Hip fracture outcomes: does surgeon or hospital volume really matter?
BACKGROUND
Current data on the association between surgeon and hospital volumes and patient outcomes after hip fracture surgery is inconclusive. We hypothesized that surgeons and hospitals with higher caseloads of hip fracture care have better outcomes as measured by decreased postoperative complications and mortality, shorter length of stay in the hospital, routine disposition of patients on discharge, and decreased cost of care.


METHODS
This is a retrospective cohort study using the Nationwide Inpatient Sample database. Data were extracted on 97,894 patients surgically treated for a hip fracture for the years 1988 through 2002. Multiple linear regression models were used to estimate the adjusted association between surgeon and hospital volume and outcomes for femoral neck and pertrochanteric hip fracture care.


RESULTS
The in-hospital mortality rate for those patients who had hip fracture fixation by a low-volume surgeon (<7 procedures/yr) was significantly higher than for those whose procedure was performed by a high-volume surgeon (>15 cases/yr) (p = 0.005). The incidence of transfusion, pneumonia, and decubitus ulcer were also higher in those patients managed by a low-volume surgeon (p = <0.05). Conversely, hospital volume was not associated with significant differences in mortality although low-volume hospitals (<57 cases/yr) were associated with higher rates of postoperative infection, pneumonia, transfusion, and nonroutine discharge (p = <0.05). Both low-volume hospitals and surgeons were associated with longer lengths of stay (p = <0.05).


CONCLUSIONS
This study provides evidence that surgeon volume, but not hospital volume, is associated with decreased mortality in the treatment of hip fractures. Both surgeon and hospital volume seem to be associated with nonfatal morbidity and length of stay.
Browne
James A
JA
Department of Surgery, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina, USA. brown351@mc.duke.edu
Pietrobon
Ricardo
R
Olson
Steven A
SA
D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000706:statistics & numerical data*; D002983:Clinical Competence / Q000706:statistics & numerical data*; D015331:Cohort Studies; D005260:Female; D005265:Femoral Neck Fractures / Q000401:mortality / Q000601:surgery*; D005593:Fracture Fixation, Internal / Q000706:statistics & numerical data*; D006276:Health Facility Size; D006620:Hip Fractures / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality; D006780:Hospitals, Rural / Q000706:statistics & numerical data*; D006786:Hospitals, Urban / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000401:mortality*; D012189:Retrospective Studies; D014481:United States; D014600:Utilization Review / Q000706:statistics & numerical data