Surgeon Volume and Experience Both Independently Drive Value in Primary Total Joint Arthroplasty: Findings from a Patient-Level Value Analysis of 4,989 Procedures with Time-Driven Activity-Based Costing.

Abstract

Surgeon and surgeon experience may influence clinical outcomes in both total knee arthroplasty (TKA) and total hip arthroplasty (THA). Clinical outcomes can be integrated with costs to calculate value. We aimed to determine if surgeon experience and volume were associated with increased value in arthroplasty. We retrospectively sourced 2,786 primary TKAs and 2,203 primary THAs from a prospectively maintained multi-institutional database. A total of 37 surgeons performed the procedures. Knee and Hip Osteoarthritis Outcome Score Physical Function-Short Forms (KOOS-PS and HOOS-PS) were collected. Costs of care were determined using Time-Driven Activity-Based Costing (TDABC) and converted from US dollars to arbitrary Cost Units (CUs). Value was calculated as the quotient of the 1-year change in HOOS-PS or KOOS-PS and the costs of care. We determined if surgeon volume and experience correlated with value after adjusting for confounders. Stratum-specific likelihood ratio (SSLR) analysis determined meaningful thresholds in any associations. In THA, increased Value _HOOS-PS was independently associated with both surgeon annual THA volume (P = 0.001) and surgeon years of experience (P < 0.001). The SSLR analysis revealed thresholds in volume (≥ 61 annual THAs) and experience (≥ three years) associated with increased Value _HOOS-PS. High-volume THA surgeons had reduced costs of care (1,055 CUs versus 1,263 CUs; P < 0.001), but similar Delta HOOS-PS (+25.2 versus +23.6; P = 0.171). High-experience THA surgeons had not only reduced costs of care (1,074 CUs versus 1,213 CUs; P < 0.001), but also marginally increased Delta HOOS-PS (+25.3 versus +20.9; P = 0.003). Similar findings were observed in TKA. Surgeon volume and experience both independently drive value in arthroplasty. High-volume and high-experience arthroplasty surgeons streamline costs of care through shorter lengths of stay, faster operative times, and increased home discharges. As surgeons progress in their careers - gaining experience and increasing their annual case volume - they may improve in their ability to deliver cost-effective arthroplasty care.