The recent article The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty and the post, The complex relationship between surgeon shoulder arthroplasty volume and outcome, have stimulated much needed thought and discussion. From this article we learned that

(1) Low-volume facilities and surgeons had higher rates of readmission, urinary tract infection, renal failure, pneumonia, and cellulitis than high volume facilities. The patients of low-volume surgeons had longer hospital lengths of stay.

and that

(2) Older, Hispanic/African American, socially deprived, non-privately insured patients were more likely to be treated by low volume facilities and surgeons.

These observations suggest that, for multiple reasons, patients treated at low volume centers and by low volume surgeons are more likely to have adverse outcomes. Furthermore, low volume centers and low volume surgeons are disadvantaged by a more complex patient population with less favorable reimbursement.

"Fixing" these disparities is a daunting task.

Some of the important aspects to consider are listed below

(1) High volume centers and providers have many advantages, including streamlined pathways, dedicated and experienced staff, economies of scale, marketing, favorable implant price negotiations, experience-based patient selection criteria, support systems enabling efficient and safe outpatient surgery, active research programs focused on optimizing patient outcomes and a larger share of individuals with the means and motivation to travel in the anticipation of improved outcome. These assets also lead to cost-savings associated with shorter hospital stays.

(2) It is likely that many patients would experience increased cost and inconvenience in moving from their local providers to seek care at higher volume providers.

(3) There may be barriers that impair access for more complex and less well insured patients to achieving care at higher volume facilities. This and item #2 above may contribute to disparities in health care for certain socioeconomic, ethnic and racial groups of patients. As pointed out by the authors of The Effects of Social and Demographic Factors on High-Volume Hospital and Surgeon Care in Shoulder Arthroplasty "Patients without private insurance received treatment more often at low-volume facilities and from low-volume surgeons, which is another concerning finding considering that surgeon reimbursement for Medicare payments after shoulder arthroplasty has decreased substantially over the past decade. It is also important to acknowledge the possible influence of the geographic location of hospitals alongside any financial incentives for high-volume providers to attract patients with insurances which offer higher reimbursement rates, most of whom may be White"

(4) "Volume shifting" has been suggested as an approach, however the mechanisms for accomplishing this are unclear. Furthermore, moving patients from low volume surgeons to high volume surgeons impairs the ability of low volume surgeons (particularly those recently starting out in practice) to increase their volume. Loss of these surgical cases would also have a negative effect on the finances of the low volume surgeons.

(5) There is a need to investigate means by which the strategies and benefits of high volume can be shared with and implemented by lower volume centers and surgeons. For example, the increased risk of complications such as pneumonia, electrolyte imbalance, urinary tract infection and acute renal failure found in low volume centers may be addressed by educational programs for both the providers and the patients.

(6) In that these issues are not unique to shoulder arthroplasty, our national organizations, such as the American Academy of Orthopaedic Surgeons, need to emphasize these important issues in their ongoing national meetings and educational programs.

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