schackman, C. Walsh, S. Lyman, E. C. Jones, R. F. Warren, and R. G. Marx Variation in Orthopaedic Surgeons' Perceptions About the Indications for Rotator Cuff Surgery J. Bone Joint Surg. Am., September 1, 2005; 87(9): 1978 - 1984. [Abstract] [Full Text] [PDF]

				K. J. Bozic and M. D. Ries The Impact of Infection After Total Hip Arthroplasty on Hospital and Surgeon Resource Utilization J. Bone Joint Surg. Am., August 1, 2005; 87(8): 1746 - 1751. [Abstract] [Full Text] [PDF]

				S. Kurtz, F. Mowat, K. Ong, N. Chan, E. Lau, and M. Halpern Prevalence of Primary and Revision Total Hip and Knee Arthroplasty in the United States From 1990 Through 2002 J. Bone Joint Surg. Am., July 1, 2005; 87(7): 1487 - 1497. [Abstract] [Full Text] [PDF]

				R. Reagans, L. Argote, and D. Brooks Individual Experience and Experience Working Together: Predicting Learning Rates from Knowing Who Knows What and Knowing How to Work Together Management Science, June 1, 2005; 51(6): 869 - 881. [Abstract] [PDF]

				S. S. Leopold, H. D. Morgan, N. J. Kadel, G. C. Gardner, D. C. Schaad, and F. M. Wolf Impact of Educational Intervention on Confidence and Competence in the Performance of a Simple Surgical Task J. Bone Joint Surg. Am., May 1, 2005; 87(5): 1031 - 1037. [Abstract] [Full Text] [PDF]

				L. Ogonda, R. Wilson, P. Archbold, M. Lawlor, P. Humphreys, S. O'Brien, and D. Beverland A Minimal-Incision Technique in Total Hip Arthroplasty Does Not Improve Early Postoperative Outcomes. A Prospective, Randomized, Controlled Trial J. Bone Joint Surg. Am., April 1, 2005; 87(4): 701 - 710. [Abstract] [Full Text] [PDF]

				K. J. Bozic, P. Katz, M. Cisternas, L. Ono, M. D. Ries, and J. Showstack Hospital Resource Utilization for Primary and Revision Total Hip Arthroplasty J. Bone Joint Surg. Am., March 1, 2005; 87(3): 570 - 576. [Abstract] [Full Text] [PDF]

				J. H. Herndon The Future of Specialization within Orthopaedics J. Bone Joint Surg. Am., November 1, 2004; 86(11): 2560 - 2566. [Full Text] [PDF]

				J. N. Katz, J. Barrett, N. N. Mahomed, J. A. Baron, R. J. Wright, and E. Losina Association Between Hospital and Surgeon Procedure Volume and the Outcomes of Total Knee Replacement J. Bone Joint Surg. Am., September 1, 2004; 86(9): 1909 - 1916. [Abstract] [Full Text] [PDF]

				O. Ethgen, O. Bruyere, F. Richy, C. Dardennes, and J.-Y. Reginster Health-Related Quality of Life in Total Hip and Total Knee Arthroplasty. A Qualitative and Systematic Review of the Literature J. Bone Joint Surg. Am., May 1, 2004; 86(5): 963 - 974. [Abstract] [Full Text] [PDF]

				N. Jain, R. Pietrobon, S. Hocker, U. Guller, A. Shankar, and L. D. Higgins The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty J. Bone Joint Surg. Am., March 1, 2004; 86(3): 496 - 505. [Abstract] [Full Text] [PDF]

				R. B. Bourne, W. J. Maloney, and J. G. Wright An AOA Critical Issue The Outcome of the Outcomes Movement J. Bone Joint Surg. Am., March 1, 2004; 86(3): 633 - 640. [Full Text] [PDF]

				D. J. Berry, M. von Knoch, C. D. Schleck, and W. S. Harmsen The Cumulative Long-Term Risk of Dislocation After Primary Charnley Total Hip Arthroplasty J. Bone Joint Surg. Am., January 1, 2004; 86(1): 9 - 14. [Abstract] [Full Text] [PDF]

				J. W. Hammond, W. S. Queale, T. K. Kim, and E. G. McFarland Surgeon Experience and Clinical and Economic Outcomes for Shoulder Arthroplasty J. Bone Joint Surg. Am., December 1, 2003; 85(12): 2318 - 2324. [Abstract] [Full Text] [PDF]

				S. L. Hervey, H. R. Purves, U. Guller, A. P. Toth, T. P. Vail, and R. Pietrobon Provider Volume of Total Knee Arthroplasties and Patient Outcomes in the HCUP-Nationwide Inpatient Sample J. Bone Joint Surg. Am., September 1, 2003; 85(9): 1775 - 1783. [Abstract] [Full Text] [PDF]

				L. B. Green, R. Pietrobon, E. Paxton, L. D. Higgins, and D. Fithian Sources of Variation in Readmission Rates, Length of Stay, and Operative Time Associated with Rotator Cuff Surgery J. Bone Joint Surg. Am., September 1, 2003; 85(9): 1784 - 1789. [Abstract] [Full Text] [PDF]

				A. S. Covey and G. E Friedlaender Financing Graduate Medical Education: Sorting Out the Confusion J. Bone Joint Surg. Am., August 1, 2003; 85(8): 1594 - 1604. [Full Text] [PDF]

				M. F. Swiontkowski Why We Should Collect Outcomes Data J. Bone Joint Surg. Am., January 21, 2003; 85(90001): S14 - 15. [Full Text] [PDF]

				C. B. Phillips, J. A. Barrett, E. Losina, N. N. Mahomed, E. A. Lingard, E. Guadagnoli, J. A. Baron, W. H. Harris, R. Poss, and J. N. Katz Incidence Rates of Dislocation, Pulmonary Embolism, and Deep Infection During the First Six Months After Elective Total Hip Replacement J. Bone Joint Surg. Am., January 17, 2003; 85(1): 20 - 26. [Abstract] [Full Text] [PDF]

				N. N. Mahomed, J. A. Barrett, J. N. Katz, C. B. Phillips, E. Losina, R. A. Lew, E. Guadagnoli, W. H. Harris, R. Poss, and J. A. Baron Rates and Outcomes of Primary and Revision Total Hip Replacement in the United States Medicare Population J. Bone Joint Surg. Am., January 17, 2003; 85(1): 27 - 32. [Abstract] [Full Text] [PDF]

				M. H. Huo What's New in Hip Arthroplasty J. Bone Joint Surg. Am., October 10, 2002; 84(10): 1894 - 1905. [Full Text] [PDF]

				T. Bhattacharyya, R. Iorio, and W. L. Healy Rate of and Risk Factors for Acute Inpatient Mortality After Orthopaedic Surgery J. Bone Joint Surg. Am., April 1, 2002; 84(4): 562 - 572. [Abstract] [Full Text] [PDF]

				C. R. Clark and J. D. Heckman Volume versus Outcomes in Orthopaedic Surgery: A Proper Perspective is Paramount J. Bone Joint Surg. Am., November 1, 2001; 83(11): 1619 - 1621. [Full Text] [PDF]

Letters to the Editor:

Stanford University Libraries' HighWire Press (TM) assists in the publication of JBJS Online.
Copyright © 2001 by The Journal of Bone and Joint Surgery, Inc. Online ISSN: 1535-1386.
The Journal of Bone and Joint Surgery®, JBJS®, JB&JS®, and eJBJS® are registered in the U.S. Patent and Trademark Office.