The role of human capital in a highly-specialized context: the case of high-volume orthopaedic surgery

Orthopaedics is increasingly central to modern health systems due to population ageing, rising joint replacement demand, and higher expectations for quality of life. Policymakers rely on structural strategies, including centralization and outsourcing, to sustain quality and sustainability, yet evidence remains mixed. This dissertation studies how organisational arrangements affect orthopaedic outcomes and system performance. Chapter 1 analyses emergency hip fracture surgery in Emilia-Romagna within a regulated system without selective referral. Testing whether accumulated experience improves outcomes, it provides causal evidence that higher surgical volumes lower 30-day mortality, supporting volume-based standards as a policy instrument. Chapter 2 examines elective knee arthroplasty, comparing long-term prosthesis survival across public and accredited private hospitals within the Italian National Health Service. It finds no systematic quality differences, indicating that outsourcing routine procedures can reduce pressure on public providers without compromising quality. Demand projections nonetheless show strong future rise in volumes, underscoring the need for capacity planning to preserve equitable access. Chapter 3 evaluates links between hospital volume and labour market and clinical outcomes following knee replacement in Norway. Using an instrumental-variable approach to address endogeneity, results show no robust volume effects on employment trajectories or adverse events. Taken together, the findings challenge the assumption that centralization and scale reliably improve outcomes, especially for routine elective care where reduced geographic access may not be justified. Procedure differences help interpret these results. Hip fracture repair is acute, complex, and time-sensitive, requiring coordinated teams and specialized expertise, so accumulated experience more strongly affects survival. Knee replacement is standardized and planned, which limits marginal gains from higher hospital volume. Outcome variation in elective surgery likely reflects surgeon-level experience and organisational practices rather than hospital scale alone. Future research should examine management, staffing, and resource allocation as performance drivers in healthcare systems.