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

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14 Volume Outcome KCE reports 113 2.3.2.1 Selection of procedures and conditions Firstly, the exclusion of a surgical procedure or medical condition for further analysis in Belgian data is based on following criteria: 1. Hospital stays in relation with this procedure or condition cannot be retrieved from the Belgian Minimal Clinical and Financial Data (MCD/MFD). • First, MCD/MFD of day-care hospital stays cannot be linked to the IMA- AIM data because of lack of correspondence tables between both databases. This implicates that out-of-hospital mortality cannot be obtained for these stays, rendering them unsuitable for analysis. Following procedures and conditions are largely performed in day-care and are therefore excluded from the analysis: cardiac catheterization, cataract surgery and inguinal hernia repair. • Second, some procedures or conditions are very difficult to identify in the MCD/MFD. In most volume outcome studies analyzing severe trauma patients, hospital stays are identified through a severity of injury score. 20 Since a similar score is not available in the MCD/MFD, trauma is excluded from analysis. 2. Procedure or treatment is already regionalized (i.e. performed in a limited number of centres) in Belgium. • In the areas of paediatric heart surgery, paediatric oncology, placement of ventriculoperitoneal shunt in paediatric surgery and overall care and treatment of human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) the provision of health care services has already been regionalized, which means that these services are already limited to expert centres. 3. Procedure or condition is rare. • Surgery for acoustic neurinoma (also called vestibular Schwannoma), pancreatic transplantation are procedures of which there are only a few cases a year in Belgium, which makes them unsuitable for analysis. 4. Volume-outcome relation was studied in previous KCE reports. • Acute myocardial infarction has been studied previously. 57 5. Outcome measure cannot be analyzed with the available data. • The out-of-hospital mortality data are available until the year 2006. Readmissions can be investigated until 2005. Several procedures or conditions have outcome measures on the long term, for example, rejection rate after kidney transplantation, amputation rate after lower extremity arterial bypass, incontinence after transurethral prostatectomy, or adhesions in women who had a caesarean section. 6. Procedure or condition is too heterogeneous or there is an overlap with other procedures. • Craniotomy, cholecystectomy, intensive care, respiratory insufficiency, COPD, urinary infection, and cirrhosis, all represent very heterogeneous patient populations. • Mechanical circulatory support and pelvic cancer surgery are complex interventions which overlap with other procedures. 7. There is not enough information on the stage of the cancers in the BCR data. For the following cancers, for example, the BCR data have only limited information on the stage: C22 Liver and intrahepatic bile ducts (44% of records with known Combined-stade); C56 Ovary (54%); C32 Larynx (53%). 58 Details on the selection process for each individual procedure or condition are described in Appendix 6.
KCE Reports 113 Volume Outcome 15 The initial idea was to study the volume outcome relationship for 32 procedures and medical conditions. To this end, we selected more than 400 000 hospital stays in the MCD 2004. This large amount of data, however, obliged us to limit the IMA data that were linked to MCD; although IMA has information on the use of (neo) adjuvant therapy, only the decease date of patients was retrieved from the IMA database. Nevertheless, when we were faced with the abundance of 32 procedures and conditions, it was decided to limit the analyses to 12 surgical procedures. These were chosen from 3 medical domains: four cardiovascular procedures, three orthopaedic and five oncologic procedures. The choice of procedures was done in agreement with Belgian Cancer Registry and internal KCE experts. 12 procedures will be analysed in Belgian data: Four cardiovascular procedures: carotid endarterectomy and carotid stenting; coronary artery bypass graft; heart valve replacement or repair; percutaneous coronary intervention. Three orthopaedic procedures: total hip replacement; total knee replacement; hip fracture surgery. Five oncologic procedures: oesophageal cancer surgery; pancreatic cancer surgery; colon cancer surgery; breast cancer surgery and lung cancer surgery. 2.3.2.2 Available outcome measures The following information is unavailable in the data: 1. Mortality within a very specific time frame i.e. 30-day mortality is impossible since the IMA-AIM mortality date only mentions month and year of decease. As best possible approximation of the 30-day mortality, we included the mortality until the last day of the month following the procedure. For convenience, this is called the approximate 30 day-mortality. The reader should be aware, though, that this outcome measure covers a post-operative window of at most 60 days. Two examples might clarify: • If a patient undergoes a CABG on January 1 st , 2004 and the data tell us that he deceased by the end of February 2004, we know that he lived at least 30 days but less than 60 days after the CABG. • A patient who has a PCI on January 31 st , 2004, who is deceased by the end of February 2004, will have lived at least 1 day but less than 30 days after the PCI. 2. Mortality data for this project (provided by IMA-AIM) were only available until the end of 2006. Consequently, mortality of three years or more after a procedure (which took place in 2004) is not available. This implies that twoyear survival is the maximum feasible outcome measure for long-term mortality. 3. Complication rates within a specific time frame are unavailable because the MCD admission date only specifies month and year. This makes it, for example, impossible to study the 30-day infection rate. 4. Information about cancer recurrence is not readily available in the BCR data. Although information on the length of stay and costs of hospital stays is available in the MFD, these measures will not be analysed while this study focuses on clinical endpoints and not on resource utilization. Table 2.1 gives an overview of the procedures and their outcome variables that were selected to be analysed with Belgian data.
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