Department of Orthopaedic Surgery, Stanford University School of Medicine, Redwood City, California.
Healthcare Research Institute (J.C.B.K. and S.L.), Hospital for Special Surgery (R.G.M., E.B., and A.S.M.), New York, NY.
J Bone Joint Surg Am. 2018 Jul 18;100(14):1203-1208. doi: 10.2106/JBJS.17.00967.
Studies of volume-outcome relationships typically subdivide volume via non-evidence-based methods, producing categories that vary widely among studies, preclude the comparison of results, and possibly obscure the true volume-outcome relationships. The goal of the current study was to use quantitative methods to derive meaningful, risk-based categories for hospital and surgeon total hip arthroplasty (THA) volume based on relationships with mortality, complications, and revision.
Using New York statewide patient data (1997 to 2014; n = 187,557), we derived risk-based hospital and surgeon-volume categories for primary THA based on relationships with 90-day complications and mortality and 2-year revision.
The following categories, based on relationships with complications, mortality, and revision, were derived for surgeon volume: 0 to 12, 13 to 25, 26 to 72, 73 to 165, 166 to 279, and ≥280 THA/year. For hospital volume, the categories derived were 0 to 11, 12 to 54, 55 to 157, 158 to 526, and ≥527 THA/year. More than 35% of THA cases in New York State were conducted by surgeons performing ≤1 THA/month (0 to 12 THA/year), and these were associated with a 2 to 2.5-fold increase in the risk for complications, mortality, and revision relative to higher-volume surgeons. Similarly, 15% of THA cases in New York State were conducted in hospitals performing ≤1 THA/week (0 to 11 or 12 to 54 THA/year), and these were associated with a nearly 1.5-fold increase in complications and between a 4 and 6-fold increase in mortality. Traditional non-evidence-based quartile categories were concentrated at lower volumes, did not capture the full magnitude of the volume-related differences, and were a poorer representation of the outcome data, as assessed by several model metrics. Thus, quartiles showed only a <2-fold increase in complications, mortality, and revision for the lowest versus the highest surgeon-volume quartile and failed to show the increased risk for lower versus higher hospital volumes.
The volume-outcome relationships in THA are more pronounced than previously apparent through standard statistical techniques. Volume-based strategies for improving outcomes in THA should use benchmarks that are evidence-based to achieve optimal results.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
研究体积-结果关系的方法通常通过非基于证据的方法对体积进行细分，产生的类别在不同的研究中差异很大，排除了结果的比较，并可能掩盖了真实的体积-结果关系。本研究的目的是使用定量方法，根据与死亡率、并发症和翻修的关系，为医院和外科医生全髋关节置换术（THA）的总容量得出有意义的、基于风险的类别。
使用纽约州全州患者数据（1997 年至 2014 年；n = 187,557），我们根据 90 天并发症和死亡率以及 2 年翻修与主要 THA 的关系，得出了基于风险的医院和外科医生手术量类别。
根据并发症、死亡率和翻修的关系，为外科医生的手术量得出了以下类别：0 至 12、13 至 25、26 至 72、73 至 165、166 至 279 和≥280 次 THA/年。对于医院的容量，得出的类别为 0 至 11、12 至 54、55 至 157、158 至 526 和≥527 次 THA/年。纽约州超过 35%的 THA 手术是由每月进行≤1 次手术的外科医生（0 至 12 次 THA/年）进行的，与高容量外科医生相比，这些手术的并发症、死亡率和翻修风险增加了 2 至 2.5 倍。同样，纽约州 15%的 THA 手术是在每周进行≤1 次手术的医院（0 至 11 次或 12 至 54 次 THA/年）进行的，这些手术的并发症增加了近 1.5 倍，死亡率增加了 4 至 6 倍。传统的非基于证据的四分位数类别集中在较低的容量，没有捕捉到与体积相关的差异的全部幅度，并且在几个模型指标的评估中，对结果数据的代表性较差。因此，四分位数仅显示出最低外科医生手术量与最高外科医生手术量相比，并发症、死亡率和翻修的增加<2 倍，并且未能显示出较低医院手术量与较高医院手术量相比的风险增加。
通过标准统计技术，THA 的体积-结果关系比以前明显。THA 中改善结果的基于体积的策略应使用基于证据的基准来实现最佳结果。
治疗水平 III。有关证据水平的完整描述，请参阅作者说明。
