JBJS: Specialty Orthopedic Hospitals Offer Better Surgical Outcomes
BY LAUREN UZDIENSKI, AUGUST 7, 2007
In the past few years, specialty hospitals have been the subject of controversy, criticized for accepting only the most profitable patients with the lowest risk of complications and for their lack of emergency and charity care. However, a retrospective study of Medicare patients shows that even after adjusting for surgical complexity and hospital procedure volume, patients at orthopedic specialty hospitals were less likely to experience adverse surgical outcomes than patients at general hospitals.
The study retrospectively evaluated more than 150,000 Medicare beneficiaries who underwent either total hip or total knee replacement in certain geographic areas between 1999 and 2003. 38 orthopedic specialty hospitals were analyzed and compared to 517 specialty hospitals. Cram et al hypothesized that a) patients admitted to specialty hospitals would have a lower prevalence of comorbidities and a higher socioeconomic status than patients at general hospitals, and b) that after adjusting for patient characteristics and procedural volume, outcomes in specialty and general hospitals would be similar.
As predicted, specialty hospitals did treat patients with fewer comorbid conditions and greater socioeconomic status (as measured by affluence of zip code.) However, the study's major finding helps to diffuse ongoing concerns about quality of care at specialty hospitals: risk of adverse outcomes is 40% lower in orthopedic specialty hospitals than in general hospitals. This result, exclusive to orthopedic hospitals, contrasts with the authors' previously published data showing no significant advantage to specialty cardiac facilities over general hospitals.
The authors suggest that the lowered risk of adverse outcomes could be attributed to procedural volumes performed by individual orthopedic surgeons, the expertise and experience of ancillary staff or organizational factors such as clinical pathways or communication among the clinical teams. Cram says that evaluating and adapting these organizational factors may be of benefit to general hospitals.
The study has its limitations, most notably its patient population, which Cram warns should not be extended to populations beyond Medicare. He recommended studies of Medicaid beneficiaries and patients with private insurance to continue the analysis. Among other limitations, Cram points out that the data came from Medicare claims and may not have accurately or completely represented differences between patients or the rates of certain adverse outcomes; there may have been systematic differences in coding between the two facility types; outcomes did not include functional status or patient satisfaction and the definition of a "specialty hospital" is not clearly established. One of the more surprising outcomes of the study was that length of stay was similar for both specialty and general hospitals, possibly suggesting that either the length of stay hasn't been optimized in newer specialty facilities or that general hospitals have shorter lengths of stay due to ongoing sensitivity to costs. Also of note is that patients at specialty hospitals were more likely to be transferred to another facility than patients in general hospitals.
Despite its limitations, Cram's finding of reduced risk in orthopedic cases introduces new data into the debate about the merits of specialty hospitals. A federal moratorium on the creation of new specialty hospitals expired in 2005, and since then lawmakers such as Chuck Grassley have fought to limit the hospitals' expansion.
