Improving quality of care in orthopedic surgery

National health policies, and the debate over those policies, have shifted dramatically in recent decades, starting with a focus on access to care, then to a concern with costs, and more recently to issues of quality and safety. From approximately 1950 to 1980, the primary goals of health care policies were to increase access to care and to assure the capacity to provide needed care. With a booming economy (and tax base) and the political optimism typified by the Great Society programs of the Johnson administration, costs were not seen as a major problem, and it was assumed that the expansion of health care resources would aid the distribution of care. In fact, these policies succeeded beyond most expectations, with the elderly and poor, in particular, benefiting from much greater access to care and the development and application of a wide variety of new medications, technologies, and procedures. By the late 1970s, however, health care costs had become a major and increasing part of most public and corporate budgets. The reaction of many public and private payers was to put restrictions on reimbursement for care, which led to a new concern that needed care might be limited inappropriately. In parallel to these changes in the reimbursement system, new studies suggested that there were major geographic, institutional, and provider differences in the use (1) and outcomes (2) of services. Thus, the focus has shifted once again, this time to quality of care. The issues of the safety and quality of care were highlighted in 2 recently published reports from the Institute of Medicine (3,4). According to the Committee on Quality of Health Care in America, “Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm” (4). Quality problems include underuse, overuse, and misuse (5,6), many instances of which result from clinical uncertainty and cost constraints (7). As documented by Wennberg (8), the large and continuing geographic variation in rates of use of specific services, apparently attributable more to differences in practice “style” than to clinical and patient characteristics, continues to be among the most compelling evidence of problems of quality in US health care. Other factors, such as socioeconomic, racial, and ethnic disparities in health and access to care also represent significant quality problems (9). Why has it taken so long to identify problems with the quality of health care in the US? The answer in large part is that clinical data systems have been woefully inadequate as sources of outcome information. Most studies of health care outcomes have used administrative data (often billing data), perhaps because of the relative ease of acquiring and analyzing secondary data compared with the laborious and costly task of collecting data from clinical records. Despite their many limitations, which include the general lack of clinical information, administrative data have produced relatively strong evidence suggesting that, for many services, the volume of services provided is positively associated with the outcomes of those services. Presumably, a positive relationship between volume and outcome rests primarily on the increased experience of higher-volume providers, although the strength of the relationship appears to vary considerably according to the type of service or procedure, and disentangling hospital volume from provider volume is often difficult. A positive relationship between volume and outcomes has been documented for various orthopedic procedures. Using Medicare data, Taylor et al showed that for several orthopedic procedures, mortality declined as volume increased (10). In a study of total hip replacements, Kreder et al observed a significant relationship between surgeon volume and the rates of postoperative complications (11). Heck et al reported a similar relationship for knee replacements (12). Jonathan Showstack, PhD, MPH: Institute for Health Policy Studies, University of California, San Francisco. Address correspondence and reprint requests to Jonathan Showstack, PhD, MPH, Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94118-1944. E-mail: jas1@itsa.ucsf.edu. Submitted for publication October 1, 2002; accepted in revised form October 7, 2002.