The Journal of Arthroplasty , Volume 33 , Issue 8 , 2398 - 2404

Evidence-Based Thresholds for the Volume and Cost Relationship in Total Hip Arthroplasty: Outcomes and Economies of Scale

Haeberle, Heather S. et al.


High-volume surgeons and hospital systems have been shown to deliver higher-value care in several studies. However, no evidence-based volume thresholds for cost currently exist in total hip arthroplasty (THA). The objective of this study was to establish meaningful thresholds in cost for surgeons and hospitals performing THA. A secondary objective was to analyze the market share of THAs for each surgeon and hospital stratifications.


Using a database of 136,501 patients undergoing THA, we used stratum-specific likelihood ratio analysis of a receiver operating characteristic curve to generate volume thresholds based on costs for surgeons and hospitals. In addition, we examined the relative proportion of annual THA cases performed by each surgeon and hospital stratifications.


Stratum-specific likelihood ratio analysis of cost by annual surgeon THA volume produced stratifications at: 0-73 (low), 74-123 (medium), and 124 or more (high). Analysis by annual hospital THA volume produced stratifications at: 0-121 (low), 122-309 (medium), and 310 or more (high). Hospital costs decreased significantly (P < .05) in progressively higher volume stratifications. High-volume centers perform the largest proportion of THA cases (48.6%); however, low volume surgeons perform the greatest share of these cases (44.6%).


Our study establishes economies of scale in THA by demonstrating a direct relationship between volume and cost reduction. High-volume hospitals are performing the greatest proportion of THAs; however, low-volume surgeons perform the largest share of these cases, which highlights a potential area for enhanced value in the care of patients undergoing THA.

Download article