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Letters to the Editor to:

Scientific Articles:
Sheleika L. Hervey, Harriett R. Purves, Ulrich Guller, Alison P. Toth, Thomas P. Vail, and Ricardo Pietrobon
Provider Volume of Total Knee Arthroplasties and Patient Outcomes in the HCUP-Nationwide Inpatient Sample
J Bone Joint Surg Am 2003; 85: 1775-1783 [Abstract] [Full text] [PDF]
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[Read Letter to the Editor] Dr. Pietrobon responds to Dr Feinstein
Ricardo Pietrobon, Sheleika L. Hervey, Harriett R. Purves, Ulrich Guller, Alison P. Toth, Thomas P. Vail   (27 October 2003)
[Read Letter to the Editor] Provider Volume of Total Knee Arthroplasties and Patient Outcomes HCUP-Nationwide Inp.Sample
Peter A. Feinstein   (2 October 2003)

Dr. Pietrobon responds to Dr Feinstein 27 October 2003
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Ricardo Pietrobon
Duke University Medical Center,
Sheleika L. Hervey, Harriett R. Purves, Ulrich Guller, Alison P. Toth, Thomas P. Vail

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Re: Dr. Pietrobon responds to Dr Feinstein

rpietro{at}duke.edu Ricardo Pietrobon, et al.

We thank Dr. Feinstein for his comments on our manuscript. Dr. Feinstein raises concerns regarding the generalizabilitiy of our findings to orthopedic surgeons who have extensive expertise but who may be regarded as low volume providers. These concerns are legitimate.

Our investigation was based solely on one year of Nationwide Inpatient Sample data (1997), and his point thus represents a limitation of our study as it might wrongly classify orthopedic surgeons who have changed the volume of their surgical activities over time. Thus, orthopedic surgeons that decreased their case load over time and were in the low volume category in our study may have better outcomes than other low volume providers. Similarly, low volume orthopedic surgeons who suddenly increased their case load and were classified in the high volume subset in our analysis might have worse outcomes than other high volume providers.

To overcome this limitation a combined analysis based on several years (or even decades) would be necessary. Nonetheless, this drawback biases our findings towards the null hypothesis and thus the real differences between low and high volume providers might be even higher than the ones reported in our study.
Provider Volume of Total Knee Arthroplasties and Patient Outcomes HCUP-Nationwide Inp.Sample 2 October 2003
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Peter A. Feinstein,
orthopedic surgeon
Wilkes-Barre General Hospital

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Re: Provider Volume of Total Knee Arthroplasties and Patient Outcomes HCUP-Nationwide Inp.Sample

marieskiro{at}aol.com Peter A. Feinstein

To the Editor:

The authors of this study found that doctors who perform joint replacement surgery more frequently apparently have fewer complications (excluding complications associated with DVT).They recommend that consideration be given to adopting a system in which a certain number of joint replacements are required to have been performed by an individual or a hospital to qualify to do that type of surgery.

The problem with this article and its conclusion is that it does not take into account whether an individual practices in a rural or metropolitan area, and to what extent the potential number of joint replacement patients exist.

I perform approximately 20 hip and knee replacements a year. According to the article, I would be less “competent” than someone doing a much higher number. However,I have been doing joint replacements for approximately 25 years and have prformed well over a 1,000 of these operations. My experience is extensive, and my record over the past 5-10 years is excellent in terms of absence of complications and happy patients.

I believe that I service my community extremely well in this regard. If the conclusions of this article were followed, my patients would have to travel anywhere from an hour and half to two and half hours to have a joint replacement done.

There are other orthopedic surgeons in my community who are in a similar situation and who provide excellent and quite competent care to our patients. I am certain that the statistics at my community hospital compare favorably to hospitals that have higher volumes. In fact, my hospital has been recognized as one of the 100 outstanding orthopedic hospitals in the country for just that reason.

I would, therefore, respectfully submit that the conclusions of this article do not reflect conditions in individual communities. They present a great danger to our ability to provide care to our patients by implying that very qualified and experienced orthopedic surgeons should not be doing this type of surgery.