Association between surgical volume and failure of primary total hip replacement in England and Wales: findings from a prospective national joint replacement register
Association between surgical volume and failure of primary total hip replacement in England and Wales: findings from a prospective national joint replacement register
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DOI：
10.1136/bmjopen-2019-033045
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发表时间：
2020-01-01
期刊：
影响因子：
2.9
通讯作者：
Blom, Ashley W.
中科院分区：
文献类型：
--
作者：
Sayers, Adrian;Steele, Fiona;Blom, Ashley W.
目的探讨全髋关节置换术患者与同一患者上一年度内置换术容积的关系以及采用多水平生存模型进行翻修的危险性。设计前瞻性队列研究，使用来自全国关节置换登记的数据。在2003年4月至2017年2月期间，在英格兰和威尔士的所有私立和公立中心设置选择性THA。参与者年龄在50岁及以上的骨关节炎患者。干预指数程序前365天内进行的THA量。主要结果和测量原发性THA的翻修手术（切除、增加或置换）。结果在579858例接受原发性THA（平均基线年龄69.8岁（SD 10.2））的患者中，61.1%为女性。多层生存研究发现，咨询师效应之间和咨询师效应内部的结果不同。咨询师之间有很强的数量-修正关联，与每年1 - 200例手术数量的咨询师相比，修正风险降低了43.3% （95% CI 29.1%至57.4%）。个别外科医生（顾问内）病例量的变化未显示与翻修相关的证据。结论分离手术容积对会诊间和会诊内的影响，揭示了容积对THA术后翻修风险的影响。咨询师内部缺乏关联表明，单独改变咨询师数量对THA后的预后影响不大。这些新发现为髋关节置换术专业化的实践提供了强有力的证据。它不支持低业务量顾问增加个人业务量的做法，因为如果这是唯一的改变，他们的结果不太可能改善。限制患者接触低容量全髋关节置换术的顾问，并更多地利用具有更好结果的高容量外科医生的中心，可能对患者有益。
Objective To investigate the association of volume of total hip arthroplasty (THA) between consultants and within the same consultant in the previous year and the hazard of revision using multilevel survival models. Design Prospective cohort study using data from a national joint replacement register. Setting Elective THA across all private and public centres in England and Wales between April 2003 and February 2017. Participants Patients aged 50 years or more undergoing THA for osteoarthritis. Intervention The volume of THA conducted in the preceding 365 days to the index procedure. Main outcome and measure Revision surgery (excision, addition or replacement) of a primary THA. Results Of the 579 858 patients undergoing primary THA (mean baseline age 69.8 years (SD 10.2)), 61.1% were women. Multilevel survival found differing results for between and within-consultant effects. There was a strong volume-revision association between consultants, with a near-linear 43.3% (95% CI 29.1% to 57.4%) reduction of the risk of revision comparing consultants with volumes between 1 and 200 procedures annually. Changes in individual surgeons (within-consultant) case volume showed no evidence of an association with revision. Conclusion Separation of between-consultant and within-consultant effects of surgical volume reveals how volume contributes to the risk of revision after THA. The lack of association within-consultants suggests that individual changes to consultant volume alone will have little effect on outcomes following THA. These novel findings provide strong evidence supporting the practice of specialisation of hip arthroplasty. It does not support the practice of low-volume consultants increasing their personal volume as it is unlikely their results would improve if this is the only change. Limiting the exposure of patients to consultants with low volumes of THA and greater utilisation of centres with higher volume surgeons with better outcomes may be beneficial to patients.