Shoulder & Elbow Clinical Paper
The effect of surgeon and hospital volume on shoulder arthroplasty perioperative quality metrics

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Background

There has been a significant increase in both the incidence of shoulder arthroplasty and the number of surgeons performing these procedures. Literature regarding the relationship between surgeon or hospital volume and the performance of modern shoulder arthroplasty is limited. This study examines the effect of surgeon or hospital shoulder arthroplasty volume on perioperative metrics related to shoulder hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty. Blood loss, length of stay, and operative time were the main endpoints analyzed.

Methods

Prospective data were analyzed from a multicenter shoulder arthroplasty registry; 1176 primary shoulder arthroplasty cases were analyzed. Correlation and analysis of covariance were used to examine the association between surgeon and hospital volume and perioperative metrics adjusting for age, sex, and body mass index.

Results

Surgeon volume is inversely correlated with length of stay for hemiarthroplasty and total shoulder arthroplasty and with blood loss and operative time for all 3 procedures. Hospital volume is inversely correlated with length of stay for hemiarthroplasty, with blood loss for total and reverse shoulder arthroplasty, and with operative time for all 3 procedures. High-volume surgeons performed shoulder arthroplasty 30 to 50 minutes faster than low-volume surgeons did.

Conclusions

Higher surgeon and hospital case volumes led to improved perioperative metrics with all shoulder arthroplasty procedures, including reverse total shoulder arthroplasty, which has not been previously described in the literature. Surgeon volume had a larger effect on metrics than hospital volume did. This study supports the concept that complex shoulder procedures are, on average, performed more efficiently by higher volume surgeons in higher volume centers.

Section snippets

Selection of the study cohort

In 2007, Institutional Review Board approval was obtained to commence prospective data collection for a multicenter institutional Shoulder Arthroplasty Registry within a large integrated health care system that serves more than 5 million individuals. Fifteen percent of members are older than 60 years, a good approximation of the U.S. population. A retrospective cohort study was performed with data including demographic information, comorbidities, ICD-9 codes, implant data, surgical metrics, and

Demographics

The average age for RSA (74.9 years [±7.67]) was significantly older than the average age for TSA (69.1 years [±8.93]) or HA (65.9 [±11.8]) (P < .001). The proportion of genders was comparable across procedure groups, with men representing 49.1% of TSA cases, 50.9% of HA cases, and 42% of RSA cases (P = .14). Body mass index within 90 days of surgery was lower in RSA, 28.4 (±5.62), compared with TSA 30.3 (±5.89) and HA 30.0 (±6.17) (P < .005). The demographic results are summarized in Table I.

Discussion

Many studies demonstrate an inverse relationship between surgeon or hospital volume and mortality rates, functional status, and complications from a variety of procedures,3 including aneurysm repair,8 cataract surgery,2 coronary artery bypass graft,31 thyroidectomy,34 carotid endarterectomy,27 and lung cancer resection.1

Several studies in the orthopaedic literature have examined the relationship between provider and institutional volume and objective outcomes such as mortality, readmission,

Conclusion

This study demonstrates that on average, high-volume surgeons and hospitals performed shoulder HA, TSA, and RSA with less blood loss, lower surgical time, and shorter length of stay compared with lower volume practitioners and hospitals.

Disclaimer

The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

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    The Kaiser Permanente Institutional Review board approved the study with IRB #5527 on July 20, 2012.

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