Should high-risk patients seek out care from high-volume surgeons?

Aims: Patients with a high comorbidity burden (HCB) can achieve similar improvements in quality of life compared with low-risk patients, but greater morbidity may deter surgeons from operating on these patients. Whether surgeon volume influences total hip arthroplasty (THA) outcomes in HCB patients has not been investigated. This study aimed to compare complication rates and implant survivorship in HCB patients operated on by high-volume (HV) and non-HV THA surgeons.
Methods: Patients with Charlson Comorbidity Index ≥ 5 and American Society of Anesthesiologists grade of III or IV, undergoing primary elective THA between January 2013 and December 2021, were retrospectively reviewed. Patients were separated into groups based on whether they were operated on by a HV surgeon (defined as the top 25% of surgeons at our institution by number of primary THAs per year) or a non-HV surgeon. Groups were propensity-matched 1:1 to control for demographic variables. A total of 1,134 patients were included in the matched analysis. Between groups, 90-day readmissions and revisions were compared, and Kaplan-Meier analysis was used to evaluate implant survivorship within the follow-up period.
Results: Years of experience were comparable between non-HV and HV surgeons (p = 0.733). The HV group had significantly shorter surgical times (p < 0.001) and shorter length of stay (p = 0.009) than the non-HV group. The HV group also had significantly fewer 90-day readmissions (p = 0.030), all-cause revisions (p = 0.023), and septic revisions (p = 0.020) compared with the non-HV group at latest follow-up. The HV group had significantly greater freedom from all-cause (p = 0.023) and septic revision (p = 0.020) than the non-HV group.
Conclusion: The HCB THA patients have fewer 90-day readmissions, all-cause revisions, and septic revisions, as well as shorter length of stay when treated by HV surgeons. THA candidates with a HCB may benefit from referral to HV surgeons to reduce procedural risk and improve postoperative outcomes.
Competing Interests: R. I. Davidovitch reports receipt of royalties or licences from Radlink and Schaerer Medical, consulting fees from Radlink, Exactech Inc, and Schaerer Medical, and stock or stock options in Radlink, all of which are unrelated to this study. J. C. Rozell reports receipt of consulting fees from Aerobiotix, payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Foundation for Physician Advancement, Depuy Synthes, and Zimmer Biomet, and membership of the AAOS Hip and Knee Evaluation Committee, all of which are unrelated to this study. R. Schwarzkopf reports receipt of royalties or licences from Smith & Nephew, consulting fees from Smith & Nephew, Zimmer Biomet, and Intellijoint, leadership or fiduciary role in AAOS, AAHKS, Arthroplasty Today, and The Journal of Arthroplasty, and stock or stock options in Gauss Surgical and Intellijoint, all of which are unrelated to this study.
(© 2024 The British Editorial Society of Bone & Joint Surgery.)