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Variation in Hospital-Level Risk-Standardized Complication Rates Following Elective Primary Total Hip and Knee Arthroplasty

Bozic, Kevin J. MD, MBA; Grosso, Laura M. PhD; Lin, Zhenqiu PhD; Parzynski, Craig S. MS; Suter, Lisa G. MD; Krumholz, Harlan M. MD, SM; Lieberman, Jay R. MD; Berry, Daniel J. MD; Bucholz, Robert MD; Han, Lein PhD; Rapp, Michael T. MD, JD; Bernheim, Susannah MD; Drye, Elizabeth E. MD, SM

Journal of Bone & Joint Surgery - American Volume: 16 April 2014 - Volume 96 - Issue 8 - p 640–647
doi: 10.2106/JBJS.L.01639
Scientific Articles

Background: Little is known about the variation in complication rates among U.S. hospitals that perform elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures. The purpose of this study was to use National Quality Forum (NQF)-endorsed hospital-level risk-standardized complication rates to describe variations in, and disparities related to, hospital quality for elective primary THA and TKA procedures performed in U.S. hospitals.

Methods: We conducted a cross-sectional analysis of national Medicare Fee-for-Service data. The study cohort included 878,098 Medicare fee-for-service beneficiaries, sixty-five years or older, who underwent elective THA or TKA from 2008 to 2010 at 3479 hospitals. Both medical and surgical complications were included in the composite measure. Hospital-specific complication rates were calculated from Medicare claims with use of hierarchical logistic regression to account for patient clustering and were risk-adjusted for age, sex, and patient comorbidities. We determined whether hospitals with higher proportions of Medicaid patients and black patients had higher risk-standardized complication rates.

Results: The crude rate of measured complications was 3.6%. The most common complications were pneumonia (0.86%), pulmonary embolism (0.75%), and periprosthetic joint infection or wound infection (0.67%). The median risk-standardized complication rate was 3.6% (range, 1.8% to 9.0%). Among hospitals with at least twenty-five THA and TKA patients in the study cohort, 103 (3.6%) were better and seventy-five (2.6%) were worse than expected. Hospitals with the highest proportion of Medicaid patients had slightly higher but similar risk-standardized complication rates (median, 3.6%; range, 2.0% to 7.1%) compared with hospitals in the lowest decile (3.4%; 1.7% to 6.2%). Findings were similar for the analysis involving the proportion of black patients.

Conclusions: There was more than a fourfold difference in risk-standardized complication rates across U.S. hospitals in which elective THA and TKA are performed. Although hospitals with higher proportions of Medicaid and black patients had rates similar to those of hospitals with lower proportions, there is a continued need to monitor for disparities in outcomes. These findings suggest there are opportunities for quality improvement among hospitals in which elective THA and TKA procedures are performed.

Level of Evidence: Therapeutic Level III. See Instruction to Authors for a complete description of levels of evidence.

1UCSF Department of Orthopaedic Surgery, 500 Parnassus Avenue, MU 320W, San Francisco, CA 94143-0728. E-mail address:

2Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE), 1 Church Street, Suite 200, New Haven, CT 06510

3Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Suite 2000, Los Angeles, CA 90033

4Department of Orthopaedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905

5Department of Orthopaedic Surgery, University of Texas Southwestern, 4005 Wingren, Irving, TX 75062

6Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244

Copyright 2014 by The Journal of Bone and Joint Surgery, Incorporated
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