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

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136 Volume Outcome KCE reports 113 IN-HOSPITAL AMI AND CVA RATE, BY HOSPITAL The following figures present the AMI rate (Figure 6.4) and CVA rate (Figure 6.5) after CEA/CAS. It was decided not to perform any further analyses on the complication rate because these are rare events, and because complications based on ICD-9 codes may be subject to coding variability. The latter might explain, for example, why one medium volume centre has a 14% CVA rate after CEA/CAS. Two other centres with lower volume are also outside 99.8% limits of variability. Figure 6.4: Funnel plot of the AMI rate following CEA/CAS treatment, by centre Figure 6.5: Funnel plot of the CVA rate following CEA/CAS treatment, by centre
KCE Reports 113 Volume Outcome 137 6.1.7 Discussion CEA is one of six procedures for which the US Agency for Healthcare Research and Quality (AHRQ) defined a volume indicator (i.e. Inpatient Quality Indicator 7) because outcome may be related to volume. 248 The AHRQ applies a lower threshold of >50 procedures per year and an upper threshold of >101 CEA per year to benchmark hospitals. 29 The US Leapfrog group is a non-profit organisation which represents many of the US' largest private and public-sector healthcare purchasers. Together, these purchasers represent more than 34 million Americans. 249 The coalition encourages both patients and payers to select hospitals that meet minimal volume standards for some high-risk procedures. 126 Until March 2004, the Leapfrog group used the cut off of 100 CEA per year to select providers. 93, 115 In April 2004, however, carotid endarterectomy was removed from the Leapfrog Group’s list of targeted procedures. 250 6.1.7.1 External validation of the definition of the procedure There is no external data source available. The external experts who commented on this report had their doubts about the number of carotid stentings (CAS) that were selected in the MCD. They argued that the ICD-9-CM procedure code 3990 (see Table 2.1) is probably not commonly used to encode CAS and that some surgeons might use the NIHDI procedure code for carotid arteriography (which was not part of our selection). Because of this limitation, additional analyses were performed on CEA alone. 6.1.7.2 Summarized results of literature review The systematic literature search identified nine systematic reviews in which the VOA for carotid endarterectomy was studied. 1, 5, 59-65 In all, these systematic reviews identified 93, 115, 116, 251-259 38 primary studies of which 12 were published between 2000 and 2005. Carotid stenting was not analysed in any of the abovementioned SRs or primary studies. The discussion below will primarily be based on the meta-analysis by Holt et al. because it is very recent (2007) and of very good quality (see Appendix 7). 61 Holt et al. performed a meta-analysis from 21 articles (885 034 cases) and quantified a pooled effect estimate of hospital volume on stroke and/or mortality rates from CEA. They found that stroke and mortality attributable to CEA occurred less frequently in highervolume hospitals (odds ratio 0.78 [0.64-0.92]). The critical volume threshold between higher- and lower-volume centres was 79 CEA per year. This conclusion corresponds to what we concluded on the basis of all systematic reviews in Chapter 2 (see Table 2.2 on page 19); that there is an inverse association between volume (hospital and surgeon) and mortality, as well as stroke rate. A detailed description of this evidence is available in Appendix 9. 6.1.7.3 Comparative analysis of literature and Belgian data DEFINITION OF VOLUME As shown in Table 6.4, Belgian hospitals had a mean annual CEA volume of 26 in 2004; 75 th Percentile is 34. The application of Holt’s hospital volume threshold of 79 CEA per year on Belgian centres would imply that only very few hospitals would comply with the threshold. 61 In 2004, the Leapfrog Group removed CEA from its list of targeted procedures. This decision was taken on the basis of Birkmeyer’s analyses which showed that the absolute difference in mortality between very-low-volume and very-high-volume hospitals was smallest for carotid endarterectomy (1.7 percent vs. 1.5 percent). 115 The analysis by Christian et al. supports the Leapfrog Group’s decision: no meaningful volume threshold could be determined for CEA, based on its relationship with mortality. 93 This result made Christian argue that despite the consistent evidence for a relationship between volume and outcome in the literature, it is still not clear how to proceed to minimum procedural volume thresholds which serve as a basis for selective referral to highvolume hospitals. 93
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