Editor's Spotlight/Take 5: Is changing hospitals for revision total joint arthroplasty associated with more complications?

Patients commonly change hospitals when undergoing revision surgery. The reasons for the switch range from the mundane (food, distance to home) to the profoundly personal and potentially important (trust in the care team whose surgery may have failed, or failed to meet expectations). But while we appropriately consider implants, anesthetics, and preoperative testing as key elements of care, there is precious little information out there describing the influence of the setting of care on the efficacy of our interventions. Dr. Stephen Lyman’s (Fig. 1) Healthcare Research Institute at the Hospital for Special Surgery (HSS), in partnership with other colleagues at HSS, along with Dr. Kevin Bozic from the University of California at San Francisco, seek to fill this gap. In this issue of CORR®, they present a paper evaluating the act of changing hospitals for revision total joint arthroplasty (TJA) as we might evaluate any other intervention. Lyman and colleagues use large administrative databases from California and New York to determine the frequency with which patients change hospitals for their revisions, what factors might be associated with the act of changing hospitals, and most importantly, whether changing hospitals is associated with a higher risk of postoperative complications Fig. 1 Dr. Lyman (above) and colleagues used large administrative databases from California and New York to determine how often patients change hospitals for their revisions, what factors might be associated with changing hospitals, and whether changing hospitals ... We learn that many patients change hospitals for revision TJA; 30% of patients in this report made a switch (5102 of 17,018 revisions they surveyed). Older patients and patients who had the index arthroplasty performed at a high-volume hospital were less likely to change hospitals, while increasing time since the index procedure was associated with a larger likelihood of patients having the revision done elsewhere; the authors identified no obvious race- or gender-related effects. Perhaps most importantly, patients who changed hospitals were more likely to experience complications at revision surgery, and maybe not surprisingly, this effect was stronger in the small group of patients (about 6% of the overall cohort) that changed from a higher- to a lower-volume hospital for the second procedure. This important work is part of a larger reality in our specialty that previously has been explored in this space [2]. To get the answers to some really important questions, we will need to become more familiar with what big databases can (and cannot) deliver. Earlier work by Dr. Lyman’s group demonstrated that the great numbers of patients, and the many comorbidities and demographic elements these databases capture, allow us access to questions we would not otherwise be able to answer [1]. The downside, of course, is that the associations they observe with these methods are just that — associations. Causation cannot be determined, and the reader sometimes is left hungering for answers to many questions that start with the word “why.” Even so, this study has profound implications in terms of the “what.” When almost one-third of patients change venue for an expensive and potentially risky intervention, this has major economic and medical implications. Join me as we explore both the “what” and the “why” in greater depth with the senior author of this fascinating study, Dr. Stephen Lyman, in the interview that follows.