The Journal of Bone and Joint Surgery (American) 85:1775-1783 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.
Provider Volume of Total Knee Arthroplasties and Patient Outcomes in the HCUP-Nationwide Inpatient Sample
Sheleika L. Hervey, MD,
Harriett R. Purves, MPH,
Ulrich Guller, MD,
Alison P. Toth, MD,
Thomas P. Vail, MD and
Ricardo Pietrobon, MD
Investigation performed at the Center for Excellence in Surgical Outcomes, Department of Surgery, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
Sheleika L. Hervey, MD
Harriett R. Purves, MPH
Ulrich Guller, MD
Alison P. Toth, MD
Thomas P. Vail, MD
Ricardo Pietrobon, MD
Center for Excellence in Surgical Outcomes, Department of Surgery, Division of Orthopaedic Surgery, Duke University Medical Center, Box 3094, Durham, NC 27710. E-mail address for R. Pietrobon: rpietro{at}duke.edu
In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institute of General Medical Sciences (Grant T35-GM08579) and Bristol-Meyers Squibb Company-NMF Fellowship Program in Academic Medicine. They did not receive 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.
Background: The relationship between volume and outcome of total knee arthroplasties has never been evaluated in a nationally representative sample, to our knowledge. We hypothesized that surgeons and hospitals with higher patient volumes would have better outcomes, as defined by lower mortality rates, shorter hospital stays, and lower postoperative complication rates.
Methods: The 1997 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample, Release 6, provided discharge abstracts of patients undergoing total knee arthroplasty from a national stratified probability sample. Logistic and multiple regression models were used to estimate the adjusted association of surgeon or hospital volume with rates of in-hospital mortality, pulmonary thromboembolism, deep venous thrombosis in the lower extremity, and postoperative wound infection as well as length of hospital stay. Estimates were calculated for a target population of 277,550 patients. Models were adjusted for comorbidity, age, gender, race, household income, and procedure (primary or revision arthroplasty).
Results: The patients were mostly white (70.2%) and female (62.7%), with a mean age of 68.9 years. The overall in-hospital mortality rate for the target population was 0.2%, and the average length of stay was 4.6 days for the primary total knee arthroplasties and 4.9 days for the revision procedures. Surgeon volumes of at least fifteen procedures per year and hospital volumes of at least eighty-five per year were significantly and linearly associated with lower mortality rates (odds ratio = 0.56 [0.24 to 1.31] for surgeon volume of  60). No other association demonstrated a significant and directionally consistent linear trend for improved outcomes.
Conclusion: Patients treated by providers with lower caseload volumes had higher rates of mortality following total knee arthroplasty in 1997. Proposing volume standards could decrease patient mortality following this procedure.
Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.
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Letters to the Editor:
Read all Letters to the Editor
- Provider Volume of Total Knee Arthroplasties and Patient Outcomes HCUP-Nationwide Inp.Sample
- Peter A. Feinstein
- JBJS Online, 2 Oct 2003
[Full text]
- Dr. Pietrobon responds to Dr Feinstein
- Ricardo Pietrobon, et al.
- JBJS Online, 27 Oct 2003
[Full text]
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