Clinical Orthopaedics and Related Research®

, Volume 475, Issue 11, pp 2669–2674 | Cite as

Are TKAs Performed in High-volume Hospitals Less Likely to Undergo Revision Than TKAs Performed in Low-volume Hospitals?

  • Elke Jeschke
  • Mustafa Citak
  • Christian Günster
  • Andreas Matthias Halder
  • Karl-Dieter Heller
  • Jürgen Malzahn
  • Fritz Uwe Niethard
  • Peter Schräder
  • Josef Zacher
  • Thorsten Gehrke
Clinical Research

Abstract

Background

High-volume hospitals have achieved better outcomes for THAs and unicompartmental knee arthroplasties (UKAs). However, few studies have analyzed implant survival after primary TKA in high-volume centers.

Questions/Purposes

Is the risk of revision surgery higher when receiving a TKA in a low-volume hospital than in a high-volume hospital?

Methods

Using nationwide billing data of the largest German healthcare insurer for inpatient hospital treatment, we identified 45,165 TKAs in 44,465 patients insured by Allgemeine Ortskrankenkasse who had undergone knee replacement surgery between January 2012 and December 2012. Revision rates were calculated at 1 and 2 years in all knees. The hospital volume was calculated using volume quintiles of the number of all knee arthroplasties performed in each center. We used multiple logistic regression to model the odds of revision surgery as a function of hospital volume. Age, sex, 31 comorbidities, and variables for socioeconomic status were included as independent variables in the model.

Results

After controlling for socioeconomic factors, patient age, sex, and comorbidities, we found that having surgery in a high-volume hospital was associated with a decreased risk of having revision TKA within 2 years of the index procedure. The odds ratio for the 2-year revision was 1.6 (95% CI, 1.4–2.0; p < 0.001) for an annual hospital volume of 56 or fewer cases, 1.5 (95% CI, 1.3–1.7; p < 0.001) for 57 to 93 cases, 1.2 (95% CI, 1.0–1.3; p = 0.039) for 94 to 144 cases, and 1.1 (95% CI, 0.9–1.2; p = 0.319) for 145 to 251 cases compared with a hospital volume of 252 or more cases.

Conclusions

We found a clear association of higher risk for revision surgery when undergoing a TKA in a hospital where less than 145 arthroplasties per year were performed. The study results could help practitioners to guide potential patients in hospitals that perform more TKAs to reduce the overall revision and complication rates. Furthermore, this study underscores the importance of a minimum hospital threshold of arthroplasty cases per year to get permission to perform an arthroplasty.

Level of Evidence

Level III, therapeutic study.

References

  1. 1.
    AQUA. Institut für angewandte Qualitätsförderung und Forschung im Gesundheitswesen GmbH. Available at: https://www.aqua-institut.de. Accessed July 31, 2017.
  2. 2.
    Badawy M, Espehaug B, Indrekvam K, Havelin LI, Furnes O. Higher revision risk for unicompartmental knee arthroplasty in low-volume hospitals. Acta Orthop. 2014;85:342–347.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Baker P, Jameson S, Critchley R, Reed M, Gregg P, Deehan D. Center and surgeon volume influence the revision rate following unicondylar knee replacement: an analysis of 23,400 medial cemented unicondylar knee replacements. J Bone Joint Surg Am. 2013;95:702–709.CrossRefPubMedGoogle Scholar
  4. 4.
    Bohm ER, Molodianovitsh K, Dragan A, Zhu N, Webster G, Masri B, Schemitsch E, Dunbar M. Outcomes of unilateral and bilateral total knee arthroplasty in 238,373 patients. Acta Orthop. 2016;87(suppl 1):24–30.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Bozic KJ, Maselli J, Pekow PS, Lindenauer PK, Vail TP, Auerbach AD. The influence of procedure volumes and standardization of care on quality and efficiency in total joint replacement surgery. J Bone Joint Surg Am. 2010;92:2643–2652.CrossRefPubMedGoogle Scholar
  6. 6.
    Dy CJ, Marx RG, Bozic KJ, Pan TJ, Padgett DE, Lyman S. Risk factors for revision within 10 years of total knee arthroplasty. Clin Orthop Relat Res. 2014;472:1198–1207.CrossRefPubMedGoogle Scholar
  7. 7.
    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998;36:8–27.CrossRefPubMedGoogle Scholar
  8. 8.
    Jasper LL, Jones CA, Mollins J, Pohar SL, Beaupre LA. Risk factors for revision of total knee arthroplasty: a scoping review. BMC Musculoskelet Disord. 2016;17:182.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Jeschke E, Gehrke T, Günster C, Hassenpflug J, Malzahn J, Niethard FU, Schräder P, Zacher J, Halder A. Five-year survival of 20,946 unicondylar knee replacements and patient risk factors for failure: an analysis of German insurance data. J Bone Joint Surg Am. 2016;98:1691–1698.CrossRefPubMedGoogle Scholar
  10. 10.
    Judge A, Chard J, Learmonth I, Dieppe P. The effects of surgical volumes and training centre status on outcomes following total joint replacement: analysis of the Hospital Episode Statistics for England. J Public Health (Oxf). 2006;28:116–124.CrossRefGoogle Scholar
  11. 11.
    Katz JN, Mahomed NN, Baron JA, Barrett JA, Fossel AH, Creel AH, Wright J, Wright EA, Losina E. Association of hospital and surgeon procedure volume with patient-centered outcomes of total knee replacement in a population-based cohort of patients age 65 years and older. Arthritis Rheum. 2007;56:568–574.CrossRefPubMedGoogle Scholar
  12. 12.
    Kreder HJ, Grosso P, Williams JI, Jaglal S, Axcell T, Wal EK, Stephen DJ. Provider volume and other predictors of outcome after total knee arthroplasty: a population study in Ontario. Can J Surg. 2003;46:15–22.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.PubMedGoogle Scholar
  14. 14.
    Kurtz SM, Lau EC, Ong KL, Adler EM, Kolisek FR, Manley MT. Which hospital and clinical factors drive 30- and 90-day readmission after TKA? J Arthroplasty. 2016;31:2099–2107.CrossRefPubMedGoogle Scholar
  15. 15.
    Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am. 2014;96:624–630.CrossRefPubMedGoogle Scholar
  16. 16.
    Laucis NC, Chowdhury M, Dasgupta A, Bhattacharyya T. Trend toward high-volume hospitals and the influence on complications in knee and hip arthroplasty. J Bone Joint Surg Am. 2016;98:707–712.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Manley M, Ong K, Lau E, Kurtz SM. Total knee arthroplasty survivorship in the United States Medicare population: effect of hospital and surgeon procedure volume. J Arthroplasty. 2009;24:1061–1067.CrossRefPubMedGoogle Scholar
  18. 18.
    Namba RS, Cafri G, Khatod M, Inacio MC, Brox TW, Paxton EW. Risk factors for total knee arthroplasty aseptic revision. J Arthroplasty. 2013;28(8 suppl):122–127.CrossRefPubMedGoogle Scholar
  19. 19.
    Norton EC, Garfinkel SA, McQuay LJ, Heck DA, Wright JG, Dittus R, Lubitz RM. The effect of hospital volume on the in-hospital complication rate in knee replacement patients. Health Serv Res. 1998;33:1191–1210.PubMedPubMedCentralGoogle Scholar
  20. 20.
    Pamilo KJ, Peltola M, Paloneva J, Makela K, Hakkinen U, Remes V. Hospital volume affects outcome after total knee arthroplasty. Acta Orthop. 2015;86:41–47.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Paterson JM, Williams JI, Kreder HJ, Mahomed NN, Gunraj N, Wang X, Laupacis A. Provider volumes and early outcomes of primary total joint replacement in Ontario. Can J Surg. 2010;53:175–183.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43:1130–1139.CrossRefPubMedGoogle Scholar
  23. 23.
    Shervin N, Rubash HE, Katz JN. Orthopaedic procedure volume and patient outcomes: a systematic literature review. Clin Orthop Relat Res. 2007;457:35–41.CrossRefPubMedGoogle Scholar
  24. 24.
    Shin CH, Chang CB, Cho SH, Jeong JH, Kang SB. Factors associated with the incidence of revision total knee arthroplasty in Korea between 2007 and 2012: an analysis of the National Claim Registry. BMC Musculoskelet Disord. 2015;16:320.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Singh JA, Kwoh CK, Boudreau RM, Lee GC, Ibrahim SA. Hospital volume and surgical outcomes after elective hip/knee arthroplasty: a risk-adjusted analysis of a large regional database. Arthritis Rheum. 2011;63:2531–2539.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Solomon DH, Losina E, Baron JA, Fossel AH, Guadagnoli E, Lingard EA, Miner A, Phillips CB, Katz JN. Contribution of hospital characteristics to the volume-outcome relationship: dislocation and infection following total hip replacement surgery. Arthritis Rheum. 2002;46:2436–2444.CrossRefPubMedGoogle Scholar
  27. 27.
    Soohoo NF, Zingmond DS, Lieberman JR, Ko CY. Primary total knee arthroplasty in California 1991 to 2001: does hospital volume affect outcomes? J Arthroplasty. 2006;21:199–205.CrossRefPubMedGoogle Scholar
  28. 28.
    Tan SC, Chan YH, Chong HC, Chin PL, Yew A, Chia SL, Tay D, Lo NN, Yeo SJ. Association of surgeon factors with outcome scores after total knee arthroplasty. J Orthop Surg (Hong Kong). 2014;22:378–382.CrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2017

Authors and Affiliations

  • Elke Jeschke
    • 1
  • Mustafa Citak
    • 2
  • Christian Günster
    • 1
  • Andreas Matthias Halder
    • 3
  • Karl-Dieter Heller
    • 4
  • Jürgen Malzahn
    • 5
  • Fritz Uwe Niethard
    • 6
  • Peter Schräder
    • 7
  • Josef Zacher
    • 8
  • Thorsten Gehrke
    • 2
  1. 1.Research Institute of the Local Health Care Funds (AOK)BerlinGermany
  2. 2.Department of Orthopaedic SurgeryHELIOS ENDO-Klinik HamburgHamburgGermany
  3. 3.Department of Orthopaedic SurgerySana Kliniken SommerfeldSommerfeldGermany
  4. 4.Department of Orthopaedic SurgeryHerzogin Elisabeth HospitalBraunschweigGermany
  5. 5.Federal Association of the Local Health Care FundsBerlinGermany
  6. 6.German Society of Orthopedics and Orthopedic SurgeryBerlinGermany
  7. 7.Department of Orthopaedic SurgeryKreisklinik JugenheimJugenheimGermany
  8. 8.HELIOS Kliniken GmbHBerlinGermany

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