Long-Term Trends in Hip Arthroplasty Use and Volume

doi:10.1016/j.arth.2011.04.043

The Journal of Arthroplasty

Volume 27, Issue 2, February 2012, Pages 278-285.e2

https://doi.org/10.1016/j.arth.2011.04.043 Get rights and content

Abstract

We used Medicare administrative data to examine trends in primary and revision total hip arthroplasty (THA) use and hospital volume. Between 1991 and 2005, primary and revision THA use increased by 40.9% and 16.8%, respectively. The percentage of primary THA procedures performed in high-volume hospitals (those in the highest quintile of volume) increased slightly from 58.0% of all procedures in 1991 to 58.7% in 2005 (P < .01). The percentage of revisions performed in high-volume hospitals increased from 60.9% to 62.4% (P < .01). The percentage of primary THA procedures performed by low-volume hospitals remained relatively stable (P = .36), whereas the percentage of revision THA performed by low-volume hospitals declined (P < .001). In aggregate, these results suggest minimal evidence that regionalization of THA is occurring.

Section snippets

Background

Total hip arthroplasty (THA) is one of the most common surgical procedures performed in the United States and worldwide 1, 2. In 2006, an estimated 280 000 THA procedures were performed in the United States at a cost of more than $12 billion [3]. Total hip arthroplasty is generally safe, with major complication rates of approximately 3% for primary procedures and 8% for revision procedures 4, 5.

More than 25 years of research have demonstrated an association between higher volume and improved

Data

We used Medicare Provider Analysis and Review part A data files to identify fee-for-service beneficiaries who underwent primary or revision THA between 1991 and 2005. Patients were identified using International Classification of Diseases, Ninth Revision, Clinical Modification, procedure codes (81.51 for primary and 80.05, 81.53, 00.70, 00.71, 00.72, and 00.73 for revision THA) 9, 20, 21, 22. The part A files contain a range of data collected from discharge abstracts for all hospitalized

Results

Our final study population included 1 146 786 elective primary THAs performed on 1 002 997 unique patients and 225 330 revision THAs performed on 189 832 unique patients between 1991 and 2005. The characteristics of patients undergoing primary and revision THAs are displayed in Table 1, Table 2, respectively. Over the study period, the mean age of patients undergoing both primary and revision THAs increased, and the proportion of procedures performed on women declined. There was also an

Discussion

In a longitudinal analysis of Medicare administrative data from 1991 to 2005, we found an increase in age and comorbidity among patients undergoing elective THA procedures. We also found that although both primary and revision THA volumes increased substantially, per capita use of primary THA increased, whereas use of revision procedures actually declined. Finally, although we found evidence of increasing concentration of primary THA procedures in high-volume hospitals, we found little evidence

References (34)

C. Doro et al.
Hospital volume and inpatient mortality outcomes of total hip arthroplasty in the United States
J Arthroplasty
(2006)
J.D. Birkmeyer et al.
Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative
Surgery
(2001)
D.L. Riddle et al.
Yearly incidence of unicompartmental knee arthroplasty in the United States
J Arthroplasty
(2008)
V. Ho
Certificate of need, volume, and percutaneous transluminal coronary angioplasty outcomes
Am Heart J
(2004)
H. Merx et al.
International variation in hip replacement rates
Ann Rheum Dis
(2003)
L.S. Lohmander et al.
Standardized incidence rates of total hip replacement for primary hip osteoarthritis in the 5 Nordic countries: similarities and differences
Acta Orthop
(2006)
Centers for Disease Control and Prevention
Health, United States, 2009
(2009)
M. Khatod et al.
Knee replacement: epidemiology, outcomes, and trends in Southern California: 17,080 replacements from 1995 through 2004
Acta Orthop
(2008)
J.N. Katz et al.
Association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery
Arthritis Rheum
(2003)
H.S. Luft et al.
Should operations be regionalized? The empirical relation between surgical volume and mortality
N Eng J Med
(1979)

H.S. Luft

The relation between surgical volume and mortality: an exploration of causal factors and alternative models

Med Care

(1980)

J.D. Birkmeyer et al.

Hospital volume and surgical mortality in the United States

N Eng J Med

(2002)

J.N. Katz et al.

Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States Medicare population

J Bone Joint Surg Am

(2001)

J.D. Birkmeyer et al.

Potential benefits of a regionalizing major surgery in Medicare patients

Effective Clin Pract

(1999)

V. Ho et al.

Trends in hospital and surgeon volume and operative mortality for cancer surgery

Ann Surg Oncol

(2006)

D.B. Mukamel et al.

Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State Cardiac Surgery Mortality Reports

Med Care

(1998)

J.P. Marcin et al.

The CABG surgery volume-outcome relationship: temporal trends and selection effects in California, 1998-2004

Health Serv Res

(2008)

Cited by (39)

Medicare Payments to Hospitals and Physicians for Total Hip and Knee Arthroplasty Declined From 2009 to 2019
2023, Journal of Arthroplasty
Recent research has reported hospital payments for total hip arthroplasty (THA) and knee arthroplasty (TKA) from commercial payers to be increasing, despite increasing price pressure from the increasing scale and scope of alternative reimbursement schemes. Therefore, the primary objective of this study was to analyze the recent trends in Medicare payments to hospitals and surgeons for primary THA and TKA.
The primary data source for this study was the Medicare Provider Analysis and Review Limited Data Set (MEDPAR) for the years 2009, 2014, and 2019. A total of 331,721 patients undergoing primary elective THA and 742,476 patients undergoing primary elective TKA were included. Total Medicare payments and total hospital reimbursements, which included Medicare payments and patient copayments, were calculated. Physician fees were obtained from the Medicare physician fee schedule (MPFS) look-up tool. All financial data were inflation-adjusted. Patient comorbidities were identified as a measure of health status. The data were stratified by year and analyzed using descriptive statistics.
From 2009 to 2019, inflation-adjusted Medicare payments declined by 11.5% and total hospital reimbursements (Medicare payments plus copayments) declined by 6.5% for THA, while Medicare payments declined by 13.4%, and total hospital reimbursements declined by 7.7% for TKA. Over the same period, surgeons’ fees declined by 13.1% for THA and 18.9% for TKA.
From 2009 to 2019, Medicare payments to hospitals and physicians declined markedly. Physician payments decreased faster than hospital payments. These results may have implications for the future viability of performing THA and TKA on Medicare patients.
How to Create an Orthopaedic Arthroplasty Administrative Database Project: A Step-by-Step Guide Part I: Study Design
2023, Journal of Arthroplasty
Use of clinical and administrative databases in orthopaedic surgery research has grown substantially in recent years. It is estimated that approximately 10% of all published lower extremity arthroplasty research have been database studies. The aim of this review is to serve as a guide on how to (1) design, (2) execute, and (3) publish an orthopaedic administrative database arthroplasty project.
In part I, we discuss how to develop a research question and choose a database (when databases should/should not be used), detailing advantages/disadvantages of those most commonly used. To date, the most commonly published databases in orthopaedic research have been the National Inpatient Sample, Medicare, National Surgical Quality Improvement Program, and those provided by PearlDiver. General advantages of most database studies include accessibility, affordability compared to prospective research studies, ease of use, large sample sizes, and the ability to identify trends and aggregate outcomes of multiple health care systems/providers.
Disadvantages of most databases include their retrospective observational nature, limitations of procedural/billing coding, relatively short follow-up, limited ability to control for confounding variables, and lack of functional/patient-reported outcomes.
Although this study is not all-encompassing, we hope it will serve as a starting point for those interested in conducting and critically reviewing lower extremity arthroplasty database studies.
Online Crowdsourcing to Explore Public Perceptions of Robotic-Assisted Orthopedic Surgery
2021, Journal of Arthroplasty
The clinical benefits of robotic-assisted technology in total joint arthroplasty are unclear, but its use is increasing. This study employed online crowdsourcing to explore public perceptions and beliefs regarding robotic-assisted orthopedic surgery.
A 30-question survey was completed by 588 members of the public using Amazon Mechanical Turk. Participants answered questions regarding robotic-assisted orthopedic surgery, sociodemographic factors, and validated assessments of health literacy and patient engagement. Multivariable logistic regression modeling was used to determine population characteristics associated with preference for robotic technology.
Most respondents believe robotic-assisted surgery leads to better results (69%), fewer complications (69%), less pain (59%), and faster recovery (62%) than conventional manual methods. About half (49%) would prefer a low-volume surgeon using robotic technology to a high-volume surgeon using conventional manual methods. The 3 main concerns regarding robotic technology included lack of surgeon experience with robotic surgery, robot malfunction causing harm, and increased cost. Only half of respondents accurately understand the actual role of the robot in the operating room. Overall, 34% of participants have a clear preference for robotic-assisted surgery over a conventional manual approach. After multivariable regression analysis, Asian race, working in healthcare, early technology adoption, and prior knowledge of robotic surgery were independent predictors of preferring robotic-assisted surgery.
The public’s unawareness of the dubious outcome superiority associated with robotic-assisted orthopedic surgery may contribute to misinformed decisions in some patients. Robotic-assisted technology appears to be a powerful marketing tool for surgeons and hospitals.
Nationwide Analysis of Lower Extremity Periprosthetic Fractures
2021, Journal of Arthroplasty
Citation Excerpt :
In our study, rates of surgically treated lower extremity periprosthetic fractures were significantly higher at large and urban teaching hospitals. An increasing percentage of both primary and revision arthroplasty procedures are being performed at high-volume centers, whereas fewer revision surgeries occur at low-volume hospitals [56,57]. This nationwide trend may be due to the decreased inpatient mortality and LOS seen for primary and revision THAs performed at higher volume hospitals [58].
Although the annual incidence of primary total joint arthroplasty is increasing, trends in the annual incidence of periprosthetic fractures have not been established. This study aimed to define the annual incidence of periprosthetic fractures in the United States.
Inpatient admission data for 60,887 surgically treated lower extremity periprosthetic fractures between 2006 and 2015 were obtained from the National Inpatient Sample database. The annual incidence of periprosthetic fractures was defined as the number of new cases per year and presented as a population-adjusted rate per 100,000 US individuals. Univariable methods were used for trend analysis and comparisons between groups.
The national annual incidence of periprosthetic fractures presented as a population-adjusted rate of new cases per year peaked in 2008 (2.72; 95% confidence interval [95% CI], 2.39-3.05), remained stable from 2010 (1.65; 95% CI, 1.45-1.86) through 2013 (1.67; 95% CI, 1.55-1.8) and increased in 2014 (1.99; 95% CI, 1.85-2.13) and 2015 (2.47; 95% CI, 2.31-2.62). The proportion of femoral periprosthetic fractures managed with total knee arthroplasty revision remained stable (P_trend = .97) with an increase in total hip arthroplasty (THA) revision (P_trend < .001) and concurrent decrease in open reduction and internal fixation (ORIF) (P_trend < .001). Revision THA was significantly more costly than revision total knee arthroplasty (P = .004), and both were significantly more costly than ORIF (P < .001 for both).
The annual incidence of periprosthetic fractures remained relatively stable throughout our study period. The proportion of periprosthetic fractures managed with revision THA increased, whereas ORIF decreased. Our findings are encouraging considering the significant burden an increase in periprosthetic fracture incidence would present to the health care system in terms of both expense and patient morbidity.
Are We Treating Similar Patients? Hospital Volume and the Difference in Patient Populations for Total Knee Arthroplasty
2020, Journal of Arthroplasty
Early findings of superior total knee arthroplasty (TKA) outcomes at high volume centers have been thought to have led to distinct referral patterns. However, the effect of these selective referral processes has not been well assessed. Therefore, this study compared the characteristics of primary TKA patients at high, intermediate, and low volume hospitals.
A total of 12,541 primary TKA patients were stratified into risk groups based on age (>65 years), body mass index (>40), and Charlson Comorbidity Index (≥4). Hospitals were classified as low, intermediate, or high volume based on mean annual TKA volumes (<250, 250-499, and >500). Multivariate logistic regression models evaluated the relationship between baseline patient characteristics and hospital volume.
There was a greater percentage of high risk patients at high volume (19%, n = 853) compared to those at intermediate (16%, n = 899) or low volume (17%, n = 444) hospitals (P < .001). Patients with a body mass index >40 were more likely to be treated at high compared to intermediate (odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.6, P < .001) and low volume centers (OR 1.4, 95% CI 1.2-1.7, P < .001). Patients with Charlson Comorbidity Index scores ≥4 were also more likely be treated at high compared to intermediate (OR 1.5, 95% CI 1.3-1.6, P < .001) or low (OR 1.2, 95% CI 1.0-1.4, P = .002) volume centers.
This study found that TKA patients at high volume centers have significantly different baseline characteristics compared to those at lower volume centers. This study highlights the importance of considering hospital volume status and the associated disparity in the preoperative risk of patients when comparing primary TKA outcomes between centers.
Differences in Function and Comorbidities Between Older Adult Users and Nonusers of Chiropractic and Osteopathic Manipulation: A Cross-sectional Analysis of the 2012 National Health Interview Survey
2019, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
Surgery was more common among DC/DO users than nonusers. The higher prevalence of musculoskeletal pain, arthritis, joint pain or stiffness, overweight, and difficulty stooping, bending, and kneeling among DC/DO users compared with nonusers suggests that these factors may be associated with degenerative conditions or with common elective surgeries used to treat degenerative conditions, such as hip or knee arthroplasty or spinal decompression or fusion.25-31 However, it is not possible to determine the type or timing of surgery relative to DC/DO services from the NHIS.
The purpose of this cross-sectional study was to compare functional limitations and comorbidity prevalence between older adult users and nonusers of chiropractic and osteopathic (DC/DO) manipulation to inform provider training.
We conducted a secondary analysis of the 2012 National Health Interview Survey data. Adults age 65 or older who responded to the survey were included. Descriptive statistics are reported for adults who used DC/DO manipulation (vs nonusers) regarding function, comorbidities, musculoskeletal complaints, and medical services. Weighted percentages were derived using SAS and compared with χ² tests.
The DC/DO users were more often female, overweight or obese, and of white race than nonusers. More DC/DO users reported arthritis (55.3% vs 47.0%, <0.01) or asthma (15.0% vs 10.0%, P < .01) than nonusers; hypertension (61.9% vs 55.5%, P = .02) and diabetes (20.3% vs 15.7%, P = .02) were more prevalent in nonusers; and other comorbidities were comparable. The DC/DO users reported more joint pain/stiffness (55.7% vs 44.8%), chronic pain (19.8% vs 14.2%), low back pain (27.8% vs 18.4%), low back with leg pain (18.8% vs 10.6%), and neck pain (24.2% vs 13.1%) than nonusers (all P < .01). Functional limitations affected two-thirds overall, but DC/DO users reported more difficulties stooping and bending; other limitations were comparable. One in 9 reported activities of daily living or instrumental activities of daily living limitations; nonusers were more affected. Surgery was more common among DC/DO users (26.1% vs 19.3%, <0.01); emergency room visits were comparable.
Differences existed between older adult manipulation users and nonusers, especially surgical utilization, musculoskeletal complaints, and comorbidities; functional differences were modest. Our findings highlight areas for provider training and awareness regarding comorbidity burden and management needs in older patients who may simultaneously use manipulation and medical care for musculoskeletal complaints.

View all citing articles on Scopus

: Supplementary material available at www.arthroplastyjournal.org.

: The Conflict of Interest statement associated with this article can be found at doi:10.1016/j.arth.2011.04.043.

View full text

Published by Elsevier Inc.

Long-Term Trends in Hip Arthroplasty Use and Volume

Abstract

Section snippets

Background

Data

Results

Discussion

J Arthroplasty

Surgery

J Arthroplasty

Am Heart J

International variation in hip replacement rates

Ann Rheum Dis

Standardized incidence rates of total hip replacement for primary hip osteoarthritis in the 5 Nordic countries: similarities and differences

Acta Orthop

Health, United States, 2009

Knee replacement: epidemiology, outcomes, and trends in Southern California: 17,080 replacements from 1995 through 2004

Acta Orthop

Association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery

Arthritis Rheum

Should operations be regionalized? The empirical relation between surgical volume and mortality

N Eng J Med

The relation between surgical volume and mortality: an exploration of causal factors and alternative models

Med Care

Hospital volume and surgical mortality in the United States

N Eng J Med

Association between hospital and surgeon procedure volume and outcomes of total hip replacement in the United States Medicare population

J Bone Joint Surg Am

Potential benefits of a regionalizing major surgery in Medicare patients

Effective Clin Pract

Trends in hospital and surgeon volume and operative mortality for cancer surgery

Ann Surg Oncol

Quality of care information makes a difference: an analysis of market share and price changes after publication of the New York State Cardiac Surgery Mortality Reports

Med Care

The CABG surgery volume-outcome relationship: temporal trends and selection effects in California, 1998-2004

Health Serv Res