American author Ray Bradbury is credited with saying, “Quantity produces quality.” Recent research by the Clarify Health Institute suggests that the quote may also be true for orthopedic surgery.
The new study—titled “Pump up the Volume: High-Volume Orthopedic Surgeons Generate Better Outcomes at Lower Costs”—indicates that surgical volume matters when it comes to quality and outcomes.
The study’s conclusion probably doesn’t come as a surprise to our readers. Several other studies have reached the same general conclusion. What makes this research particularly relevant is its focus on large joint reconstruction and its recency—the surgical data underlying this work is from 2021 and the associated surgeon volume data was from 2017 through 2020.
According to the American College of Surgeons, “Every year, 15 million Americans have some kind of surgery.” Patients who have the option of choosing their provider may decide to use surgical volume as one of their criteria. While the information is not likely to be readily available, it is something that the patient can inquire about during their initial consultation with the surgeon. Taking a few minutes to ask the surgeon about their experience may, according to the research, provide them with a better outcome.
The Data: Relevancy and Recency
The research team at Clarify Health Institute used commercial claims data from 2017 to 2020 to calculate historical surgical volume. They then mined 2021 hip and knee replacement claims data to assess hospital performance.
The study sample size was 178,000 orthopedic procedures performed by more than 23,500 providers. Clarify estimated that the study sample represented 14% of all hip and knee replacements performed in the United States every year.
Specifically:
- 66,367 hip replacements performed by 10,100 providers, and
- 111,666 knee replacements performed by 13,432 providers.
Clarify found a “wide variation in prior surgical volume (2017-2020) for hip and knee replacements performed in 2021. Almost a third of the “2021 hip and knee replacement episodes were performed by providers with 100 or more prior surgeries.”
Additionally, “17% of hip replacements and 13% of knee replacements in 2021 were performed by surgeons with less than 10 prior (documented) surgeries.”
Perhaps most significantly, half of the hip and knee replacement episodes were performed by providers who “had performed less than 50 surgeries from 2017-2020.”
Higher Volumes Equal Better Outcomes and Lower Costs
Yes, Virginia, there is a learning curve.
The Clarify team found that “low provider surgical volume negatively impacts post-acute outcomes across inpatient and outpatient settings, even after we control for patient characteristics and other factors.”
Secondly, Clarify reported that “treatment by higher-volume surgeons is particularly important for more clinically complex patients.”
Most importantly, the Clarify team found that for both hip and knee replacements (even when adjusting for variations in patient characteristics) higher provider surgical volume is associated with better outcomes including the following:
- Lower rates of post-acute inpatient readmission at both 7 and 60 days
- Lower rates of revision surgeries
- Lower rates of post-surgical stay orthopedic specialist visits, emergency department visits, and inpatient days
- Lower costs with total hip and knee episode costs approximately $2,800 and $1,500 lower, respectively, when performed by a high-volume versus a low-volume surgeon
Clarify Health Institute Chief Analytics and Privacy Officer Niall Brennan said, “Hip and knee replacements are the most common elective orthopedic surgeries where it is possible for patients to choose their provider. Thousands of adverse clinical events could be avoided each year by making surgical volume information easily accessible and steering patients to high-volume providers.”
Brennan also noted that many factors could influence the results, including patient characteristics.
To control for these factors, the Clarify team “performed an adjusted, multivariate analyses for hip and knee episodes, respectively, and surgical volume controlling for place of service, provider teaching affiliation status, provider state, patient demographics, and comorbidity status.”
Something that was not mentioned when going through the data was the COVID-19 pandemic. The pandemic had and continues to have a dramatic impact on elective surgery. Of course, the pandemic did not discriminate in terms of high or low volume surgical sites—so, perhaps, Clarify chalked the pandemic up to an exogenous variable that affected all providers equally.
That, it seems is a large assumption—if indeed, Clarify even considered COVID.
Is a Shift Really the Answer?
Ezekiel Emanuel, M.D., a strategic advisor to Clarify Health, vice provost for global initiatives at the University of Pennsylvania, and co-director of the Healthcare Transformation Institute said, “There is a clear linear relationship—the more operations a surgeon performs the better the patient does.”
“If we shift more patients to get their hip and knee replacements by high-volume surgeons, it will be a huge win-win. Patients will win with fewer complications, fewer revisions, and fewer hospital readmissions. And the system will win by having lower costs. Now the challenge is to shift patients to see more experienced surgeons.”
The Clarify Health Institute
Based in San Francisco, California, the Clarify Health Institute is the “research arm” of Clarify Health. It utilizes Clarify Health’s data assets from 300 million patients to explore important healthcare issues and provide data-driven research.
