These authors hypothesized that hospitals that perform a higher volume of reverse total shoulders (RSAs) would have improved outcomes. They also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA.
They queried the Nationwide Readmissions Database for patients who had undergone elective RSA from 2011 to 2015.
Annual hospital volume and 90-day outcome data were collected, including readmission, revision, complications, hospital length of stay (LOS), supramedian cost, and discharge disposition.
SSLR analysis was performed to determine hospital volume cutoffs associated with increased risks for adverse events.
Higher-volume centers had improved outcomes.
Higher-volume centers had improved outcomes.
The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year.
Cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year.
Analysis of 90-day readmission produced 3 hospital volume categories (1 to 16, 17 to 69, and >70 RSAs/year), each significantly different from each other.
The strata for 90-day revision were similar (1 to 16, 17 to 53, and >54 RSAs/year)
The strata for 90-day complications were also similar (1 to 9, 10 to 68, and ‡69 RSAs/year).
They found 6 hospital volume categories for cost of care over the median value (1 to 5, 6 to 25, 26 to 47, 48 to 71, 72 to 105, and >106 RSAs/year), and 5 categories for an extended length of stay (1 to 10, 11 to 25, 26 to 59, 60 to 105, and ‡106 RSAs/year), and 4 categories for non-home discharge (1 to 31, 32 to 71, 72 to 105, and >106 RSAs/year).
They suggest that these volume effects are likely to be related to surgical experience, ancillary staff familiarity, and protocolized pathways.
Comment: We were impressed by the rather high rate of adverse outcomes for all volume categories
These adverse outcome rates from a national data base - reflecting the outcomes from all surgeons - are quite a bit higher than those reported in case series of reverse total shoulders from individual centers. For example, even in the highest volume centers, the 90 day complication rate was almost 12% and almost 8% of patients were readmitted. While increased hospital volume is associated with better outcomes, we clearly have other work to do in making this procedure safer for our patients.
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