Editorial Commentary: Volume and Outcome: 100 Years of Perspective on Value From E.A. Codman to M.E. Porter.

Outcome is the numerator for the value equation, with the denominator being cost; measurement of each is essential to determine the most effective care. With regard to both total shoulder arthroplasty and rotator cuff repair, outcomes of low (vs high) volume providers are associated with longer hospital stay, longer length of operating room time, increased hospital complications, and cost. This suggests that volume thresholds are a key to providing greater value. However, this effect can be modified through systematic efforts to measure outcome and thus improve. To quote Codman, "To effect improvement, the first step is to admit and record the lack of perfection. The next step is to analyze the causes of failure and to determine whether these causes are controllable." Thus, although volume most certainly plays a role in determining outcomes and cost, the more important principle is to measure outcomes and improve with such measurement.