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A Comparison of Total Hip and Knee Replacement in Specialty and General Hospitals

¹ Division of General Medicine, Mail Stop 152; 3E-09, Iowa City Veterans Affairs Medical Center, Iowa City, IA 52246. E-mail address: peter-cram{at}uiowa.edu
² Center for Research in the Implementation of Innovative Strategies for Practice (CRIISP), Iowa City Veterans Affairs Medical Center, Iowa City, IA 52246
³ Department of Orthopaedic Surgery, University of Iowa Carver College of Medicine, Iowa City, IA 52242
⁴ Division of Rheumatology, Immunology and Allergy, and Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115

Investigation performed at the Division of General Internal Medicine, the University of Iowa Carver College of Medicine, Iowa City, Iowa

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Department of Veterans Affairs, Health Services Research and Development Program to the Center for Research in the Implementation of Innovative Strategies for Practice (CRIISP), and a K23 career development award (RR01997201) from the National Center for Research Resources, National Institutes of Health. Neither they nor a member of their immediate families 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 authors, or a member of their immediate families, are affiliated or associated.

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The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Methods: We conducted a retrospective cohort study of 51,788 Medicare beneficiaries who underwent total hip replacement and 99,765 who underwent total knee replacement in thirty-eight specialty orthopaedic hospitals and 517 general hospitals between 1999 and 2003. We compared demographic data, rates of comorbid illness, and socioeconomic status of patients treated in specialty and general hospitals. Logistic regression was used to calculate the odds of an adverse outcome (death or selected surgical complications) after adjustment for patient characteristics and hospital procedural volume.

Results: The demographic data and the ratio of primary to revision arthroplasties were similar, but patients who received care in specialty hospitals had less comorbidity and resided in more affluent zip codes than their counterparts in general hospitals in 2003. Specialty hospitals had significantly greater mean procedural volumes in 2003 than did general hospitals for both total hip replacement (thirty-three compared with twenty procedures; p = 0.05) and total knee replacement (seventy-five compared with forty procedures; p = 0.006). The unadjusted rate of adverse outcomes was lower in specialty hospitals than in general hospitals for total hip replacement (3.0% compared with 6.9%; p < 0.001) and total knee replacement (2.1% compared with 3.9%; p < 0.001). After adjusting for patient characteristics and procedural volume, the odds of adverse outcomes occurring were significantly lower for patients in specialty hospitals than for those in general hospitals for both primary joint replacement (odds ratio, 0.64; 95% confidence interval, 0.56 to 0.75; p < 0.001) and revision joint replacement (odds ratio, 0.49; 95% confidence interval, 0.36 to 0.66; p < 0.001).

Conclusions: After adjustment for patient characteristics and hospital volume, the specialty orthopaedic hospitals had better patient outcomes, as measured by Medicare administrative data, than did the general hospitals.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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