Tuesday, November 11, 2014

Total shoulder arthroplasty - why have it done at a high volume hospital?

Hospital Volume Predicts Outcomes and Complications after Total Shoulder Arthroplasty in the United States.

The authors used the U.S. Nationwide Inpatient Sample from 1998-2011 to study the association of hospital annual total shoulder arthroplasty (TSA) procedure volume with patient characteristics and TSA outcomes, including discharge disposition (home vs. inpatient facility), length of index hospitalization, post-arthroplasty periprosthetic fracture and revision surgery.

Compared to lower volume hospitals, patients receiving TSA at higher volume hospitals had significantly lower likelihood of costly outcomes, such as (1) being discharged to an inpatient medical facility rather than home,  (2) longer hospital stay; (3) post-arthroplasty fracture; (4) blood transfusion; and (5) TSA revision. 

There were some notable differences in patient demographics, with patients having TSAs at higher volume hospitals were more likely to be male, to have race other than black, to have lower co-morbidity scores, to have private insurance, and to have diagnoses other than fracture. Low volume hospitals were frequently in rural areas.

Interestingly,  patients with higher complexity (i.e. higher Deyo-Charlson index) were more likely to be operated upon in hospitals with higher TSA volume. Thus, TSA procedures at high volume hospitals were associated with better outcomes despite a higher patient complexity. While lower volume hospitals differed in hospital characteristics (location, teaching status) and patient profile (age, gender, race, underlying diagnosis) and patient’s insurance status in this study, the multivariable-adjusted analyses accounted for these differences and the associations with outcomes noted were independent of these factors.

Comment: Avoiding adverse outcomes is desirable from the standpoint of the patient, the surgeon, the hospital and the insurance company. Hospitals with larger case volumes have the opportunity to optimize their approach to the surgical and postoperative care of patient having TSA. What is interesting is that the effect of volume appeared to continue with increasing hospital case volume (See chart below that we made from their data). We wonder what these metrics would look like for hospitals that do 200 or more total shoulders / year.


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