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BACKGROUND:
It has been argued that surgeons and hospitals with higher operative volume have improved outcomes in digital replantation. However, this relationship has not been specifically demonstrated. An analysis of a large, national database was performed to investigate the relationship of hospital volume to the success of finger and thumb replantation.
METHODS:
The National Inpatient Sample (NIS) of the Healthcare Utilization Project was queried to identify all patients that underwent a finger or thumb replantation from 2000-2010. Diagnoses related to patient injury, patient comorbidities, and complications, were identified from diagnosis codes. Two authors (PR, HM) independently analyzed the diagnosis, procedure codes, and length of stay data for each patient to determine relevant peri-operative details (i.e. number of threatened digits at injury, number of replants and revascularizations performed) as well as the success or failure of any replantation or revascularization. Any disagreement between the independent examiners was settled by the senior author (VT). Hospital volume was categorized into high (>10 cases per year), medium (5-10 cases), and low (<5 cases) based on distribution of case volume and analysis of the literature. The success or failure of replantation was analyzed on a per-finger basis across multiple patient-specific and hospital specific variables. Univariate and multivariate analyses were performed with R (Mac v.2.15.0, 2012).
RESULTS:
Over this 11-year period, the NIS recorded 2602 patients with 3049 digital replantations, performed at 556 unique hospitals. 510 (92%) of these hospitals are low volume, 26 (4.5%) medium volume, and 20 (3.5%) are high volume. 60% of hospitals performed an average of only 1 replantation per year. Collectively, low volume hospitals performed 43% of all operations. High and medium volume hospitals are more likely to be metropolitan (p=0.057), teaching hospitals (p<0.0001) relative to low volume hospitals.
After elimination of patients with inadequate data, 1944 patients with 2524 replantations and revascularizations were identified for analysis. The overall success rate for a reattached digit was 70.8%. Increased hospital volume was significantly associated with a better success of replantation - high 82%, medium 74%, and low volume 61% success, p<0.0001. High volume hospitals were more likely to operate on multiple digit injuries (54% vs. 43%, p<0.0001) and perform multiple replantations and revascularizations at the time of operation (46% vs. 35%, p <0.0001) relative to low volume hospitals. After adjusting for patient demographics, comorbidities, and injury characteristics hospital volume remained the most significant predictor of the success of replantation.
CONCLUSIONS:
The paper is the first to demonstrate that high-volume hospitals have improved outcomes in digital replantation. However, the majority of hospitals performing replantation procedures perform only one per year. This is likely due, in part, to disparities in the geographic distribution of high volume centers. Given the high patient and system cost associated with digital replantation, organization of resources in regional centers of excellence should be considered to optimize outcomes and care for patients.