The rapidly growing utilization of total joint arthroplasty (TJA) [1,2] and increasing emphasis on value [3] substantiate the need for strategies to continuously improve efficiency and quality. The literature demonstrates the benefits of undergoing TJA at high volume institutions with high volume surgeons, as summarized in two systematic reviews [4,5]. The volume–outcomes relationship has prompted calls for selectively referring patients to high volume centers for total hip and knee arthroplasty [6–8], also referred to as regionalization [9,10]. While selective referral could potentially improve outcomes after TJA, previous work indicates that there may be unintended consequences for access to care and complication risk.

Although many patients undergo TJA at high volume hospitals (HVHs), 5%–8% of patients of all insurance types [15,16] and 10%–37% of Medicare beneficiaries received care at low volume hospitals (LVHs) [9,12,13,17,18]. While patients often attribute this pattern to convenience and proximity [13,18,19], 13-34% of the patients who underwent total knee arthroplasty at an LVH had traveled further than a local HVH [12,19]. Although it is expected that this pattern of care (choosing an LVH when an HVH was closer) would have a negative effect on outcomes, this relationship has not been directly evaluated. The factors contributing to selection of a hospital and a surgeon are multifactorial [18,20] and may not be entirely under the patient’s control. However, this evaluation of complication rates for patients who underwent surgery at an LVH instead of HVH within the same vicinity is needed to guide future decision making.