Volume distribution of primary shoulder arthroplasty among low- and high-volume surgeons

Abstract

BackgroundCare from high-volume surgeons has been shown to improve patient outcomes and reduce revision rates, complications, and hospital stays. According to prior research, most shoulder arthroplasties are performed by lower volume surgeons. However, this research is limited as it does not account for the recent increase in case numbers and projected growth of shoulder arthroplasty, and was focused only to states with urban populations. The purpose of this study is to identify and compare contemporary shoulder arthroplasty practice patterns and volume distributions in the state of Iowa. MethodsThe Iowa Hospital Association Databank was queried using International Classification of Diseases (ICD)-10 procedure codes for primary total shoulder arthroplasty. Surgeon and hospital volume were stratified according to procedures performed yearly as: low-volume <15 arthroplasties yearly, medium-volume 15-49, and high-volume ≥50 arthroplasties yearly. The proportion of surgeon and hospital volume, and number of procedures performed by each group were assessed. Distance traveled by patients to visit high-volume vs. low-volume surgeons and hospitals was compared. ResultsIn 2019, 1847 primary shoulder arthroplasties were performed in the state of Iowa by 144 surgeons at 49 institutions. Seventy four percent (106/144) of these surgeons were considered low-volume, 20% (29/144) medium-volume, and only 6% (9/144) were high-volume. However, 43% (793/1847) of shoulder arthroplasties were performed by high-volume surgeons, and 18% (333/1847) by low-volume surgeons. Eighteen percent (9/49) of hospitals where shoulder arthroplasties were performed qualified as high-volume institutions, whereas 45% (22/49) were low-volume. Compared to previous results, 65% (1194/1847) of procedures were performed at high-volume institutions and 6% (118/1847) at low-volume institutions. There was a significant difference in median distance traveled for patients to access high vs. low-volume surgeons (34 vs. 14 miles, P < .0001), and high-volume vs. low-volume hospitals (30 vs. 14.5, P < .0001). DiscussionIn the state of Iowa, while only a small portion of surgeons are considered “high-volume”, almost half of primary shoulder arthroplasties are performed by high-volume surgeons. These findings differ from the previous literature regarding volume distribution in shoulder arthroplasty. Furthermore, the results from this study demonstrate a shift from former documented trends which in the past had indicated that most shoulder arthroplasties were performed by low-volume surgeons. Data from this current study provides a glimpse into the evolution in practice patterns for shoulder arthroplasty. As practice patterns continue to evolve, further investigation may demonstrate improved patient outcomes in patients undergoing shoulder arthroplasty at higher volume hospitals with high-volume surgeons.