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
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.