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

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154 Volume Outcome KCE reports 113 These scores, however, could not be used in this study because their clinical parameters are not available in the MCD. The STS score is comprised of over 40 clinical parameters, whereas the EuroSCORE involves 18 clinical characteristics. 276, 277 The EuroSCORE system identified three groups of risk factors (with their weights i.e. additive % predicted mortality in brackets): • Patient-related factors were age over 60 (one per 5 years or part thereof), female (1), chronic pulmonary disease (1), extracardiac arteriopathy (2), neurological dysfunction (2), previous cardiac surgery (3), serum creatinine >200 micromol/l (2), active endocarditis (3) and critical preoperative state (3). • Cardiac factors were unstable angina on intravenous nitrates (2), reduced left ventricular ejection fraction (30-50%: 1,
KCE Reports 113 Volume Outcome 155 Key points on volume outcome association for coronary artery bypass grafting (CABG) with/without heart valve replacement or repair • In the Minimal Clinical Data 2004, we identified a total of 10 679 hospital stays during which CABG with/without heart valve replacement or repair was performed. Three types of procedures are distinguished: 7 071 isolated CABG; 1 655 CABG combined with heart valve replacement/repair; 1 953 isolated heart valve replacement/repair. • These procedures were performed in the 29 so-called B2 and B3 cardiology services. With respect to isolated CABG, these centres had a mean annual volume of 243 CABGs per year (median 211). The average CABG volume per surgeon is 68 per year, performed by 100 surgeons. • The cut off of 200 CABG procedures is actually still considered sufficient to maintain quality according to both the American College of Surgeons as the AHRQ. In 2004, 16 out of 29 Belgian B2/B3 centres reached this volume threshold. • In this study, in-hospital mortality (retrieved from MCD) was 4.7% overall: 3.5% after isolated CABG, 5.6% after isolated heart valve procedure, and 8.6% after combined intervention. In-hospital mortality combined with approximate 30-day mortality was 5.15%. Regression models were fitted to assess the association between hospital or surgeon volume on this outcome. The following factors were taken into account in all analyses: age, sex, Charlson score (co morbidity), principal diagnosis and type of procedure (isolated CABG, isolated heart valve or both combined). • CABG is probably the most studied procedure in the volume outcome relationship, starting in the early 80s. Old studies showed a very consistent and strong effect of volume of centre and surgeon, while results of more recent studies are less straightforward. • Belgian data showed a consistent effect of hospital volume on in-hospital mortality: 5.3% in low volume centres (= 200/year). This association was not explained by observed differences in case mix. An inverse association was also observed for combined interventions, but not for the isolated heart valve repairs or replacements. • With respect to the association between surgeon volume and in-hospital mortality, the findings of the literature review are confirmed by Belgian data: there is an inverse association between both although the effect is smaller than with hospital volume. • Off pump CABGs are not identifiable in the MCD and can therefore not be taken into account in the case-mix adjustment. • With respect to cardiac surgery, the EuroSCORE (the most frequently used risk profile system in cardiology) would be better for risk adjustment than the applied Charlson score (which takes into account only co morbidities and not patient disease severity). These clinical parameters are, however, not encoded in the MCD.
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KCE reports 1. Effectiviteit en kos
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73. Financiering van het zorgprogra
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