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. 2014 May 23:348:g3284.
doi: 10.1136/bmj.g3284.

Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study

Bheeshma Ravi  1 , Richard Jenkinson  2 , Peter C Austin  3 , Ruth Croxford  4 , David Wasserstein  2 , Benjamin Escott  2 , J Michael Paterson  3 , Hans Kreder  5 , Gillian A Hawker  6
Affiliations

Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study

Bheeshma Ravi et al. BMJ. .

Abstract

Objectives: To identify a cut point in annual surgeon volume associated with increased risk of complications after primary elective total hip arthroplasty and to quantify any risk identified.

Design: Propensity score matched cohort study.

Setting: Ontario, Canada.

Participants: 37,881 people who received their first primary total hip arthroplasty during 2002-09 and were followed for at least two years after their surgery.

Main outcome measure: The rates of various surgical complications within 90 days (venous thromboembolism, death) and within two years (infection, dislocation, periprosthetic fracture, revision) of surgery.

Results: Multivariate splines were developed to visualize the relation between surgeon volume and the risk for various complications. A threshold of 35 cases a year was identified, under which there was an increased risk of dislocation and revision. 6716 patients whose total hip arthroplasty was carried out by surgeons who had done ≤ 35 such procedure in the previous year were successfully matched to patients whose surgeon had carried out more than 35 procedures. Patients in the former group had higher rates of dislocation (1.9% v 1.3%, P=0.006; NNH 172) and revision (1.5% v 1.0%, P=0.03; NNH 204).

Conclusions: In a cohort of first time recipients of total hip arthroplasty, patients whose operation was carried by surgeons who had performed 35 or fewer such procedures in the year before the index procedure were at increased risk for dislocation and early revision. Surgeons should consider performing 35 cases or more a year to minimize the risk for complications. Furthermore, the methods used to visualize the relationship between surgeon volume and the occurrence of complications can be easily applied in any jurisdiction, to help inform and optimize local healthcare delivery.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Ethical approval: Not required.

Figures

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Fig 1 Selection of patients for inclusion in study of effect surgeon volume on risk of complications after total hip arthroplasty
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Fig 2 Probability of specific complications after total hip arthroplasty according to surgeon volume
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Fig 3  Probability of dislocation and revision after total hip arthroplasty according to surgeon volume
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Fig 4 Area under curve in multivariate models for various cut points of surgeon volume
See this image and copyright information in PMC

Comment in

References

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