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Does early return to theatre add value to rates of revision at 3 years in assessing surgeon performance for elective hip and knee arthroplasty? National observational study
  1. Alex Bottle1,
  2. Helen E Chase2,
  3. Paul P Aylin3,
  4. Mark Loeffler2
  1. 1 Department of Primary Care and Public Health, Imperial College, London, UK
  2. 2 Colchester General Hospital, Colchester, UK
  3. 3 Department of General Practice and Public Health, Imperial College London, London, UK
  1. Correspondence to Dr Alex Bottle, Department of Primary Care and Public Health, Imperial College, London EC4Y 8EN, UK; robert.bottle{at}


Background Joint replacement revision is the most widely used long-term outcome measure in elective hip and knee surgery. Return to theatre (RTT) has been proposed as an additional outcome measure, but how it compares with revision in its statistical performance is unknown.

Methods National hospital administrative data for England were used to compare RTT at 90 days (RTT90) with revision rates within 3 years by surgeon. Standard power calculations were run for different scenarios. Funnel plots were used to count the number of surgeons with unusually high or low rates.

Results From 2006 to 2011, there were 297 650 hip replacements (HRs) among 2952 surgeons and 341 226 knee replacements (KRs) among 2343 surgeons. RTT90 rates were 2.1% for HR and 1.5% for KR; 3-year revision rates were 2.1% for HR and 2.2% for KR. Statistical power to detect surgeons with poor performance on either metric was particularly low for surgeons performing 50 cases per year for the 5 years. The correlation between the risk-adjusted surgeon-level rates for the two outcomes was +0.51 for HR and +0.20 for KR, both p<0.001. There was little agreement between the measures regarding which surgeons had significantly high or low rates.

Conclusion RTT90 appears to provide useful and complementary information on surgeon performance and should be considered alongside revision rates, but low case loads considerably reduce the power to detect unusual performance on either metric.

  • health services research
  • performance measures
  • statistics

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  • Contributors AB and ML conceived the study. AB prepared and analysed the data and wrote the manuscript, with HEC contributing to the literature review. All authors critically interpreted the analysis results and the draft manuscript. All authors have approved the final version. AB is the guarantor.

  • Competing interests The Dr Foster Unit at Imperial College London is partly funded by a research grant from Dr Foster, a Telstra Health company (an independent health service research organisation).

  • Ethics approval London - South East Ethics Committee (REC ref 15/LO/0824).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Due to information governance rules applicable to HES data, no individual-level data are available for sharing.