Study compares specialty orthopedic and general hospitals

Specialty orthopedic hospitals serve a healthier population of Medicare patients compared to 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.

Medicare patients who receive hip or knee replacement at specialty orthopedic hospitals also have a 40 percent lower risk of complications after surgery compared to Medicare patients at general hospitals.

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.

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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