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

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198 Volume Outcome KCE reports 113 Table 7.31: Total knee arthroplasty: Case mix description by volume category of surgeon Tertile based on volume ≤7 TKR 7 TKR > and ≤21 >21 TKR Number surgeons 177 149 162 488 Number stays 611 2062 8344 11017 Male % 25.5 28.1 28.1 27.9 Age Mean 68.3 69.5 69.7 69.6 Std 11.6 9.8 9.4 9.7 Charlson index score TKR Mean 0.5 0.5 0.5 0.5 Std 1.1 1.0 0.9 1.0 Charlson ≥ 3 Principal diagnosis % 5.2 4.8 4.4 4.5 715 Osteoarthrosis % 96.7 95.9 97.1 96.9 736 Other acquired deformities of limbs % 0.2 0.7 1.3 1.1 Other principal diagnosis Severity index (APR-DRG) for stays with % 3.1 3.4 1.6 2.0 principal diagnosis 715 All 591 1977 8104 10672 1 % 48.6 47.8 49.9 49.4 2 % 43.3 43.6 42.9 43.1 3 % 7.8 7.8 6.7 6.9 4 % 0.3 0.9 0.6 0.6 Complication rate (any) within 90 days % 3.9 3.2 3.1 3.2 Revision within 1 year % 1.1 1.1 0.9 1.0 RELATION BETWEEN SURGEON VOLUME AND 90-DAY COMPLICATION (ANY) RATE As presented in Table 7.32, the association between a 10% increase in surgeon volume and complication rate was an effect of -2.29% (-3.96%, -0.62%), without adjusting for case-mix differences. Case-mix has no impact of since the effect sustains after such casemix adjustment although the decrease is slightly less important (-2.16; -3.82%, -0.5%). Both effects were statistically significant. Similar to the results by hospital, odds for complication are worse for women. Table 7.32: Total knee arthroplasty: Results of regression: relative effects of 10% increase volume of surgeon on 90-day complication (any) Model without adjustment for case mix Effect 1 95% CI Surgeon volume (increase of 10%) -2.29 -3.96 -0.62 Model with adjustment for case mix Effect 1 95% CI Surgeon volume (increase of 10%) -2.16 -3.82 -0.50 Odds Ratio 95% CI Sex (male vs. female) 0.55 0.34 0.88 Age (increase of 1 year) 0.96 0.94 0.98 Charlson score (increase of 1 category) 1.19 0.89 1.60 715 vs. other PDX 2.34 0.56 9.72 1 Effect of 10% increase in volume of surgeon on the odds of complication within 90 days
KCE Reports 113 Volume Outcome 199 RELATION BETWEEN SURGEON VOLUME AND REVISION RATE AT 1 YEAR Logistic regression results for the revision rate are presented in Table 7.33. There was an effect of -3.72% (-5.94%, -1.5%) on the revision rate when the volume of surgeon increased by 10%. When we adjusted for case-mix, this effect was slightly reduced to - 3.65%, but it remained statistically significant. Table 7.33: Total knee arthroplasty: Results of regression: relative effects of 10% increase volume of surgeon on revision rate within 1 year Model without adjustment for case mix Effect 1 95% CI Surgeon volume (increase of 10%) -3.72 -5.94 -1.50 Model with adjustment for case mix Effect1 95% CI Surgeon volume (increase of 10%) -3.65 -5.86 -1.44 Odds Ratio 95% CI Sex (male vs. female) 0.56 0.35 0.91 Age (increase of 1 year) 0.96 0.94 0.98 Charlson score (increase of 1 category) 1.14 0.83 1.55 715 vs. other PDX 2.31 0.55 9.75 1 Effect of 10% increase in volume of surgeon on the odds of revision within 1 year 7.2.7 Discussion 7.2.7.1 External validation of the definition of the procedure We analyzed about 11 000 stays out of 14 000 stays (revisions included) identified in the MFD or MCD with a code of knee arthroplasty (see Table 7.19). When we take into account a yearly increase in numbers, our number corresponds well with the annual number of stays observed in the MCD between 1997 and 2002, which was around 10 000 (revisions included) in the KCE report by Jacques et al.. 246 7.2.7.2 Summarized results of literature review The systematic literature search identified seven systematic reviews in which the VOA for TKR was studied. 1, 5, 59, 60, 62, 64, 68 In all, these systematic reviews identified 16 primary studies of which 5 were published between 2002 and 2004, 325-329 and 10 between 1995 and 1999. 309, 317, 321, 330-336 This number was considered sufficient for the discussion. The best systematic review is the meta-analysis by Stengel et al. because it is quite recent (2004) and of good quality (see Appendix 7). 68 Stengel et al. meta-analysed data from 5 articles of which 4 included risk-adjustment. 309, 317, 326, 328, 329 They analyzed the effect of hospital volume on in-hospital mortality, 90-day mortality, overall complication rate, infection rate and DVT rate. The results of these analyses are described in Appendix 10, and are mentioned in the discussion below. 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 in-hospital mortality. For post-operative complications, on the other hand, there were conflicting results in relation to the association with hospital volume. The term “conflicting results” is used because there is a mix of primary studies that indicate a positive relation with volume and others that indicate a negative relation with volume. Since there was only one low-quality systematic review which studied the revision rate, these results could not be summarized in the evidence table in Appendix 10. 62
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