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. 2025 Sep 1:17585732251360756.
doi: 10.1177/17585732251360756. Online ahead of print.

Volume-outcome relationships for primary total elbow arthroplasty surgery in England: Analysis of the hospital episode statistics dataset

Thomas D Stringfellow  1   2 , David Butt  2 , Deborah Higgs  2 , Mark Falworth  2 , Timothy Wr Briggs  1   2 , William K Gray  1
Affiliations

Volume-outcome relationships for primary total elbow arthroplasty surgery in England: Analysis of the hospital episode statistics dataset

Thomas D Stringfellow et al. Shoulder Elbow. .

Abstract

Background: Total elbow arthroplasty (TEA) is a low-volume, high-complexity procedure and clinical guidelines recommend moving to a centralised network model. The aim of the study was to assess the effect of surgeon and unit volume on patient and service level clinical outcomes.

Methods: Analysis the Hospital Episodes Statistics database (HES) for elective and emergency primary TEA surgery between January 2014 and December 2023 was performed. The exposures of interest were surgeon and trust volume in the 12 months preceding index surgery. The primary outcome was revision surgery within 12 months of index procedure. Secondary outcomes were 30-day emergency readmission and length of stay (LOS) greater than the median.

Results: In total, 4101 primary TEA cases performed in 123 trusts were included. One-year revision and 30-day emergency readmission were not associated with trust or surgeon volume. LOS greater than the median showed a significant association with both surgeon and unit TEA volume. Patients undergoing primary TEA by surgeons performing fewer than 10 cases per year have three times the likelihood of LOS over three days.

Conclusion: There are significant resource savings from networked service reconfiguration. Careful monitoring of clinical outcomes is required, ideally using patient reported outcomes in addition to implant survival, readmission and LOS.

Keywords: Total elbow arthroplasty; elbow replacement; observational dataset; outcomes‌; volume-outcome relationship.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: TDS, WKG and TWRB were employed by GIRFT during this work, MF is a member of the BESS council. DB and DH have no conflicts to declare.

Figures

Figure 1.
Figure 1.
Flow diagram (STROBE) showing data extraction and cleaning steps.
Figure 2.
Figure 2.
Comparative graph showing number of annual primary TEA cases recorded in each UK dataset. HES; (admitted patient care) hospital episode statistics, NJR: national joint registry and SAP; Scottish arthroplasty project. N.B., NJR data includes England, Northern Ireland and Wales, HES data is for England only and SAP is just Scottish activity.
Figure 3.
Figure 3.
Cox proportional hazards implant survival analysis for each volume group. (a) Surgeon volume; (b) Trust volume.
Figure 4.
Figure 4.
Restricted cubic splines are showing non-linear association with median length of stay greater than median (3 days) and average surgeon (a) and trust (b) volume in the 12-months prior to any given procedure.
See this image and copyright information in PMC

References

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