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Surgeon Experience and Clinical and Economic Outcomes for Shoulder Arthroplasty
Jason W. Hammond, MD1; William S. Queale, MD, MS, MHS1; Tae Kyun Kim, MD, PhD1; Edward G. McFarland, MD1
1 Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, Johns Hopkins University, 10753 Falls Road, Suite 215, Lutherville, MD 21093. E-mail address for E.G. McFarland: emcfarl@jhmi.edu
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, and the Department of Medicine, Johns Hopkins University, Baltimore, Maryland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2003 Dec 01;85(12):2318-2324
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Background: Previous studies have demonstrated that a high surgical volume for certain surgical procedures reduces morbidity and improves economic outcome; however, to our knowledge, no study has demonstrated a similar relationship between volume and outcome for total shoulder arthroplasty and hemiarthroplasty. The objective of this study was to determine whether increased surgeon experience was associated with improved clinical and economic outcomes for patients undergoing total shoulder arthroplasty or hemiarthroplasty.

Methods: We analyzed discharge data on patients treated between 1994 and 2000 from the Maryland Health Services Cost Review Commission, which has a statewide hospital discharge database of all patients in the state of Maryland. The database included all patients undergoing total shoulder arthroplasty and hemiarthroplasty. We assessed the relationship between surgeon volume (low, medium, and high) and the risk of complications, length of stay, and total charges. The statistics were adjusted for procedure, age, gender, race, marital status, comorbidity, diagnosis, insurance type, income, and hospital volume.

Results: For the 1868 discrete total shoulder arthroplasties and hemiarthroplasties done in the state of Maryland, the risk of at least one complication associated with the procedures done by the high-volume surgeon group was nearly half that associated with the procedures done by the low-volume surgeon group (adjusted odds ratio, 0.6; 95% confidence interval, 0.4 to 0.9). High-volume surgeons were three times more likely than were low-volume surgeons to have patients with a hospital stay of less than six days (odds ratio, 0.3; 95% confidence interval, 0.2 to 0.6). Although the average cost of hospitalization was $1000 less in the high-volume surgeon group compared with the low-volume surgeon group, this reduction did not reach significance after adjustment for multiple variables (odds ratio, 0.8; 95% confidence interval, 0.5 to 1.4).

Conclusions: This study indicates that the patients of surgeons with higher average annual caseloads of total shoulder arthroplasties and hemiarthroplasties have decreased complication rates and hospital lengths of stay compared with the patients of surgeons who perform fewer of these procedures. These analyses of hospital discharge data are limited because of a lack of prospective data, operative details, and patient outcomes data. However, this study emphasizes the importance of continued education for orthopaedic surgeons who perform shoulder arthroplasty.

Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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