Comparison of the volume of scoliosis surgery between spine and pediatric orthopaedic fellowship-trained surgeons in New York and California

Background: Controversy exists regarding the optimal fellowship training experience for surgeons who perform scoliosis surgery in pediatric patients. While many studies have demonstrated that higher surgical volumes are associated with superior outcomes, the volume of scoliosis procedures performed by pediatric orthopaedic-trained surgeons as opposed to spine surgery-trained surgeons has not been reported. Methods: Validated, statewide hospital discharge databases from the states of New York and California were utilized to examine the volume of spinal fusion procedures performed for the treatment of scoliosis in patients who were eighteen years of age or less. Fellowship training of surgeons in New York who had performed more than fifty procedures from 1992 to 2001 (that is, more than five procedures per year) was determined, and the operative volumes of surgeons who had received pediatric orthopaedic as opposed to spine fellowship training were compared. Hospitals in California with either type of fellowship program were identified, and the operative volumes of hospitals and fellows with pediatric orthopaedic or spine fellowship training from 1995 to 1999 were compared. Results: Among the 228 surgeons in New York who had performed one or more spinal fusion procedures in patients eighteen years of age or less from 1992 to 2001, only 13% (thirty) had performed more than five procedures per year. However, these thirty surgeons accounted for 75% (3858) of all 5136 procedures in this age-group. Surgeons who had completed a pediatric orthopaedic fellowship had performed a mean of 14.5 procedures per physician per year, whereas those who had completed a spine fellowship had performed a mean of 10.5 procedures per physician per year. Surgeons who had not completed either type of fellowship had performed a mean of 14.4 procedures per physician per year. In California, the mean annual volume of scoliosis procedures from 1995 to 1999 was 59.0 procedures per year at hospitals with pediatric orthopaedic fellowship programs and 15.7 procedures per year at those with spine surgery programs. The mean number of procedures per fellow at hospitals with pediatric orthopaedic fellowship programs was 31.6 procedures per fellow per year, and the mean number at hospitals with spine surgery programs was 12.7 procedures per fellow per year. Over time, there was a significant increase in the number of procedures per year at hospitals with both types of fellowship programs, but the percentage increase was greater for hospitals with pediatric orthopaedic fellowship programs than for hospitals with spine surgery fellowship programs (45.2% compared with 13.5%). Conclusions: These data indicate that, on the average, a large number of surgeons in New York performed five scoliosis procedures per year or fewer. Among higher-volume surgeons in New York, those with pediatric orthopaedic fellowship training performed more scoliosis procedures on children and adolescents than those with orthopaedic spine training did. In California, the volume of scoliosis procedures at hospitals with pediatric orthopaedic fellowship programs was nearly four times greater than that at hospitals with spine fellowship programs and the volume of procedures per fellow was more than two times greater, and this disparity is widening over time. These data are an important element in establishing what type of fellowship best prepares surgeons for scoliosis surgery.