Association of hospital and surgeon procedure volume with patient‐centered outcomes of total knee replacement in a population‐based cohort of patients age 65 years and older

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Abstract
Objective: To study the association between procedure volume and patient‐centered outcomes such as functional status.Methods: We performed an observational study of a stratified random sample of Medicare beneficiaries who underwent primary total knee replacement (TKR) in 2000. Low‐volume surgeons were defined as surgeons performing ≤6 TKRs per year in the Medicare population, and low‐volume centers were defined as those in which ≤25 TKRs per year were performed. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) functional status score (0–100 scale; 100 = best) 2 years after TKR. We defined a WOMAC functional status score of <60 as a poor functional outcome. Analyses were adjusted for sociodemographic factors, preoperative functional status, and comorbidities.Results: Fifty‐eight percent of 1,597 eligible patients agreed to participate. Twelve percent of participating patients had a WOMAC score <60 2 years following TKR. Patients operated upon by low‐volume surgeons in low‐volume hospitals were twice as likely to have a poor WOMAC functional status score as patients operated upon by higher volume surgeons and in higher volume hospitals (odds ratio 2.1, 95% confidence interval 1.1–4.2).Conclusion: Patients operated upon in low‐volume hospitals by low‐volume surgeons had worse functional outcomes 2 years after TKR. These findings add a new and important dimension to the discussion of whether to promote selective referral of procedures such as TKR to high‐volume centers.