Association Between Institutional Factors and Long‐Term Survival Following Transjugular Intrahepatic Portosystemic Shunt

Abstract

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure designed to treat portal hypertension. Hospital teaching status is an institutional factor found to be predictive of outcomes following several complex procedures; however, its impact on outcomes following TIPS is unknown. The aim of this study was to determine the association between hospital teaching status and long‐term survival in patients with cirrhosis receiving TIPS. We performed a retrospective population‐based cohort study using linked administrative health data from Ontario, Canada. Adult patients with cirrhosis who received TIPS between January 1, 1998, and December 31, 2016, with follow‐up until December 31, 2017, were included. Hospital teaching status was defined based on hospital participation in the instruction of medical students and/or resident physicians. Liver transplant‐free (LTF) survival was evaluated using Kaplan‐Meier analysis, and overall survival was assessed using competing risks regression analysis, which accounted for hospital clustering. A total of 857 unique patients were included (mean age 57.1 years; 69.1% male). The TIPS procedures were performed in teaching hospitals (84.3%) as well as nonteaching hospitals (15.7%). Median LTF survival was more than twice as long for procedures performed in teaching hospitals compared to nonteaching hospitals (2.2 years versus 0.9 year, respectively; P < 0.001). After adjusting for confounders and clustering, hospital teaching status was not independently associated with mortality (nonteaching subdistribution hazard ratio [sHR], 1.32; 95% confidence interval [CI], 0.97‐1.81; P = 0.08); however, annual hospital procedure volume was (per unit increase sHR, 0.96; 95% CI, 0.93‐0.99; P = 0.003). Conclusion: Hospital procedure volume is associated with long‐term survival following TIPS. These results further support the centralization of TIPS to high‐volume hospitals to improve long‐term outcomes in this population.

Attitudes towards transjugular intrahepatic portosystemic shunt (TIPS) in Australia: a national survey of TIPS centres

“…An American study in 2017 found that the risk of inpatient mortality was lower in hospitals performing ≥20 TIPS per year 22. Consistent with this study, a recent Canadian study found that outcomes improved with units performing a minimum of 10 procedures per year 23. With only seven units performing more than 10 procedures in Australia, there is a need to address centralisation versus decentralisation of services: the advantage of centralised provision of TIPS would provide expert care, high-level infrastructure, state-of-the-art diagnostic tests and therapies.…”

Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension

“…Additionally, there were units reporting a total number of procedures performed (elective and emergency) in a year of eight, raising the challenging question of numbers required for competency. A recent Canadian publication indicated that outcomes improved with units performing a minimum of 10 procedures per year 186. Furthermore, between 2006–2017, there was no clear evidence of an increase in emergency procedures, despite published evidence and recommendations.…”

“…For complex TIPSS (thrombosed portal or hepatic veins, or previous transplant) it is recommended that these are performed in centres with >20 cases per annum and given the small numbers of outcome data and benchmarking, is difficult 187. Further evidence supports the need to ensure that centres wishing to start a TIPSS perform at least 10 procedures a year, regardless of whether the centre is a teaching hospital or not 186…”

Effects of Primary Sclerosing Cholangitis on Risks of Cancer and Death in People With Inflammatory Bowel Disease, Based on Sex, Race, and Age

“…Covariates yielding a P-value of 0.1 on univariate analysis were fed into respective multivariable models. [28][29][30][31][32] P-values <0.05 were deemed statistically significant.…”