Surgeon Case Volume Research Articles

Analysis of Surgeon and Center Case Volume and Stroke or Death after Transcarotid Artery Revascularization.

It has been suggested that the annual hospital volume of cases may affect the number of adverse events following carotid endarterectomy (CEA). We aim to study the associations between hospital as well as surgeon volume and the risk of stroke/death following TCAR. Retrospective review of the Vascular Quality Initiative data of patients undergoing TCAR from 2016 to 2021. Surgeon and center volume were calculated based on the mean number of cases (MNC) performed yearly by each surgeon and center. The primary outcome was a composite endpoint of in-hospital stroke/death. A total of 22,624 cases were included. Surgeon volume was divided into three quantiles: low (MNC=4), medium (MNC=10), and high (MNC=26). Center volume was also divided into low (MNC=14), medium (MNC=32), and high (MNC=64). After adjusting for potential confounders, and when compared to high volume centers, low and medium center volume was not associated with any increased odds of in-hospital stroke/death, stroke, death, or stroke/TIA. Compared to high volume surgeons, low surgeons' volume was associated with a higher odd of stroke (OR: 1.5, 95%CI (1.1-2.04), P=0.008), and stroke/TIA (OR: 1.5, 95%CI (1.2-1.9), P=.002). However, medium surgeon volume was not associated with higher odds of stroke/death, stroke, and stroke/TIA. Neither low nor medium surgeon volume was associated with a difference in mortality compared to high surgeon volume. In this retrospective study, center volume was not associated with any differences in outcomes among patients undergoing TCAR. On the other hand, surgeons with low volume were associated with a higher risk of stroke/death/MI and stroke/TIA when compared to high surgeon volume. There was no difference in outcomes between medium and high surgeon volume.

Is surgeon annual case volume related with intra and postoperative complications after ventral hernia repair? Uni- and multivariate analysis of prospective registry-based data

BackgroundLiterature on a potential relationship between surgeon case volume and intra- or postoperative complications after ventral hernia repair remains scarce.MethodsPatients who underwent ventral hernia repair between 2011 and 2023 were selected from the prospectively maintained French Hernia-Club Registry. Outcome variables were: intraoperative events, postoperative general complications, surgical site occurrences, surgical site infections, length of intensive care unit (ICU), and patient-reported scar bulging during follow-up. Surgeons’ annual case volume was categorized as 1–5, 6–50, 51–100, 101–125, and > 125 cases, and its association with outcome volume was evaluated using uni- and multivariable analyses.ResultsOver the study period, 199 titular or temporary members registered 15,332 ventral hernia repairs, including 7869 primary, 6173 incisional, and 212 parastomal hernia repairs. In univariate analysis, surgeons’ annual case volume was significantly related with all the postoperative studied outcomes. After multivariate regression analysis, annual case volume remained significantly associated with intra-operative complications, postoperative general complications and length of ICU stay. A primary repair was independently associated with fewer intra- and post-operative complications.ConclusionIn the present multivariable analysis of a large registry on ventral hernia repairs, higher surgeon annual case volume was significantly related with fewer postoperative general complications and a shorter length of stay, but not with fewer surgical site occurrences, nor with less patient-reported scar bulging. Factors in the surgeons’ case mix such as the type of hernia have significant impact on complication rates.

What is the Case Volume of Orthopaedic Trauma Surgeons in the Military Health System? An Assessment of Wartime Readiness and Skills Sustainment.

Complex, high-energy extremity trauma secondary to explosive mechanisms has been increasingly common in modern warfare, accounting for a majority of combat wounds throughout the conflicts in Iraq and Afghanistan. Fellowship-trained orthopaedic trauma surgeons treated many of these complex injuries; however, as the number of casualties continue to decrease during a period of relative peace, a growing concern over maintaining military trauma readiness exists. The Military Health System Data Repository was queried for all Common Procedural Terminology (CPT) codes associated with 18 fellowship-trained orthopaedic trauma surgeons from 2013 to 2019. The codes were further analyzed and categorized based on common trauma subspecialty procedures such as fracture fixation of the pelvic ring, acetabulum, upper and lower extremity, peri-articular, and nonunion/malunion surgery. We used descriptive statistics to quantify both the average number of cases per surgeon per year in each of the subcategories and case volume among Military Treatment Facilities (MTFs) during the study period. We identified 7,769 CPT codes for surgical procedures throughout the study period. The most common surgical procedures performed were: removal of implant (n = 836, 11%), knee arthroscopy (n = 507, 7%), and debridement of devitalized tissue (n = 345, 4%). The total trauma subspecialty procedural codes and average cases per surgeon per year were as follows: pelvic ring (n = 54, <1 case/year), acetabulum (n = 90, 1 case/year), upper extremity (n = 1,314, 15 cases/year), lower extremity (n = 2,286, 25 cases/year), peri-articular (n = 675, 8 cases/year), and nonunion/malunion (n = 288, 3 cases/year). San Antonio Military Medical Center (SAMMC) accounted for the most fracture-related CPT codes overall (35%), while all other MTFs contributed approximately 10% or less of all fracture-related codes. These results highlight the lack of orthopaedic trauma volume at other MTFs outside of SAMMC, raising concern for maintaining military readiness during an inter-war period of relative peace. The DoD continues to make concerted efforts to maintain readiness through civilian partnerships and subsequently increase surgical case volume for military trauma surgeons. Future efforts should include an in-depth analysis of caseloads of military trauma surgeons providing care at both MTFs and civilian institutions to optimize preparedness in future conflicts.

The Association Between Surgeon Volume and Dislocation After Total Hip Arthroplasty: A Nationwide Evaluation of 5,106 Orthopaedic Surgeons.

The relationship between surgeon volume and risk of dislocation after total hip arthroplasty (THA) is debated. This study sought to characterize this association and assess patient outcomes using a nationwide patient and surgeon registry. The Premier Healthcare Database was queried for adult primary elective THA patients from January 1, 2016, to December 31, 2019. Annual surgeon volume and 90-day risk of dislocation were modeled using multivariable logistic regression with restricted cubic splines. Bootstrap analysis identified a threshold annual case volume, corresponding to the maximum decrease in dislocation risk. Surgeons with an annual volume greater than the threshold were deemed high volume, and those with an annual volume less than the threshold were low volume. Each surgeon within a given year was treated as a unique entity (surgeon-year unit). 90-day complications of patients treated by high-volume and low-volume surgeons were compared. From 2016 to 2019, 352,131 THAs were performed by 5,106 surgeons. The restricted cubic spline model demonstrated an inverse relationship between risk of dislocation and surgeon volume (threshold: 109 cases per year). A total of 9,967 (87.8%) low-volume surgeon-year units had individual dislocation rates lower than the average of the entire surgeon cohort. Patients treated by high-volume surgeons had decreased risk of dislocation (adjusted odds ratio [aOR], 0.60; 95% CI, 0.54 to 0.67), periprosthetic fracture (aOR, 0.87; 95% CI, 0.76 to 0.99), periprosthetic joint infection (aOR, 0.63; 95% CI, 0.56 to 0.69), readmission (aOR, 0.70; 95% CI, 0.67 to 0.73), and in-hospital death (aOR, 0.60; 95% CI, 0.46 to 0.80). While most of the low-volume surgeons had dislocation rates lower than the cohort average, increasing annual surgeon case volume was associated with a reduction in risk of dislocation after primary elective THA. Level IV.

Impact of surgeon volume, experience, and training on outcomes after arthroscopic rotator cuff repair: a nationwide analysis of 1489 surgeons

BackgroundGiven the complexity of arthroscopic rotator cuff repair (ARCR) and increasing prevalence, there is a need for comprehensive, large-scale studies that investigate potential correlations between surgeon-specific factors and postoperative outcomes after ARCR. This study examines how surgeon-specific factors including case volume, career length, fellowship training, practice setting, and regional practice impact two-year reoperation rates, conversion to total shoulder arthroplasty (anatomic or reverse) (TSA), and 90-day post-ARCR hospitalization. MethodsThe PearlDiver Mariner Database was used to collect surgeon-specific variables and query patients who underwent ARCR from 2015 to 2018. Patient outcomes were tracked for two years, including reoperations, hospitalizations, and ICD-10 codes for revision rotator cuff repair (RCR) laterality. Hospitalizations were defined as any emergency department (ED) visit or hospital readmission within 90 days after primary ARCR. Surgeon-specific factors including surgeon case volume, career length, fellowship training, practice setting, and regional practice were analyzed in relation to postoperative outcomes using both univariate and multivariate logistic regression. Results94,150 patients underwent ARCR by 1,489 surgeons. On multivariate analysis, high volume surgeons demonstrated a higher risk for two-year total reoperation (OR = 1.06, 95% CI: 1.01-1.12, P = 0.03) and revision RCR (OR = 1.06, 95% CI: 1.01-1.12, P = 0.02) compared to low volume surgeons. Early-career surgeons showed higher rates of 90-day ED visits (mid-career surgeons: OR = 0.78, 95% CI: 0.73-0.83, P < 0.001; late-career surgeons: OR = 0.73, 95% CI: 0.68-0.78, P < 0.001) and hospital readmission (mid-career surgeons: OR = 0.74, 95% CI: 0.63-0.87, P < 0.001; late-career surgeons: OR = 0.73, 95% CI: 0.61-0.88, P = 0.006) compared to mid- and late-career surgeons. Sports Medicine and/or Shoulder and Elbow fellowship-trained surgeons demonstrated lower two-year reoperation risk (OR = 0.95, CI: 0.91-0.99, P = 0.04) and fewer 90-day ED visits (OR = 0.93, 95% CI = 0.88-0.98, P = 0.002). Academic surgeons experienced higher readmission rates compared to community surgeons (OR = 1.16, 95% CI = 1.01-1.34, P = 0.03). Surgeons practicing in the Northeast demonstrated lower two-year reoperation (OR = 0.88, 95% CI: 0.83-0.93, P < 0.001) and revision (OR = 0.88, 95% CI: 0.83-0.94, P < 0.001) rotator cuff repair risk, compared to surgeons in the Southern United States. ConclusionsHigh-volume surgeons exhibit higher two-year reoperation rates after ARCR compared to low-volume surgeons. Early-career surgeons demonstrate increased hospitalizations. Sports Medicine or Shoulder and Elbow Surgery fellowships correlate with reduced two-year reoperation rates and 90-day ED visits.

Satisfactory 5-year functional outcomes following primary ACL reconstructions from the UK National Ligament Registry.

The aim of this study was to describe the 10-year findings from the UK National Ligament Registry (NLR). A retrospective review was performed for prospectively collected data on the NLR between January 2013 and December 2022. All patients who underwent primary ACL reconstruction (ACLR) on the registry were included. Surgical characteristics were analysed, including surgeon grade and case volume, concomitant knee procedures, venous thromboembolic prophylaxis, graft characteristics, femoral and tibial tunnel drilling, and fixation methods. Clinical outcomes were collected preoperatively and at 6 months, 1 year, 2 yearsand 5 years following the index procedure. During the study period, 17,492 unilateral ACLR procedures were recorded. Autograft was used in 98%, most commonly a combined semitendinosus and gracilis graft (77%) or patella tendon graft (31%). Allograft was used in only 1% of the patients. In 52% of cases, ACLR was associated with an additional procedure, with isolated medial meniscal surgery being the most common (21%). Femoral tunnel drilling was mostly performed through an anteromedial portal (73%) and tibial tunnel drilling using an outside-in technique (92%). The most common method of femoral graft fixation was with an Endobutton fixed loop suspensory device (77%), while interference screws predominated for tibial tunnel fixation (86%). Patients who underwent ACLR surgery showed significant improvement in their functional outcome scores at six months, 1 year, 2 yearsand 5 years postoperatively. Data from the NLR shows a detailed description of the current trends and evolution of ACLR in the United Kingdom over the last 10 years. Satisfactory functional outcomes were observed 5 years postoperatively. This study provides useful information on the prevalence of ACL-associated injuries and current surgical techniques with the aim of improving the quality of clinical care and patients' outcomes. Moreover, it provides surgeons with a benchmark against which to compare current practices and functional outcomes following ACLR across the United Kingdom. Level III.

Impact of Surgeon Case Volume on Outcomes After Reverse Total Shoulder Arthroplasty.

Despite a rapid increase in utilization of reverse total shoulder arthroplasty (rTSA), volume-outcome studies focusing on surgeon volume are lacking. Surgeon-specific volume-outcome studies may inform policymakers and provide insight into learning curves and measures of efficiency with greater case volume. This retrospective cohort study with longitudinal data included all rTSA cases as recorded in the Centers for Medicare & Medicaid Services Limited Data Set (2016 to 2018). The main effect was surgeon volume; this was categorized using two measures of surgeon volume: (1) rTSA case volume and (2) rTSA + TSA case volume. Volume cutoff values were calculated by applying a stratum-specific likelihood ratio analysis. Among 90,318 rTSA cases performed by 7,097 surgeons, we found a mean annual rTSA surgeon volume of 6 ± 10 and a mean rTSA + TSA volume of 9 ± 14. Regression models using surgeon-specific rTSA volume revealed that surgery from low (<29 cases) compared with medium (29 to 96 cases) rTSA-volume surgeons was associated with a significantly higher 90-day all-cause readmission (odds ratio [OR], 1.17; confidence interval [CI], 1.10 to 1.25; P < 0.0001), higher 90-day readmission rates because of an infection (OR, 1.46; CI, 1.16 to 1.83; P = 0.0013) or dislocation (OR, 1.43; CI, 1.19 to 1.72; P = 0.0001), increased 90-day postoperative cost (+11.3% CI, 4.2% to 19.0%; P = 0.0016), and a higher transfusion rate (OR, 2.06; CI, 1.70 to 2.50; P < 0.0001). Similar patterns existed when using categorizations based on rTSA + TSA case volume. Surgeon-specific volume-outcome relationships exist in this rTSA cohort, and we were able to identify thresholds that may identify low and medium/high volume surgeons. Observed volume-outcome relationships were independent of the definition of surgeon volume applied: either by focusing on the number of rTSAs performed per surgeon or anatomic TSAs performed. III.

Increasing Hip Arthroscopy Case Volume Is Associated With Increased Risk for Revision Surgery but Not Conversion to Total Hip Arthroplasty or 90-Day Hospitalizations: A Cross-Sectional Analysis of 468 Surgeons

To analyze the effects of surgeon-specific factors, including case volume, career duration, fellowship training, practice type, and region of practice, on rates of 2-year revision surgery, conversion to total hip arthroplasty (THA), and 90-day hospitalizations following hip arthroscopy. The PearlDiver Mariner Database was used to query patients undergoing hip arthroscopy between 2015 and 2018. Surgeons performing these procedures were identified, and surgeon-specific demographics and variables were collected from publicly available data. Patients were followed for 2 years to assess for reoperations, including revision hip arthroscopy and conversion to THA, as well as 90-day hospitalizations, including emergency department visits and hospital readmissions. International Classification of Diseases, Tenth Revision codes were used to track the laterality of revision hip procedures. Associations between surgeon-specific factors and postoperative outcomes were assessed through univariate and multivariate analyses. In total, 20,834 patients underwent hip arthroscopy procedures by 468 surgeons. Multivariate analysis with logistic regression adjusted for patient-related factors (age, sex, obesity, Charlson Comorbidity Index, and smoking status) identified increasing surgeon case volume to be associated with increased risk for 2-year revision hip arthroscopy (P < .001), but not 2-year conversion to THA or 90-day hospitalizations. Nonsports medicine fellowship-trained surgeons were associated with greater risk for 2-year THA conversion (P < .001) and 90-day hospital readmissions (P < .01). Surgeons practicing in an academic setting demonstrated greater risk for 90-day hospital readmissions (P < .001). Surgeons practicing in the West region of the United States were more likely to incur 2-year revision hip arthroscopy procedures compared to surgeons in the South, Midwest or Northeast (P < .001). Increasing surgeon hip arthroscopy case volume is associated with an increased risk for 2-year revision hip arthroscopy but not conversion to THA or 90-day hospitalizations. Further, non-sports medicine fellowship-trained surgeons were associated with higher risk for 2-year THA conversion after hip arthroscopy. Level III, retrospective cohort analysis.

The impact of surgeon volume on subscapularis repair and postoperative management following reverse shoulder arthroplasty

BackgroundReverse shoulder arthroplasty (RSA) recognition and acceptance is growing as patients report improved pain and function. Therefore, it is crucial to identify and modify factors that affect outcomes, some of the current aspects under discussion are subscapularis (SSc) management and postoperative rehabilitation (rehab) protocols. Our study seeks to evaluate the practices of American Shoulder and Elbow Surgeons members in managing the SSc during surgery and determining the best approach for postoperative rehab after RSA. MethodsAn eight-question survey was distributed to 1217 members of the American Shoulder and Elbow Surgeons, inquiring about SSc management and rehab practices following RSA. The survey included multiple-choice questions that evaluated characteristics of surgeon’s approach to rehab and perspectives of formal supervised outpatient therapy programs. The cohort was divided based on yearly RSA case volume and whether SSc is routinely repaired during RSA. ResultsMore than one third of surgeons (35.3%) reported ordering formal rehab due to patient expectations, but did not believe it was critical, and only 8.9% believed formal rehab to be critical in the recovery of patient strength. Almost two thirds (60.7%) of surgeons did not place a limitation on internal rotation. Of the 72.3% of surgeons that repaired the SSc, 49.7% restrict external rotation. When separating the cohort based on surgical volume, surgeons who performed more than 100 cases were significantly more likely to immobilize patients for more than 4 weeks postoperatively (P = .041). Surgeons who repaired the SSc were significantly more likely to immobilize patients for more than 4 weeks compared to surgeons who did not repair SSc (P < .001). ConclusionManagement of the SSc and surgeon case volume are critical factors in postoperative rehab after RSA. The majority of surgeons tend to repair the SSc, while only half of those that repair it immobilize it after surgery. Further studies that better evaluate the impact of postoperative immobilization on patient reported outcomes and satisfaction scores are needed in order to develop a more standardized approach and definitive guidelines.

Variations in Duration of Clinical Follow-up After Spinal Fusion for Adolescent Idiopathic Scoliosis: A Survey of POSNA and SRS Membership

Background: There are currently no evidence-based guidelines addressing the optimal duration of follow-up after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Despite the safety and efficacy of PSF for AIS, long-term complications exist, including infection, pseudoarthrosis, adjacent segment disease, deformity progression, persistent pain, and junctional deformities. In this study, we describe practice variation existing among surgeons regarding duration and intervals of patient follow-up after surgical treatment of AIS in addition to factors influencing provider recommendations for duration of radiographic and clinical follow-up. This investigation of practice variation is important, as opportunities exist for both limiting unnecessary radiation exposure, while also identifying opportunities for timely intervention to help decrease the morbidity of late complications arising after spinal fusion.Methods: An anonymous online survey was created and subsequently distributed to members of POSNA and SRS to assess practice demographics and surgeon opinions surrounding duration of surveillance following surgery for AIS. Only surgeons who treated at least five operative AIS cases within the past year were included. Descriptive statistics and comparative sub-analyses are presented.Results: Forty-nine participants met inclusion criteria. Respondents were mainly pediatric orthopaedic surgeons (92%) in practice for 21-50 years (49%) who performed approximately 21-50 operative AIS cases per year (49%). Forty-eight percent of providers had an age limit in their practice, and 52% regularly followed operative AIS patients over 18 years of age. Sixty-two percent of surgeons followed operative AIS patients for 2-5 years postoperatively, whereas only 4% followed for more than 10 years. The most cited factors impacting follow-up recommendations were junctional deformities, adjacent segment disease, and symptomatic implants. There were no significant associations between years in practice, operative volume, and recommendations for duration of follow-up after routine operative AIS cases.Conclusions: Significant variability in duration of follow-up after PSF for AIS exists. Although most patients are clinically followed for 2 years after surgery, only a small percentage of providers follow AIS patients for more than 10 years postoperatively. Numerous AIS revisions occur more than 5 years after the index surgery. Further investigations to determine the optimal duration of surveillance following PSF for AIS should be conducted.Level of Evidence: V Key Concepts•Late complications following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) may occur 5-10 years after the index surgery and currently, there are no guidelines that outline the optimal duration of postoperative follow-up.•Significant variability exists in pediatric orthopaedic provider recommendations for long-term follow-up after PSF for AIS and is not associated with surgeon experience or case volume.•Most providers follow operative AIS patients for 1-2 years postoperatively, and only a small minority follow operative AIS patients for more than 10 years after the index surgery.•Persistent back pain, junctional deformity, and symptomatic implants are the most common factors affecting provider recommendations for duration of follow-up.•These survey findings may be useful for pediatric orthopaedic providers to operatively manage AIS patients in determining the need and frequency for routine radiographic and/or clinical follow-up.

Practice Patterns in the Management of Chronic Limb Threatening Ischemia by BEST-CLI Investigators

BEST-CLI trial investigators had diverse practice patterns in treating complex chronic limb-threatening ischemia (CLTI). We assessed investigator practices and comfort towards complex open surgical and endovascular procedures. An electronic survey was sent out to 1180 BEST-CLI investigators at 150 sites in 2022, after trial conclusion and before announcement of results. The survey consisted of 43 questions focused on practice patterns. There were 238 investigators (20.2%) that submitted responses. Respondents were 80% male, 68.2% White, and 15.3% from outside the United States. Respondents included vascular surgeons (76.3%), interventional cardiologists (11.4%), and interventional radiologists (11.6%). The majority (72.6%) were in academic practice, with 39.1% in practice >20 years and 30.5% in practice 11 to 20 years. For initial CLTI workup, respondents always/usually ordered an arterial duplex (65.8%), computed tomography angiography (42.6%), magnetic resonance angiography (4.5%), and vein mapping (55.9%). Surgeon case volumes in a typical year, recorded as 0, 1 to 10, and >10, for alternative autogenous vein were 12.6%, 69.5%, and 17.8%; composite vein 17.2%, 79.9%, and 2.9%; prosthetic conduit 4%, 84.6%, and 11.4%; composite sequential bypass 58.8%, 38.2%, and 2.9%; bypass to pedal targets 8%, 81.7%, and 10.3%; and hybrid procedures 2.3%, 56.7%, and 41%. Postoperatively, 99% and 81.9% reported performing routine duplex surveillance of vein and prosthetic bypass, respectively. Among all interventionalists, yearly endovascular interventions were 0, 1 to 10, and >10, utilized radial access 54.5%, 37.6%, and 8%; pedal/tibial access 24%, 61%, and 24%; pedal loop revascularization 62.3%, 29.7%; 8%. The majority (86%) ordered routine duplex surveillance following endovascular revascularization. Most respondents reported routinely using paclitaxel balloons (88.1%) and stents (67.5%). There were 73.3% that altered practice when safety concerns were raised, whereas 63.9% resumed use of these devices. A minority reported always/usually using WIfI (25.8%), GLASS (8.3%), and a risk calculator (14.8%) in their clinical practice. There is a wide range of practice patterns among vascular specialists treating CLTI. The majority of investigators in BEST-CLI had experience in both advanced open and endovascular techniques and represent a real-world sample of technical expertise.

Medicaid Patients Undergo Total Joint Arthroplasty at Lower-Volume Hospitals by Lower-Volume Surgeons and Have Poorer Outcomes.

Medicaid insurance coverage among patients undergoing total hip arthroplasty (THA) or those undergoing total knee arthroplasty (TKA) has been associated with worse postoperative outcomes compared with patients without Medicaid. Surgeons and hospitals with lower annual total joint arthroplasty (TJA) volume have also been associated with worse outcomes. This study sought to characterize the associations between Medicaid insurance status, surgeon case volume, and hospital case volume and to assess the rates of postoperative complications compared with other payer types. The Premier Healthcare Database was queried for all adult patients who underwent primary TJA from 2016 to 2019. Patients were divided on the basis of their insurance status: Medicaid compared with non-Medicaid. The distribution of annual hospital and surgeon case volume was assessed for each cohort. Multivariable analyses were performed accounting for patient demographic characteristics, comorbidities, surgeon volume, and hospital volume to assess the 90-day risk of postoperative complications by insurance status. Overall, 986,230 patients who underwent TJA were identified. Of these, 44,370 (4.5%) had Medicaid. Of the patients undergoing TJA, 46.4% of those with Medicaid were treated by surgeons performing ≤100 TJA cases annually compared with 34.3% of those without Medicaid. Furthermore, a higher percentage of patients with Medicaid underwent TJA at lower-volume hospitals performing ≤500 cases annually, 50.8% compared with 35.5% for patients without Medicaid. After accounting for differences among the 2 cohorts, patients with Medicaid remained at increased risk for postoperative deep vein thrombosis (adjusted odds ratio [OR], 1.16; p = 0.031), pulmonary embolism (adjusted OR, 1.39; p < 0.001), periprosthetic joint infection (adjusted OR, 1.35; p < 0.001), and 90-day readmission (adjusted OR, 1.25; p < 0.001). Patients with Medicaid were more likely to undergo TJA performed by lower-volume surgeons at lower-volume hospitals and had higher rates of postoperative complications compared with patients without Medicaid. Future research should assess socioeconomic status, insurance, and postoperative outcomes in this vulnerable patient population seeking arthroplasty care. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Provision of revision knee arthroplasty services across Scotland: A national audit

BackgroundThere is increasing evidence that both low surgeon and centre case volumes are associated with poorer outcomes following Revision Knee Arthroplasty (rTKA). Given the unique challenges faced in Scotland relating to funding and geography, understanding details on the complexity of cases is required to guide development of future rTKA services. MethodsUtilising the Scottish Collaborative Orthopaedic Trainee Research Network (SCOTnet) a retrospective review of all Scottish 2019 rTKA cases was undertaken. Regional leads co-ordinated local data collection using individual case note review. The number of cases performed by regions, hospitals and individual surgeons were identified. Patient demographics and case complexity (Revision Knee Complexity Classification [RKCC]) were also collected. Results were compared against current standards. Results17 units performed rTKA, delivered by 77 surgeons. A total of 506 cases were included. The mean age was 69 years (46% male). Revision for infection accounted for 147/506 (29%) cases. Extensor compromise was present in 35/506 (7%) and 11/506 (2%) required soft tissue reconstruction. According to the RKCC − 214/503 (43%) were classified as R1 (Less complex cases), 228/503 (45%) R2 (complex cases), and 61/503 (12%) R3 (most complex / salvage cases).5/17 (29%) units met current national guidelines for case volume/year, with only 11/77 (14%) surgeons meeting recommended individual case volumes. 37/77 (48%) surgeons performed ≤ 2 cases per year. ConclusionsMost individual centre volumes could be increased by re-organising services or locations providing rTKA within a region. This should provide better access to Multidisciplinary Team (MDT) involvement. We recorded a significant number of very low volume surgeons (≤2 year) that is contradictory to current evidence-based practice.

The Effect of Surgeon and Hospital Volume on Morbidity and Mortality After Femoral Shaft Fractures.

The aim of this study was to characterize the case volume dependence of both facilities and surgeons on morbidity and mortality after femoral shaft fracture (FSF) fixation. Adults who had an open or closed FSF between 2011 and 2015 were identified in the New York Statewide Planning and Research Cooperative System database. Claims were identified by International Classification of Disease-9, Clinical Modification diagnostic codes for a closed or open FSF and International Classification of Disease-9, Clinical Modification procedure codes for FSF fixation. Readmission, in-hospital mortality, and other adverse events were compared across surgeon and facility volumes using multivariable Cox proportional hazards regression, controlling for patient demographic and clinical factors. Surgeon and facility volumes were compared between the lowest and highest 20% to represent low-volume and high-volume surgeons/facilities. Of 4,613 FSF patients identified, 2,824 patients were treated at a high or low-volume facility or by a high or low-volume surgeon. Most of the examined complications including readmission and in-hospital mortality showed no statistically significant differences. Low-volume facilities had a higher 1-month rate of pneumonia. Low-volume surgeons had a lower 3-month rate of pulmonary embolism. There is minimal difference in outcomes in relation to facility or surgeon case volume for FSF fixation. As a staple of orthopaedic trauma care, FSF fixation is a procedure that may not require specialized orthopaedic traumatologists at high-volume facilities.

One-year patient-reported outcomes following primary arthroscopic rotator cuff repair vary little by surgeon

This study's purpose was to investigate the extent to which differences among operating surgeons may influence 1-year patient-reported outcome measures (PROMs) in patients undergoing rotator cuff repair (RCR) surgery, after controlling for general and disease-specific patient factors. We hypothesized that surgeon would be additionally associated with 1-year PROMs, specifically the baseline to 1-year improvement in Penn Shoulder Score (PSS). We used mixed multivariable statistical modeling to assess the influence of surgeon (and alternatively surgical case volume) on 1-year PSS improvement in patients undergoing RCR at a single health system in 2018, controlling for eight patient- and six disease-specific preoperative factors as possible confounders. Contributions of predictors to explaining variation in 1-year PSS improvement were measured and compared using Akaike's Information Criterion. 518 cases performed by 28 surgeons met inclusion criteria, with median (quartiles) baseline PSS of 41.9 (31.9, 53.9) and 1-year PSS improvement of 42 (29.1, 55.3) points. Contrary to expectation, surgeon and surgical case volume were neither statistically significantly nor clinically meaningfully associated with 1-year PSS improvement. Baseline PSS and mental health status (VR-12 MCS) were the dominant and only statistically significant predictors of 1-year PSS improvement, with lower baseline PSS and higher VR-12 MCS predicting larger 1-year PSS improvement. Patients generally reported excellent 1-year outcomes following primary RCR. This study did not find evidence that the individual surgeon or surgeon case volume influences 1-year PROMs, independently of case-mix factors, following primary RCR in a large employed hospital system.

Hospital and surgeon experience and patient health outcomes after coronary artery bypass graft surgery

AbstractThe Hospital Readmissions Reduction Program imposes financial penalties on hospitals with excess readmission rates for various conditions, including coronary artery bypass graft (CABG) surgery. While prior research has focused mainly on hospital‐specific factors and their impact on patient mortality, surgeon risk factors and patient outcomes, such as readmission risk, have received less attention. We study three drivers of CABG readmission risk—hospital and surgeon case volume, variation in surgeon volume, and surgeon familiarity with hospitals. Drawing on unique patient data sets of CABG surgeries spanning 3 years, we study the relationships between hospital and surgeon case volume, readmission risk, and postoperative length of stay (PLOS). We find evidence of an inverted U‐shaped relationship between case volume and readmission risk and a U‐shaped relationship with PLOS. Our results also indicate that surgeon volume variation moderates the relationship between surgeon volume and readmission risk, where readmission risk increases with greater variation in surgeon volume. We observe that the impact of surgeon experience on readmission risk at the focal hospital outweighs their experience at other hospitals. Our study has significant implications for hospital resource management as it highlights the role of surgeon and hospital experience in improving patient outcomes after CABG surgery.

The implications of surgeon case volume and hospital volume on outcomes of aortobifemoral bypasses in obese patients

BackgroundAortobifemoral (ABF) bypass is the gold standard for treating symptomatic aortoiliac occlusive disease. In the era of heightened interest in the length of stay (LOS) for surgical patients, this study aims to investigate the association of obesity with postoperative outcomes at the patient, hospital, and at surgeon levels. MethodsThis study used the Society of Vascular Surgery Vascular Quality Initiative suprainguinal bypass database from 2003 to 2021. The selected study cohort was divided into obese patients (body mass index ≥30) (group I) and nonobese patients (body mass index <30) (group II). Primary outcomes of the study included mortality, operative time, and postoperative LOS. Univariate and multivariate logistic regression analyses were performed to study the outcomes of ABF bypass in group I. Operative time and postoperative LOS were transformed into binary values by median split for regression analysis. A P value of .05 or less was deemed statistically significant in all the analyses of this study. ResultsThe study cohort consisted of 5392 patients. In this population, 1093 were obese (group I) and 4299 were nonobese (group II). Group I was found to have more females with higher rates of comorbid conditions, including hypertension, diabetes mellitus, and congestive heart failure. Patients in group I had increased odds of prolonged operative time (≥250 minutes) and an increased LOS (≥6 days). Patients in this group also had a higher chance of intraoperative blood loss, prolonged intubation, and required vasopressors postoperatively. There was also an increased odds of postoperative decline in renal function in the obese population. Patients with prior history of coronary artery disease, hypertension, diabetes mellitus, and urgent or emergent procedures were found to be risk factors for a LOS of more than 6 days in obese patients. An increase in the surgeons' case volume was associated with lesser odds of an operative time of 250 minutes or more; however, no significant impact was found on postoperative LOS. Hospitals where 25% or more of ABF bypasses were performed on obese patients were also more likely to have LOS of less than 6 days after ABF operations, compared with hospitals where less than 25% of ABF bypasses were performed on obese patients. Patients undergoing ABF for chronic limb-threatening ischemia or acute limb ischemia had a longer LOS and increased operative times. ConclusionsABF bypass in obese patients is associated with prolonged operative times and a longer LOS than in nonobese patients. Obese patients operated by surgeons with more cases of ABF bypasses have shorter operative times. A hospital's increasing proportion of obese patients was related to a decreased LOS. These findings support the known volume-outcome relationship that, with a higher surgeon case volume and increased proportion of obese patients in a hospital, there is an improvement in outcomes of obese patients undergoing ABF bypass.

Effect of annualized surgeon volume on major surgical complications for abdominal and laparoscopic radical hysterectomy for cervical cancer in China, 2004–2016: a retrospective cohort study

BackgroundPrevious studies have suggested that higher surgeon volume leads to improved perioperative outcomes for oncologic surgery; however, the effect of surgeon volumes on surgical outcomes might differ according to the surgical approach used. This paper attempts to evaluate the effect of surgeon volume on complications or cervical cancer in an abdominal radical hysterectomy (ARH) cohort and laparoscopic radical hysterectomy (LRH) cohort.MethodsWe conducted a population-based retrospective study using the Major Surgical Complications of Cervical Cancer in China (MSCCCC) database to analyse patients who underwent radical hysterectomy (RH) from 2004 to 2016 at 42 hospitals. We estimated the annualized surgeon volumes in the ARH cohort and in the LRH cohort separately. The effect of the surgeon volume of ARH or LRH on surgical complications was examined using multivariable logistic regression models.ResultsIn total, 22,684 patients who underwent RH for cervical cancer were identified. In the abdominal surgery cohort, the mean surgeon case volume increased from 2004 to 2013 (3.5 to 8.7 cases) and then decreased from 2013 to 2016 (8.7 to 4.9 cases). The mean surgeon case volume number of surgeons performing LRH increased from 1 to 12.1 cases between 2004 and 2016 (P < 0.01). In the abdominal surgery cohort, patients treated by intermediate-volume surgeons were more likely to experience postoperative complications (OR = 1.55, 95% CI = 1.11–2.15) than those treated by high-volume surgeons. In the laparoscopic surgery cohort, surgeon volume did not appear to influence the incidence of intraoperative or postoperative complications (P = 0.46; P = 0.13).ConclusionsThe performance of ARH by intermediate-volume surgeons is associated with an increased risk of postoperative complications. However, surgeon volume may have no effect on intraoperative or postoperative complications after LRH.

HIGHER RISK OF MEDIAL MENISCAL REPAIR FAILURE FOLLOWING CONCURRENT ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH A HAMSTRING TENDON AUTOGRAFT

Meniscal repairs are commonly performed during anterior cruciate ligament (ACL) reconstruction. This study aimed to identify the risk factors for meniscal repair failure following concurrent primary ACL reconstruction.Primary ACL reconstructions with a concurrent repair of a meniscal tear recorded in the New Zealand ACL Registry between April 2014 and December 2018 were analyzed. Meniscal repair failure was defined as a patient who underwent subsequent meniscectomy, and was identified after cross-referencing data from the ACL Registry with the national database of the Accident Compensation Corporation (ACC). Multivariate Cox regression was performed to produce hazard ratios (HR) with 95% confidence intervals (CI) to identify the patient and surgical risk factors for meniscal repair failure.2041 meniscal repairs were analyzed (medial = 1235 and lateral = 806). The overall failure rate was 9.4% (n = 192). Failure occurred in 11.1% of medial (137/1235) and 6.8% of lateral (55/806) meniscal repairs. The risk of medial failure was higher with hamstring tendon autografts (adjusted HR = 2.00, 95% CI 1.23 – 3.26, p = 0.006) and in patients with cartilage injury in the medial compartment (adjusted HR = 1.56, 95% CI 1.09 – 2.23, p = 0.015). The risk of lateral failure was higher when the procedure was performed by a surgeon with an annual case volume of less than 30 ACL reconstructions (adjusted HR = 1.92, 95% CI 1.10 – 3.33, p = 0.021). Age, gender, time from injury-to-surgery and femoral tunnel drilling technique did not influence the risk of meniscal repair failure.When repairing a meniscal tear during ACL reconstruction, the use of a hamstring tendon autograft or the presence of cartilage injury in the medial compartment increases the risk of medial meniscal repair failure. Lower surgeon case volume increases the risk of lateral meniscal repair failure.

Report of the 2022 Society of Thoracic Surgeons Congenital Heart Surgery Practice Survey

BackgroundThe Society of Thoracic Surgeons Workforce on Congenital Surgery performed a practice survey to analyze contemporary data. MethodsAn electronic survey was sent to congenital heart surgeons in North America. Details on demographics, training paradigm, clinical practice, and work satisfaction were queried, tabulated, and analyzed. ResultsOf 312 unique contacts, 201 (64.4%) responded. Of these, 178 (89%) were practicing. The median age was 52 years (interquartile range, 43, 59 years), and 157 (88%) were male. The number of female respondents increased from 12 (7%) in 2015 to 18 (11%) at present. Practice composition was predominantly mixed pediatric and adult (141; 79%), although 15 (8%) surgeons practiced exclusively pediatric surgery. Most surgeons (154; 87%) reported performing the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 and 5 procedures. One-fourth (42; 24%) reported performing fewer than 50 pediatric cases per year, and 18 (10%) stated that their primary role was as a surgical assistant. Individual surgeon case volume was most commonly 100 to 149 total cases (29%). Although one-half (91; 51%) reported their volume as being “just right,” 74 (42%) reported that their case volume was “too small.” Seventy-six (43%) reported too many surgeons in their region. Of the 201 practicing surgeons, 30 (14.9%) plan retirement in the next 5 years. Most described career satisfaction, with 102 (57%) being very satisfied and 48 (27%) somewhat satisfied. ConclusionsAlthough most congenital heart surgeons in North America are satisfied with their careers, more than 40% believe that their caseload is inadequate and that there are too many surgeons in their region. Further analysis is warranted regarding career dissatisfaction and diversity.