TO THE EDITOR:
I read with interest "Relationship between the Volume of Total Hip Replacements Performed by Providers and the Rates of Postoperative Complications in the State of Washington" (79-A: 485—494, April 1997), by Kreder et al. I have the utmost respect for the clinical studies performed by this group in Seattle, and over the years their contributions to the knowledge and patient care in the orthopaedic community have been invaluable to all of us. However, when we start doing studies that lump together all orthopaedic surgeons, whether they have a high-volume or low-volume practice, we are inviting trouble. Certainly there are orthopaedic surgeons who would be considered to have a low-volume practice but who perform total joint replacements (many times in rural situations) and perform them well. To suggest that these surgeons need to stop doing joint replacements sentences their patients to either not having a total joint replacement done or having it done tens if not hundreds of miles away from home and family. In many instances, the patient will choose not to have the replacement, thereby decreasing his or her quality of life. There may also be surgeons who, for economic reasons, are forced to relocate, thereby depriving their communities of all of their orthopaedic care. I, for one, do not believe that this is good patient care.
I think that we need to be very careful before making judgments of each other. There are enough people in our society who are willing to tear down physicians; they do not need us to aid and abet them.
David L. Bowles, M.D.: 500 Richardson Street, Athens, Texas 75751
Dr. Kreder, Dr. Deyo, Dr. Koepsell, Dr. Swiontkowski, and Mr. Kreuter reply:
We would like to clarify several issues raised by Dr. Bowles. Our paper made no policy recommendation regarding mandatory restriction of hip replacements to surgeons who perform a high volume of such procedures. Moreover, we did not compare urban and rural rates of complications.
Dr. Bowles predicts serious economic consequences for surgeons with a low-volume practice who might choose to give up performing elective hip replacements. One must recall that such surgeons perform less than two hip replacements a year. It is difficult to imagine how giving up such a small number of cases would lead to financial ruin. Dr. Bowles is also concerned about the impact on patients who might be reluctant to travel a long distance to receive care. Geographic distance represents one of many barriers that prevent certain individuals from receiving medical and operative care. These are important political issues that need to be addressed, but they were beyond the scope of our paper. Travel subsidies may ultimately cost society less than the consequences of failed operations.
Dr. Bowles objects to the concept of orthopaedic surgeons performing a study that evaluates patient outcome as a function of surgeon or hospital volume. We remind Dr. Bowles that non-orthopaedists have been performing this type of investigation and will continue to do so. We believe that orthopaedists should be leaders in any branch of research that may ultimately affect our practice. We need to continue with efforts to collect high-quality primary data in a prospective fashion in order to work on improving patient function and minimizing complications. Armed with appropriate information, the orthopaedic community can only enhance its ability to self-determine its future. The alternative is to ignore what is happening around us except to react to changes that others impose on us without our input.
Hans J. Kreder, M.D.: Musculoskeletal Health Status Working Group, Division of Orthopaedics, Sunnybrook Health Science Center, Suite A-315, 2075 Bayview Avenue, North York, Ontario M4N 3M5, Canada
Richard A. Deyo, M.D.; Thomas Koepsell, M.D.; Marc F. Swiontkowski, M.D.: Department of Orthopaedics, University of Washington, Harborview Medical Center, Box 359798, 325 Ninth Avenue, Seattle, Washington 98104
William Kreuter, M.P.A.: Department of Health Services, University of Washington, Box 354807, Seattle, Washington 98195-4807