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TKR adverse outcomes are multifactorial
Investigator calls for increased vigilance for patients with comorbid conditions having TKR.
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The issue of hospital and surgical volume and how it is related to patient outcomes is discussed frequently within the health care community. Many factors influence patient outcomes in addition to volume.
In this interview, I asked Jay R. Lieberman, MD, questions related to a study that he and his co-authors published looking at some of these variables.
Douglas W. Jackson, MD: What factors should a surgeon consider to help avoid complications?
Jay R. Lieberman, MD: The goal of our study was to examine the relative importance of hospital volume in comparison to factors such as age, comorbidity, race/ethnicity and insurance type. Our research group, led by Nelson F. Soohoo, MD, assistant professor of orthopedic surgery at UCLA, believed that this was a timely topic because there is ongoing debate as to how the known relationship between hospital volume should factor in decisions about how orthopedic care is delivered.
Our findings indicate that volume is one of many factors that have similar or greater effect on the risk of adverse outcomes, with age and comorbidity the strongest predictors of outcome.
Jackson: Is there a comorbidity index that can be helpful to the clinician in assessing an individual patient’s risk factors?
Lieberman: The Charlson comorbidity index described in our study was designed for use in reviewing administrative databases. Our results indicate that the more comorbid conditions a patient has, the more likely the patient is to have a complication. This should be one factor that physicians consider in counseling patients on risks and benefits. It also highlights the need for increased vigilance in patients with multiple comorbid conditions.
Jackson: What does the existing literature suggest regarding the relationship between hospital volume of TKR and complication rates?
Lieberman: Our research adds to existing studies describing the relationship between hospital volume and the risk of mortality and other complications. The goal of this study was to put this relationship in perspective by comparing the relative impact of hospital volume to other factors such as patient age, comorbidity, race/ethnicity and insurance type. Policy-makers should consider all of these factors as they consider how to best improve the care of patients undergoing total knee arthroplasty.
Jackson: What is the relationship on individual surgeon volume and complication rates?
Lieberman: Our study did not examine the role of surgeon volume, because this information is not available in the California database. However, studies by other authors indicate that surgeon volume is an important predictor of outcomes, with an effect comparable to that seen with hospital volume in our study.
For more information:
- Soohoo NF, Lieberman JR, Ko CY. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88:480-485.
- Jay R. Lieberman, MD, is with the University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030. He can be contacted at 860-679-2640, fax: 860-679-2109.