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Scientific Articles   |    
The Influence of Procedure Volumes and Standardization of Care on Quality and Efficiency in Total Joint Replacement Surgery
Kevin J. Bozic, MD, MBA1; Judith Maselli, MSPH2; Penelope S. Pekow, PhD3; Peter K. Lindenauer, MD, MSc3; Thomas P. Vail, MD4; Andrew D. Auerbach, MD, MPH5
1 Department of Orthopaedic Surgery, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 500 Parnassus Avenue, MUW320, San Francisco, CA 94143-0728. E-mail address: kevin.bozic@ucsf.edu
2 Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, 3333 California Street, Suite 430, Box 1211, San Francisco, CA 94118
3 Center for Quality of Care Research, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199
4 Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MUW320, San Francisco, CA 94143-0728.
5 Division of Hospital Medicine, University of California, San Francisco, 533 Parnassus Avenue, San Francisco, CA 94143-0131
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Orthopaedic Research and Education Foundation (OREF) and the California HealthCare Foundation. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (United Healthcare, Pacific Business Group on Health, Integrated Healthcare Association, and DePuy).

Investigation performed at the University of California, San Francisco, San Francisco, California

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Nov 17;92(16):2643-2652. doi: 10.2106/JBJS.I.01477
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Abstract

Background: 

The relationship between surgeon and hospital procedure volumes and clinical outcomes in total joint arthroplasty has long fueled a debate over regionalization of care. At the same time, numerous policy initiatives are focusing on improving quality by incentivizing surgeons to adhere to evidence-based processes of care. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardization of care on short-term postoperative outcomes and resource utilization in lower-extremity total joint arthroplasty.

Methods: 

An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta-blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first thirty days after discharge. Hierarchical models were used to estimate the effects of hospital and surgeon procedure volume and process standardization on individual and combined surgical outcomes and length of stay.

Results: 

After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of hospital stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality, lower risk of readmission, and higher likelihood of being discharged home. The impact of process standardization was substantial; maximizing adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume.

Conclusions: 

Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardization is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established; however, our findings suggest that process standardization could help providers optimize quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume.

Level of Evidence: 

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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