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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.

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