Defining the Volume-Outcome Relationship in Reverse Shoulder Arthroplasty

Background: As the utilization of reverse total shoulder arthroplasty (RSA) grows, it is increasingly important to examine the relationship between hospital volume and RSA outcomes. We hypothesized that hospitals that perform a higher volume of RSAs would have improved outcomes. We also performed stratum-specific likelihood ratio (SSLR) analysis with the aim of delineating concrete definitions of hospital volume for RSA.

Methods: The Nationwide Readmissions Database was queried 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. Cutoffs generated through SSLR analysis were confirmed via binomial logistic regression.

Results: The proportion of patients receiving care at high-volume centers increased from 2011 to 2015. SSLR analysis produced hospital volume cutoffs for each outcome, with higher-volume centers showing improved outcomes. The volume cutoffs associated with the best rates of 90-day outcomes ranged from 54 to 70 RSAs/year, whereas cost and resource utilization cutoffs were higher, with the best outcomes in hospitals performing >100 RSAs/year. SSLR 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. These were similar to the strata for 90-day revision (1 to 16, 17 to 53, and ≥54 RSAs/year) and 90-day complications (1 to 9, 10 to 68, and ≥69 RSAs/year). SSLR analysis produced 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), 5 categories for an extended LOS (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).

Conclusions: We have defined hospital surgical volumes that maximize outcomes after RSA, likely related to surgical experience, ancillary staff familiarity, and protocolized pathways. This information may be used in future policy decisions to consolidate complex procedures, such as RSA, at high-volume destinations, or to encourage lower-volume institutions to strategize an approach to function as a higher-volume center.

Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.