[Are there relevant minimum procedure volumes in trauma and orthopedic surgery?]

Abstract

Introduction: The introduction of minimum surgical volumes aimed at improving the quality of care is currently the subject of controversial debate. One relevant issue is whether the data from external quality assurance can be used to predict outcomes that justify the introduction of minimum surgical volumes.

Method: Analysis was carried out on the procedures total knee replacements (arthroplasties) (TKA) and femoral neck fractures (FNF). A total of 31,657 data records from North Rhine Westphalia (2002/2003) were included in TKA evaluation. The data records provided by the External Quality Assurance Department of the General Medical Council, Westphalia Lippe (from 1993 to 2000) were merged with data compiled between 2001 and 2004 by the German National Quality Assurance Center (BQS) in a survey conducted in North Rhine Westphalia. A total of 49,928 cases were analyzed. The analysis aimed to determine any connections between number of cases and outcome quality.

Results: No connection between outcome quality and number of cases was postulated for TKA in terms of general complications such as cardiovascular events, pneumonia, pulmonary embolism and thrombosis. By contrast, the incidence of specific complications secondary to TKA (wound infections, abscesses, hematomas and postoperative bleeding) was much rarer in hospitals with high case volumes. The trend noted in the overall group may appear a contrary one when the individual departments and hospitals are considered. No connection was established for FNF outcomes.

Discussion: In line with reports in the literature, it can be presumed that a connection exists between outcome quality and surgical volume for TKA. However, no threshold value can be deduced on the basis of current outcome data. Debate continues as to whether the introduction of minimum surgical volumes might be economically motivated and how minimum surgical volumes might impact healthcare structures. Lastly, it is discussed whether or not diagnostic related groups (DRG) inherently lead to a concentration of services that would make the introduction of minimum surgical volumes superfluous.