A volume-outcomes relationship has been shown in other forms of cardiothoracic surgery including coronary artery bypass grafting , pediatric cardiac surgery. Volume-outcome relationships in coronary artery bypass graft surgery patients: 5- year major cardiovascular event outcomes. Herng Ching Lin, Sudha Xirasagar. BackgroundThe impact of surgical risk on the relationship between hospital volume and outcomes in coronary artery bypass grafting (CABG) is uncertain.
This risk may be counteracted by the potential benefit of experience and facilities available at high-volume centers including multidisciplinary teams of cardiothoracic surgeons, consultant anesthetists, specialist nurses, the protocols and intensive care equipped to provide optimal post-operative cardiovascular support [ 12 ]. Creating specialist centers concentrates the cases of ATAAD and enables research, treatment advances and exposure and training in a risky and complex procedure. Two of the researchers MD and RA independently screened each of the 51 articles generated for inclusion against the inclusion and exclusion criteria Table 1.
The final list of generated articles by each researcher was cross-checked. The same two researchers then independently extracted data from articles which met the inclusion criteria into a preformatted excel database.
All data extracted was cross-checked. The articles representing the highest level of evidence were included in this study.
Results and Discussion 12 articles met the inclusion criteria Figure 1and relevant article details are presented in Supplementary Table 1. The overall in-hospital mortality was There was little relationship between mortality and hospital volume and a wide variation of in-hospital mortality around the country. In the most recent of these, Chikwe et al. There was insufficient data in this time period to calculate surgeon-specific volume.
In a similar study Iribarne et al. Multivariate regression revealed a significant effect of hospital volume on mortality rates LVC In the final of the 5 studies using the NIS database Zimmerman et al. One single-center study analyzed surgeon volume as a predictor of mortality. The range of surgical experience across all 8 surgeons was repairs, but the method for categorizing surgeons and the individual surgeon caseloads were not reported.
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Single-center cohort studies have been conducted in Germany, the UK and three have been conducted in the US. Ho expressed some concerns about unintended consequences of its application: The focus on high-volume providers may prove a distracting priority. More may not always be better: Might inappropriate utilization be stimulated by volume-based rewards? Procedures counting toward high volume may not always be indicated or appropriate.
More than a consensus on volume is needed.
Provider Group Perspective Dr. Nielsen described the overarching goals of the health care system —improving health status, access to care, and the coordination and continuity of care—and suggested that information that furthers these goals needs to be disseminated to all stakeholders in a form that is accurate, reliable, and easily understood.
In addition, higher volumes do not necessarily mean that there are decreases in associated morbidities such as infections or that certain critical steps in the process of care are utilized. There is the potential for misuse of such information, for example, misrepresentation in advertising. Furthermore, perverse incentives to do more procedures may well be created with the establishment of volume thresholds that could contribute to inappropriate care being rendered.
There is also a potential for consumers to misinterpret the information and make decisions about care that are unwarranted e. Nielsen concluded that volume should not be used alone but should instead be supplemented with ancillary information and disclosed with all of its caveats. Fraser from the Agency for Healthcare Research and Quality noted that much of the research conducted to date has examined the clinical processes of care that underlie the volume— outcome relationship, but it has not yet addressed how systems of care might mediate this relationship.
A study of the relationship between volume and outcome in acute myocardial infarction, for Page 15 Share Cite Suggested Citation: Knowing what systems of care are associated with the appropriate use of beta-blockers in high-volume hospitals is critical to implementing this finding. How the volume—outcome relationship varies by community or health care market, and how the relationship might vary within hospital and by procedure, has pragmatic implications.
A set of risk-adjusted quality indicators has been developed that could be used as benchmarks for health services researchers. Procedure-specific data sets could be produced for researchers with a specialty interest. Market-specific data, even if qualitative, would be of interest to purchasers to assist in their decision-making.
Exceptions to the expected relationship—for example, high-volume, low-quality hospitals, could be explained by a low pricing strategy adopted by a particular hospital. Fraser suggests that research is also needed on the process and outcome of the purchasing strategy itself—its consequences on the quality of care and its market impact.
For implementation, we need to know what kinds of data are most useful to purchasers and how employees can best use this information.
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Fraser also pointed out that consumer use of information about volume of services is limited by the fact that it is usually employers, not employees, who choose a health plan. Most employers offer only one or two plans to their employees, and a minority offers plans that provide a great deal of choice at the point of care. Berwick led off the discussion by asking whether the potential for unintended consequences of public disclosure of volume—outcome data was sufficient to delay or limit public disclosure.
Simone pointed out that consumers are bombarded with medical information, much of it through advertising. He suggested that consumers need explanation but that it cannot be too complicated. Chassin suggested that there are different thresholds for different actions. In his view, data on volume should be publicly available with appropriate explanation.
All states have some kind of hospital discharge database, and probably two-thirds of states have publicly available hospital data. New York, through its CON process, has utilized evidence on volume to achieve regionalized cardiac surgery. New York has 32 hospitals offering cardiac surgery, while California has such programs. The net effect is that close to 80 percent of patients having bypass surgery in New York obtain it in hospitals doing more than procedures a year.
In contrast, less than one-half of patients in California undergo surgery in such high-volume settings. The New York regulatory process exists alongside a voluntary program, the cardiac surgery reporting system.
With the adoption of these programs, there has been a significant decline in the mortality associated with cardiac surgery in New York, one that exceeds the general decline across the country. There is no evidence that the procedures are overused. In fact, estimates of rates of overuse of angioplasty, angiography, and bypass surgery are very low—4 percent for percutaneous cardiac angioplasy and 2 percent for bypass surgery. Furthermore, estimates of rates of underuse are similar to those observed in California.
Lastly, access to these procedures in New York and California is similar—patients need not travel farther for high-volume care. The combined regulatory and state-sponsored voluntary program works, but difficult political battles had to be won before it could be implemented Page 16 Share Cite Suggested Citation: DelBanco, from the Leapfrog Group, felt optimistic that its evidence-based outcome referral program would motivate change.
Hillner added that data systems tend to get better with use e. Hannan again stated the limitations of making inferences about the performance of individual providers with administrative data e.
Volume-Outcome Relationship for Coronary Artery Bypass Grafting in an Era of Decreasing Volume
Although these data can be used to say that, in the aggregate, outcomes for certain procedures are worse in low-volume hospitals, the performance of individual small-volume providers cannot be predicted with confidence because of the instability of small numbers e.
Similar problems arise when evaluating rare conditions or procedures e. Hannan recommends against using volume data alone to judge the performance of individual providers. Instead, volume data, if used, should be coupled with risk-adjusted outcome data from administrative databases or used in concert with crude mortality rates. The use of a combination of sources is preferable to using any nonclinical source alone. This will minimize referrals to the numerous high-volume hospitals with poor outcomes.
He also pointed out that referrals are generally made to physicians practicing within hospitals, and ideally, one would have quality data at both levels of care. Hannan suggests that the most important use of volume data is to identify processes and structures of care that distinguish high-and low-volume providers and that predict outcomes.Robotic Coronary Artery Bypass Surgery
Findings can then be used to enhance the performance of providers. In an examination of the surgeon volume—outcome relationship among patients undergoing carotid endarterectomy in New York State, volume effects disappeared when type of surgeon was controlled for in the analysis i.
Furthermore, the use of more appropriate medications and surgical techniques by vascular surgeons explained their mortality advantage.