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

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182 Volume Outcome KCE reports 113 Since there was only one systematic review which studied other outcome measures such as revision rate and 90-day complication rate, these results could not be summarized in the evidence table in Appendix 10. 62 Detailed results of the literature review, using the data extraction template, are described in the evidence tables in Appendix 10. 7.1.7.3 Comparative analysis of literature and Belgian data DEFINITION OF VOLUME As shown in Table 7.6, Belgian hospitals had a mean annual elective THR volume of 103 in 2004; median is 84; 75 th Percentile is 121. These volumes seem higher than in the US, where 44% of US hospitals performed ten or fewer elective THR, in 2003. 323 Table 7.7 shows that Belgian orthopaedic surgeons performed on average 23 elective THR in 2004; median is 11; 75 th Percentile is 27 THR per year. These annual volumes per surgeon seem rather high when compared with foreign data. Zahn et al. calculated that 28% of all US elective THR in 2003 were performed by surgeons who carried out five or fewer of these procedures annually. 323 In Belgium, in 2004, only 5% of elective THR were performed by surgeons with six or fewer elective THR (see Table 7.14). It has to be mentioned that elective surgery can be supply induced. OUTCOME A great disadvantage of the MCD is the fact that they do not capture clinically relevant outcome measures such as loss of dependence, loss of mobility or residual pain. In addition, it has to be acknowledged that the Charlson score is an inappropriate score for risk adjustment. For orthopaedic surgery, the Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) adapted for orthopaedic patients was assessed as a useful tool to predict morbidity and mortality. 324 However, the orthopaedic POSSUM system includes a physiological assessment and an analysis of operative severity; information that is not available in the MCD. In-hospital mortality after total hip replacement Although it was decided not to study the volume-outcome association for in-hospital mortality after THR, it remains interesting to compare this study’s unadjusted percentages with other studies. The in-hospital mortality rate associated with THR was 0.24% in this KCE study (see Table 7.8). Zahn et al. used 2003 nationwide United States data and they reported a similar in-hospital mortality rate of 0.33% (95% CI 0.27%, 0.36%). 323 90-day complication rate after total hip replacement Table 7.17 gives an overview of the rates that were found in the primary studies, in comparison with those found in this KCE study. Overall, the 90-day complication rates after THR are lower in Belgian administrative data than in those published by Katz and Solomon. Katz et al. published 90-day postoperative outcomes based on Medicare US claims data for 1995-1996. 311 The complication rates were respectively 3.13% (hip dislocation), 0.23% (deep wound infection) and 0.93% (pulmonary embolism). Solomon et al. used a subset of Katz’s data and found 0.4% postoperative deep wound infection within 90 days and 2.3% hip dislocation within 90 days. 315 Table 7.17: Total hip arthroplasty: 90-day complication rate: comparison of Volume-Outcome KCE study with scientific literature COMPLICATION WITHIN 90 DAYS KCE study Volume outcome Katz 2001 USA Solomon 2002 USA Pulmonary embolism 0.38% 0.93% - Deep wound infection 0.18% 0.23% 0.4% Dislocation of hip 1.69% 3.13% 2.3%
KCE Reports 113 Volume Outcome 183 There are several possible explanations for these differences. First, deep wound infection was defined differently by Katz and Solomon. They only included deep wound infections that required either surgical debridement or removal of the prosthesis, while the KCE study searched for the diagnostic code 996.66 “Infection and inflammatory reaction due to internal joint prosthesis”. Second, the low 90-day complication rates are probably related to the fact that complications are not well coded in the MCD. As it happens, a previous KCE study assessed the accuracy of Belgian MCD for detecting adverse events. Gillet et al. 111 concluded that deep venous thrombosis or pulmonary embolism and postoperative wound infection were no valid indicators for an adequate detection of these adverse events. In case of pulmonary embolism and deep venous thrombosis, these results are surprising since the diagnostic codes 415.1 and 451.1x have an initial level of severity of, respectively, 3 and 4. Omitting to code them is not in the interest of the hospital since the Belgian hospital financing system is based on the hospital case-mix. The diagnostic code for deep wound infection (996.66), on the other hand, has an initial level of severity that equals 1, which means that coding it cannot modify the stays global level of severity. On the basis of these practical implications, one would expect that hospitals would be financially motivated to encode DVT and pulmonary embolism. The report by Gillet et al. proved this assumption to be wrong. 111 Third, Katz and Solomon used both inpatient as outpatient claims data. Fourth, Katz and Solomon took into account secondary diagnoses coded during readmissions to calculate the complication rate, whereas the KCE study did not include the secondary diagnoses. As the population might have needed orthopaedic care for other joints than the operated hip due to their degenerative disease or arthritis, we chose not to select complication codes present as secondary diagnoses in posterior stays. Consequently, the reliability of the link to the hip placement was preferred to the detriment of a possible underestimation of the rate. Fifth, the selection process applied in our study focused on single total hip arthroplasty, excluding bilateral procedures and patients with more than one procedure during 2004- 2005. These patients stayed included in the US studies. Finally, Katz and Solomon, on the other hand, excluded patients who were less than 65 years old. Revision rate at 18 months after total hip replacement Table 7.18 shows similar revision rates at 18 months in different studies. The 1.84% revision rate in the 2004 Belgian MCD (see Table 7.10) is very comparable to the +/- 2% which was observed by Losina et al. in the Medicare claims data for 1995-1996. 314 In 2000, Diels et al. calculated an 18 month revision rate of approximately 1.5% among all members of the Belgian Christian Sickness Funds who underwent a total hip replacement between 1990 and 1999. 312 Table 7.18: Total hip arthroplasty: revision rate at 18 months: comparison of Volume-Outcome KCE study with other studies COMPLICATION WITHIN 18 MONTHS KCE study Volume outcome Losina 2004 USA Diels 2000 Belgium Revision rate at 18 months 1.84% +/- 2% +/- 1.5% PATIENT CASE MIX Table 7.11 and Table 7.14 showed that low-volume hospitals (
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