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Patients treated by surgeons who average over 10 shoulder replacements a year have a lower risk of reoperation and serious complications, and a shorter hospital stay than those treated by surgeons who do fewer operations, finds a study published by The BMJ.

Woman with shoulder pain © Shutterstock

These findings build on similar evidence for hip and knee replacements and should help guide future resource planning in this area, say the researchers at NDORMS who carried out the study.

Shoulder replacements are becoming increasingly common globally, particularly in high income countries as populations continue to age. In the UK alone, more than 8,000 shoulder replacements are carried out each year.

Previous studies of hip and knee replacement surgery show that patients treated by "high volume" surgeons experience better outcomes than patients of lower volume surgeons. This has 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, a team of UK researchers set out to explore the association between surgeon volume and outcomes after non-urgent (elective) shoulder replacement surgery.

'Improving outcomes and reducing complications after joint replacement surgery is of clear benefit to patients and their families,' said Epaminondas Markos Valsamis, NIHR Doctoral Research Fellow at NDORMS. 'But these results also provide timely evidence for healthcare systems that are overburdened, under-resourced, and in need of recovery planning post pandemic.'

Their findings are 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 hospitals from 2012 to 2020.

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 stay (more than 3 nights). All participants were aged 18 or over and were receiving shoulder replacement surgery for the first time.

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.

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.

'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,' concluded Markos.
This research was funded by the National Institute for Health and Care Research (NIHR). It was supported by the NIHR Oxford Biomedical Research Centre and National Joint Registry. 

Read the full paper in the BMJ