Centralisation: Putting Patients First
2010; Elsevier BV; Volume: 40; Issue: 5 Linguagem: Inglês
10.1016/j.ejvs.2010.08.019
ISSN1532-2165
Autores Tópico(s)Surgical Simulation and Training
ResumoIn the accompanying article, Marlow et al.1Marlow N.E. Barraclough B. Collier N.A. Dickinson I.C. Fawcett J. Graham J.C. Maddern G.J. Effect of hospital and surgeon volume on patient outcomes following treatment of abdominal aortic aneurysms: a systematic review.Eur J Vasc Endovasc Surg. 2010; 40: 572-579Google Scholar addressed the relationship between the annual caseload preformed by individual hospitals and the outcome from AAA repair. There are concerns, however, in respect to the incomplete search strategy and selective reporting employed, each of which alters the nature and strength of the conclusions. Only 22 articles were included in this time-limited review, which does not encompass the available literature. A more complete and similarly contemporary review has been published by a different research group and draws different conclusions from the data.2Karthikesalingam A. Hinchliffe R. Poloniecki J. Loftus I. Thompson M. Holt P. Centralization harnessing volume–outcome relationships in vascular surgery and aortic aneurysm care should not focus solely on threshold operative caseload.Vasc Endovascular Surg. 2010 Jul 30; Google Scholar The quality of the evidence in each of the published studies is dependent on the completeness and accuracy of the administrative datasets that they utilise. Whilst this and the validity of the design of health services research studies may be open to debate, they currently remain the best available tools from which to derive such evidence. One clear issue that the authors have not adequately addressed is that data drawn from numerous resources across different healthcare systems and analysed by numerous research groups using a variety of statistical methodologies have independently drawn the same conclusion: Higher volume hospitals have better outcomes for AAA repair. A relationship maintained even when highly complex risk adjustment models are employed, including multi-level modelling. In addition, these data have been subjected to meta-analysis previously, which provided an estimate of the relationship for both elective and ruptured AAA repair.3Holt P.J. Poloniecki J.D. Gerrard D. Loftus I.M. Thompson M.M. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery.Br J Surg. 2007; 94: 395-403Google Scholar, 4Young E.L. Holt P.J. Poloniecki J.D. Loftus I.M. Thompson M.M. Meta-analysis and systematic review of the relationship between surgeon annual caseload and mortality for elective open abdominal aortic aneurysm repairs.J Vasc Surg. 2007; 46: 1287-1294Google Scholar In both situations the volume–outcome relationship was shown to be one significant factor in achieving the best outcomes for patients. There are few such examples of absolute concordance within the medical literature. This concordance was highlighted further recently in the UK when surgeon’s own data, reported to a national newspaper as a Freedom of Information Act data request, were analysed.5Boseley S. Huge disparity in NHS death rates revealed. The Guardian, 2010 13th JuneGoogle Scholar The same conclusions were drawn that a volume–outcome relationship for AAA repair currently exists and is significant. The obvious conclusion of this finding is that a number of patients are dying each year in the UK unnecessarily from AAA repair, both elective and non-elective. The question of the effect of a volume–outcome relationship for EVAR and for ruptured AAA (rAAA) are rightly posed as secondary issues to that of elective open AAA repair. With respect to EVAR, large population-based studies from two healthcare systems have independently verified that even this minimally invasive modality of repair is best delivered from specialist institutions.6Holt P.J. Poloniecki J.D. Khalid U. Hinchliffe R.J. Loftus I.M. Thompson M.M. Effect of endovascular aneurysm repair on the volume–outcome relationship in aneurysm repair.Circ Cardiovasc Qual Outcomes. 2009; 2: 624-632Google Scholar, 7Dimick J.B. Upchurch Jr., G.R. Endovascular technology, hospital volume, and mortality with abdominal aortic aneurysm surgery.J Vasc Surg. 2008; 47: 1150-1154Google Scholar For rAAA, robust historical evidence exists through meta-analysis.3Holt P.J. Poloniecki J.D. Gerrard D. Loftus I.M. Thompson M.M. Meta-analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery.Br J Surg. 2007; 94: 395-403Google Scholar More recently, large studies from three countries, described how significant reductions in mortality were being achieved through rAAA repair being delivered in centres performing a large number of elective cases.8Holt P.J.E. Karthikesalingam A. Poloniecki J.D. Hinchliffe R.J. Loftus I.M. Thompson M.M. Ruptured aneurysms in England: a propensity scored analysis of outcomes.Br J Surg. 2010; 97: 496-503Google Scholar, 9Giles K.A. Hamdan A.D. Pomposelli F.B. Wyers M.C. Dahlberg S.E. Schermerhorn M.L. Population-based outcomes following endovascular and open repair of ruptured abdominal aortic aneurysms.J Endovasc Ther. 2009; 16: 554-564Google Scholar, 10Egorova N. Giacovelli J. Greco G. Gelijns A. Kent C.K. McKinsey J.F. National outcomes for the treatment of ruptured abdominal aortic aneurysm: comparison of open versus endovascular repairs.J Vasc Surg. 2008; 48: 1092-1100Google Scholar This appeared to be true whether surgery was undertaken using open or endovascular techniques, with EVAR conferring a benefit in addition to volume. Furthermore, high-volume hospitals operated on a higher percentage of patients with rAAA than smaller units, which served to reduce the overall population mortality from this condition. It is a concern that none of these more contemporary articles on EVAR or rAAA were included in Marlow’s review. Also omitted were crucial articles that defined patient preferences for aneurysm repair. These have been clear that patients wish to have routine access to EVAR in a service delivering low mortality and complication rates and, importantly, to be treated in centres performing over 50 AAA repairs per annum.11Reise J.A. Sheldon H. Earnshaw J. Naylor A.R. Dick F. Powell J.T. et al.Patient preference for surgical method of abdominal aortic aneurysm repair: postal survey.Eur J Vasc Endovasc Surg. 2010; 39: 55-61Google Scholar, 12Holt P.J.E. Gogalniceanu P. Murray S. Poloniecki J.D. Loftus I.M. Thompson M.M. Screened patients’ preferences in the delivery of abdominal aortic aneurysm repair: a rating scale analysis.Br J Surg. 2010; 97: 504-510Google Scholar Patients were willing to travel significant distances to be treated under these conditions, and patient preferences should not be underestimated in any service reorganisation. There is no doubt that a number of smaller hospitals have seemingly excellent results. However, with low case numbers the ability to prove evidence of surgical safety is not possible and so this statement is bounded in fallacy.13Holt P.J. Poloniecki J.D. Loftus I.M. Thompson M.M. Demonstrating safety through in-hospital mortality analysis following elective abdominal aortic aneurysm repair in England.Br J Surg. 2008; 95: 64-71Google Scholar Statistical evidence of safety can only be achieved in hospitals providing more than 50 elective repairs of AAA per annum if mean mortality rate of 3.5% is achieved. Some might argue that even this mortality rate is too high for elective infra-renal AAA repair. Further work is required to determine the complete nature of the volume–outcome relationship, the inter-relationship of outcomes of different procedures and in establishing why high-volume hospitals have better outcomes. This last point is perhaps the most critical as only once the mechanisms underlying the relationship are understood can the emphasis be moved away from ‘how many do I need to do’ towards ‘what organisational features are necessary to ensure the best results for patients.’ Finally, the authors assert “with the exception of the relationship between hospital and surgeon a volume and mortality, there is little comprehensive evidence for the centralisation of care of either unruptured or ruptured abdominal aortic aneurysms.” It would appear that the very relationship that they dismiss so readily is the critical reason to centralise AAA, in tandem with other vascular services. The relationship is robust and if centralisation does not follow, then health services and the medical profession will have failed their patients. Effect of Hospital and Surgeon Volume on Patient Outcomes Following Treatment of Abdominal Aortic Aneurysms: A Systematic ReviewEuropean Journal of Vascular and Endovascular SurgeryVol. 40Issue 5PreviewThis systematic review assessed the efficacy of centralisation for the treatment of unruptured and ruptured abdominal aortic aneurysms. Patient outcomes achieved by low and high volume hospitals/surgeons, including morbidity, mortality and length of hospital stay, were used as proxy measures of efficacy. Full-Text PDF Open Archive
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