Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA.
Cooper Bone and Joint Institute, Camden, NJ, USA.
Clin Orthop Relat Res. 2023 Aug 1;481(8):1572-1580. doi: 10.1097/CORR.0000000000002605. Epub 2023 Feb 28.
Studies assessing the relationship between surgeon volume and outcomes have shown mixed results, depending on the specific procedure analyzed. This volume relationship has not been well studied in patients undergoing total shoulder arthroplasty (TSA), but it should be, because this procedure is common, expensive, and potentially morbid.
QUESTIONS/PURPOSES: We performed this study to assess the association between increasing surgeon volume and decreasing rate of revision at 2 years for (1) anatomic TSA (aTSA) and (2) reverse TSA (rTSA) in the United States.
In this retrospective study, we used Centers for Medicare and Medicaid Services (CMS) fee-for-service inpatient and outpatient data from 2015 to 2021 to study the association between annual surgeon aTSA and rTSA volume and 2-year revision shoulder procedures after the initial surgery. The CMS database was chosen for this study because it is a national sample and can be used to follow patients over time. We included patients with Diagnosis-related Group code 483 and Current Procedural Terminology code 23472 for TSA (these codes include both aTSA and rTSA). We used International Classification of Diseases, Tenth Revision, procedural codes. Patients who underwent shoulder arthroplasty for fracture (10% [17,524 of 173,242]) were excluded. We studied the variables associated with the subsequent procedure rate through a generalized linear model, controlling for confounders such as patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, hospital size and teaching status, assuming a binomial distribution with the dependent variable being whether an episode had at least one subsequent procedure within 2 years. The regression was fitted with standard errors clustered at the hospital level, combining all TSAs and within the aTSA and rTSA groups, respectively. Hospital and surgeon yearly volumes were calculated by including all TSAs, primary procedure and subsequent, during the study period. Other hospital-level and surgeon-level characteristics were obtained through public files from the CMS. The CMS Hierarchical Condition Category risk score was controlled because it is a measure reflecting the expected future health costs for each patient based on the patient's demographics and chronic illnesses. We then converted regression coefficients to the percentage change in the odds of having a subsequent procedure.
After controlling for confounding variables including patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, and hospital size and teaching status, we found that an annual surgeon volume of ≥ 10 aTSAs was associated with a 27% decreased odds of revision within 2 years (95% confidence interval 13% to 39%; p < 0.001), while surgeon volume of ≥ 29 aTSAs was associated with a 33% decreased odds of revision within 2 years (95% CI 18% to 45%; p < 0.001) compared with a volume of fewer than four aTSAs per year. Annual surgeon volume of ≥ 29 rTSAs was associated with a 26% decreased odds of revision within 2 years (95% CI 9% to 39%; p < 0.001).
Surgeons should consider modalities such as virtual planning software, templating, or enhanced surgeon training to aid lower-volume surgeons who perform aTSA and rTSA. More research is needed to assess the value of these modalities and their relationship with the rates of subsequent revision.
Level III, therapeutic study.
评估外科医生手术量与手术结果之间关系的研究结果不一，具体取决于分析的特定手术。在接受全肩关节置换术（TSA）的患者中，尚未对这种手术量关系进行充分研究，但应该进行研究，因为这种手术较为常见、费用高昂，而且可能存在潜在风险。
问题/目的：我们进行本研究的目的是评估美国全肩关节置换术（aTSA）和反式全肩关节置换术（rTSA）中，外科医生手术量逐年增加与术后 2 年翻修率降低之间的关系。
在这项回顾性研究中，我们使用了 2015 年至 2021 年医疗保险和医疗补助服务中心（CMS）的按服务收费住院和门诊数据，以研究每年外科医生进行 aTSA 和 rTSA 的手术量与初次手术后 2 年内进行翻修手术的几率之间的关系。选择 CMS 数据库进行本研究，是因为它是一个全国性的样本，可以用来跟踪患者随时间的变化。我们纳入了接受 TSA 的患者（这些代码包括 aTSA 和 rTSA），诊断相关组码为 483，和当前操作术语码为 23472。我们使用国际疾病分类，第十次修订版，操作代码。排除了因骨折而接受肩关节置换术的患者（10%[17,524/173,242]）。我们通过广义线性模型研究与随后手术几率相关的变量，通过患者年龄、合并症风险评分、外科医生和医院手术量、外科医生毕业年份、医院规模和教学地位等混杂因素进行控制，假设二项分布，因变量为在 2 年内是否至少进行了一次后续手术。回归采用标准误差在医院水平上聚类，分别对所有 TSA 和 aTSA 和 rTSA 组进行组合。在研究期间，通过 CMS 的公共文件获得了所有 TSA、主要手术和后续手术的医院和外科医生每年手术量。还获得了其他医院和外科医生的特征信息。CMS 分层条件类别风险评分被控制，因为它是一种根据患者的人口统计学和慢性疾病来衡量每位患者未来健康成本的指标。然后，我们将回归系数转换为后续手术几率的百分比变化。
在控制包括患者年龄、合并症风险评分、外科医生和医院手术量、外科医生毕业年份以及医院规模和教学地位等混杂因素后，我们发现，每年外科医生手术量≥10 例 aTSA 与术后 2 年内翻修几率降低 27%相关（95%置信区间 13%至 39%；p<0.001），而每年外科医生手术量≥29 例 aTSA 与术后 2 年内翻修几率降低 33%相关（95%置信区间 18%至 45%；p<0.001），与每年手术量少于 4 例相比。每年外科医生手术量≥29 例 rTSA 与术后 2 年内翻修几率降低 26%相关（95%置信区间 9%至 39%；p<0.001）。
外科医生应考虑采用虚拟规划软件、模板或增强型外科医生培训等方法来帮助进行 aTSA 和 rTSA 的低手术量外科医生。需要进一步研究这些方法的价值及其与随后翻修率的关系。
III 级，治疗性研究。
