Het volume van chirurgische ingrepen en de impact ervan op ... - KCE

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104 Volume Outcome KCE reports 113 Guller et al. performed stratified analyses based on whether breast-conserving or breast-ablative therapy was performed. 219 These categories correspond with the following APR-DRGs in the MCD: • APR-DRG 363 “Breast procedures except mastectomy” = breastconserving therapy (BCT); • APR-DRG 362 “Mastectomy procedures” = breast-ablative therapy (BAT). 5.5.5 Definition of outcomes 5.5.5.1 Mortality Table 5.54 shows that in-hospital and approximate 30-day mortality is 0.25% after breast cancer surgery (24 deaths). Survival 1 year after surgery is 97.6%. After 2 years it is 94.8%. Mean survival time (median not defined) was 34 months (not visible in Table 5.54). Table 5.54: Breast cancer surgery: Mortality results Number Number deaths % deaths Survival In-hospital and approximate 30-day mortality 9 450 24 0.25 1-year mortality 9 450 223 2.4 97.6 2-year mortality 9 450 488 5.2 94.8 Figure 5.23 presents survival after breast cancer surgery, per stage. Figure 5.24: Breast cancer surgery: Survival curve by stage X means stage missing.
KCE Reports 113 Volume Outcome 105 5.5.6 Volume outcome relationship 5.5.6.1 Analysis by hospital 2-YEAR MORTALITY RATE, BY HOSPITAL Figure 5.24 presents the funnel plot of the number of breast cancer procedures per centre and the 2-year mortality (observed, i.e. without risk adjustment). The size of the point is proportional to the number of hospitals with the same volume and the same outcome. The horizontal line represents the overall 2-year mortality i.e. 5%. There are only 3 centres that are above the 99.8% limits of variability. Figure 5.25: Breast cancer surgery: Funnel plot of 2-year mortality rate, by hospital DESCRIPTION OF DIFFERENCES IN CHARACTERISTICS ACCORDING TO THE VOLUME CATEGORY OF THE HOSPITAL Table 5.55 presents the differences in case mix and outcomes for the 114 centres, divided in groups of five based on their annual volume. The international cut off of 10 procedures per year (see discussion section) was not retained as only one centre did not reach this cut off. Volume thresholds were defined by increases of 50 interventions (25 for small volume centres). Patients treated in low volume centres have a worse case mix: • patients are older in low volume hospitals (mean age is 62.4 compared to 59.2 in very high volume centres); • patients have higher levels of co morbid illness in low volume hospitals (4.0% with at least 3 co morbidities versus 2.2% national mean); • patients in low volume hospitals have a higher likelihood of undergoing breast-ablative surgery (67%) than those in high volume centres (52%); • patients in low volume hospitals have more stage III and IV patients (together 22.8%) than in the highest volume centres (12.8%). However, with respect to tumour stage and differentiation, we noticed that low volume centres also have a much higher percentage of missing data than high volume centres: • 30% (low-volume) versus 16.5% (high volume) missing data for stage; • 37% (low-volume) versus 22% (high volume) missing data for tumour differentiation.
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