High-volume surgeons, not high-volume hospitals linked with THA survivorship

Researchers found high-volume surgeons, however, were more likely to work in high-volume hospitals.

A population-based cohort study that reviewed the association between total hip arthroplasty survivorship and both hospital THA volume and surgeon THA volume in France showed greater survivorship was associated with high-volume surgeons.

Perspective from Monti Khatod, MD

“This study brings evidence in support of the notion that THAs performed by high-volume surgeons operating in the private system in France have higher survivorship in the first 4 years of follow-up,” Sandrine Colas, MSc, MPH, told Healio.com/Orthopedics.

Colas and her colleagues used the French National Health Insurance Database to identify 62,906 patients who underwent THA from 2010 to 2011. The researchers followed patients until the end of 2014 for an outcome of THA revision. Procedure volumes were divided into tertiles of low-, medium- and high-activity surgeons and hospital groups.

Based on the results, the mean hospital volume was 23 THA procedures per month and mean surgeon volume was eight procedures per month. Low-, medium- and high-activity surgeons implanted 5%, 72% and 22% of THAs, respectively, and 7%, 28% and 65% of THA implantations were done in low-, medium- and high-activity hospitals, respectively.

Researchers found 2,276 patients underwent THA revision and there was a higher risk of revision among men and younger patients, as well as with the use of benzodiazepine, antidepressants and oral corticosteroids. Prosthetic survivorship was associated with hospital and surgeon procedure volumes, according to univariate analysis.

Although surgeon volume continued to be associated with risk of prosthetic revision in the full model, which was adjusted for both surgeon and hospital volumes and all covariates, the researchers found hospital volume was no longer associated with prosthetic revision.

Univariate analyses showed all covariates were associated with hospital and surgeon procedure volumes, except for gender, benzodiazepines regarding hospital procedure volume and except anti-osteoporotic medications regarding surgeon procedure volume. Researchers found a correlation between hospital and surgeon procedure volumes whereby high-volume surgeons were more likely to work in high-volume hospitals.

“[Total hip replacements] THRs are technically demanding surgical procedures,” Colas said. “Nonetheless, our results highlight for the first time a role of the surgeon’s experience, even when taking into account the characteristics of the hospital.”

According to Colas, several additional studies are ongoing in THR, as well as total knee replacement, to study the association between prosthetic survivorship and characteristics of the implants, the patient and the surgeon. – by Casey Tingle

Reference:

Cossec CL, et al. Arthroplast Today. 2017;doi:10.1016/j.artd.2017.03.010.

For more information:

Sandrine Colas, MSc, MPH, can be reached at 143-147 Boulevard Anatole France, F-93285 Saint-Denis Cedex, France; email: sandrine.colas@ansm.sante.fr.

Disclosure: Colas reports no relevant financial disclosures.

Perspective

Monti Khatod, MD

The authors do a wonderful job of evaluating outcomes from hip replacement procedures in France. Their research shows that surgeons with high volumes (defined as more than 4 cases per month) have better outcomes than low volume surgeons who perform fewer than 1.5 cases per month, while hospital volume was not associated with outcome. This contrasts with the Kaiser Permanente experience, but is in line with other studies. While regional differences may account for some of the differences in this study, the lack of a definition for high-volume surgeon causes difficulties in the comparison of cohorts. The Kaiser Permanente study evaluated surgeons with more than 30 cases per year to surgeons with fewer cases per year. No medium volume was evaluated as was the case with this study. If the same definition was used on the Kaiser Permanente patient cohort, perhaps equivalent outcomes could be found.

Of note, regional differences may also affect outcomes. The average length of stay for a French patient is 9 days while patients stay, on average, 2 days to 3 days at Kaiser Permanente facilities. Further, Kaiser Permanente hospitals have aligned arthroplasties to be done by experienced and higher volume surgeons to reduce variability and improve outcomes as the preponderance of evidence supports such a practice. In conclusion, the study supports the use of high-volume surgeons and shows these surgeons are predominantly found in high-volume hospitals, which is similar to the Kaiser Permanente model.

Reference:

Khatod M, et al. J Arthroplasty. 2014;doi:10.1016/j.arth.2014.01.023.

Monti Khatod, MD

Kaiser Permanente

West Los Angeles Medical Center

Los Angeles

Disclosures: Khatod reports no relevant financial disclosures.