Relation between operation volume of individual surgeon

The Katz’s report (see August 2002 News: Preferred hospital for your total hip) on the relation between the operation volume of an individual surgeon and the results of his /her total hip operations evoked a debate.

Doctor Frederic Matsen, from the Department of Orthopaedics and Sports Medicine, University of Washington in Seattle, USA, sent a Letter to the Editor of the Journal of Bone and Joint Surgery raising several questions about one important problem: Does good operation results beget operation volume (many patients seek large orthopaedic centers because these centers have excellent fame thanks to good results) or does high operation volume begets outcomes (large practice makes perfect results)?

In an answer to this Letter, doctor Jeffrey Katz and his colleagues specified that it is the surgeon’s experience that produces the good results and not his / her association with a high volume hospital. Even within high operation volume hospitals, patients whose surgeons perform five or fever total hip replacements per year have hip dislocation rates that are three fold those of the patients whose surgeons perform more than fifty hip replacements per year.

During the last years there were published more than twenty reports that studied the relationship between the operation volume of the individual surgeon and the results of his /her total joint operations. Seventy seven percent of these reports demonstrated that there is a direct relationship between the operation volume and the operation results also for other total joint operations.'

One facet of the problem " low operation volume - worse operation results"  is related to the question  "Why are there so many surgeons who carry out so few total joint operations".

Some authors believe that the manufacturers of total joint prostheses contribute to this problem. In their drive to increase the sales of their total joint products, manufacturers arrange "bone cutting curses" learning the attendants to use just one technique of total joint surgery. These curses are attended by surgeons with different surgical experience, many of them with low experience of total joint surgery. These surgeons then find only few patients to operate on Moreover, many of their patients also have higher operation risks.

The patients routinely ask "Who is the best surgeon to do my total joint surgery" and they get usually these answers: "Someone on the provider list of your health plan", "Someone near your home", or "Someone suggested by your primary-care physician".

According to doctor Matsen, the author of the Letter to the Editor, the answers should be "Someone who can document his / her personal efficacy in performing total joint surgery" and "Someone who is performing a large volume of total joint operations". This recommendation is based on the available results that show that " practice makes perfect".

The advantages of total joint operations done at high operation volume centers are clear. The decision of whether to have total joint surgery in a high or a low operation volume center is, however, difficult for patients living a great distance from a high volume center.

As a rule, it is difficult for the patients to know the operation volume of "their surgeon". Many patients are also shy to ask directly.

Doctor Katz says that "it would seem fully disclose data on surgeon and hospital (operation) volume".

The ongoing debate about the dependence of the operation results on the operation volume has led the Centers for Medicare and Medicaid Services to initiate a pilot program that designates centers of excellence for total hip and knee replacement surgery.

What is your opinion? Should the hospital / the surgeon disclose openly the annual volume of total joint operations?

(Matsen FA. J Bone Joint Surg-Am, 2002; 84-A: 1482 -1485)