Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery

Awopetu, Ayoola; Moxey, Paul; Hinchliffe, Robert J.; Jones, Katie; Thompson, Matt; Holt, Peter

doi:10.1002/bjs.7089

Cited by 31 publications

(20 citation statements)

References 38 publications

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“…However, of the seven total studies only three showed a volume-outcome relationship. 22 Our study does not demonstrate any effect of either institutional or surgeon volume on amputation-free survival, but does show an effect of surgeon volume on major adverse limb events, which includes major amputation.…”

Section: Discussioncontrasting

confidence: 59%

“…They report that five of those studies demonstrated a positive volume-outcome relationship, whereas the other four did not find any evidence of a volume effect on postoperative mortality yielding a meta-analysis that supports the effect of increased volume leading to decreased mortality, but this finding is also associated with significant heterogeneity and thus must be interpreted with caution. 22 In the same review, seven studies examined the rates of amputation at low vs. high volume hospitals, three of which were suitable for inclusion in the meta-analysis. The pooled effect estimate was an odds ratio of 0.88 with low heterogeneity favoring high volume hospitals.…”

Section: Discussionmentioning

confidence: 99%

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Surgeon, not institution, case volume is associated with limb outcomes after lower extremity bypass for critical limb ischemia in the Vascular Quality Initiative

Johnston

Tracci

Kern

et al. 2017

Journal of Vascular Surgery

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Objectives Studies from large administrative databases have demonstrated associations between institutional case volume and outcomes after lower extremity bypass (LEB). We hypothesized that increased institutional and surgeon volume would be associated with improved outcomes after LEB. Using a national, prospectively collected clinical database, the objective of this study was to determine the effects of both surgeon and institutional volume on outcomes after LEB. Methods The Vascular Quality Initiative (VQI) was queried to identify all LEB for critical limb ischemia or claudication between 2004–2014. Average annual case volume was calculated by dividing an institution or surgeon’s total LEB volume by the number of years they reported to VQI. Institutional and surgeon volumes were analyzed as continuous variables to determine the impact of volume on major adverse cardiac events (MACE), major adverse limb events (MALE), graft patency, and amputation free survival. Hierarchical regression models were used with cases clustered by surgeon and center. Time-dependent outcomes were evaluated with multivariable shared frailty Cox proportional hazards models. Results From 2004–2014, 14,678 LEB operations were performed at 114 institutions by 587 surgeons. Average annual institutional volume ranged from 1.0–137.5 LEBs per year, with a median of 26.9 [IQR 14–45.3]. Average annual surgeon volume ranged from 1–52 LEBs per year with a median of 5.7 [IQR 2.5–9.3]. Institutional LEB volume was not associated with major adverse cardiac or limb events, nor with loss of patency. However, average annual surgeon volume was independently associated with reduced MALE and improved primary patency. Institutional and surgeon volume did not predict MACE. Conclusions In contradistinction to previous studies, there was no relationship in this study between institutional LEB volume and outcomes after LEB. However, greater average annual surgeon volume was associated with improved primary patency and decreased risk of major adverse limb events. Open LEB remains a safe and effective procedure for limb salvage. Limb-related outcomes in CLI and claudication will be optimized if surgeons maintain adequate volume of LEB.

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Section: Discussioncontrasting

confidence: 59%

Section: Discussionmentioning

confidence: 99%

Surgeon, not institution, case volume is associated with limb outcomes after lower extremity bypass for critical limb ischemia in the Vascular Quality Initiative

Johnston

Tracci

Kern

et al. 2017

Journal of Vascular Surgery

View full text Add to dashboard Cite

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“…Similar improvements with centralisation have been noted for liver [12], oesophageal [13], complex urological [14] and vascular surgery [15]. Despite these findings the population benefits of regionalisation are more difficult to demonstrate.…”

Section: Discussionmentioning

confidence: 68%

Variation in survival after surgery for peri-ampullary cancer in a regional cancer network

et al. 2017

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BackgroundCentralisation of specialist surgical services requires that patients are referred to a regional centre for surgery. This process may disadvantage patients who live far from the regional centre or are referred from other hospitals by making referral less likely and by delaying treatment, thereby allowing tumour progression. The aim of this study is to explore the outcome of surgery for peri-ampullary cancer (PC) with respect to referring hospital and travel distance for treatment within a network served by five hospitals.MethodsReview of a unit database was undertaken of patients undergoing surgery for PC between January 2006 and May 2014.Results394 patients were studied. Although both the median travel distance for patients from the five hospitals (10.8, 86, 78.8, 54.7 and 89.2 km) (p < 0.05), and the annual operation rate for PC (2.99, 3.29, 2.13, 3.32 and 3.07 per 100,000) (p = 0.044) were significantly different, no correlation was noted between patient travel distance and population operation rate at each hospital. No difference was noted between patients from each hospital in terms of resection completion rate or pathological stage of the resected tumours. The median survival after diagnosis for patients referred from different hospitals ranged from 1.2 to 1.7 years and regression analysis revealed that increased travel distance to the regional centre was associated with a small survival advantage.ConclusionAlthough variation in the provision and outcome of surgery for PC between regional hospitals is noted, this is not adversely affected by geographical isolation from the regional centre.Trial registrationThis study is part of post-graduate research degree project. The study is registered with ClinicalTrials.gov (unique identifier NCT02296736) November 18, 2014.

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“…Holt et al have also found that high volume centres are more likely to operate on ruptured AAAs [30], perhaps due to the greater number and confidence of the operating surgeons and support staff, access to the latest technology and intensive therapy unit facilities [31]. Awopetu et al found that higher-volume centres were associated with reduced amputation and mortality rates post lower limb vascular surgery although they did point to significant heterogeneity within their data [32].…”

Section: Discussionmentioning

confidence: 99%

Towards National Surgical Surveillance in the UK – A Pilot Study

Agha

2012

PLoS ONE

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ObjectiveThe Bristol heart inquiry in the United Kingdom (UK) highlighted the lack of standards for evaluating surgical performance and quality. In 2009, the World Health Organisation (WHO) proposed six standardised metrics for surgical surveillance. This is the first study to collect and analyse such metrics from a cohort of National Health Service (NHS) Trusts in England, helping to determine their feasibility and utility in measuring surgical performance, its impact on public health and mortality, and for tracking surgical trends over time.MethodsFreedom of Information Act 2000 (FOI) requests for WHO standardised surgical metrics were made to 36 NHS Trusts in England during July to November 2010. Additional data on Hospital Standardised Mortality Ratio (HSMR), Patient Safety Score and Abdominal Aortic Aneurysm (AAA) volume and mortality was obtained from Dr Foster Health and The Guardian Newspaper. Analysis was performed using mixed-effect logistic regression.Results30/36 trusts responded (83%). During 2005–9, 5.4 million operations were performed with a 24.2% increase in annual number of operations. This rising volume within hospitals was associated with lower mortality ratios. A 10% increase in operative volume was associated with a lower day of surgery death rate (DDR OR = 0.94, p = 0.056) and post-operative inpatient 30-day mortality (PDR30 OR = 0.93, p = 0.001). For every 10,000 more operations that an NHS Trust does, a 4% drop in PDR30 mortality was achieved. A 10% increase in the volume of elective AAAs was associated with lower elective AAA (OR = 0.96, p = 0.032) and emergency AAA (OR = 0.95, p = 0.009) PDR30 mortality. Lower DDR mortality was noted for emergency AAA mortality (OR = 0.95, p = 0.025) but not elective AAAs (OR = 0.97, p = 0.116).ConclusionStandarised surgical metrics can provide policy makers and commissioners with valuable summary data on surgical performance allowing for statistical process control of a complex intervention. This study has shown their collection is feasible albeit using FOI and the first to show a statistically significant volume-outcome relationship for surgery as a whole within hospitals. It adds weight to the argument that patients are safer in larger hospitals or those that become larger by growing their patient base. Together with other measures, such metrics can help build a picture of surgical surveillance in the UK and potentially lead us to safer surgery.

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Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery

Abstract: : Higher-volume hospitals were associated with reduced amputation and mortality rates after lower limb vascular surgery. These data were not as conclusive as those for other vascular surgical procedures owing to significant heterogeneity.

Cited by 31 publications

References 38 publications

Surgeon, not institution, case volume is associated with limb outcomes after lower extremity bypass for critical limb ischemia in the Vascular Quality Initiative

Surgeon, not institution, case volume is associated with limb outcomes after lower extremity bypass for critical limb ischemia in the Vascular Quality Initiative

Variation in survival after surgery for peri-ampullary cancer in a regional cancer network

Towards National Surgical Surveillance in the UK – A Pilot Study

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