Document Detail

The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery.
MedLine Citation:
PMID:  21084575     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: The relationship between surgeon and hospital procedure volumes and clinical outcomes in total joint arthroplasty has long fueled a debate over regionalization of care. At the same time, numerous policy initiatives are focusing on improving quality by incentivizing surgeons to adhere to evidence-based processes of care. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardization of care on short-term postoperative outcomes and resource utilization in lower-extremity total joint arthroplasty.
METHODS: An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta-blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first thirty days after discharge. Hierarchical models were used to estimate the effects of hospital and surgeon procedure volume and process standardization on individual and combined surgical outcomes and length of stay.
RESULTS: After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of hospital stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality, lower risk of readmission, and higher likelihood of being discharged home. The impact of process standardization was substantial; maximizing adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume.
CONCLUSIONS: Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardization is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established; however, our findings suggest that process standardization could help providers optimize quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume.
Kevin J Bozic; Judith Maselli; Penelope S Pekow; Peter K Lindenauer; Thomas P Vail; Andrew D Auerbach
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Publication Detail:
Type:  Comparative Study; Evaluation Studies; Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  The Journal of bone and joint surgery. American volume     Volume:  92     ISSN:  1535-1386     ISO Abbreviation:  J Bone Joint Surg Am     Publication Date:  2010 Nov 
Date Detail:
Created Date:  2010-11-18     Completed Date:  2010-12-21     Revised Date:  2011-06-08    
Medline Journal Info:
Nlm Unique ID:  0014030     Medline TA:  J Bone Joint Surg Am     Country:  United States    
Other Details:
Languages:  eng     Pagination:  2643-52     Citation Subset:  AIM; IM    
Department of Orthopaedic Surgery, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA 94143-0728, USA.
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MeSH Terms
Arthroplasty, Replacement, Hip / standards*,  statistics & numerical data
Arthroplasty, Replacement, Knee / standards*,  statistics & numerical data
Clinical Competence*
Databases, Factual
Follow-Up Studies
Length of Stay
Middle Aged
Patient Care / standards,  trends
Postoperative Care / standards,  trends
Postoperative Complications / epidemiology
Prosthesis Failure
Quality of Health Care*
Reoperation / statistics & numerical data
Retrospective Studies
Treatment Outcome
United States

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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