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Study: Below standard volumes of knee revisions done at most centers in England
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MANCHESTER — In an audit of 400 hospitals in England and Wales, researchers found a median of eight revision knee arthroplasties were performed at these centers per year, leading them to question the cost-effectiveness of performing these procedures at low-volume hospitals.
“We find a significant proportion of centers in England and Wales performing knee revisions in small volumes,” Paul N. Baker, MSc, FRCS (Eng), of the Institute of Cellular Medicine in Newcastle upon Tyne, England, said during his presentation at the British Orthopaedic Association Congress. “The majority of these centers fell below one or both of our audit standards, and this included nearly all independent hospitals. We have to ask ourselves, is it cost-effective [and] in the best interest of patients to render service where the majority of centers are performing small numbers of these complex procedures?”
He noted that similar audits published in the literature contend that increases in the number of procedures performed benefit physicians and patients by improving technical outcomes, enhancing surgical training and developing clinical research networks to foster collaboration between physicians. Some investigators have also suggested centralizing these complex procedures to higher-volume hospitals to improve patient outcomes.
Baker and colleagues designed a study to examine the volume of revision knee replacements performed at 400 hospitals between July 2008 and June 2010. Using data from the National Joint Registries of England and Wales, they identified the number of primary knee replacements and revisions, and hospital type (independent, members of the National Health Service Trust or an independent sector treatment center [ISTC]). They used two standards to measure volumes: the first standard was less than 10 revisions per year and the second standard was 2.5 revisions per 100 knee arthroplasties. There were 208 NHS centers, 141 independent centers and 10 ISTCs included in the study. There were 9,659 revisions.
Paul N. Baker
A median of eight revision knee arthroplasties were performed at the centers overall per year, less than the 10 per-year standard. The NHS centers performed “the bulk” of the procedures (14 per year), while the independent hospitals performed the least revisions (three per year), Baker said. Overall, the researchers found that 212 centers performed more than 10 revisions per year. Of these centers, according to the study abstract, 80 also performed greater than 2.5 revisions per 100 primary procedures. For the second standard, the researchers found a median of five revisions were performed per 100 arthroplasties at the 400 centers, with NHS hospitals performing most of the revisions. The researchers did not account for surgeon volume in the study.
“There is a clear association in the literature between both surgeon and hospital volume in terms of outcomes in both primary and revision knee surgery. We must therefore critically ask ourselves if we are doing enough of these procedures and whether it might be best if this work was concentrated in fewer, higher volume centers.” Baker said. – by Renee Blisard Buddle
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Disclosure: Baker has no relevant financial disclosures.