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

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20 Volume Outcome KCE reports 113 MAIN FINDINGS (on volume outcome association) INVERSE relation between: - hospital volume - mortality - surgeon volume – mortality Heart valve replacement or repair Limited evidence does not allow a conclusion on the VOA for heart valve replacement or repair. Percutaneous coronary intervention (PCI) CONFLICTING results (i.e. mix of positive and negative relation) for: - hospital volume - mortality for PCI for mixed indications - operator volume – mortality for PCI for mixed indications - hospital volume – emergency CABG rate INVERSE relation between: - hospital volume – mortality for primary PCI - operator volume – mortality for primary PCI - operator volume - emergency CABG rate Orthopaedic procedures Total hip arthroplasty/replacement (THR) CONFLICTING results (i.e. mix of positive, negative and no relation) for: - hospital volume – in-hospital mortality Total knee arthroplasty/replacement (TKR) INVERSE relation between: - hospital volume - mortality CONFLICTING results (i.e. mix of positive and negative relation) for: hospital volume – post-operative complication rate Hip fracture surgery INVERSE relation between: - hospital volume - mortality THRESHOLD VOLUME Minimal hospital volume threshold = 200 CABG per annum. QUALITY OF EVIDENCE - 1 out of 7 SRs has Grade B evidence level 60 1, 5, 59, 62, 64, 66 - 6 out of 7 SRs have Grade C evidence level No threshold available. Only 1 SR with Grade C evidence level. 62 Minimal hospital volume threshold: - threshold 1: 200 PCI per annum - threshold 2: 400 PCI per annum. Minimal hospital volume threshold: - threshold 1: 10 THR per annum - threshold 2: 100 THR per annum. Minimal hospital volume threshold: - threshold 1: 10 TKR per annum - threshold:2 100 TKR per annum. 5, 60, 67 - 3 out of 6 SRs have Grade B evidence level 1, 59, 64 - 3 out of 6 SRs have Grade C evidence level - 1 out of 5 SRs has Grade B evidence level 60 1, 5, 59, 62 - 4 out of 5 SRs have Grade C evidence level - 1 SR has Grade B evidence level 68 1, 5, 59, 60, 62, 64 - 6 out of 7 SRs have Grade C evidence level 1, 5, 64 Threshold not possible to summarize. - 3 out of 3 SRs have Grade C evidence level
KCE Reports 113 Volume Outcome 21 3 CRITICAL REVIEW OF METHODS TO ASSESS THE VOLUME OUTCOME RELATIONSHIP 3.1 INTRODUCTION After considering the available evidence on the volume-outcome relationship, it is important to address a series of more methodological questions. These questions include: the completeness and reliability of administrative data, the determination of the volume (surgeon or centre), the statistical methods used, the need for adjustment for case-mix and the causal linkage. This will help not only to place individual studies in perspective, but also to understand why findings may vary across studies. 82 3.2 RESEARCH QUESTION The second research question of this project is the following: What are the different statistical methods used in the literature to assess the volume-outcome relationship in the health care context, and which of these methods specifically assess the question of the causality? The aim of this chapter is to guide the reader through the different statistical methodologies that have been used so far in that area, to critically assess these methods (pros and cons), and to provide a list of useful methodological references. 3.3 METHODS 3.3.1 Search strategy to select articles The purpose of this review was to identify methods used to analyze the volumeoutcome relationship in the health care context. The limitations of such review need to be acknowledged. While a systematic search of the literature is fully appropriate when answering questions about clinical effects (as in the first question), such search becomes quickly tricky when the aim is to review methods. First because systematic search always rely to some extend to the quality and consistency of the coding of the keywords, and the usual clinical databases (Medline and Embase) are meant for that purpose (keywords not specific enough). Second because good methodological references are often books, not articles, discussing methods that are not specific to the volume outcome relationship but can be used to address it. Therefore, the search was less systematic than in the first chapter, and served mainly to identify and describe the methods used in the volume outcome literature. Our first step was thus to identify important key words used in analysis of volumeoutcome studies. To that end, eight journals with strong methodological emphasis were searched (Statistics in Medicine, Statistical Methods in Medical Research, Biometrics, Journal of Clinical Epidemiology, Journal of Epidemiology and Community Health, Controlled Clinical Trials, Clinical Trials, Journal of biopharmaceutical statistics), with “volume OR outcome” as text in the title, abstract, keywords and text. Based on the articles selected, a list of keywords was identified, and the MESH equivalent of these keywords was searched. The results are: • ("Diagnosis-Related Groups"[Mesh] OR "Risk Adjustment"[Mesh]) • "Cluster Analysis"[Mesh] • "Causality"[Mesh] • "Longitudinal Studies"[Mesh] Because not all keywords had a MESH-equivalent, some searches were also based on text only: • instrumental • threshold
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73. Financiering van het zorgprogra
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