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The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty

¹ VA Boston Healthcare System, 1400 VFW Parkway, Pulmonary IIIB, West Roxbury, MA 02132. E-mail address: nitin_jain{at}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

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 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.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

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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