There's No Difference Between High and Low Ranked Orthopedic Hospitals for Outcomes of TSA?

Dear CSS Colleagues:


Enclosed is an article entitled “Total Shoulder Arthroplasty (TSA) at U.S. News & World Report Top-Ranked Hospitals in Orthopaedics – Do Rankings Correlate with Complications and Cost?” by Sridharan and colleagues soon to be published in Seminars in Arthroplasty. I came across this as it was sent to my email and freely available online. As the conclusions and the methodology seemed questionable and the conclusions suspect, I share it with you here. I asked Derek Haas (CEO of Avant-Garde Health, https://www.avantgardehealth.com/ ) to look over this article, and the following are our collective comments. This is relevant as the conclusion of the article is that “high ranked” hospitals are equivalent at 90-days to “low ranked” hospitals in terms of complications. One might also conclude that Value is equivalent or even better at a lower ranked hospital. Here is why we believe the author’s conclusions are erroneous:


1. The data analyzed is from 2011-14 so it is quite dated and may not reflect the current situation.

2. There is no clear presentation of “cost data” and there is little information provided on calculation of costs, so it is impossible to know how 90-day costs were measured and whether or not confounding factors were accounted for.

3. While the outcomes were not statistically significantly different, in 7 of the 9 outcome categories the ranked hospitals were better, in 1 they were tied and 1 they were worse. Since a lot of these adverse event rates are very low there might not have been enough cases to detect a statistically significant difference of this magnitude.

4. They define High-volume as > 23 cases/year and low as <23 cases per year. Learning curves for at least reverse replacement are probably much higher and on the order of 40 cases before complication rates drop from double digits to single digits for a surgeon. (Kempton LB, Ankderson E, Wiater JM: A Complication-based learning curve from 200 reverse shoulder arthroplasties. Clin Orthop Relat Res. 2011 Sep;469(9):2496-504)


Finally, It seems, at least to me, that the conclusions of the authors flie in the face of the concept of expertise being correlated to value. Here is a link to a posting I made on this blog on this subject some time ago. There you will find an article which delivers exactly the opposite conclusion to the one above, as well as a commentary on this concept of Volume = Value: https://www.codmansociety.org/single-post/2018/05/01/value-based-shoulder-care-volume-vs-value .


These are important concepts as they speak to our efforts to measure outcomes and shorten learning curves, all to the benefit of our patients. In the case of the article by Sridharan and colleagues I have to wonder what would happen if the decision-makers and politicians really believed it makes no difference where a patient goes for a shoulder arthroplasty, and that better value is to be achieved at lower ranked facilities if they have lower costs. You be the judge….


Best Regards,


“JP” Warner MD

Founder, CSS



Sridharan et al- Seminars in Arthroplast
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