Abstract
Background
The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardisation of care on short-term post-operative outcomes and resource utilisation 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 30 days after discharge. Hierarchical models were used to estimate effects of hospital and surgeon procedure volume and standardisation 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 stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality and lower risk of readmission and higher likelihood of being discharged home. The impact of process standardisation was substantial; maximising 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.
Conclusion
Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardisation 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 standardisation could help providers optimise quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume.
