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Senior Citizen Health & Medicine
Medicare Patients Do Better at Specialty Orthopedic
Hospitals – Cream of Crop?
Study looks at hip, knee replacement in specialty,
general hospitals
Aug. 1, 2007 - Medicare patients who receive hip or knee
replacement at specialty orthopedic hospitals have a 40 percent lower
risk of complications after surgery compared to Medicare patients at
general hospitals, according to a new study by investigators at the
University of Iowa and Department of Veterans Affairs (VA) Iowa City
Health Care System.
The difference in complications holds even after
accounting for the fact that specialty orthopedic hospitals admit less
complex cases, the researchers report in the August issue of the Journal
of Bone and Joint Surgery.
The team focused on orthopedic specialty hospitals
because specialty hospitals are controversial yet little is known about
the quality of care they deliver, said Peter Cram, M.D., the study's
lead author and assistant professor of internal medicine in the UI Roy
J. and Lucille A. Carver College of Medicine.
"The findings were somewhat surprising and
important," Cram said. "We suspected that specialty orthopedic hospitals
were selecting low-risk patients for admission and that is what our
analysis found. But we also found that complications were less common in
specialty hospitals even after accounting for the types of patients each
hospital admitted -- this was quite surprising."
Nonetheless, Cram urged caution in interpreting the
results. "While our study provides new information on the quality of
care in specialty hospitals, it is important that these findings be
replicated in populations other than Medicare patients and using other
approaches to measure complications than claims data," he said.
"In addition, our study focused on surgical
complications and did not analyze other important markers such as
patient satisfaction, costs and symptom relief," he added. Surgical
complications included infection, blood clots, bleeding and death, which
is a rare event in hip and knee replacement.
The investigation was based on records of Medicare
beneficiaries age 65 and older who received either total hip (51,788
cases) or total knee (99,765 cases) replacement surgery between 1999 and
2003. The patients, whose average age was 75, received treatment either
at one of 38 specialty orthopedic hospitals or one of 517 general
hospitals in the same markets.
Compared to general hospitals, specialty orthopedic
hospitals admitted patients with fewer medical problems, including
obesity, heart failure and diabetes. "Yet even after you adjust for
these factors, so that you can compare apples to apples, specialty
orthopedic hospitals still seem to have a significant and unexpected
edge," Cram said.
"One potential explanation for the better outcomes
seen in orthopedic specialty hospitals in the current study," Cram
added, "is that specialization by hospitals can offer real advantages,
particularly when it comes to surgical procedures."
The results of this study contrast with findings
about specialty cardiac hospitals in a previous UI and VA study
published by Cram and colleagues in 2005. That study showed that
Medicare patients treated for angioplasty -- considered a non-surgical
procedure -- or heart bypass surgery did not do any better or worse at
specialty cardiac hospitals when compared to general hospitals.
Specialty hospitals exist primarily in states in
the Midwest and South that have less hospital regulation. There are no
specialty hospitals in Iowa. Specialty hospitals founded in earlier
years focused on broad patient groups, such as women or children. More
recently, they have focused on lucrative disease areas, such as heart
disease or orthopedic care, which makes them controversial, Cram noted.
"It remains a concern that specialty hospitals will
damage the health care system by worsening disparities. The concern is
that people with good insurance will be able to get care from these
hospitals, and the general hospitals will be left to treat all others,"
Cram said.
"There has been talk about banning specialty
hospitals altogether, yet there has been a lack of data assessing
quality of care," he added.
Cram and colleagues will next examine how specialty
hospitals affect access to care for vulnerable patient populations.
Editor's Notes:
In addition to Cram, the study team included senior
author Gary Rosenthal, M.D., UI professor of internal medicine and
director of the UI Division of General Internal Medicine, and Brian
Wolf, M.D., UI assistant professor of orthopaedics and rehabilitation.
Rosenthal also is a staff physician and researcher with the VA Iowa City
Health Care System and directs the VA Center for Research in the
Implementation of Innovative Strategies in Practice.
The study was funded in part by the Veterans Health
Administration and the National Institutes of Health.
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