Changing Surgeons for Revision Hip Arthroscopic Surgery Is Associated With Insurance Status,Geography,and Diagnosis of Anxiety or Depression

Abstract

Background:

Patients undergoing revision hip arthroscopic surgery may elect to undergo the procedure with their index surgeon or, in many instances, will change surgeons. Factors and outcomes associated with switching surgeons are likely multifactorial and require further study.

Purpose:

To (1) examine clinical and demographic variables associated with switching surgeons between primary and revision hip arthroscopic surgery and (2) assess whether the rates of postoperative emergency department (ED) visits, complications, and conversion to total hip arthroplasty (THA) differed for patients who returned to the same surgeon versus those who switched surgeons.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A national administrative claims database was used to identify patients with ICD (International Classification of Diseases)–10 diagnosis codes for femoroacetabular impingement and/or a labral tear who underwent primary hip arthroscopic surgery between 2015 and 2022, followed by ipsilateral revision hip arthroscopic surgery. National Provider Identifier numbers were used to track patients who returned to the same surgeon versus patients who switched surgeons for revision arthroscopic surgery. Factors associated with switching surgeons were identified. Rates of 30-day ED visits, 90-day adverse events, and 5-year conversion to THA after revision surgery were compared between groups.

Results:

Of 1332 revision hip arthroscopic procedures, 496 (37.2%) were performed by the index surgeon, and 836 (62.8%) were performed by a different surgeon. Age and sex were similar between groups; however, patients who switched surgeons were more likely to have commercial health insurance (90.7% vs 85.9%, respectively), be from the Midwest (40.7% vs 34.1%, respectively) or West (16.5% vs 13.5%, respectively) region, and have a diagnosis of depression or anxiety (16.4% vs 11.9%, respectively) than patients who did not switch (P < .05 for each). Rates of 30-day ED visits, 90-day adverse events, and 5-year conversion to THA were similar between groups.

Conclusion:

This large national study found that 62.8% of patients switched surgeons for revision hip arthroscopic surgery and that switching surgeons was associated with clinical factors (anxiety or depression) and nonclinical factors (health insurance and geographic region). Nevertheless, rates of postoperative ED visits, adverse events, and conversion to THA were similar between groups.

Keywords

femoroacetabular impingement revision hip arthroscopic surgery switching surgeons risk factors conversion to THA

Because of the recognition of femoroacetabular impingement (FAI) as the predominant cause of symptomatic acetabular labral tears and idiopathic early-onset osteoarthritis,⁷ arthroscopic labral repair with femoroacetabular osteoplasty has become the standard of care for the treatment of reparable labral tears and underlying FAI.^3,18,28 Although hip arthroscopic surgery is typically a safe and successful intervention,^10,20 revision surgery is becoming increasingly common after primary hip arthroscopic surgery, with a recent systematic review demonstrating secondary arthroscopic surgery rates ranging from 4.5% to 24% at a minimum 10-year follow-up.¹⁷ The most common indications for revision hip arthroscopic surgery are resection of a residual cam- or pincer-type deformity, labral and/or chondral abnormalities, and lysis of adhesions.^5,25

While revision hip arthroscopic surgery has been demonstrated to still benefit patients, the literature suggests inferior postoperative functional outcomes for revision versus primary hip arthroscopic surgery.^4,5,12 Given the rising rate of primary hip arthroscopic procedures being performed, a proportional increase in the prevalence of revision hip arthroscopic surgery is likely to occur.^11,12 Therefore, there is value in evaluating potential risk factors surrounding revision hip arthroscopic surgery that may affect cost-effectiveness and clinical outcomes.

If required to undergo revision hip arthroscopic surgery, patients are faced with the decision to remain with the same surgeon or change to a different surgeon. In other areas of orthopaedic surgery, continuity with the same surgeon has been shown to have variable effects on patient outcomes and satisfaction. Issa et al¹⁵ found that continuity of care with the same surgeon reduced the hospital length of stay and associated health care costs for revision lumbar spinal fusion. In contrast, Mann et al¹⁹ showed that patients with unsatisfactory primary total joint arthroplasty had better outcomes after changing surgeons for their subsequent primary contralateral total joint arthroplasty. Finally, in a small cohort of hip arthroscopic surgery cases at a single institution, Ankem et al¹ showed that revision hip arthroscopic surgery had favorable outcomes, regardless of whether surgery was performed by the same surgeon or a different surgeon. These conflicting findings and the rising frequency of revision hip arthroscopic surgery highlight the need for a better understanding of the factors that predict whether patients switch surgeons as well as the relationship between staying with the same surgeon and outcomes specific to hip arthroscopic surgery.

A systematic review on the diagnoses, operative findings, and outcomes of revision hip arthroscopic surgery demonstrated that only 25% of patients returned to the same surgeon for their revision surgery⁵; however, only 5 studies (n = 348 hips) were eligible for inclusion in that review. Furthermore, that study did not explore the predictors of patients electing to switch surgeons for revision surgery, nor did it stratify outcomes by whether patients switched surgeons for their revision. Thus, the purposes of the present study were to (1) examine clinical and demographic variables associated with switching surgeons between primary and revision hip arthroscopic surgery and (2) to assess whether the rates of 30-day emergency department (ED) visits, 90-day adverse events, and 5-year conversion to total hip arthroplasty (THA) differed for patients who returned to the same surgeon versus those who switched surgeons for revision surgery.

Methods

Study Population

All data were collected from the time period of October 1, 2015 to April 30, 2022 from the Mariner 161 Ortho database (PearlDiver Technologies), a commercially available administrative claims database containing the records of 161 million patients in the United States. This is a deidentified and HIPAA (Health Insurance Portability and Accountability Act)–compliant database that is well established for sports medicine studies.^8-10,16,21 Given the deidentified nature of the data, our institutional review board found studies using this database to be exempt from approval.

Patients were queried based on International Classification of Diseases (ICD)–10 and Current Procedural Terminology (CPT) codes, all of which are outlined in Appendix Table A1. Inclusion criteria were primary ICD-10 diagnosis codes for FAI and/or a labral tear; concurrent codes for first-time hip arthroscopic surgery with femoroplasty (CPT 29914), acetabuloplasty (CPT 29915), and/or labral repair (CPT 29916); 90-day follow-up data after primary hip arthroscopic surgery; and subsequently undergoing ipsilateral revision hip arthroscopic surgery (CPT 29914, 29915, or 29916) with laterality-specific ICD-10 diagnosis codes.

Exclusion criteria were a history of ipsilateral hip arthroscopic surgery (CPT 29860, 29861, 29862, or 29863), THA (CPT 27130), or conversion of previous hip surgery to THA (CPT 27132); concomitant or up to 30 days prior ICD-10 codes for infections, neoplasm, or fractures; and age ≥60 years at the time of primary hip arthroscopic surgery. In addition, to avoid potential confounding by incorrectly counting contralateral hip arthroscopic surgery as ipsilateral revision surgery, patients with contralateral hip arthroscopic surgery performed within 10 years after primary hip arthroscopic surgery were excluded from analysis based on laterality-specific ICD-10 diagnosis codes; this ensured that all revision hip arthroscopic procedures assessed were true ipsilateral revision procedures.

Surgeon Delineation

To track whether patients returned to the same surgeon or sought care from a different surgeon for revision hip arthroscopic surgery, each CPT code was linked to the National Provider Identifier (NPI) number of the attending surgeon who performed the hip arthroscopic procedure. Those patients who had different NPI numbers between primary and revision surgery were classified as not returning to the same surgeon, while those who had the same NPI number associated with both procedures were classified as returning to the same surgeon.

Risk Factors for Changing Surgeons

Patient characteristics were obtained from the dataset, including age range, sex, insurance provider type, geographic region, and Elixhauser Comorbidity Index score (ECI; a commonly used measure of comorbidities⁶). Further, specific comorbidities, including depression/anxiety, diabetes, obesity, and tobacco use, were assessed within 1 year before primary hip arthroscopic surgery based on ICD-9 and ICD-10 codes. These baseline demographic characteristics and comorbidities were identified and compared between patients who did and did not return to the same surgeon.

Postoperative ED Visits

The incidence of ED visits within 30 days after revision hip arthroscopic surgery was assessed in both groups using appropriate CPT codes corresponding to ED visits (ie, CPT 99281, 99282, 99283, 99284, or 99285).

Adverse Events

The incidence of adverse events within 90 days after revision surgery in patients who returned versus did not return to the same surgeon was assessed. Individual adverse events were evaluated based on ICD-9 and ICD-10 codes. Adverse events identified included deep vein thrombosis, hematoma formation, hip dislocation, nerve injury (to the sciatic, peroneal, femoral, or cutaneous nerve), pulmonary embolism, sepsis, surgical site infection, and wound dehiscence. Any adverse event was noted if there was an occurrence of at least 1 adverse event for a given patient within the 90-day postoperative period. To protect patient confidentiality, the PearlDiver database does not report exact counts for results with ≤10 patients.

Conversion to THA

The incidence of THA within 5 years after primary hip arthroscopic surgery among patients who returned to the same surgeon versus those who switched surgeons for revision hip arthroscopic surgery was investigated. Conversion to THA was defined with corresponding CPT (CPT 27130 and 27132) and same-day ICD-10 codes.

The laterality inherent in ICD-10 coding was used to ensure true conversion to THA: that is, right-sided THA followed right-sided primary and revision arthroscopic surgery, and left-sided THA followed left-sided primary and revision arthroscopic surgery. Patients without laterality coding for hip arthroscopic surgery and/or THA were excluded from the analysis of conversion to THA.

Statistical Analysis

Continuous variables were compared using an unpaired 2-tailed t test, and categorical variables were compared using the Pearson chi-square test. Multivariable logistic regression was applied to identify independent factors associated with the odds of postoperative complications and ED visits, and each result is reported as an adjusted odds ratio (OR) with the corresponding 95% confidence interval (CI). These models were adjusted for age group, sex, insurance provider type, geographic region, ECI score, and individual comorbidities.

Kaplan-Meier analysis was used to determine the cumulative incidence of conversion to THA during the 5-year period after primary hip arthroscopic surgery for patients who returned versus did not return to the same surgeon for revision hip arthroscopic surgery. All patients in these groups were included in the analysis of survivorship. The Kaplan-Meier function of the PearlDiver database censored patients who lacked further follow-up at the time point when data became unavailable (eg, because of a change in insurance coverage, no further physician follow-up, or death), thus yielding a 5-year THA conversion rate only for ICD-10–coded patients with complete records, noting either a reoperation or reoperation-free survivorship.

All statistical analyses were performed using PearlDiver software or Prism (Version 9; GraphPad Software). Significance was defined as P < .05 for all analyses.

Results

Characteristics of Study Population and Risk Factors for Changing Surgeons

After applying inclusion/exclusion criteria, a total of 1332 patients were identified who underwent revision hip arthroscopic surgery and formed the basis for this study. Of this overall cohort, 496 patients (37.2%) returned to the same surgeon for revision, while 836 patients (62.8%) switched surgeons (Table 1).

Table 1

Characteristics of Study Population^a

	Same Surgeon (n = 496)	Different Surgeon (n = 836)	P
Age, y	32.9 ± 12.0	33.0 ± 11.5	.885
<20	99 (20.0)	155 (18.5)
20-29	105 (21.2)	175 (20.9)
30-39	124 (25.0)	245 (29.3)
40-49	118 (23.8)	195 (23.3)
50-59	50 (10.1)	66 (7.9)
Sex			.603
Male	121 (24.4)	216 (25.8)
Female	375 (75.6)	620 (74.2)
Insurance			.016
Commercial	426 (85.9)	758 (90.7)
Medicaid	61 (12.3)	59 (7.1)
Unknown	9 (1.8)	19 (2.3)
Region			.002
Midwest	169 (34.1)	340 (40.7)
Northeast	84 (16.9)	117 (14.0)
South	175 (35.3)	231 (27.6)
West	67 (13.5)	138 (16.5)
Unknown	1 (0.2)	10 (1.2)
ECI score	2.38 ± 2.27	2.58 ± 2.56	.127
0	99 (20.0)	164 (19.6)
1-2	215 (43.3)	338 (40.4)
3-4	101 (20.4)	185 (22.1)
≥5	81 (16.3)	149 (17.8)
Comorbidities
Depression/anxiety	59 (11.9)	137 (16.4)	.031
Diabetes	22 (4.4)	38 (4.5)	>.999
Obesity	41 (8.3)	60 (7.2)	.536
Tobacco use	52 (10.5)	91 (10.9)	.891

Data are presented as mean ± SD or n (%). Bold font indicates a statistically significant difference between groups (P < .05). ECI, Elixhauser Comorbidity Index.

Neither mean age (33.0 ± 11.5 vs 32.9 ± 12.0 years, respectively) nor sex (74.2% vs 75.6% female, respectively) was significantly different between patients who switched surgeons versus those who returned to the same surgeon (P > .05 for each). However, insurance status significantly differed between groups (P = .016); patients who switched surgeons were more likely to have commercial health insurance (90.7% vs 85.9%, respectively; 4.8% greater) and less likely to be covered by Medicaid (7.1% vs 12.3%, respectively; 5.2% lesser) than those who did not switch. In addition, patients who switched surgeons had a significantly different geographic region (P = .002), with a greater likelihood of being from the Midwest or West but a lower likelihood of being from the Northeast or South, relative to patients who returned to the same surgeon. Finally, with regard to comorbidities, the mean ECI score (2.58 vs 2.38, respectively) was not significantly different between patients who switched surgeons versus those who returned to the same surgeon. However, on analysis of select individual comorbidities, a diagnosis of depression or anxiety was associated with a greater likelihood of switching surgeons than returning to the same surgeon (16.4% vs 11.9%, respectively; P = .031) (Table 1).

Postoperative ED Visits

In the first 30 days after primary hip arthroscopic surgery, 5.7% of patients in the overall cohort had an ED visit. Returning to the same surgeon was not associated with greater odds of experiencing an ED visit within 30 days (OR, 0.80 [95% CI, 0.47-1.33]; P = .396), with 4.8% (n = 24) of patients returning to the same surgeon versus 6.2% (n = 52) of patients switching surgeons experiencing an ED visit within 30 days after primary hip arthroscopic surgery.

Adverse Events

The prevalence of adverse events occurring within 90 days after primary hip arthroscopic surgery for patients who returned versus did not return to the same surgeon was tabulated. Rates of individual adverse events were low, with the most frequently reported adverse event, deep vein thrombosis, reported in <1.0% (n < 5) of patients who returned to the same surgeon and <1.3% (n < 11) of patients who switched surgeons. Other complications including hematoma formation, nerve injury, sepsis, surgical site infection, and wound dehiscence occurred in ≤10 patients in each group; given the blinding of sample sizes ≤10 patients in the database to protect confidentiality, further comparisons for these individual complications could not be made. Hip dislocation and pulmonary embolism occurred in no patients in either group.

Overall rates of any adverse events within 90 days of surgery were low in both groups, with 1.0% of patients (n = 5) who returned to the same surgeon and 1.9% of patients (n = 16) who switched surgeons experiencing any complication that was assessed. On multivariable logistic regression analysis, returning to the same surgeon was not associated with a significantly higher overall 90-day complication rate (OR, 1.22 [95% CI, 0.85-1.75]; P = .280).

Conversion to THA

Conversion to THA after revision arthroscopic surgery was determined as the cumulative incidence of conversion to THA for patients who returned to the same surgeon versus those who switched surgeons for revision hip arthroscopic surgery by Kaplan-Meier survivorship analysis in Figure 1. Over 5 years, 22 patients (7.6%) who returned to the same surgeon converted to THA (95% CI, 4.2%-10.9%), while 36 patients (7.6%) who switched surgeons converted to THA (95% CI, 4.9%-10.3%). Overall 5-year THA conversion rates were similar between groups (P = .9).

Figure 1.

The incidence of conversion to total hip arthroplasty (THA) within 5 years after revision hip arthroscopic surgery for patients who returned to the same surgeon versus those who switched surgeons for revision hip arthroscopic surgery, with 95% confidence intervals (shown as dotted lines). Survival curves were analyzed by the log-rank test, with cumulative rates of secondary surgery of 7.6% for patients who returned to the same surgeon versus 7.6% for patients who switched surgeons for revision surgery (P = .9).

Discussion

The present study found that factors associated with a greater likelihood of switching surgeons for revision surgery after primary hip arthroscopic surgery were having commercial health insurance, residing in the Midwest or West region of the United States, and having a psychological diagnosis of anxiety or depression. Second, the present study demonstrated that switching surgeons for revision hip arthroscopic surgery was not associated with increased rates of 30-day ED visits, 90-day adverse events, or 5-year conversion to THA. Given the rising incidence of primary and revision hip arthroscopic surgery in the United States^2,13 as well as the large proportion of patients who switch surgeons for revision hip arthroscopic surgery,⁵ identifying the factors associated with patients switching surgeons, and whether outcomes are improved by this decision, represents a key area of investigation.

Regarding demographic factors, the present study found that patients with commercial health insurance had a greater likelihood of switching surgeons for revision surgery, with 90.7% of those who switched surgeons having commercial insurance (while 85.9% of those who did not switch surgeons had commercial insurance). While similar findings have not been previously identified in the literature, a plausible explanation for this difference is that patients with commercial insurance have a greater range of covered in-network surgeons from which to choose,²⁷ allowing them to conveniently switch surgeons after a potentially dissatisfactory initial result. Conversely, patients with Medicaid have more limited options for surgeons in their area as well as greater rates of insurance refusal for sports medicine procedures.²⁷ These factors may limit these patients’ ability to switch surgeons for revision surgery without imposing a significant financial burden.

In addition to differences in insurance status, significant geographic differences were observed, with patients more likely to switch surgeons living in the Midwest and West regions at notably higher rates. A potential explanation for this finding may be the desire of patients to move closer to higher volume surgeons at large academic centers for revision surgery. Illgen et al¹⁴ showed that patients undergoing THA were more likely to travel to a new surgeon at a large teaching hospital for revision surgery if they underwent their initial surgery at a small hospital. Specifically in hip arthroscopic surgery, Nosrat et al²³ found that the highest mean hip arthroscopic surgery case volumes were in the Midwest, suggesting that the availability of centers with high-volume surgeons in this region provides an accessible option for patients after unsuccessful primary surgery.

Finally, the present study found that underlying comorbidities may also play a role, as patients with diagnoses of depression and anxiety were more likely to switch surgeons. One potential reason for this finding could be that patients with these psychological conditions may have more difficulty in trusting a surgeon after a suboptimal initial outcome. Anxiety, depression, bipolar disorder, and schizophrenia have all previously been noted as risk factors for seeking a new surgeon in patients undergoing contralateral total knee arthroplasty.²² Nevertheless, the potential effect of these conditions on patients undergoing revision hip arthroscopic surgery requires further study and may ultimately require coordination with mental health experts to adequately address the issue.

With the rising incidence of primary hip arthroscopic surgery in the United States,^2,13 an estimated revision rate of 4.5% to 24% at a minimum 10-year follow-up,¹⁷ and an estimated 75% of patients switching surgeons for revision procedures,⁵ the present study sought to explore whether patients received a benefit from switching surgeons with respect to postoperative ED visits, complications, or conversion to THA. Our results demonstrated that patients who switched surgeons had equivalent odds of experiencing 30-day postoperative ED visits. In addition, patients who switched surgeons did not have a decreased risk of 90-day postoperative adverse events compared with those who returned to the same surgeon. This absence of a difference in 90-day postoperative adverse events is consistent with outcomes observed by Issa et al¹⁵ in spine surgery, with the authors finding no change in 90-day readmission rates for revision spinal fusion when it was performed by the same surgeon versus a different surgeon. Thus, switching surgeons for revision hip arthroscopic surgery had no significant improvement on short-term postoperative metrics assessed in this study.

In addition, the odds of conversion to THA within 5 years were also unaffected by the decision to switch surgeons. Previous long-term studies have reported a THA conversion rate of 0% to 44.1% after primary hip arthroscopic surgery,¹⁷ with revision surgery noted to be a significant predictor for subsequent conversion to THA.²⁴ Thus, while concern about the need for subsequent THA may motivate some patients to seek a different surgeon after unsatisfactory primary hip arthroscopic surgery, the results of the present study suggest that returning to the same surgeon is not associated with a higher incidence of this outcome. Altogether, the present study suggests that switching surgeons for revision surgery offers no statistically significant improvements in the metrics assessed; however, this study was not able to evaluate more detailed measures of patient outcomes such as patient-reported outcome scores or the achievement of psychometric thresholds, which are areas worthy of future research.

Limitations

There are several limitations inherent to this large national database study. First, data from this national database are based on insurance claims, and thus, variables are limited to those coded within the database; factors such as patient-specific surgical indications, radiological and intraoperative findings, and patient-reported outcome scores are not available for analysis. Second, the PearlDiver database lacks information on surgeon experience and case volume, both of which could augment further analysis of how surgeon factors may affect the decision to switch surgeons as well as outcomes after revision hip arthroscopic surgery.^23,26 Third, some cases of combined hip arthroscopic surgery and periacetabular osteotomy could have been captured in this study’s cohort. Finally, the patient’s experience and the decision of whether to return to the same surgeon are shaped by many factors, including the patient not only perceiving suboptimal clinical care from the surgeon but also having suboptimal perceptions of other members of the clinical team (nurses, physician assistants, anesthesiologists, and/or physical therapists), complications after index surgery, the surgeon making an external referral, the surgeon or patient moving geographically, or the surgeon retiring, among others. The present study cannot isolate whether switching surgeons resulted from the patient’s elective decision or whether one of these noted reasons or another dictated undergoing revision surgery from a different surgeon.

Conclusion

Supplemental Material

sj-docx-1-ojs-10.1177_23259671251332604 – Supplemental material for Changing Surgeons for Revision Hip Arthroscopic Surgery Is Associated With Insurance Status, Geography, and Diagnosis of Anxiety or Depression

Supplemental material, sj-docx-1-ojs-10.1177_23259671251332604 for Changing Surgeons for Revision Hip Arthroscopic Surgery Is Associated With Insurance Status, Geography, and Diagnosis of Anxiety or Depression by Stephen M. Gillinov, Anshu Jonnalagadda, Kevin Girardi, Soheil Sabzevari, Jay Moran, Harold G. Moore, Michael S. Lee, Ronak J. Mahatme, Jonathan N. Grauer and Andrew E. Jimenez in The Orthopaedic Journal of Sports Medicine

Footnotes

Final revision submitted November 25, 2024; accepted December 16, 2024.

One or more of the authors has declared the following potential conflict of interest or source of funding: A.E.J. has received compensation for services other than consulting and a grant from Arthrex; hospitality payments from Stryker, Smith + Nephew, and Abbott Laboratories; and educational support from Arthrex, Polaris Technology Solutions, Gotham Surgical, and Medwest Associates. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval for this study was waived by the Yale University Institutional Review Board.

ORCID iDs

Stephen M. Gillinov

Anshu Jonnalagadda

Kevin Girardi

Michael S. Lee

Ronak J. Mahatme

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Supplementary Material

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