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

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152 Volume Outcome KCE reports 113 These data are introduced by the cardio-thoracic surgeons in the registry of the BWGIC and the BACTS, and unlike the NIHDI data, the BWGIC data are not used to invoice services but for peer reviewed quality control. The absolute number of CABG corresponds to the selection in our project, but the percentage of CABG combined with heart valve is higher with our definition. There are thus more combined procedures identified in the administrative database than in the registry. This is in contradiction with what was observed in the study of Shahian, which compared definitions of combined CABG-heart valve procedures between clinical and administrative databases. 266 Table 6.24: Number of CABG and heart valve repairs or replacements: Comparison with BWGIC KCE project 2004 Volume Outcome BWGIC 2004 Number Pct. Number Pct. Isolated CABG 7 071 81% 7 422 85% CABG & valve 1 655 19% 1 338 15% Total CABG 8 726 100% 8 760 100% 6.2.7.2 Summarized results of literature review The systematic literature search identified seven systematic reviews (SR) in which the volume outcome association (VOA) for CABG was studied. 1, 5, 59, 60, 62, 64, 66 In all, these systematic reviews identified 29 primary studies of which 10 were published between 2000 and 2004. 93, 115, 116, 267-273 This number was considered sufficient for the discussion. Because the SR by Kalant et al. focuses on CABG, it will be discussed first, followed by the primary studies. d The systematic review by Kalant in 2004 focuses on the relationship between CABG volume and outcome and includes 16 primary studies with CABG performed between 1972 and 1999. The main conclusion of that review is that, although studies from the 70’s and the 80’s clearly showed that better outcomes were achieved in high volume centres, this relationship has been virtually eliminated in more recent studies. This is explained by the authors by the results of “multifaceted learning curves, improved surgical training and technical advances”. Their conclusion is based on all studies comparing low volume centres (usually < 200 interventions per year) to high volume centres (> 200 interventions per year), and showing odds ratio very close to 1 for the recent studies. 66 On the basis of all seven systematic reviews, it was concluded in Chapter 2 (see Table 2.2 on page 19) that there is an inverse relation between hospital volume and mortality, and between surgeon volume and mortality. It was emphasised, however, that only one out of 7 SRS had a Grade B evidence level. A detailed description of this evidence is available in Appendix 9. 6.2.7.3 Comparative analysis of literature and Belgian data DEFINITION OF VOLUME The total volume in our study is based on the sum of all isolated CABG, all CABG with intervention on heart valve and all isolated heart valve interventions performed in 2004. A total of 10 673 stays are included in the analysis, distributed over the 29 B2/B3 centres (mean of 367 interventions per centre) and 105 surgeons (mean of 101 interventions per surgeon). The mean annual volume of isolated CABG was 242 interventions per centre and 68 per surgeon. To compare the Belgian CABG volume to the current Leapfrog criterion of 450 CABG interventions per centre per year makes little sense, as this criterion has been heavily criticized. 33, 126 The cut off of 200 procedures is actually considered sufficient to maintain quality according to the American College of Surgeons. 33 Our data show that 16 out of 29 Belgian B2/B3 centres perform more than 200 CABG procedures per year. d The study of Nallamothu is not discussed here, because of the methodological problems described by Kalant. 268
KCE Reports 113 Volume Outcome 153 OUTCOME In this KCE study, in-hospital mortality was 4.7% overall: 3.5% after isolated CABG, 5.6% after isolated heart valve intervention, and 8.6% after combined intervention. The order of magnitude of these rates can be compared to the in-hospital mortality (or operative mortality, defined as in-hospital or within 30 days after operation) published by the studies summarized in Table 6.25. Differences in rates can be indicative of differences in patient population and procedure selection (isolated CABG or CABG and combined intervention). Table 6.25: CABG with/without heart valve repairs or replacements: Comparison of Volume-Outcome KCE study with primary studies Study Year of Type of procedure Mortality Age Male patients interven rate (mean or (%) -tions median) Volume 2004 Isolated CABG 3.5% 68 years (for 69.4% Outcome Isolated heart valve 5.6% all (for all study KCE Combination 8.6% procedures) procedures) Hannah 271 and Wu 273 1997- Isolated CABG 2.2% - - 1999 Peterson 272 2000- 2001 Isolated CABG 2.7% 66 years 70.7-72.1% Christian 93 1999- 2000 Isolated CABG 3.9% 65.5 years 71% Carey 269 1997- Isolated CABG 3.0% - - 1999 Isolated heart valve 5.0% Combination 9.2% Birkmeyer 115, 1994- Isolated CABG From 4.8% 64.6-65.1% 116 1999 to 6.1% Gammie 274 2000- 2003 Isolated Heart valve 2.12% Ricciardi 275 2003 CABG (isolated and combined) 3.3% 67.5% PATIENT CASE MIX The age of patients (mean age is 68 years old) and 69.4% of them are male. This is comparable to studies described in literature (see Table 6.25). However, the percent of patients with a Charlson score ≥ 3, as described by Birkmeyer and Ricciardi, does not correspond at all to our data. Birkmeyer and Ricciardi describe that, respectively, 10 and 7% of patients in their study had a Charlson score ≥ 3. 115, 116, 275 This is not at all comparable to the 25% of patients in our study. This might be explained by the fact that in the studies of Birkmeyer, the Charlson Score excluded conditions that “were likely to reflect either the primary indication for surgery or postoperative complications”. The authors also explored two alternative approaches to incorporating coexisting conditions in their risk adjustment model, and reported that the three approaches gave virtually identical results. In our analyses, when principal diagnoses were not taken into account in the calculation of the Charlson score, the percent of patients with AMI (ICD-9 410 or 411) was still 22%. This can indicate some overcoding in the co morbidities in the MCD. No other clinical predictors of CABG mortality, such as those described by Hannan were available in our analysis (e.g. a lower ejection fraction, recent myocardial infarction, left main artery diseases, compromised hemodynamic state, previous open heart operation). 271 It has to be acknowledged that the Charlson score is not the most appropriate risk score for risk adjustment. For the prediction of mortality after cardiac surgery, the Society of Thoracic Surgeons mortality risk score (STS) and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) scoring system are the two most frequently used risk profile systems. 276
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