Surgeons doing more than 10 shoulder replacement operations on average a year achieve better results
Patients treated by surgeons who perform more than 10 shoulder replacements in an average year are less likely to need a further operation or experience serious complications. They also have shorter stays in hospital when compared to their counterparts who were treated by surgeons with fewer operations under their belts, according to a study published in today’s edition of The BMJ (22 June).
The research was funded by the National Institute for Health and Care Research (NIHR) and the NIHR Oxford Biomedical Research Centre. The lead author is Epaminondas Markos Valsamis, who is based at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, at the Botnar Research Centre, University of Oxford,
The findings build on similar evidence for hip and knee replacements and should help to guide future resource planning in this area, say the researchers.
Shoulder replacement operations more common
Once a rarity, shoulder replacements are becoming increasingly common, particularly in high income countries with ageing populations. In the UK, for example, more than 8,000 shoulder replacements are carried out a year.
Earlier studies of hip and knee replacement surgery showed that patients treated by ‘high volume’ surgeons experience better outcomes than patients of lower volume surgeons. This prompted some providers to introduce minimum volume thresholds for surgeons to improve patient outcomes, but evidence for other types of joint replacement surgery is more limited.
To fill this knowledge gap, Dr Valsamis and his colleagues explored the association between surgeon volume and outcomes after non-urgent (elective) shoulder replacement surgery. Their findings were based on data from the National Joint Registry and Hospital Episode Statistics in England for 39,281 elective shoulder replacements performed by 638 consultant surgeons at 416 public and private sector hospitals from 2012-2020.
This study offers evidence for local hospitals and national healthcare services that informs workforce and resource planning to ensure the best outcomes for patients undergoing shoulder replacement surgery [Epaminondas Markos Valsamis et al]
Statistical models were used to investigate the effect of annual surgeon volume on revision, reoperation within 12 months, serious adverse events at 30 and 90 days, and prolonged hospital stays (more than three nights). All participants were aged 18 or above and were receiving shoulder replacement surgery for the first time.
Significant results
After adjusting for a range of potentially influential factors, the researchers identified a mean annual volume threshold of 10.4 procedures, below which there was a significantly increased risk of revision surgery.
For example, patients treated by surgeons who performed at least 10.4 procedures a year showed a 4 per cent lower risk of revision surgery than those treated by surgeons who performed fewer than this.
Patients treated by higher volume surgeons also showed a 53 per cent lower risk of reoperation, a reduction in serious adverse events (40 per cent at 30 days and 37 per cent at 90 days), and a 62 per cent reduction in the risk of a prolonged hospital stay, although no minimum case volume threshold was identified for these outcomes.
Annual variations in case volume did not affect patient outcomes, suggesting that a surgeon’s average annual volume of procedures over the course of their career is more important for better patient outcomes than variation in annual procedure volumes.
Some caveats
As their findings are observational in nature, Dr Valsamis and his colleagues say their models may have simplified real-life practice and that other unmeasured factors could possibly have affected their results.
But they say the data used represent all the main types of shoulder replacement procedures, patients of different age, ethnicity, and socioeconomic groups, providing a complete picture of shoulder replacement activity across a national healthcare system.
‘Improving outcomes and reducing complications after joint replacement surgery is of clear benefit to patients and their families,’ they write, but also note that the results ‘provide timely evidence for healthcare systems that are overburdened, under-resourced, and in need of recovery planning post pandemic’.
They conclude: ‘This study offers evidence for local hospitals and national healthcare services that informs workforce and resource planning to ensure the best outcomes for patients undergoing shoulder replacement surgery.’
Data need 'careful interpretation'
In a linked editorial, Marta Karbowia from Portsmouth Hospitals NHS Trust and a colleague say the study is a useful addition to the knowledge base but suggest that the association between surgeons and patient outcomes can be hard to evaluate scientifically.
They point out that registry data do not reliably capture patient reported outcomes – such as quality of life or functional and wellbeing measures – and often report only revision rates or major adverse outcomes. 'Registry data need to be interpreted carefully at surgeon, hospital, and national level, as currently available outcome measures may not tell the whole story.'
To read then full version of the research article – titled Association between surgeon volume and patient outcomes after elective shoulder replacement surgery: population based cohort study doi: 10.1136/bmj-2023-075355 – click
To read the editorial – titled Surgeon volume and patient outcomes in shoulder replacement surgery doi: 10.1136/bmj.p1334 – click
Author: Ian A McMillan
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