Cram Peter, Vaughan-Sarrazin Mary S, Wolf Brian, Katz Jeffrey N, Rosenthal Gary E
Division of General Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
J Bone Joint Surg Am. 2007 Aug;89(8):1675-84. doi: 10.2106/JBJS.F.00873.
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.
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.
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).
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.
专科骨科医院的出现引发了广泛争议，但对于其提供的医疗质量却知之甚少。我们的目标是比较在专科骨科医院和综合医院接受大关节置换手术患者的特征及治疗结果。
我们对1999年至2003年间在38家专科骨科医院接受全髋关节置换术的51788名医疗保险受益人和在517家综合医院接受全膝关节置换术的99765名医疗保险受益人进行了一项回顾性队列研究。我们比较了专科和综合医院患者的人口统计学数据、合并症发生率以及社会经济状况。采用逻辑回归分析来计算在对患者特征和医院手术量进行调整后出现不良结局（死亡或特定手术并发症）的几率。
人口统计学数据以及初次置换与翻修置换的比例相似，但2003年在专科医院接受治疗的患者合并症较少，居住的邮政编码区域比综合医院的患者更为富裕。2003年，专科医院全髋关节置换术（分别为33例和20例；p = 0.05）和全膝关节置换术（分别为75例和40例；p = 0.006）的平均手术量显著高于综合医院。全髋关节置换术（3.0% 对比6.9%；p < 0.001）和全膝关节置换术（2.1% 对比3.9%；p < 0.001）中，专科医院未经调整的不良结局发生率低于综合医院。在对患者特征和手术量进行调整后，专科医院初次关节置换（优势比为0.64；95% 置信区间为0.56至0.75；p < 0.001）和翻修关节置换（优势比为0.49；95% 置信区间为0.36至0.66；p < 0.001）患者出现不良结局的几率显著低于综合医院。
根据医疗保险管理数据衡量，在对患者特征和医院手术量进行调整后，专科骨科医院的患者治疗结果优于综合医院。
