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

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42 Volume Outcome KCE reports 113 date would therefore have enormous implications for the patient. When a hospital, on the other hand, encodes a death in the MCD, this has no consequences for the patient concerned since MCD data are only used for financing the hospital. 3. Complication rate during index admission or readmission: retrieved from the MCD. The problem with this outcome is that it relies heavily on the quality of the hospital coding. Since the recent KCE report by Gillet et al. pointed out that complication data based on MCD cannot be used for hospital benchmarking, only descriptive analyses are performed on the complication rate. 111 4.3 STATISTICAL ANALYSES ON VOLUME OUTCOME RELATIONSHIP 4.3.1 Funnel Plots Funnel plots as described in Chapter 2, are used as a first informal assessment of the volume-outcome relationship. 4.3.2 Risk adjustment For all procedures, different risk factors are taken into account in the regression models (no matter their statistical significance). These factors are 1. patient’s age (as a linear variable) 2. patient’s gender 3. principal diagnosis of admission (as categories combined based on frequencies and impact on mortality) 4. Charlson score (co-morbidity) 5. stage (for cancer procedures). The severity of illness (SOI) which is encoded in the MCD was not used for risk adjustment. The reason for this decision is the fact that SOI is encoded at the end of the admission which implies that the patient’s complications are taken into account. 4.3.2.1 Charlson score The Charlson score is a validated score based on patient’s co-morbidities, which predicts the 1-year mortality. 112-114 The Charlson score is the sum of some predefined weights attributed to some specific conditions (see Table 2.1). The higher the score, the higher the probability of 1-year mortality is. In the regression models applied in this report, the score is transformed into a five level scale 0, 1, 2, 3 and 4 respectively for scores 0, 1-2, 3-4, 5-6- and > 6, and is analyzed as a continuous variable, as suggested by D’Hoore. 114 The information on co-morbidities is retrieved from the variable ‘secondary diagnosis’ which is encoded in the MCD.
KCE Reports 113 Volume Outcome 43 Table 4.3: Charlson score: Scoring the co-morbidity index from secondary diagnoses Weight Conditions ICD-9-CM code 1 Myocardial infarct 410, 411 Congestive heart failure 398, 402, 428 Peripheral vascular disease 440-447 Dementia 290, 291, 294 Cerebrovascular disease 430-433, 435 Chronic pulmonary disease 491-493 Connective tissue disease 710, 714, 725 Ulcer disease 531-534 Mild liver disease 571, 573 2 Hemiplegia 342, 434, 436, 437 Moderate or severe renal disease 403, 404, 580-586 Diabetes 250 Any tumour 140-195 Leukaemia 204-208 Lymphoma 200, 202, 203 3 Moderate or severe liver disease 070, 570, 572 6 Metastatic solid tumour Source of data: D’hoore 196-199 114 A well known problem of the secondary diagnosis variable in the MCD data is that it is impossible to make the distinction between the complications which occurred during the hospital stay and the co-morbidities that were present at admission, as these are all together encoded in this same variable. c For all co-morbidities in the Charlson score, except acute myocardial infarction and cerebrovascular disease, it is a logical assumption that they were present at admission. For acute myocardial infarction and cerebrovascular disease, on the other hand, it is not clear whether they were present at admission or whether they were a complication of cardiovascular procedures. This implies that the Charlson score for patients who underwent a CEA or a PCI can be erroneously high because an AMI which occurred after the procedure was counted as co-morbidity. This problem was partially solved by excluding myocardial infarct and cerebrovascular diseases from the calculation of the Charlson score, which is called the modified Charlson score. This is in line with the approach followed by Birkmeyer in 115, 116 studies on cardiovascular procedures. When the Charlson score is used for risk adjustment in cancer surgery procedures, it is modified in a different way. In these cases, the two co-morbidity categories specific to cancer, i.e. any tumour and metastatic solid tumour, are excluded from the calculation of the Charlson score, based on methods previously described by others. 117 4.3.2.2 Cancer stage The stage of a cancer is a descriptor of how much the cancer has spread. The stage often takes into account the size of a tumour, whether it has invaded adjacent organs, how many lymph nodes it has metastasized to and whether it has spread to distant organs. Cancer stage is important because the stage at diagnosis is a powerful predictor of survival and often determines the kind of treatment. The TNM system is one of the most commonly used stage systems. It is based on the extent of the tumour (T), spread to the lymph nodes (N), and metastasis (spread to other parts of the body) (M). A number is added to each letter to indicate the size or extent of the tumour and the extent of spread. 118 c The new version of MCD, starting from the second part of 2008 and available from 2010 onward, will contain this information. 111
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