What Is the Association Between Hospital Volume and Complications After Revision Total Joint Arthroplasty: A Large-database Study

Abstract

Background Studies of primary total joint arthroplasty (TJA) show a correlation between hospital volume and outcomes; however, the relationship of volume to outcomes in revision TJA is not well studied. Questions/purposes We therefore asked: (1) Are 90-day readmissions more likely at low-volume hospitals relative to high-volume hospitals after revision THA and TKA? (2) Are in-hospital and 90-day complications more likely at low-volume hospitals relative to high-volume hospitals after revision THA and TKA? (3) Are 30-day mortality rates higher at low-volume hospitals relative to highvolume hospitals after revision THA and TKA? Methods Using 29,948 inpatient stays undergoing revision TJA from 2008 to 2014 in the Statewide Planning and Research Cooperative System (SPARCS) database for New York State, we examined the relationship of hospital revision volume by quartile and outcomes. The top 5 percentile of hospitals was included as a separate cohort. Advantages of the SPARCS database include comprehensive catchment of all cases regardless of payer, and the ability to track each patient across hospital admissions at different institutions within the state. The outcomes of interest included 90-day all-cause readmission rates and 30-and 90-day reoperation rates, postoperative complication rates, and 30-day mortality rates. The initial cohort that met the MS-DRG and ICD-9 criteria consisted of 30,354 inpatient stays for revision hip or knee replacements. Exclusions included patients with a missing patient identifier (n = 221), missing admission or discharge dates (n = 5), and stays from hospitals that were closed during the study period (n = 180). Our final analytic cohort comprised 29,948 inpatient stays for revision hip and knee replacements from 25,977 patients who had nonmissing data points for the variables of interest. Outcomes were adjusted for underlying hospital, surgeon, and patient confounding variables. The analytic cohort included observations from 25,977 patients, 138 hospitals, 929 surgeons, 14,130 revision THAs, 11,847 revision TKAs, 15,341 female patients (59% of cohort). Each author certifies that neither he or she, nor any member of his or her immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use. Each author certifies that his or her institution waived approval for the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.

Are high‐risk patient and revision arthroplasty effective indications for closed‐incisional negative‐pressure wound therapy after total hip or knee arthroplasty? A systematic review and meta‐analysis

“…The prevalence of revision THA and TKA have been increasing with time as primary arthroplasties that have been performed in the past decades require revision and the surgical indications for primary arthroplasties had been broadened recently. 10,14,26,32 Compared with primary arthroplasties, the revision procedure of THA or TKA requires a longer surgical time, has a longer surgical incision and results in more difficult wound healing because of the previous scar, which frequently causes SSC and consequently increases the risk of PJI. 2,4,10,18,33 Many studies have identified that the revision procedure is one of the most crucial risk factors for SSC and PJI after THA or TKA, resulting in poorer clinical outcomes, longer hospital stay, and greater economic burden.…”

Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline

“…Currently revision KR in England and Wales is undertaken by a large number of surgeons performing a small number of procedures (data in press and [22]). The relationship between improved outcomes and higher surgeon and higher unit volume has been established in many areas of medicine, surgery and orthopaedics [23][24][25], and recent data has confirmed this relationship in revision hip and knee replacement [26][27][28].…”

CORR Insights®: What is the Association Between Hospital Volume and Complications After Revision Total Joint Arthroplasty: A Large-database Study

“…In light of that, we must ask what the implications might be of such a policy, and how we might balance the benefits of this approach against its costs and harms. The authors also found that hospitals in the mid-range of volume provided rates of short-term readmissions, complications, and mortality after TJA revision that were not different from the highest-volume institutions [11]. That being so, might it be more-efficient (and less burdensome) to use both mid-and highvolume hospitals if regionalization is considered?…”

“…We do not know if previous definitions of high-volume institutes are still accurate today, and there is the possibility that previous associations between procedure volume and outcomes are now quite different [8]. Traditional nonevidence-based quartile categories of hospitals have not captured the full extent of volume-related differences [7] [11] noted, regionalization is complicated; for example, it can burden already-strained safety-net institutions, and pose unbearable (and unaffordable) travel demands on vulnerable rural populations. In light of that, we must ask what the implications might be of such a policy, and how we might balance the benefits of this approach against its costs and harms.…”

“…Regionalized primary TJA may reduce early readmissions and postoperative complications [3], but we lack sufficient evidence to advocate widespread implementation of regionalization of revision TJA. Ricciardi and colleagues [11] also point out a number of serious operational hurdles associated with this kind of regionalization.…”