Surgical volume, the frequency with which surgeons and surgery centers perform complex surgical procedures, is clearly understood as a key determinant of healthcare quality.
The Agency for Healthcare Research and Quality (AHRQ) includes “how many times have you done this procedure” as one of the 10 questions patients should ask their doctor. Consumer Reports similarly recommends patients inquire about surgical volume when choosing a physician.
Prior studies concluded that providers with higher surgical volume are expected to have fewer medical errors and defects, better acute outcomes overall, and other post-acute benefits following the surgical procedure. However, existing studies have only been able to leverage relatively small samples of data for specific surgical procedures.
In this new paper, Clarify Health used a large, observational sample of national health insurance claims for patients undergoing hip and knee replacement surgeries performed in 2021. Hip and knee surgeries are the most common elective orthopedic surgical procedures where provider choice is possible for patients. It found that low provider surgical volume negatively impacts post-acute outcomes across inpatient and outpatient settings, even after it controlled for patient characteristics and other factors. And it found that treatment by higher-volume surgeons is particularly important for more clinically complex patients.
Clarify Health analyzed two of the most common types of surgical episodes, total hip arthroplasty (THA), commonly known as hip replacements, and total knee arthroplasty (TKA), commonly known as knee replacements. For both hip and knee replacements, higher provider surgical volume is associated with better outcomes across multiple dimensions and multiple care settings, even after adjusting for differences in patient characteristics. Major findings included:
– – Lower rates of post-acute inpatient readmission at both 7 and 60 days
– – Lower rates of revision surgeries
– – Lower rates of post-surgical stay orthopedic specialist visits, emergency department visits, and inpatient days
– – Lower episode-level and orthopedic-specific standard dollar amounts
When Clarify Health stratified hip and knee replacements by place of service (inpatient (IP), outpatient (OP), and ambulatory surgical center (ASC) settings), volume-outcome relationships largely remain.
– – Post-surgical ED utilization rates are approximately 21% lower for high-volume surgeons in an IP setting compared to low-volume surgeons, 35% lower in an OP setting, and 34% lower in an ASC setting
– – Readmission rates are approximately 32% lower for high-volume surgeons in an IP setting compared to low-volume surgeons, 47% lower in an OP setting, and 74% lower in an ASC setting
– – Revision surgery rates are approximately 7% lower for high-volume surgeons in an IP setting compared to low-volume surgeons, 40% lower in an OP setting, and 5% higher in an ASC setting
Its findings imply clinical benefits for patients who undergo hip and knee replacement surgeries with high-volume surgeons, even after adjusting for patient and other characteristics.
Payers and health systems have begun to concentrate volume of surgeries and other procedures at specific sites within their networks, often referring to these locations as “centers of excellence” (COEs). For orthopedic surgeries, COEs are often implemented in OP or ASC settings.
COEs have higher relative volume, are actively educating care teams about best practices and current medical research, often obtain special accreditations from national organizations and consistently generate improved outcomes versus lower-volume sites of care.