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A Comparison of Total Hip and Knee Replacement in Specialty and General
Hospitals
Conclusions: After adjustment for patient characteristics and hospital
volume, the specialty orthopaedic hospitals had better patient outcomes, as
measured by Medicare administrative data, than did the general hospitals.
Link
http://www.ejbjs.org/cgi/content/abstract/89/8/1675
Peter Cram, MD, MBA1, Mary S. Vaughan-Sarrazin, PhD2, Brian Wolf, MD3,
Jeffrey N. Katz, MD, MS4 and Gary E. Rosenthal, MD2
1 Division of General Medicine, Mail Stop 152; 3E-09, Iowa City Veterans Affairs
Medical Center, Iowa City, IA 52246. E-mail address: peter-cram@uiowa.edu
2 Center for Research in the Implementation of Innovative Strategies for
Practice (CRIISP), Iowa City Veterans Affairs Medical Center, Iowa City, IA
52246
3 Department of Orthopaedic Surgery, University of Iowa Carver College of
Medicine, Iowa City, IA 52242
4 Division of Rheumatology, Immunology and Allergy, and Department of
Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75
Francis Street, Boston, MA 02115
Investigation performed at the Division of General Internal Medicine, the
University of Iowa Carver College of Medicine, Iowa City, Iowa
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 Department of Veterans Affairs, Health Services
Research and Development Program to the Center for Research in the
Implementation of Innovative Strategies for Practice (CRIISP), and a K23 career
development award (RR01997201) from the National Center for Research Resources,
National Institutes of Health. Neither they nor a member of their immediate
families received payments or other benefits or a commitment or agreement to
provide such benefits from a commercial entity. No commercial entity paid or
directed, or agreed to pay or direct, any benefits to any research fund,
foundation, division, center, clinical practice, or other charitable or
nonprofit organization with which the authors, or a member of their immediate
families, are affiliated or associated.
A commentary is available with the electronic versions of this article, on our
web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription
department, at 781-449-9780, to order the CD-ROM).
The views expressed in this article are those of the authors and do not
necessarily represent the views of the Department of Veterans Affairs.
Background: The emergence of specialty orthopaedic hospitals has generated
widespread controversy, but little is known about the quality of care they
deliver. Our objective was to compare the characteristics and outcomes of
patients undergoing major joint replacement in specialty orthopaedic and general
hospitals.
Methods: We conducted a retrospective cohort study of 51,788 Medicare
beneficiaries who underwent total hip replacement and 99,765 who underwent total
knee replacement in thirty-eight specialty orthopaedic hospitals and 517 general
hospitals between 1999 and 2003. We compared demographic data, rates of comorbid
illness, and socioeconomic status of patients treated in specialty and general
hospitals. Logistic regression was used to calculate the odds of an adverse
outcome (death or selected surgical complications) after adjustment for patient
characteristics and hospital procedural volume.
Results: The demographic data and the ratio of primary to revision arthroplasties were similar, but patients who received care in specialty
hospitals had less comorbidity and resided in more affluent zip codes than their
counterparts in general hospitals in 2003. Specialty hospitals had significantly
greater mean procedural volumes in 2003 than did general hospitals for both
total hip replacement (thirty-three compared with twenty procedures; p = 0.05)
and total knee replacement (seventy-five compared with forty procedures; p =
0.006). The unadjusted rate of adverse outcomes was lower in specialty hospitals
than in general hospitals for total hip replacement (3.0% compared with 6.9%; p
< 0.001) and total knee replacement (2.1% compared with 3.9%; p < 0.001). After
adjusting for patient characteristics and procedural volume, the odds of adverse
outcomes occurring were significantly lower for patients in specialty hospitals
than for those in general hospitals for both primary joint replacement (odds
ratio, 0.64; 95% confidence interval, 0.56 to 0.75; p < 0.001) and revision
joint replacement (odds ratio, 0.49; 95% confidence interval, 0.36 to 0.66; p <
0.001).
Conclusions: After adjustment for patient characteristics and hospital volume,
the specialty orthopaedic hospitals had better patient outcomes, as measured by
Medicare administrative data, than did the general hospitals.
Level of Evidence: Therapeutic Level III. See Instructions to Authors for a
complete description of levels of evidence.
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