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**3** 

*Canada* 

**Provider Volumes and Surgical Outcomes** 

S. Rodriguez-Elizalde, R. Jenkinson, H. Kreder and J.M. Paterson *Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of* 

There has been much discussion of the role of provider (both surgeon and hospital) surgical volumes and their effect on patient outcomes after total joint replacement (TJR)1-14. Common sense would suggest that individuals and institutions with greater experience should demonstrate reduced rates of complications and improved outcomes, however, in the setting of surgical outcomes, the question remains: does practice really make perfect? As medical costs continue to rise, institutions look for ways to optimize outcomes while decreasing complication rates and their associated financial and legal liabilities. There is ongoing debate as to whether the centralization of hospital resources to create large volume regional specialty centers and the sub-specialization of surgeons to increase their procedure volumes is an effective means of reducing cost and complications,2,5,7,12. Potential disadvantages of such centralization include increased wait times and travel distances for patients, and the possible closure of viable institutions. While most would likely agree that a volume exists below which procedure performance is suboptimal, where this threshold lies with respect to surgeon and

institutional volumes in the field of hip and knee arthroplasty has yet to be defined.

demonstrating volume-outcome associations requires enormous sample sizes4,8.

Much of the literature on surgical volume-outcome associations comes from our colleagues in cardio-vascular, thoracic surgery and general surgery15. The early studies in this field were landmark in that they demonstrated a clear-cut reduction in mortality for procedures performed in specialized centers and by high volume surgeons15. In the past few decades, the frequency of total hip and knee arthroplasty has increased dramatically and these procedures are now considered among the most successful and reproducible medical procedures routinely performed 5,14,. Overall, complication rates are low and consequently

Previous studies of the effect of provider volumes on the outcomes of hip and knee replacement have shown mixed results with respect to both surgeon volume and institutional volume1-14. Furthermore, difficulty arises when attempts are made to compare the results of studies across different institutions and countries due to the different methods used for defining procedure volumes, as well as for handling case complexity and patient comorbidities. This lack of consistency coupled with differences in health care delivery have

Below we review and comment on the key TJR volume-outcome studies from England and North America, where most TJR surgeries are performed. Results from the American and

**1. Introduction** 

contributed to inconsistent findings.

Canadian studies are summarized in Tables 1 and 2.

**in Total Hip and Knee Replacement** 

*Toronto; and the Institute for Clinical Evaluative Sciences* 

