The association between hospital volume and total shoulder arthroplasty outcomes

The purpose of this study was to evaluate the relationship between increasing hospital volume and the following outcomes for total shoulder arthroplasties done in the state of New York: length of stay, hospital costs, readmission within 60 days, revision surgery within 24 months, and death within 60 days. The Statewide Planning and Research Cooperative System (SPARCS) database from the New York State Department of Health, a census of all hospital discharges in the state, was used to evaluate the relationship between hospital volume and outcomes for total shoulder arthroplasties for 1996 to 1999. One thousand three hundred seven total shoulder arthroplasties were done in New York from 1996 to 1999. Nearly (1/2) were done at the five highest-volume hospitals. Middle-volume hospitals has the least lengths of stay and hospital costs. Independent of age and comorbidities, patients at hospitals with greater volumes of total shoulder arthroplasties were at reduced risk of patients being readmitted within 60 days. No other outcomes were significantly associated with hospital volume. The finding that greater hospital volume decreases risk of readmission may have important public health implications, but additional research is needed before implementing policy changes.     

Relationship between hospital size and teaching status on outcomes for reverse shoulder arthroplasty

MUSCULOSKELETAL SURGERY - The use of reverse shoulder arthroplasty (RSA) continues to grow with expanding indications and increased surgeon awareness. Previous data for other lower extremity joint...     

Association between hospital and surgeon procedure volume and the outcomes of total knee replacement

BACKGROUND: The annual volume of major cardiovascular and oncologic procedures performed in hospitals and by surgeons has been inversely associated with the rates of perioperative mortality and complications. The relationship between hospital and surgeon volume and perioperative outcomes following total knee replacement has received little study. METHODS: We analyzed claims data for Medicare patients who had elective primary total knee replacement between January 1 and August 31, 2000. Hospital and surgeon volumes were defined as the number of primary and revision total knee replacements performed in the hospital or by the surgeon in Medicare recipients in 2000. We examined the associations between the annual volumes of total knee replacement performed in the hospitals and by the surgeons and the rates of mortality and complications (infection, pulmonary embolus, myocardial infarction, or pneumonia) in the first ninety days postoperatively. The analyses were adjusted for age, gender, comorbid conditions, Medicaid eligibility (a marker of low income), and arthritis diagnosis. Analyses of hospital volume were adjusted for surgeon volume and vice versa. RESULTS: Twenty-five percent of the primary total knee replacements were done by surgeons who performed twelve of these procedures or fewer in the Medicare population annually, and 11% were done in hospitals with an annual volume of twenty-five of these procedures or fewer. Compared with the patients who had a primary total knee replacement in hospitals with an annual volume of twenty-five procedures or fewer, those managed in hospitals with an annual volume exceeding 200 procedures had a lower risk of pneumonia (odds ratio, 0.65; 99% confidence interval, 0.47 to 0.90) and any of the adverse outcomes examined (death, pneumonia, pulmonary embolus, acute myocardial infarction, or deep infection) (odds ratio, 0.74; 99% confidence interval, 0.60 to 0.90). Similarly, patients who had a primary total knee replacement done by surgeons who performed more than fifty such procedures in Medicare recipients annually had a lower risk of pneumonia (odds ratio, 0.72; 99% confidence interval, 0.54 to 0.95) and any adverse outcome (odds ratio, 0.81; 99% confidence interval, 0.68 to 0.98) compared with patients of surgeons with an annual volume of twelve procedures or fewer. CONCLUSIONS: Patients managed at hospitals and by surgeons with greater volumes of total knee replacement have lower risks of perioperative adverse events following primary total knee replacement. Patients and clinicians should incorporate these findings into discussions about selecting a surgeon and a hospital for total knee replacement. These data should also be integrated into the policy debate about the advantages and drawbacks of regionalizing total joint replacement to high-volume centers.     

Long-term relation between deltoid muscle volume and clinical outcomes in a reverse shoulder arthroplasty

BackgroundDeltoid muscle function is important in reverse shoulder arthroplasty (RSA). Concerns are raised on the resistance of the deltoid muscle against the postoperative distalization. We hypothesize that a decreased volume of the deltoid muscle is related to worse clinical outcomes after a long-term follow-up. An observational study was conducted to evaluate the relation between volume of the deltoid muscle and clinical outcomes after a long-term follow-up on RSA.MethodsEligible for inclusion was patients who underwent RSA for cuff arthropathy after minimum 3 years follow-up. Fifty-nine patients were enrolled in this study. Preoperative volume was measured on magnetic resonance imaging or computed tomography. Postoperative deltoid volume was evaluated on ultrasonography. Distalization of the humerus was measured on radiographs. Clinical outcomes were measured by the Constant-Murley Score (CMS), Oxford Shoulder Score, and range of motion. Multivariable linear regression models were used to examine the association between the deltoid volume and clinical outcomes, and between distalization and deltoid volume or clinical outcomes.ResultsThe mean follow-up period was 88.7 ± 29.1 months. Postoperative deltoid volume positively correlated with both CMS (P = .045) and abduction strength, in both operated (P = .01) and contralateral side (P < .001). No association between deltoid volume and Oxford Shoulder Score or range of motion, and no association between preoperative volume and postoperative CMS was found. The mean distalization of the humerus was 21.2 mm [95% CI: 19.4-22.9 mm]. Distalization negatively correlated with deltoid volume (P = .012) and CMS (P = .009).ConclusionsPostoperative deltoid volume correlated with clinical outcomes as measured by CMS and abduction strength after a long-term follow-up on RSA.     

Impact of surgeon and hospital volume on outcomes of radical prostatectomy

An emerging body of literature has established a relationship between case volume and outcomes after radical prostatectomy (RP). Such findings come in the context of an already well-established association between both surgeon and hospital case volume in the field of cardiovascular surgery and for several high-risk cancer operations. The purpose of this review is to identify and summarize the seminal studies to date that investigate the impact of RP volume on patient outcomes.We performed a literature search of the English language studies available through PubMed that pertain to this topic. Thirteen original studies and a meta-analysis were found, which focus on the impact of hospital RP volume on surgical outcomes (including length of stay, perioperative complication rate, perioperative mortality, readmission rate, and several long term measures of treatment effect). Eight studies were identified that interrogated the relationship between individual surgeon case volume and outcomes.Across multiple outcome metrics, there is a pervasive association between higher hospital RP case volume and improved outcomes. Increasing individual surgeon volume may also portend better outcomes, not only perioperatively, but even with respect to long-term cancer control and urinary function. While most data arise from retrospective cohort studies, these studies, for the most part, are of sound design, show an impressive magnitude of effect, and demonstrate an impact on outcome that is proportional to surgical volume.Further research should focus on finding a means by which to translate these observations into improvements in the quality of prostate cancer care. To address differences in outcome between low volume and high volume surgeons, some have proposed and implemented subspecialization within practice groups, while others have looked toward subspecialty certification for urologic oncologists. With regard to differences in hospital volume, regionalization of care has been proposed as a solution, but is fraught with pitfalls. It may be more pragmatic and, ultimately more beneficial to patients, however, to identify processes of care that are already in place at high volume hospitals and implement them at lower volume centers. Similarly, we advocate careful studies to identify successful surgical techniques of high volume surgeons and efforts to disseminate these techniques.     

Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures

BackgroundA relationship between surgical volume and improved surgical outcomes has been described in gastric bypass patients but the relative importance of surgeon versus hospital volume is unknown. Our objective was to examine whether in-hospital and 30-day mortality are determined more by surgeon volume or hospital volume or whether each has an independent effect. A retrospective cohort study was performed of all hospitals in Pennsylvania providing gastric bypass surgery from 1999 to 2003.MethodsData from the Pennsylvania Health Care Cost Containment Council included 14,714 gastric bypass procedures in patients aged >18 years. In-hospital and 30-day mortality were stratified by hospital volume categories (high [≥300], medium [125–299], and low [<125]) and surgeon volume categories (high [≥50] and low [<50]). Multivariate analyses were performed using logistic regression analysis to control for patient demographics and severity.ResultsHigh-volume surgeons at high-volume hospitals had the lowest in-hospital mortality rates of all categories (.12%) and low-volume surgeons at low-volume hospitals had the poorest outcomes (.57%). The same trend was observed for 30-day mortality (.30% versus .98%). After controlling for other covariates, high-volume surgeons at high-volume hospitals also had significantly lower odds of both in-hospital (odds ratio 20, P = .002) and 30-day mortality (odds ratio .30, P = .001). This relationship held true even after excluding surgeons who only performed procedures within a single year.ConclusionIn Pennsylvania, both higher surgeon and hospital volume were associated with better outcomes for bariatric surgical procedures. Although a high-surgeon volume correlated with lowered mortality, we also found that high-volume hospitals demonstrated improved outcomes, highlighting the importance of factors other than surgical expertise in determining the outcomes.     

Measuring outcomes in shoulder arthroplasty

No standard assessment for the patient with a shoulder arthroplasty has been universally accepted to date. Traditional assessment tools can be divided into three levels of resolution including: (1) assessments of the quality of life and general health, (2) global shoulder assessments, and (3) assessments for a particular disorder of the shoulder. In this article, examples of each of these groups are discussed. Each of these levels of sensitivity offers a different perspective on the outcome of shoulder arthroplasty and until the ideal, universal outcome measure is developed, outcomes should be reported using assessments in each of these levels.     

Relation of surgeon and hospital volume to processes and outcomes of colorectal cancer surgery

BACKGROUND: Greater hospital volume has been associated with lower mortality after colorectal cancer surgery. The contribution of surgeon volume to processes and outcomes of care is less well understood. We assessed the relation of surgeon and hospital volume to postoperative and overall mortality, colostomy rates, and use of adjuvant radiation therapy. METHODS: From the California Cancer Registry, we studied 28,644 patients who underwent surgical resection of stage I to III colorectal cancer during 1996 to 1999 and were followed up to 6 years after surgery to assess 30-day postoperative mortality, overall long-term mortality, permanent colostomy, and use of adjuvant radiation therapy. RESULTS: Across decreasing quartiles of hospital and surgeon volume, 30-day postoperative mortality ranged from 2.7% to 4.2% (P < 0.001). Adjusting for age, stage, comorbidity, and median income among patients with colorectal cancer who survived at least 30 days, patients in the lowest quartile of surgeon volume had a higher adjusted overall mortality rate than those in the highest quartile (hazard ratio, 1.16; 95% confidence interval, 1.09-1.24), as did patients in the lowest quartile of hospital volume relative to those treated in the highest quartile (hazard ratio, 1.11; 95% confidence interval, 1.05-1.19). For rectal cancer, adjusted colostomy rates were significantly higher for low-volume surgeons, and the use of adjuvant radiation therapy was significantly lower for low-volume hospitals. CONCLUSIONS: Greater surgeon and hospital volumes were associated with improved outcomes for patients undergoing surgery for colorectal cancer. Further study of processes that led to these differences may improve the quality of colorectal cancer care.     

A study of 11,003 patients with hypertrophic pyloric stenosis and the association between surgeon and hospital volume and outcomes

Aim

The availability of large clinical databases allows for careful evaluation of surgical practices, indicators of quality improvement, and cost. We used a large clinical database to compare the effect of surgeon and hospital volume for the care of children with hypertrophic pyloric stenosis (HPS).

Methods

Patients with International Classification of Diseases-9 codes for HPS and pyloromyotomy were selected from the 1994 to 2000 National Inpatient Samples database. Multiple and logistic regression models were used to evaluate the risk-adjusted association between provider volume and outcomes.

Results

Postoperative complications occurred in 2.71% of patients. Patients operated on by low- and intermediate-volume surgeons were more likely to have complications compared with those operated on by high-volume surgeons (95% confidence interval [CI], 1.25-3.78 and 95% CI, 1.25-2.69, respectively). Patients operated at low-volume hospitals were 1.6 times more likely to have complications compared with those operated at intermediate- or high-volume hospitals (95% CI, 1.19-2.20). Procedures performed at high-volume hospitals were less expensive than those at intermediate-volume hospitals by a margin of $910 (95% CI, $443-$1377).

Conclusions

These data represent the largest study to date on the epidemiology, complication rate, and cost for care for HPS. Patients treated by both high-volume surgeons and at high-volume hospitals have improved outcomes at less cost.     

Midterm outcomes of revision shoulder arthroplasty

BackgroundSince the introduction of shoulder arthroplasty, the indications have been expanding. Because of the increasing number of arthroplasty procedures, revision surgeries are also inevitable. The purpose of our study is to delineate a large number of revision shoulder arthroplasty cases treated in different ways, including antibiotic spacer placement (ABX), hemiarthroplasty (HA), anatomic total shoulder arthroplasty (aTSA), and reverse total shoulder arthroplasty (rTSA), and to analyze the relationship between preoperative factors and clinical outcomes.MethodsWe reviewed our institution's records of revision shoulder arthroplasty between January 1, 2000, and October 1, 2017. Preoperative information included age at the time of surgery, gender, body mass index, and infection status. Pre- and postoperatively, we gathered 6 patient-reported clinical outcomes and 3 range-of-motion parameters (elevation, abduction, and external rotation). Postoperative complications were also assessed. Then, we examined the differences between the pre- and postoperative outcomes. As a secondary analysis, we performed multivariable regression analysis on the same outcomes, accounting for age at the time of surgery, infection status, and previous surgery type.ResultsAmong the 341 revisions performed, 138 cases met inclusion criteria of at least a 2-year follow-up with pre- and postoperative functional outcome scores. The majority of our revision procedures were to a rTSA (92 cases, 67%), followed by aTSA (28 cases, 20%), and ABX/HA (18 cases, 13%). The mean age at the time of our index surgery was 66 years old. In aTSA and rTSA, all the postoperative outcomes (ie, ASES, Constant, UCLA, SST, SPADI, SF-12 scores, and 3 AROMs) were significantly improved beyond the minimal clinically important difference (MCID) except SF-12 scores in aTSA (P = .25) and active external rotation in rTSA (P = .73). None of the ABX/HA's postoperative outcomes achieve significant improvement or MCID. Multivariable regression analysis showed that older age at the time of surgery was significantly associated with better outcomes in 3 of the 6 patient-reported outcomes (ASES, SST, and SPADI; P = .023, .023, and .028, respectively).ConclusionRevision aTSA and rTSA showed statistically and clinically significant improvement postoperatively. ABX and HA did not achieve meaningful postoperative improvement. Overall, patients getting revision shoulder arthroplasty at an older age had better patient-reported outcomes.Level of evidenceLevel III; Retrospective Cohort Study     

The relationship between age and short-term complications following reverse total shoulder arthroplasty for proximal humerus fractures

BackgroundProximal humerus fractures (PHFx) are common orthopedic injuries among the elderly. Although nonoperative management remains the primary treatment modality, more than one-third of PHFx are now treated surgically. Over the past decade, reverse total shoulder arthroplasty (RTSA) has gained popularity as a treatment option for PHFx, both in elderly patients with complex fractures and patients younger than 65 years. While the age range of patients undergoing RTSA for PHFx has expanded, little is known about the impact of age on postoperative complications. The purpose of this study was to examine the relationship between age and 30-day complication rates following RTSA for PHFx.MethodsThe National Surgical Quality Improvement Program database was queried for patients who underwent RTSA for PHFx between 2006 and 2018. Patient demographic data, surgical characteristics, and adverse outcomes were extracted. Patients were divided into four cohorts by age (<65, 65-75, 76-85, >85 years), and univariate as well as multivariate analyses were performed.ResultsA total of 1099 patients were identified with a mean age of 72.7 years. Overall, 6.73% of patients experienced one or more complications. Mean operative duration decreased with age (135 minutes in the <65 years old cohort vs. 119 minutes in the >85 years old cohort, P < .001), while average hospital stay increased with age (2.8 days in the <65 years old cohort vs. 4.2 days in the >85 years old cohort, P < .001). Neither the overall complication rate nor the mortality rate was significantly different between cohorts. Relative to the <65 years old cohort, perioperative blood transfusion and non-home discharge were significantly more common in the 76-85 years old and >85 years old cohorts. Age >75 years, preoperative dependent functional status, and ASA class 3 or 4 were found to be independent risk factors for perioperative blood transfusion. Age ≥65 years, female gender, congestive heart failure, preoperative dependent functional status, and ASA class 3 or 4 were found to be independent risk factors for non-home discharge. The rate of unplanned hospital readmission was highest in the >85 years old cohort (17.65%), though this difference did not reach statistical significance.ConclusionsWhile RTSA appears to be a safe treatment option for PHFx in appropriately selected elderly patients, a longer hospitalization and more frequent non-home discharge should be anticipated. Additionally, elderly patients should be closely monitored for postoperative anemia.Level of evidenceLevel III; Retrospective Cohort Study     

The relationship between surgeon and basic scientist

Basic science research has always been the cornerstone of a solid academic career, even for surgeons. In the past, many cardiothoracic and cardiovascular surgeons have used the large animal laboratory to design surgical operations, refine extracorporeal circulation, improve myocardial protection or simply validate clinical concepts. Today, funding for large animal research has almost disappeared. The basic science areas of 'cellular, molecular, genomics or gene therapy' must be involved to be considered for national or even local funding. This endeavor requires a new generation of surgical scientists and perhaps even more importantly, a new environment for the performance of such research. Academic surgery does not exist without active and long-standing commitment to research. Clinical research focusing on patient outcome remains an important task of the academic surgeon but this paper will focus on the relationship between surgeons and basic scientists and shall concentrate primarily on translational research and its challenge now and in the future. The collaboration between basic scientist and clinician is more essential than ever, because the society still optimally rewards science that has potential clinical applicability [1]. Even within surgical departments, active support and very close contact with PhDs can be essential for the clinical faculty members to be productive, using cellular and molecular techniques. In cardiovascular medicine and biology, there is a great potential to prevent or treat diseases with these techniques. The potential to modify ischemia-reperfusion, inflammation, angiogenesis, restenosis, organ tolerance or cardiomyocyte transplantation to remodel ventricles will be accomplished by a better understanding of cardiovascular biology. Surgeons must plan for a speciality that may look quite different in the next future.