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The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty
Nitin Jain, MBBS, MSPH1; Ricardo Pietrobon, MD2; Shawn Hocker, MD2; Ulrich Guller, MD, MHS3; Anoop Shankar, MBBS, MPH4; Laurence D. Higgins, MD2
1 VA Boston Healthcare System, 1400 VFW Parkway, Pulmonary IIIB, West Roxbury, MA 02132. E-mail address: nitin_jain@hms.harvard.edu
2 Center for Excellence in Surgical Outcomes, Division of Orthopaedic Surgery, Duke University Medical Center, Box 3435, Finch Yeager Building (N.J.), Box 3094 (R.P.), Box 3615 (S.H. and L.D.H.), Duke University, Durham, NC 27710.
3 Division of General Surgery and Sugical Research, Department of Surgery, University of Basel, Basel 4031, Switzerland
4 601 Eagle Heights, Apartment D, Madison, WI 53705
View Disclosures and Other Information
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 Center for Excellence in Surgical Outcomes and Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina; Department of General Surgery, University of Basel, Basel, Switzerland; and Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2004 Mar 01;86(3):496-505
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Abstract

Background: As far as we know, no previous study has determined the relationship between volume and outcomes for shoulder arthroplasty. We hypothesized that surgeons and hospitals with higher caseloads of total shoulder arthroplasties and hemiarthroplasties have better outcomes as measured by decreased mortality rate, shorter length of stay in the hospital, reduced postoperative complications, and routine disposition of patients on discharge.

Methods: Data on patients undergoing shoulder arthroplasty were extracted from the Nationwide Inpatient Sample databases for the years 1988 through 2000. Logistic regression with generalized estimating equations and multiple linear regression models were used to estimate the adjusted association between surgeon and hospital volume and outcomes for total shoulder arthroplasty and hemiarthroplasty after adjusting for comorbidity, age, race, household income, and sex.

Results: The mortality rates for patients who had a total shoulder arthroplasty performed by surgeons who did fewer than two procedures per year (0.36%) or who did between two and fewer than four procedures per year (0.32%) were higher than those for patients who had a total shoulder arthroplasty performed by surgeons who did four procedures or more per year (0.20%). The risk-adjusted rate of postoperative complications after hemiarthroplasty was significantly higher for patients managed by surgeons who performed fewer than two procedures per year (1.68%) than for those managed by surgeons with a volume of five procedures or more per year (0.97%). The possibility of postoperative complications when total shoulder arthroplasty was performed in hospitals with a volume of fewer than five procedures (1.44%) or in those with a volume of five to ten procedures per year (1.45%) was significantly higher than that in hospitals where ten procedures or more were performed every year (0.64%). The mean lengths of stay in the hospital after total shoulder arthroplasty and hemiarthroplasty were significantly longer when the operations were performed by surgeons who did fewer than two procedures per year or when they were done in hospitals with a volume of fewer than five procedures per year or with a volume of five to fewer than ten procedures per year than when they were done in hospitals or by surgeons in the highest volume category (p < 0.001).

Conclusions: Patients who have a total shoulder arthroplasty or hemiarthroplasty performed by a high-volume surgeon or in a high-volume hospital are more likely to have a better outcome.

Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See Instructions to Authors for a complete description of levels of evidence.

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    References

    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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    Nitin Jain
    Posted on March 25, 2004
    Dr. Jain responds:
    Duke University

    To the Editor:

    We appreciate Dr. Littlejohn’s comments regarding our study. It is evident from our study that high volume surgeons and hospitals have better outcomes as compared with low volume surgeons/hospitals for shoulder arthroplasty. This compelling evidence is based on national databases and is consistent across all outcomes. Hence, our conclusion that “better outcomes can be achieved for shoulder arthroplasty when patients are referred to high volume surgeons and hospitals” are valid and thoroughly substantiated. Shoulder arthroplasty is a technically demanding procedure that is not performed routinely, with most surgeons (75%) performing only 1 or 2 arthroplasties per year [1]. These data are in agreement with our study where most of the shoulder arthroplasties were performed by low volume surgeons or in low volume hospitals. Our findings and conclusions are even more relevant, if not disturbing, in light of these reports.

    However, we realize the need to study a wide spectrum of factors before a decision on centralization of orthopaedic care can be made. The finding that high volume providers achieve better outcomes is an important component of this spectrum.

    In response to Dr. Littlejohn’s comment, “an individual surgeon may have better outcomes than many physicians at large referral centers”, This statement may be true but irrelevant, since in our opinion, health policies should not be formulated based on individual provider outcomes but instead on aggregate results. In our study, on an average, high volume providers had better outcomes as compared with low volume providers.

    The conclusions from our study are valid and important for making policies that encourage better outcomes in patients undergoing shoulder arthroplasty.

    By the way the “old saying” is “Those who can, do, those who can do more, teach.”

    Reference List

    1.Hasan, S. S., J. M. Leith, K. L. Smith, and F. A. Matsen, III. 2003. The distribution of shoulder replacement among surgeons and hospitals is significantly different than that of hip or knee replacement. J.Shoulder.Elbow.Surg. 12:164-169.

    Stephen G. Littlejohn
    Posted on March 15, 2004
    Volume versus Outcomes--The Problem with Generalizations
    Longview Orthopaedic Clinic

    To the Editor:

    Do you remember the old saying "Those who can, do. And, those who can't teach." Duke University is turning this around a bit. Their recent article on "The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty" essentially encourages patients to have shoulder arthroplasties at major referral centers. This is based on data from NIS databases. The article is summed up in the last paragragh where the authors state,"... better outcomes can (not 'may') be achieved for shoulder arthroplasty when patients are referred to high volume surgeons and hospitals."

    Statements like this not only encourage but seem to insist on the centralization of orthopaedic care. They do not take into account the individual orthopaedic surgeon who, despite excellent surgical skills and outcomes, has chosen to live and work in a community that is not a major city but is still a fully functional hospital setting. It actually excludes some areas that have better outcomes but not the volume of places such as university hospitals. Thus, an individual surgeon may have better outcomes than many physicians at large referral centers but his/her results will be obscured by co-mingling them with the data from all other small volume centers.

    The generalizations in this article encourage formulations of health policies based on the presented data alone. I think the authors presented some interesting data. A little toning down of their conclusions is in order.

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