Nationwide Study Reveals 20% of Shoulder Surgeons Performed Over 70% of Total Shoulder Arthroplasties, With a 30% Lower Revision Rate

Summary of Findings

A nationwide research study conducted by the Avant-garde Health and Codman Shoulder Society Value Based Care Group has identified the following correlations:

• About 20% of shoulder surgeons performed 10 or more total shoulder arthroplasties, and they accounted for over 70% of all total shoulder arthroplasties in the US
• Shoulder surgeons performing more than 10 aTSAs (anatomic total shoulder arthroplasty) per year are correlated with a 27% decrease in the likelihood of a revision procedure within 2 years
• Shoulder surgeons performing more than 29 aTSAs per year are correlated with a 33% decrease in the likelihood of a revision procedure within 2 years
• Shoulder surgeons performing more than 29 rTSAs (reverse total shoulder arthroplasty) per year are correlated with a 26% decrease in the likelihood of a revision procedure within 2 years
• Conversely, shoulder surgeons performing fewer than 4 aTSAs per year are correlated with a 30% increase in the likelihood of a revision procedure within 2 years

The full study titled "Higher Surgeon Volume is Associated With a Lower Rate of Subsequent Revision Procedures After Total Shoulder Arthroplasty: A National Analysis" can be accessed from The Association of Bone and Joint Surgeons website Clinical Orthopaedics and Related Research here.

Study Objectives

The study assessed the association between higher surgeon volumes and lower rates of revision procedures within 2 years for anatomic TSA (aTSA) and reverse TSA (rTSA) in the United States.

This volume relationship has not been widely studied in patients undergoing total shoulder arthroplasty (TSA), but it should be, because this procedure is common, expensive, and potentially morbid.

About the Study Methodologies

This Level III, Therapeutic Study 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.

Considerations for Closing the Gap

Lower-volume shoulder surgeons may consider virtual planning, templating, and/or enhanced surgeon training.

About the Avant-garde Health and Codman Shoulder Society Value Based Care Group

We welcome more surgeon members who want to join us on our journey of measuring and improving value. For more information please contact Porter Jones (porter@avantgardehealth.com) or JP Warner (jpshoulder@msn.com) or visit https://www.codman-shoulder-society.com/