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

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138 Volume Outcome KCE reports 113 OUTCOME In-hospital mortality was 0.98% after CEA (Table 6.5). This is slightly lower than the mean in-hospital mortality of 1.6% (range 0.3 to 5.2%) reported by Holt and associates. 61 The funnel plot (Figure 2.1) revealed two outlying centres with a higher mortality. We would need additional information to investigate and explain these observed results. The observed in-hospital and approximate 30-day mortality is higher after CAS (2.0%) than after CEA (1.1%) (see Table 6.5). Mas et al. had to prematurely stop their trial when it became clear that the 30-day incidence of any stroke or death was 3.9% after endarterectomy (95% CI, 2.0 to 7.2) and 9.6% after stenting (95% CI, 6.4 to 14.0). 260 Stroke rate after CEA was 1.51% in Belgian centres (Table 6.5). This is lower than in Holt’s meta-analysis which showed a stroke rate of 2.7% (range 0.23 to 6.1%). 61 There is, however, a problem in the coding of post-operative stroke since it is impossible to distinguish between patients who are admitted due to a stroke, and patients who suffer from a stroke post-operatively. Either of these may be miscoded, as Holt points out. 61 Therefore, he suggests that post-operative death is a more valid measure for CEA outcome than stroke. AMI rate after CEA was 0.66% in Belgium (Table 6.5). This outcome measure has a limited value since the abovementioned coding problem applies in the same way to AMI. In addition, it has to be acknowledged that, in practice, surgeons might miss an AMI because they are not looking for it. Yadav et al., for example, found a 1-year AMI rate of 3.0 and 7.5% after, respectively, CAS and CEA. 261 They defined AMI as an increase of creatinine kinase higher than two times the upper limit with a positive MB fraction. Christian et al. pointed out that complication rate would actually be a better end point than mortality for procedures such as CEA where death is a rare outcome. The difficulty is, however, the unreliability of the coding of complication data in administrative databases. 93 PATIENT CASE MIX Belgian patients with a CEA or CAS procedure were on average 71 years old and predominantly male (66%). One out of five patients (19.5%) had a Charlson score of at least three. Even when AMI and cerebrovascular diseases are excluded from the calculation of the Charlson score (modified Charlson score, explained in section 4.3.2.1), this percentage decreases only slightly to 18%. See Table 6.6. While age and sex seem comparable with other studies, the percentage of patients with Charlson score >3, on the other hand, is only 10% in Birkmeyer’s study. 115 Information on the symptomatic status of the patient and the degree of carotid stenosis are supplementary risk factors that are often used for further risk adjustment, but that 61, 115, 256 are not available in the administrative MCD. VOLUME OUTCOME ASSOCIATION The meta-analysis performed by Holt et al. showed persistent and reproducible evidence for an inverse relationship between hospital volume and mortality: death attributable to CEA occurred less frequently in higher-volume hospitals (odds ratio 0.76 [0.74-0.81]). 61 The validity of this result was supported by the fact that exclusion of the largest study did not change the pooled effect estimate. In Belgian data, a CEA volume increase of 10% is associated with a decrease of 6% in the odds of death. The validity of this result is, however, undetermined by the fact that the volume outcome relationship is influenced by three centres (see Table 6.8). RELATIONSHIP BETWEEN CASE MIX AND VOLUME Our results (see Table 6.7) show that differences in case-mix between higher- and lower-volume hospitals do not underlie the volume-outcome relationship. This is supported by the analysis by Birkmeyer where significant crude results also remain significant after case mix adjustment. 115
KCE Reports 113 Volume Outcome 139 Key points on volume outcome association for carotid endarterectomy (CEA) and carotid stenting (CAS) • In the Minimal Clinical Data 2004, we identified a total of 3 368 hospital stays during which CEA (2 860 stays; 85%) or CAS (508 stays; 15%) was performed. Identification of CAS procedures in MCD is difficult because of lack of a specific procedure code, and, therefore, probably not complete in this study. • A total of 110 hospitals performed CAS/CEA procedures in 2004, with an average of 31 interventions (median 24). The average CEA volume per surgeon is 12 per year, performed by 236 surgeons. • International thresholds for CEA defined by AHRQ and Leapfrog were 50 or 100 procedures per centre per year. In 2004, however, CEA was removed from the Leapfrog list of targeted procedures because the inverse association between volume and mortality was consistent but very weak. • In-hospital mortality (retrieved from MCD) is a very rare event (
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