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

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184 Volume Outcome KCE reports 113 VOLUME OUTCOME ASSOCIATION RELATION BETWEEN HOSPITAL OR SURGEON VOLUME AND 90-DAY COMPLICATION (ANY) RATE After adjustment for age, gender, Charlson score and principal diagnosis, higher hospital volume was associated with a lower rate of complications within 90 days after the index THR, but the trend did not reach significance (see Table 7.12). Higher surgeon volume, on the other hand, was statistically significant associated with a lower 90-day complication rate (see Table 7.15). Katz and colleagues assessed the relationship between surgeon and hospital procedure volume and mortality, hip dislocation, deep wound infection (requiring surgical debridement or removal of the prosthesis) and pulmonary embolism in the first ninety days postoperatively. 311 This assessment was done with claims data of Medicare patients who underwent an elective THR in 1995-1996. Analyses were adjusted for age, gender, arthritis diagnosis, a proxy for low income and the Charlson co-morbidity index. In addition, analyses of hospital volume were adjusted for surgeon volume, and analyses of surgeon volume were adjusted for hospital volume. Higher hospital volume was significantly associated with lower rates of 90-day mortality and hip dislocation after primary total hip replacement (p value 25 THR/year had lower failure rates than hospitals with less THR. For low-volume surgeons, there was no association between revision rate and hospital volume. 314
KCE Reports 113 Volume Outcome 185 Espehaug and al. found a similar association between hospital volume and revision rate at 4 years (threshold at 11 THR/year). In addition, they investigated the effect of cemented versus uncemented prostheses and found that the volume effect was primarily seen in patients who received uncemented prostheses. 318 Diels and colleagues also found an association between hospital volume and revision rate; when the hospital volume increased with one THR procedure, the revision risk decreased with 0.3%. Their analyses also showed that patients with an uncemented prosthesis had 50% more risk of a revision than patients with a cemented monobloc inox-prosthesis. 312 RELATION BETWEEN HOSPITAL OR SURGEON VOLUME AND POSTOPERATIVE FUNCTIONAL STATUS AND PAIN RELIEF Although these outcome measures could not be studied in the Belgian MCD, it seems important to discuss the results of other studies on this topic to provide a more complete picture of the influence of volume on outcome. Katz and colleagues evaluated whether hospital and surgeon volume of THR are associated with patient-reported pain and functional status (the so-called Harris hip score) and satisfaction with surgery 3 year postoperatively. 322 As mentioned earlier, Katz et al. observed that patients with low levels of income and education and those with worse recalled preoperative functional status, were more likely to have THR performed at low-volume hospitals. Before adjusting for these factors, low hospital volume was associated with worse Harris hip scores at follow-up. After adjustment for socio-demographic and clinical variables, however, the association between higher hospital volume and better functional status following primary THR was weak and statistically non-significant. Satisfaction with primary THR, on the other hand, remained greater among patients whose operations were performed in higher-volume hospitals. Thompson and colleagues used medical records and questionnaires to assess the association between hospital and surgeon volume of elective THR and several outcomes i.e. in-hospital operative complications, in-hospital general complications, 6-month difficulty walking and 6-month residual pain. 316 Contrary to most other studies that are limited to claims data, Thompson disposed of a variety of preoperative clinical risk factors for case-mix adjustment, i.e. activity level, ADL scale, ASA score, walking distance and hip pain score. He also made separate analyzes for patients receiving cementless and cemented prostheses. Thompson et al. did not conclude that, in general, surgeon nor hospital volume had any significant association with the likelihood of operative or general complications, nor with walking and pain outcomes.
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