JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Nitin Jain, Ricardo Pietrobon, Shawn Hocker, Ulrich Guller, Anoop Shankar, and Laurence D. Higgins
The Relationship Between Surgeon and Hospital Volume and Outcomes for Shoulder Arthroplasty
J Bone Joint Surg Am 2004; 86: 496-505 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Dr. Jain responds:
Nitin Jain, Ricardo Pietrobon, Shawn Hocker, Ulrich Guller, Anoop Shankar, and Laurence D. Higgins   (25 March 2004)
[Read Letter to the Editor] Volume versus Outcomes--The Problem with Generalizations
Stephen G. Littlejohn   (24 March 2004)

Dr. Jain responds: 25 March 2004
Previous Letter to the Editor Top
Nitin Jain,
Epidemiologist
Duke University,
Ricardo Pietrobon, Shawn Hocker, Ulrich Guller, Anoop Shankar, and Laurence D. Higgins

Send letter to journal:
Re: Dr. Jain responds:

Nitin_Jain{at}hms.harvard.edu Nitin Jain, et al.

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.
Volume versus Outcomes--The Problem with Generalizations 24 March 2004
Next Letter to the Editor Top
Stephen G. Littlejohn,
Orthopaedic Surgeon
Longview Orthopaedic Clinic

Send letter to journal:
Re: Volume versus Outcomes--The Problem with Generalizations

sglj{at}swbell.net Stephen G. Littlejohn

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.