Effect of Surgeon and Hospital Volume on Complications After Operative Tarsal Fracture Repair.

OBJECTIVE

To determine whether increased surgeon and hospital volume is associated with lower rates of complications after tarsal fractures.

DESIGN

Retrospective cohort study of the State Inpatient Databases.

SETTING

Two hundred ninety-nine hospitals in Florida (2005-2012) and New York (2006-2008).

PATIENTS/

PARTICIPANTS

Four thousand one hundred thirty-two tarsal fractures that underwent fixation by 1223 surgeons.

INTERVENTION: Surgical repair of tarsal fractures.

MAIN OUTCOME MEASUREMENTS: Composite of readmission for infection requiring operative treatment, wound dehiscence, nonunion, avascular necrosis, or amputation within 2 years of the index procedure.

RESULTS

The mean age was 44 (±15) years, a majority were men (70%) and white (69%), and the mean number of Charlson comorbidities was 0.21 (±0.58). Multivariable logistic regression demonstrated a reduction in the likelihood of complications by 9% for each 5 additional surgeries performed by the operating surgeon [odds ratio (OR), 0.91 per 5 surgeries; 95% confidence interval (CI), 0.82-0.99]. Other factors associated with complications included increased age (OR, 1.23 per 10 years; 95% CI, 1.10-1.36), male sex (OR, 1.56; 95% CI, 1.12-2.17), open fractures (OR, 2.84; 95% CI, 1.92-4.19), number of Charlson comorbidities (OR, 1.23; 95% CI, 1.02-1.48), income quartile (OR, 1.48; 95% CI, 1.00-2.17), uninsured (OR, 2.47; 95% CI, 1.39-4.39), and other government program insurance (OR, 1.52; 95% CI, 1.06-2.18).

CONCLUSIONS

We observed a significant inverse relationship between surgeon volume and complication rates when controlling for patient and injury characteristics. In contrast to previous research, a volume-outcome relationship was not observed at the hospital level. These results suggest that such complex injuries should be triaged to the most experienced providers.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.