Implications of the getting it right first time initiative for regional knee arthroplasty services

The aim of this case study of regional orthopaedic practice was to estimate the potential impact of the GIRFT recommendations (iGIRFT) of minimum unit and surgeon specific volumes to orthopaedic units within the Severn Region, UK.

Practice profiles for surgeons and units were generated using the UK National Joint Registry Surgeon and Hospital Profile Database. Minimum volume thresholds were set at 13 procedures/year for surgeons and 30 procedures/year for units.

Five thousand five hundred seventeen knee arthroplasty procedures were recorded within the Severn Region between 1st of January and 31st December 2012 and these were performed by 94 surgeons in 18 units. During this time, 4232 (76.7%) primary TKR, 751 (13.6%) primary UKR, 97 (1.7%) primary PFJR and 437 (7.9%) revision TKR were performed. Median surgeon volumes were 33 (range two to 180) for primary TKR, ten (range 2 to 64) for UKR, two (range two to 41) for PFJR and five (range two to 57) for Revision TKR. Amongst 48 surgeons performing UKR, 26 (54%) performed less than 13 procedures per year accounting for 108 (14%) procedures. Amongst 20 surgeons performing PFJR, 19 (95%) performed <13/year, accounting for 56 (58%) of cases. Fifty surgeons performed revision TKR with 37 (74%) performing <13 revisions per annum, accounting for 151 (35%) procedures. Amongst 16 units performing UKR, eight (50%) performed <30/year, accounting for 16% overall. Revision TKR was performed in 15 units whilst eight (53%) performed <30/year, accounting for 62 (15%) cases.

We have hypothesised the impact of implementing minimum unit and surgeon volume thresholds for the organisation of regional arthroplasty services. Our analysis suggests that whilst these effects may be considerable, they may be mitigated by local rationalisation to achieve an appropriate caseload mix.