Surgeon experience, case volume, what difference do they make in outcome?

Center and surgeon volume influence the revision rate following unicondylar knee replacement: an analysis of 23,400 medial cemented unicondylar knee replacements

The effects of the learning curve and surgical experience on the rate of revision surgery is of extreme interest in a technical field like orthopaedics. If we skip to the bottom line of this article, we see that the authors suggest that the surgical workload for an orthopaedic procedure (in this case a unicondylar knee replacement, but it could be any other) be concentrated in centers and with surgeons, allowing them to accumulate the necessary volumes required to improve patient outcomes.

So here's the study. The authors analyzed 23,400 medial cemented Oxford unicondylar knee replacements for the treatment of osteoarthritis. Total center and surgeon operative volumes were calculated over an eight-year time span since the inception of the registry (April 2003 to December 2010). The revision rate was calculated according to center volume and surgeon volume.

A total of 919 surgeons and a total of 366 centers performed at least one replacement, with the majority performing a small number of procedures. The revision rate for the surgeons with the lowest volume (twenty-five or fewer procedures), 2.16 revisions per 100 component years, was significantly higher than that for the surgeons with the highest volume (more than 200 procedures), 0.80 revisions per 100 component years. The five-year survival rate of 90.1% for the lowest-volume surgeons was also significantly lower than the rate of 96.0% for the highest-volume surgeons. Stating this in the other way, the five year failure rate for low volume surgeons is 10%  in contrast to 4% per year for highest volume surgeons - less than half.

While the authors suggest a threshold level, their data indicates that the benefit of experience continues to increase with increasing volume:

In any event, their evidence indicates that high-volume centers and surgeons specializing in such procedures had superior results compared with their low-volume counterparts.

The mechanisms by which experience exerts its effect are probably multiple, including optimizing patient selection, surgical technique, surgical teamwork and rehabilitation.  What is clear is that a >50% reduction in failure rate is something  to consider.

===
Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.


See the countries from which our readers come on this post.

Physicians With The Least Experience Have Higher Cost Profiles Than Do Physicians With The Most Experience - Health Affairs

Physicians With The Least Experience Have Higher Cost Profiles Than Do Physicians With The Most Experience - Health Affairs

This article has gotten a lot of press in that it touches so many buttons - cost, experience and the status of things for young physicians. It has attracted the attention of insurance companies, the government and the lay press.

A cost profile is a case-mix adjusted measure of resource use in comparison to that of a peer group.  This study of costs/episode of treatment was based on inpatient and outpatient costs regarding over 1,000,000 patients aged 18-65 and over 12,000 physicians who rendered over 2,800,000 episodes of treatment (average 236/physician) in 2004-2005.  This study included the full range of physician specialties; orthopaedic surgeons comprised 4.6% of all physicians rendering 2.4% of all episodes and having 125 episodes/physician.

Compared to physicians with 40 or more years of experience, physicians with fewer than 10 years, 20–29 years, and 30–39 years of experience had 13.2 percent, 10.0 percent, 6.5 per- cent, and 2.5 percent higher cost-profile scores, respectively. Higher volume physicians had somewhat lower cost-profiles. Just as for episode-based costs,  mean per capita patient costs were lower for more experienced physicians: $14,906 for physicians with fewer than 10 years of experience, $15,623 for those with 10–19 years, $14,066 for those with 20–29 years, $12,028 for those with 30–39 years, and $10,104 for those with more than 40 years.

The authors suggest that as a result of this finding, physicians with less experience are more likely to be negatively impacted by policies that implement cost profiles, for example by receiving lower payments under Medicare's 'value based' system or by being excluded from certain provider networks or insurance plans.  

While the reasons behind these differences in cost profiles are not identified in this study, this research does call attention to the fact that cost profile methodology is in place and that payers of health care will be collecting and using these data. It is important, therefore, that as providers - whether young or old -  we are equally aware of these metrics and consider them in our decision making regarding the ordering of more expensive tests and implants unless there is clear benefit to our patients.

----

If you have suggestions for topics you'd like us to address in this blog, please send an email to
shoulderarthritis@uw.edu

Use the "Topics" box to the right to find other posts of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.

Surgeon experience, the learning curve, revision rates, and patient safety.

A recent article in Clinical Orthopaedics explored the effects of introducing a new total knee prosthesis design. They found that the first 15 patients having the new prosthesis had a 48% greater risk of needing a revision surgery during the first two years after the procedure.

While knees are not shoulders, a surprisingly similar result was obtained regarding the learning curve for reverse total shoulders.

Other articles have pointed to the importance of surgeon case volume to the result, such as this one and this one.

Interestingly, many shoulder replacements are performed by surgeons with relatively little experience.

These articles serve to point out the importance of recognizing the importance of experience to the result.  While there is much emphasis on suggested advantages of one design of implant over another, the most important variable may be the experience of the surgeon - not only in doing the procedure, but also in selecting and preparing the patients and in guiding the recovery.

As we say, 'the surgeon is the method'.

--

Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.