State of evidence on the relationship between high-volume hospitals and outcomes in surgery: a systematic review of systematic reviews

Caseload per Year in Robotic-Assisted Minimally Invasive Esophagectomy: A Narrative Review

Esophageal surgery is deemed one of the most complex visceral operations. There is a well-documented correlation between higher caseload and better outcomes, with hospitals that perform more surgeries experiencing significantly lower mortality rates. The approach to caseload per year varies across different countries within Europe. Germany increased the minimum annual required caseload of complex esophageal surgeries from 10 to 26 starting in 2023. Furthermore, the new regulations present challenges for surgical training and staff recruitment, risking the further fragmentation of training programs. Enhanced regional cooperation is proposed as a solution to ensure comprehensive training. This review explores the benefits of robotic-assisted minimally invasive esophagectomy (RAMIE) in improving surgical precision and patient outcomes and aims to evaluate how the caseload per year influences the quality of patient care and the efficacy of surgical training, especially with the integration of advanced robotic techniques.

National centralization of Hirschsprung's disease in Sweden: a comparison of postoperative outcome

BACKGROUND

In Sweden, surgical treatment of Hirschsprung's disease (HSCR) was centralized from four to two pediatric surgery centers 1st of July 2018. In adults, centralization of surgical care for complex or rare diseases seems to improve quality of care. There is little evidence supporting centralization of pediatric surgical care. The aim of this study was to assess surgical management and postoperative outcome in HSCR patients following centralization of care.

METHODS

This study retrospectively analyzed data of patients with HSCR that had undergone pull-through at a pediatric surgery center in Sweden from 1st of July 2013 to 30th of June 2023. Patients managed from 1st of July 2013 to 30th of June 2018 (before centralization) were compared with patients managed from 1st of July 2018 to 30th of June 2023 (after centralization) regarding surgical treatment, unplanned procedures under general anesthesia or readmissions up to 90 days after pull-through as well as complications classified according to Clavien-Madadi up to 30 days after pull-through.

RESULTS

In the 5-year period prior to centralization, 114 individuals from 4 treating centers were included and compared to 83 patients from 2 treating centers in the second period. There was no difference regarding age at pull-through or proportion of patients with a stoma prior to pull-through. An increase of laparoscopically assisted endorectal pull-through (8.8% to 39.8%) was observed (p < 0.001). No significant differences were seen in postoperative hospital stay, unplanned procedures under general anesthesia, or readmissions up to 90 days after pull-through. There was no difference in severe complications (Clavien-Madadi ≥ 3); however, HAEC treated with antibiotics increased following centralization (10.5-24.1%; p = 0.018).

CONCLUSION

Centralization of care for HSCR does not seem to delay time to pull-through nor reduce severe complications, unplanned procedures under general anesthesia or readmissions up to 90 days after pull-through. The increased HAEC rate may be due to increased awareness of mild HAEC.

LEVEL OF EVIDENCE

 Level III.

The impact of distance to facility on treatment modality, short-term outcomes, and survival of patients with HPV-positive oropharyngeal squamous cell carcinoma

PURPOSE

This study compared treatment and outcomes for patients with HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) based on their travel distance to treatment facility.

MATERIALS AND METHODS

Patients with cT1-4, N0-3, M0 HPV-positive OPSCC in the National Cancer Database from 2010 to 2019 were identified and split into four quartiles based on distance to facility, with quartile 4 representing patients with furthest travel distances. Multivariable-adjusted logistic regression and Cox proportional hazards modeling were used to analyze the primary outcome of treatment received, and secondary outcomes of clinical stage, overall survival, surgical approach (i.e., TORS versus other), and 30-day surgical readmissions.

RESULTS

17,207 patients with HPV-positive OPSCC were evenly distributed into four quartiles. Compared to patients in quartile 1, patients in quartile 4 were 40 % less likely to receive radiation versus surgery (OR = 0.60; 95 % CI = 0.54-0.66). Among the patients who received surgery, quartile 4 had a higher odds of receiving TORS treatment compared to quartile 1 (4v1: OR = 2.38; 95 % CI = 2.05-2.77), quartile 2 (4v2: OR = 2.31, 95 % CI = 2.00-2.66), and quartile 3 (4v3: OR = 1.75; 95 % CI = 1.54-1.99). Quartile 4 had a decreased odds of mortality compared to Quartile 1 (4v1: OR = 0.87; 95 % CI = 0.79-0.97). There were no differences among the quartiles in presenting stage and 30-day readmissions.

CONCLUSIONS

This study found that patients with furthest travel distance to facility were more often treated surgically over non-surgical management, with TORS over open surgery, and had better overall survival. These findings highlight potential disparities in access to care for patients with HPV-positive OPSCC.

Health impact of borders: general reflections and a case study from the Polish-German border

BACKGROUND AND OBJECTIVE

Political, economic, communicative and cultural borders still limit the accessibility of acute healthcare services for patients so that they frequently have to accept longer distances to travel to the next provider within their own country. In this paper, we analyze the impact of borders and opening of borders on acute medical care in hospitals and on patients in border regions.

METHODS

We develop a conceptual framework model of cross-border healthcare and apply it to the Polish-German border area. The model combines the distance decay effect, a catchment area analysis, economies of scale and the learning curve.

RESULTS

Borders have a major impact on acute medical care in hospitals and on patients. Setting of new borders will reduce the accessibility of health facilities for patients or require the establishment of new hospitals. Reopening borders might induce a vicious circle leading to the insolvency of a hospital which might result in poorer health for some patients.

CONCLUSION

Strong effort should be invested to overcome political and cultural borders to improve the health of the population in border regions. Similarly, increased cross-border acute healthcare must be seen in the context of rural health and the special situation of small rural hospitals in rural peripheral areas.

Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds

Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.

[Effects of new minimum volume standards in visceral surgery on healthcare in Brandenburg, Germany, from the perspective of healthcare providers]

BACKGROUND

The legally prescribed minimum volume standards for complex esophageal and pancreatic surgery have been increased or will increase in 2023 and 2025, respectively. Hospitals not reaching the minimum volume standards are no longer allowed to perform these surgeries and are not entitled tor reimbursement.

OBJECTIVE

The study aims to explore which effects are expected by healthcare professionals and patient representatives and what possible solutions exist for Brandenburg, a rural federal state in northeast Germany.

MATERIAL AND METHODS

In this study 19 expert interviews were conducted with hospital employees (head/senior physicians, nursing director), resident physicians and patient representatives between July 2022 and January 2023. The data analysis was based on content analysis.

RESULTS

Healthcare professionals and patient representatives expect a redistribution into a few clinics for surgical care (specialized centres); conversely more clinics that do not (no longer) perform the defined surgeries but could function as gatekeeping hospitals for basic care, diagnostics and follow-up (regional centres). The redistribution could also impact forms of treatment that are not directly defined within the regulation for minimum volume standards. The increased thresholds could also affect medical training and staff recruitment. A solution could be collaborations between different hospitals, which would have to be structurally promoted.

CONCLUSION

The study showed that minimum volume standards not only influence the quality of outcomes and accessibility but also have a multitude of other effects. Particularly for rural regions, minimum volume standards are challenging for access to esophageal and pancreatic surgery as well as for communication between specialized and regional centres or resident providers.

Valve Surgery in a Low-Volume Center in a Low- and Middle-Income Country: A Retrospective Cross-Sectional Study

Background

Valvular heart disease (VHD) has a significant prevalence and mortality rate with surgical intervention continuing to be a cornerstone of therapy. We aim to report the outcome of patients undergoing heart valve surgery (HVS) in a low-volume center (LVC) in a low- and middle-income country (LMIC).

Methods

A cross-sectional retrospective study was conducted at the Jordan University Hospital (JUH), a tertiary teaching hospital in a developing country, between April 2014 and December 2019. Patients who underwent mitral valve replacement (MVR), aortic valve replacement (AVR), tricuspid valve replacement (TVR), double valve replacement (DVR), CABG + MVR, and CABG + AVR patients were included. Thirty-day and two-year mortalities were taken as the primary and secondary outcomes, respectively.

Results

A total number of 122 patients were included, and the mean age was 54.46 ± 14.89 years. AVR was most common (42.6%). There was no significant association between STS mortality score or Euroscore II with 30-day and 2-year mortality.

Conclusion

LVC will continue to have a role in LMICs, especially during development to HICs. Further global studies are needed to assert the safety of HVS in LVC and LMICs.

Surgeon supply and healthcare quality: Are revision rates for hip and knee replacements lower in hospitals that employ more surgeons?

We study the link between department-wide surgeon supply and quality of care for two major elective medical procedures. Several countries have adopted policies to concentrate medical procedures in high-volume hospitals. While higher patient volumes might translate to higher quality, we provide evidence for a positive relationship between surgeon supply and hospital revision rates for hip and knee replacement surgery. Hence, hospital performance decreases with higher surgeon supply, and this finding holds conditional on patient volumes.

Textbook Outcome in Bariatric Surgery: Evolution During 15 Years in a Referral Center

BACKGROUND

Textbook outcome (TO) is a multidimensional measure used to assess the quality of care. It is the "ideal" surgical result, based on a series of established indicators. In the field of bariatric surgery (BS), only one publication on TO is available.

OBJECTIVES

To determine TO in our BS unit and identify the factors linked to TO.

SETTING

University public hospital in Alicante (Spain).

METHODS

Retrospective observational study of all primary BS was performed. TO for BS was defined in relation to the following features: no major postoperative complications (Clavien-Dindo >II), hospital stay <75th percentile, and no mortality or readmissions within 30 days of surgery. Comparative analysis of the characteristics of the TO and non-TO groups was performed, as well as univariate and multivariate logistic regressions, to identify the independent factors associated with obtaining TO.

RESULTS

In 970 patients, TO was achieved in 71.5%. The hospital stay was the one that most affected achievement of TO. Analysis according to the type of procedure (sleeve gastrectomy and gastric bypass) did not reveal any differences between both procedures in terms of obtaining TO (71.5 vs 71.26%). Logistic regression identified smoking, heart disease, operative time, and upper gastrointestinal bleeding as independent factors associated with obtaining TO (p<0.05). Analysis of the annual evolution of TO reveals a progressive increase in its achievement (7.7-86.4%).

CONCLUSION

In our series, TO was obtained in 71.5% of patients. The standardization of the technique and the experience gained over the years has improved our TO results.

Minimum Volume Standards: An Incentive To Perform More Radical Cystectomies?

Background

Minimum volume standards (MVS) for hospitals and/or surgeons remain a subject of debate. Opponents of MVS emphasize the possible negative effects of centralization, such as an unwanted incentive to perform surgery.

Objective

To evaluate whether the introduction of MVS for radical cystectomy (RC) in the Netherlands resulted in more RCs outside guideline-recommended indications.

Design setting and participants

All RCs performed for bladder cancer in the Netherlands between January 1, 2006 and December 31, 2017 were identified in the Netherlands Cancer Registry. During this period, two MVS were sequentially implemented for RC. RCs in intermediate-volume hospitals (hospitals that approximated the MVS) were compared with RCs in high-volume hospitals (hospitals exceeding the MVS by ≥5 RCs/yr) in a period before and a period after implementation of each of the two MVS.

Outcomes measurements and statistical analysis

Descriptive analyses were performed to evaluate whether hospitals performed more RCs outside the recommended indication (cT2-4a N0 M0) and whether an increase in the number of RCs towards the end of the year could be observed.

Results and limitations

After MVS implementation, no clear shift towards disease stages outside the recommended indication for RC was observed in comparison to the period before the MVS. Results for high-volume and intermediate-volume hospitals were similar. In addition, no increase in RCs towards the end of the year was evident.

Conclusions

We did not find evidence indicating an unwanted incentive to perform more RCs as a result of MVS in the Netherlands. Our results further strengthen the case for MVS implementation.

Patient summary

We evaluated whether criteria for the minimum number of radical cystectomies (surgical removal of the bladder) that hospitals have to perform caused urologists to perform more of these operations than necessary in order to meet the minimum level. We found no evidence that minimum criteria led to such an unwanted incentive.

Protocol for the development of a core outcome set for studies on centralisation of healthcare services

INTRODUCTION

Centralisation defined as the reorganisation of healthcare services into fewer specialised units serving a higher volume of patients is a potential measure for healthcare reforms aiming at reducing costs while improving quality. Research on centralisation of healthcare services is thus essential to inform decision-makers. However, so far studies on centralisation report a variability of outcomes, often neglecting outcomes at the health system level. Therefore, this study aims at developing a core outcome set (COS) for studies on centralisation of hospital procedures, which is intended for use in observational as well as in experimental studies.

METHODS AND ANALYSIS

We propose a five-stage study design: (1) systematic review, (2) focus group, (3) interview studies, (4) online survey, (5) Delphi survey. The study will be conducted from March 2022 to November 2023. First, an initial list of outcomes will be identified through a systematic review on reported outcomes in studies on minimum volume regulations. We will search MEDLINE, EMBASE, CENTRAL, CINHAL, EconLIT, PDQ-Evidence for Informed Health Policymaking, Health Systems Evidence, Open Grey and also trial registries. This will be supplemented with relevant outcomes from published studies on centralisation of hospital procedures. Second, we will conduct a focus group with representatives of patient advocacy groups for which minimum volume regulations are currently in effect in Germany or are likely to come into effect to identify outcomes important to patients. Furthermore, two interview studies, one with representatives of the German medical societies and one with representatives of statutory health insurance funds, as well as an online survey with health services researchers will be conducted. In our analyses of the suggested outcomes, we will largely follow the categorisation scheme developed by the Cochrane EPOC group. Finally, a two-round online Delphi survey with all stakeholder groups using predefined score criteria for consensus will be employed to first prioritise outcomes and then agree on the final COS.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Committee at the Brandenburg Medical School Theodor Fontane (MHB). The final COS will be disseminated to all stakeholders involved and through peer-reviewed publications and conferences.

Evidence-based health policy in Germany: lack of communication and coordination between academia and health authorities?

Health-care decision making should consider the best available evidence, often in the form of systematic reviews (SRs). The number of existing SRs and their overlap make their identification and use difficult. Decision makers often rely on de novo SRs instead of using existing SRs. We describe two cases of duplicate reviews (minimum volume threshold of total knee arthroplasties and lung cancer screening) and one case of duplicate primary data analysis (transcatheter aortic valve implantation). All cases have in common that unintended duplication of research occurred between health authorities and academia, demonstrating a lack of communication and coordination between them.It is important to note that academia and health authorities have different incentives. Academics are often measured by the number of peer-reviewed publications and grants awarded. In contrast, health authorities must comply with laws and are commissioned to deliver a specific report within a defined period of time. Most replication is currently unintended. A solution may be the collaboration of stakeholders commonly referred to as integrated knowledge translation (IKT). The IKT approach means that research is conducted in collaboration with the end users of the research. It requires active collaborations between researchers and decision-makers or knowledge users (clinicians, managers, policy makers) throughout the research process. Wherever cooperation is possible in spite of requirements for independence or confidentiality, legal regulations should facilitate and support collaborative approaches between academia and health authorities.

The effect of minimum volume standards in hospitals (MIVOS) - protocol of a systematic review

BACKGROUND

The volume-outcome relationship, i.e., higher hospital volume results in better health outcomes, has been established for different surgical procedures as well as for certain nonsurgical medical interventions. Accordingly, many countries such as Germany, the USA, Canada, the UK, and Switzerland have established minimum volume standards. To date, there is a lack of systematically summarized evidence regarding the effects of such regulations.

METHODS

To be included in the review, studies must measure any effects connected to minimum volume standards. Outcomes of interest include the following: (1) patient-related outcomes, (2) process-related outcomes, and (3) health system-related outcomes. We will include (cluster) randomized controlled trials ([C]RCTs), non-randomized controlled trials (nRCTs), controlled before-after studies (CBAs), and interrupted time-series studies (ITSs). We will apply no restrictions regarding language, publication date, and publication status. We will search MEDLINE (via PubMed), Embase (via Embase), CENTRAL (via Cochrane Library), CINHAL (via EBSCO), EconLit (via EBSCO), PDQ evidence for informed health policymaking, health systems evidence, OpenGrey, and also trial registries for relevant studies. We will further search manually for additional studies by cross-checking the reference lists of all included primary studies as well as cross-checking the reference lists of relevant systematic reviews. To evaluate the risk of bias, we will use the ROBINS-I and RoB 2 risk-of-bias tools for the corresponding study designs. For data synthesis and statistical analyses, we will follow the guidance published by the EPOC Cochrane group (Cochrane Effective Practice and Organisation of Care (EPOC), EPOC Resources for review authors, 2019).

DISCUSSION

This systematic review focuses on minimum volume standards and the outcomes used to measure their effects. It is designed to provide thorough and encompassing evidence-based information on this topic. Thus, it will inform decision-makers and policymakers with respect to the effects of minimum volume standards and inform further studies in regard to research gaps.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022318883.

Volume-Outcome Relationship in Cancer Survival Rates: Analysis of a Regional Population-Based Cancer Registry in Japan

BACKGROUND

There is limited data on the relationship between hospital volumes and outcomes with respect to cancer survival in Japan. The primary objective of this study was to evaluate the effect of hospital volume on cancer survival rate using a population-based cohort database.

METHODS

Using the Kanagawa cancer registry, propensity score matching was employed to create a dataset for each cancer type by selecting 1:1 matches for cases from high- and other-volume hospitals. The 5-year survival rate was estimated and the hazard ratio (HR) for hospital volume was calculated using a Cox proportional hazard model. Additional analyses were performed limited to cancer patients who underwent surgical operation, chemotherapy, and other treatments in each tumor stage and at the time of diagnosis.

RESULTS

The number of cases with complete data, defined as common cancers (prostate, kidney, bladder, esophagus, stomach, liver, pancreas, colon, breast, and lung), was 181,039. Adjusted HR differed significantly among hospital volume categories for the most common cancers except bladder, and the trends varied according to cancer type. The HR ranged from 0.76 (95%CI, 0.74-0.79) for stomach cancer to 0.85 (0.81-0.90) for colon cancer.

CONCLUSIONS

This study revealed that a relationship may exist between hospital volume and cancer survival in Japan.

Bariatric surgery practice patterns among pediatric surgeons in the United States

BACKGROUND

Metabolic and bariatric surgery (MBS) in adolescents has been shown to be safe and effective, but current practice patterns are variable and poorly understood. The aim of this study is to assess current MBS practice patterns among pediatric surgeons in the United States.

METHODS

American Pediatric Surgical Association members were surveyed on current bariatric surgery practices.

RESULTS

Four hundred and three (40%) surgeons out of a total of 1013 pediatric surgeons responded to the survey. Only 2 respondents had additional training in MBS (0.5%). One hundred thirty-two (32.6%) report that their practice participates in metabolic and bariatric surgery, with 123 (30.4%) having a specific partner specializing in MBS. Most respondents (92%) stated that they believe high volume is associated with better outcomes with regard to MBS. Only 17 (4.2%) surgeons performed a metabolic and bariatric surgery in the last year. All routinely perform sleeve gastrectomy as their primary procedure. Most (82%) perform procedures with an additional surgeon, either another pediatric surgeon (47%) or an adult bariatric surgeon (47%). All pediatric bariatric surgeons responded that they believe high volume led to better outcomes. Adolescent MBS programs most commonly included pediatric nutritionists (94%), pediatric psychologists (94%), clinical nurses (71%), clinical coordinators (59%), pediatric endocrinologists (59%), and exercise physiologists (52%).

CONCLUSION

Only 17 (4.2%) respondents had performed a metabolic and bariatric surgery in the past year, and few of those had additional training in MBS. Future work is necessary to better understand optimal practice patterns for adolescent metabolic and bariatric surgery.

TYPE OF STUDY

Review article.

LEVEL OF EVIDENCE

Level III.

Relationship between volume and outcome for gastroschisis: A systematic review

BACKGROUND

Newborns with gastroschisis need surgery to reduce intestines into the abdominal cavity and to close the abdominal wall. Due to an existing volume-outcome relationship for other high-risk, low-volume procedures, we aimed at examining the relationship between hospital or surgeon volume and outcomes for gastroschisis.

METHODS

We conducted a systematic literature search in Medline, Embase, CENTRAL, CINAHL and Biosis Previews in June 2021 and searched for additional literature. We included (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and mortality, morbidity or quality of life. We assessed risk of bias of included studies using ROBINS-I and performed a systematic synthesis without meta-analysis and used GRADE for assessing the certainty of the evidence.

RESULTS

We included 12 cohort studies on hospital volume. Higher hospital volume may reduce in-hospital mortality of neonates with gastroschisis, while the evidence is very uncertain for other outcomes. Findings are based on a low certainty of the evidence for in-hospital mortality and a very low certainty of the evidence for all other analyzed outcomes, mainly due to risk of bias and imprecision. We did not identify any study on surgeon volume.

CONCLUSION

The evidence suggests that higher hospital volume reduces in-hospital mortality of newborns with gastroschisis. However, the magnitude of this effect seems to be heterogeneous and results should be interpreted with caution. There is no evidence on the relationship between surgeon volume and outcomes.

Volume creates value: The volume-outcome relationship in Scandinavian obesity surgery

This study establishes the relationship between surgical volume and cost and quality outcomes, using patient-level clinical data from a national quality registry for bariatric surgery in Sweden. Data include patient characteristics with comorbidities, surgical and follow-up data for patients that underwent gastric bypass or gastric sleeve operations between 2007 and 2016 (52,703 patients in 51 hospitals). The relationships between surgical volume (annual number of bariatric procedures) and several patient-level outcomes were assessed using multilevel, mixed-effect regression models, controlling for patient characteristics and comorbidities. We found that hospitals with higher volumes had lower risk of intraoperative complications as well as complications within 30 days post-surgery (odds ratios per 100 procedures are 0.78 and 0.87, respectively, p<0.01). In addition, higher-volume hospitals had substantially shorter procedure time (17 min per 100 procedures, p<0.01) and length of stay (0.88 incidence-rate ratio per 100 procedures p<0.01). Our results support the claim that increased surgical volume significantly improves quality. Further, the results strongly suggest that increased volume leads to lower cost per surgery, by reducing cost drivers such as procedure time and length of stay.

Volume-outcome relationship in intra-abdominal robotic-assisted surgery: a systematic review

As robotic-assisted surgery (RAS) expands to smaller centres, platforms are shared between specialities. Healthcare providers must consider case volume and mix required to maintain quality and cost-effectiveness. This can be informed, in-part, by the volume-outcome relationship. We perform a systematic review to describe the volume-outcome relationship in intra-abdominal robotic-assisted surgery to report on suggested minimum volumes standards. A literature search of Medline, NICE Evidence Search, Health Technology Assessment Database and Cochrane Library using the terms: "robot*", "surgery", "volume" and "outcome" was performed. The included procedures were gynecological: hysterectomy, urological: partial and radical nephrectomy, cystectomy, prostatectomy, and general surgical: colectomy, esophagectomy. Hospital and surgeon volume measures and all reported outcomes were analysed. 41 studies, including 983,149 procedures, met the inclusion criteria. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale and the retrieved data was synthesised in a narrative review. Significant volume-outcome relationships were described in relation to key outcome measures, including operative time, complications, positive margins, lymph node yield and cost. Annual surgeon and hospital volume thresholds were described. We concluded that in centres with an annual volume of fewer than 10 cases of a given procedure, having multiple surgeons performing these procedures led to worse outcomes and, therefore, opportunities should be sought to perform other complimentary robotic procedures or undertake joint cases.

Defining minimum volume thresholds to increase quality of care: a new patient-oriented approach using mixed integer programming

A positive relationship between treatment volume and outcome quality has been demonstrated in the literature and is thus evident for a variety of procedures. Consequently, policy makers have tried to translate this so-called volume-outcome relationship into minimum volume regulation (MVR) to increase the quality of care-yet with limited success. Until today, the effect of strict MVR application remains unclear as outcome quality gains cannot be estimated adequately and restrictions to application such as patient travel time and utilization of remaining hospital capacity are not considered sufficiently. Accordingly, when defining MVR, its effectiveness cannot be assessed. Thus, we developed a mixed integer programming model to define minimum volume thresholds balancing utility in terms of outcome quality gain and feasibility in terms of restricted patient travel time and utilization of hospital capacity. We applied our model to the German hospital sector and to four surgical procedures. Results showed that effective MVR needs a minimum volume threshold of 125 treatments for cholecystectomy, of 45 and 25 treatments for colon and rectum resection, respectively, of 32 treatments for radical prostatectomy and of 60 treatments for total knee arthroplasty. Depending on procedure type and incidence as well as the procedure's complication rate, outcome quality gain ranged between 287 (radical prostatectomy) and 977 (colon resection) avoidable complications (11.7% and 11.9% of all complications). Ultimately, policy makers can use our model to leverage MVR's intended benefit: concentrating treatment delivery to improve the quality of care.

Between-hospital variations in 3-year survival among patients with newly diagnosed gastric, colorectal, and lung cancer

Due to increases in cancer survivability, quality assessments of cancer care must include long-term outcomes. This multicenter retrospective cohort study evaluated between-hospital variations in the 3-year survival rates of patients with gastric, colorectal, and lung cancer irrespective of treatment modality. We linked cancer registry data and administrative data from patients aged 18–99 years who were diagnosed with gastric, colorectal, or lung cancer between 2013 and 2015 in Osaka Prefecture, Japan. The 3-year survival rates were adjusted for potential prognostic factors using multilevel logistic regression models. Between-hospital variations were visually evaluated using funnel plots. We analyzed 10,296 gastric cancer patients from 30 hospitals, 9276 colorectal cancer patients from 30 hospitals, and 7978 lung cancer patients from 28 hospitals. The 3-year survival rate was 70.2%, 75.2%, and 45.0% for gastric, colorectal, and lung cancer, respectively. In the funnel plots, the adjusted survival rates of gastric and colorectal cancer for all hospitals lay between the lower and upper control limits of two standard deviations of the average survival rates. However, the adjusted survival rates of lung cancer for four hospitals lay below the lower limit while that for two hospitals lay above the upper limit. Older age, men, advanced cancer stage, comorbidities, functional disability, emergency admission, current/ex-smokers, and underweight were independently associated with poorer survival. In conclusion, there were between-hospital variations in 3-year survival for lung cancer even after adjusting for case mix. Quality improvement initiatives may be needed to raise the consistency of care.

Variation in Deescalated Axillary Surgical Practices in Older Women with Early-Stage Breast Cancer

BACKGROUND

Randomized controlled trials show that certain axillary surgical practices can be safely deescalated in older adults with early-stage breast cancer. Hospital volume is often equated with surgical quality, but it is unclear whether this includes performance of low-value surgeries. We sought to describe how utilization of two low-value axillary surgeries has varied by time and hospital volume.

METHODS

Women aged ≥ 70 years diagnosed with breast cancer from 2013 to 2016 were identified in the National Cancer Database. The outcomes of interest were sentinel lymph node biopsy (SLNB) in cT1N0 hormone receptor-positive cancer patients and axillary lymph node dissection (ALND) in cT1-2N0 patients undergoing breast-conserving surgery with ≤ 2 pathologically positive nodes. Time trends in procedure use and multivariable regression with restricted cubic splines were performed, adjusting for patient, disease, and hospital factors.

RESULTS

Overall, 83.4% of 44,779 women eligible for omission of SLNB underwent SLNB and 20.0% of 7216 patients eligible for omission of ALND underwent ALND. SLNB rates did not change significantly over time and remained significantly different by age group (70-74 years: 93.5%; 75-79 years: 89.7%, 80-84 years: 76.7%, ≥ 85 years: 48.9%; p < 0.05). ALND rates decreased over the study period across all age groups included (22.5 to 16.9%, p < 0.001). In restricted cubic splines models, lower hospital volume was associated with higher likelihood of undergoing SLNB and ALND.

CONCLUSIONS

ALND omission has been more widely adopted than SLNB omission in older adults, but lower hospital volume is associated with higher likelihood of both procedures. Practice-specific deimplementation strategies are needed, especially for lower-volume hospitals.

Hospital volume-outcome relationship in total knee arthroplasty: a systematic review and dose-response meta-analysis

PURPOSE

This systematic review and dose-response meta-analysis aimed to investigate the relationship between hospital volume and outcomes for total knee arthroplasty (TKA).

METHODS

MEDLINE, Embase, CENTRAL and CINAHL were searched up to February 2020 for randomised controlled trials and cohort studies that reported TKA performed in hospitals with at least two different volumes and any associated patient-relevant outcomes. The adjusted effect estimates (odds ratios, OR) were pooled using a random-effects, linear dose-response meta-analysis. Heterogeneity was quantified using the I²-statistic. ROBINS-I and the GRADE approach were used to assess the risk of bias and the confidence in the cumulative evidence, respectively.

RESULTS

A total of 68 cohort studies with data from 1985 to 2018 were included. The risk of bias for all outcomes ranged from moderate to critical. Higher hospital volume may be associated with a lower rate of early revision ≤ 12 months (narrative synthesis of k = 7 studies, n = 301,378 patients) and is likely associated with lower mortality ≤ 3 months (OR = 0.91 per additional 50 TKAs/year, 95% confidence interval [0.87-0.95], k = 9, n = 2,638,996, I² = 51%) and readmissions ≤ 3 months (OR = 0.98 [0.97-0.99], k = 3, n = 830,381, I² = 44%). Hospital volume may not be associated with the rates of deep infections within 1-4 years, late revision (1-10 years) or adverse events ≤ 3 months. The confidence in the cumulative evidence was moderate for mortality and readmission rates; low for early revision rates; and very low for deep infection, late revision and adverse event rates.

CONCLUSION

An inverse volume-outcome relationship probably exists for some TKA outcomes, including mortality and readmissions, and may exist for early revisions. Small reductions in unfavourable outcomes may be clinically relevant at the population level, supporting centralisation of TKA to high-volume hospitals.

LEVEL OF EVIDENCE

III.

REGISTRATION NUMBER

The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42019131209 available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131209 ).

Accreditation of specialized surgical units in general and digestive surgery: A step forward by the AEC for quality improvement and subspecialized Fellowship training

At present, in daily practice, the Departments of Surgery in most hospitals in Spain are organized into "Specialized Surgical Units", including specific structure, human resources, organization, teaching and research in the different subspecialties included in General and Digestive Surgery (GDS). Furthermore, there are also several specialized "fellowship-like", training programs in the different subspecialties already working in some of these "Specialized Surgical Units", although not officially financed. However, until now there was no model for accreditation or recognition of these Units or fellowship programs. The AEC has designed a regulation for the accreditation of Specialized Surgical Units in GDS, that will also serve as a model to define subspecialty training in these areas. The accreditation process, and with it, the process of quality improvement, includes different quality indicators, including unit structure, process quality, and result indicators.

Ontario wait times for delayed surgical treatment of traumatic peripheral nerve injury

Background:

To better understand the occurrence and operative treatment of peripheral nerve injury (PNI) and the potential need for additional resources, it is essential to define the frequency and distribution of peripheral nerve procedures being performed. The objective of this study was to evaluate Ontario’s wait times for delayed surgical treatment of traumatic PNI.

Methods:

We retrieved data on wait times for peripheral nerve surgery from the Ontario Ministry of Health and Long-Term Care Wait Time Information System. We reviewed the wait times for delayed surgical treatment of traumatic PNI among adult patients (age ≥ 18 yr) from April 2009 to March 2018. Data collected included total cases, mean and median wait times, and demographic characteristics.

Results:

Over the study period, 7313 delayed traumatic PNI operations were reported, with variability in the case volume distribution across Local Health Integration Networks (LHINs). The highest volume of procedures (2788) was performed in the Toronto Central LHIN, and the lowest volume (< 6) in the Waterloo Wellington and North Simcoe Muskoka LHINs. The population incidence of traumatic PNI requiring surgery was 5.1/10 000. The mean and median wait times from surgical decision to surgical repair were 45 and 27 days, respectively. Both the longest and shortest wait times occurred in LHINs with low case volumes. The provincial target wait time was met in 93% of cases, but women waited significantly longer than men (p < 0.001).

Conclusion:

The provincial distribution of traumatic PNI surgery was variable, and the highest volumes were in the LHINs with large populations. The provincial wait time strategy for traumatic PNI surgery is effective, but women waited longer than men. Precise reporting from all hospitals is necessary to accurately capture and understand the delivery of care after traumatic PNI.

Low Volume Hospitals Are Not Associated with Inferior Outcomes After Thoracic Endovascular Aortic Repair

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) has been used increasingly to treat complex thoracic aortic pathology. This study aimed to assess hospital volume's impact on outcomes in patients undergoing TEVAR.

STUDY DESIGN

Patients undergoing TEVAR between January 2015 and December 2019 were identified in the Vascular Quality Initiative (VQI) database. The participating centers were grouped into either low-volume hospitals (LVH) or high-volume hospitals (HVH). We assessed the impact of hospital volume on 30-day mortality and major postoperative complications using a multivariable logistic regression analysis.

RESULTS

A total of 3,584 TEVAR patients (asymptomatic = 1,720; symptomatic/ruptured =1,864) were identified at 147 centers. The median average annual number of TEVAR cases at LVH and HVH was 6 and 17 cases, respectively. There was no significant difference in 30-day mortality between LVH and HVH (asymptomatic: 3.7% vs. 3.7%, p = 0.98; symptomatic/rupture: 9.3% vs. 7.3%, p = 0.13). After adjusting for multiple clinical and anatomical factors, being treated in LVH was not associated with increased 30-day mortality (asymptomatic: OR = 0.98, 95% CI: 0.52, 1.87, p = 0.96; symptomatic/rupture: OR = 1.15, 95%CI: 0.75, 1.77, p = 0.53) nor an increased risk of major complications, including renal, neurological, cardiac, pulmonary, and femoral artery access complication (all p > 0.05).

CONCLUSION

Using a large national database, we demonstrate that LVH is not associated with inferior TEVAR outcomes than HVH. The technical aspect of the procedure might play a role in the similarity of outcomes across the different institutional experiences.

Beyond the operating room: do hospital characteristics have an impact on surgical site infections after colorectal surgery? A systematic review

Background

Hospital characteristics have been recognized as potential risk factors for surgical site infection for over 20 years. However, most research has focused on patient and procedural risk factors. Understanding how structural and process variables influence infection is vital to identify targets for effective interventions and to optimize healthcare services. The aim of this study was to systematically review the association between hospital characteristics and surgical site infection in colorectal surgery.

Main body

A systematic literature search was conducted using PubMed, Scopus and Web of Science databases until the 31st of May, 2021. The search strategy followed the Participants, Exposure/Intervention, Comparison, Outcomes and Study design. The primary outcome of interest was surgical site infection rate after colorectal surgery. Studies were grouped into nine risk factor typologies: hospital size, ownership affiliation, being an oncological hospital, safety-net burden, hospital volume, surgeon caseload, discharge destination and time since implementation of surveillance. The STROBE statement was used for evaluating the methodological quality.

A total of 4703 records were identified, of which 172 were reviewed and 16 were included. Studies were published between 2008 and 2021, and referred to data collected between 1996 and 2016. Surgical site infection incidence ranged from 3.2 to 27.6%. Two out of five studies evaluating hospital size adjusted the analysis to patient and procedure-related risk factors, and showed that larger hospitals were either positively associated or had no association with SSI. Public hospitals did not present significantly different infection rates than private or non-profit ones. Medical school affiliation and higher safety-net burden were associated with higher surgical site infection (crude estimates), while oncological hospitals were associated with higher incidence independently of other variables. Hospital caseload showed mixed results, while surgeon caseload and surveillance time since implementation appear to be associated with fewer infections.

Conclusions

Although there are few studies addressing hospital-level factors on surgical site infection, surgeon experience and the implementation of a surveillance system appear to be associated with better outcomes. For hospitals and services to be efficiently optimized, more studies addressing these variables are needed that take into account the confounding effect of patient case mix.

Perspective of potential patients on the hospital volume-outcome relationship and the minimum volume threshold for total knee arthroplasty: a qualitative focus group and interview study

BACKGROUND

Total knee arthroplasty (TKA) is performed to treat end-stage knee osteoarthritis. In Germany, a minimum volume threshold of 50 TKAs/hospital/year was implemented to ensure outcome quality. This study, embedded within a systematic review, aimed to investigate the perspectives of potential TKA patients on the hospital volume-outcome relationship for TKA (higher volumes associated with better outcomes).

METHODS

A convenience sample of adults with knee problems and heterogeneous demographic characteristics participated in the study. Qualitative data were collected during a focus group prior to the systematic review (n = 5) and during telephone interviews, in which preliminary results of the systematic review were discussed (n = 16). The data were synthesised using content analysis.

RESULTS

All participants (n = 21) believed that a hospital volume-outcome relationship exists for TKA while recognising that patient behaviour or the surgeon could also influence outcomes. All participants would be willing to travel longer for better outcomes. Most interviewees would choose a hospital for TKA depending on reputation, recommendations, and service quality. However, some would also choose a hospital based on the results of the systematic review that showed slightly lower mortality/revision rates at higher-volume hospitals. Half of the interviewees supported raising the minimum volume threshold even if this were to increase travel time to receive TKA.

CONCLUSIONS

Potential patients believe that a hospital volume-outcome relationship exists for TKA. Hospital preference is based mainly on subjective factors, although some potential patients would consider scientific evidence when making their choice. Policy makers and physicians should consider the patient perspectives when deciding on minimum volume thresholds or recommending hospitals for TKA, respectively.

Comparing practice and outcome of laparoscopic liver resection between high-volume expert centres and nationwide low-to-medium volume centres

BACKGROUND

Based on excellent outcomes from high-volume centres, laparoscopic liver resection is increasingly being adopted into nationwide practice which typically includes low-medium volume centres. It is unknown how the use and outcome of laparoscopic liver resection compare between high-volume centres and low-medium volume centres. This study aimed to compare use and outcome of laparoscopic liver resection in three leading European high-volume centres and nationwide practice in the Netherlands.

METHOD

An international, retrospective multicentre cohort study including data from three European high-volume centres (Oslo, Southampton and Milan) and all 20 centres in the Netherlands performing laparoscopic liver resection (low-medium volume practice) from January 2011 to December 2016. A high-volume centre is defined as a centre performing >50 laparoscopic liver resections per year. Patients were retrospectively stratified into low, moderate- and high-risk Southampton difficulty score groups.

RESULTS

A total of 2425 patients were included (1540 high-volume; 885 low-medium volume). The median annual proportion of laparoscopic liver resection was 42.9 per cent in high-volume centres and 7.2 per cent in low-medium volume centres. Patients in the high-volume centres had a lower conversion rate (7.4 versus 13.1 per cent; P < 0.001) with less intraoperative incidents (9.3 versus 14.6 per cent; P = 0.002) as compared to low-medium volume centres. Whereas postoperative morbidity and mortality rates were similar in the two groups, a lower reintervention rate (5.1 versus 7.2 per cent; P = 0.034) and a shorter postoperative hospital stay (3 versus 5 days; P < 0.001) were observed in the high-volume centres as compared to the low-medium volume centres. In each Southampton difficulty score group, the conversion rate was lower and hospital stay shorter in high-volume centres. The rate of intraoperative incidents did not differ in the low-risk group, whilst in the moderate-risk and high-risk groups this rate was lower in high-volume centres (absolute difference 6.7 and 14.2 per cent; all P < 0.004).

CONCLUSION

High-volume expert centres had a sixfold higher use of laparoscopic liver resection, less conversions, and shorter hospital stay, as compared to a nationwide low-medium volume practice. Stratification into Southampton difficulty score risk groups identified some differences but largely outcomes appeared better for high-volume centres in each risk group.

Mesh fixation techniques in primary ventral or incisional hernia repair

BACKGROUND

The use of a mesh in primary ventral or incisional hernia repair lowers the recurrence rate  and is the accepted standard of care for larger defects. In laparoscopic primary ventral or incisional hernia repair the insertion of a mesh is indispensable. Different mesh fixation techniques have been used and refined over the years. The type of fixation technique is claimed to have a major impact on recurrence rates, chronic pain, health-related quality of life (HRQOL) and complication rates.

OBJECTIVES

To determine the impact of different mesh fixation techniques for primary and incisional ventral hernia repair on hernia recurrence, chronic pain, HRQOL and complications.

SEARCH METHODS

On 2 October 2020 we searched CENTRAL, MEDLINE (Ovid MEDLINE(R)) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R)), Ovid Embase, and two trials registries. We also performed handsearches, and contacted experts from the European Hernia Society (EHS).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including adults with primary ventral or incisional hernia that compared different types of mesh fixation techniques (absorbable/nonabsorbable sutures, absorbable/nonabsorbable tacks, fibrin glue, and combinations of these techniques).

DATA COLLECTION AND ANALYSIS

We extracted data in standardised piloted tables, or if necessary, directly into Review Manager 5. We assessed risks of bias with the Cochrane 'Risk of bias' tool. Two review authors independently selected the publications, and extracted data on results. We calculated risk ratios (RRs) for binary outcomes and mean differences (MDs) for continuous outcomes. For pooling we used an inverse-variance random-effects meta-analysis or the Peto method in the case of rare events. We prepared GRADE 'Summary of findings' tables. For laparoscopic repair we considered absorbable tacks compared to nonabsorbable tacks, and nonabsorbable tacks compared to nonabsorbable sutures as key comparisons.

MAIN RESULTS

We included 10 trials with a total of 787 participants. The number of randomised participants ranged from 40 to 199 per comparison. Eight studies included participants with both primary and incisional ventral hernia. One study included only participants with umbilical hernia, and another only participants with incisional hernia. Hernia size varied between studies. We judged the risk of bias as moderate to high. Absorbable tacks compared to nonabsorbable tacks Recurrence rates in the groups were similar (RR 0.74, 95% confidence interval (CI) 0.17 to 3.22; 2 studies, 101 participants). It is uncertain whether there is a difference between absorbable tacks and nonabsorbable tacks in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Nonabsorbable tacks compared to nonabsorbable sutures At six months there was one recurrence in each group (RR 1.00, 95% CI 0.07 to 14.79; 1 study, 36 participants). It is uncertain whether there is a difference between nonabsorbable tacks and nonabsorbable sutures in recurrence because the certainty of evidence was very low. Evidence suggests that the difference between groups in early postoperative, late follow-up and chronic pain is negligible. We found no study that assessed HRQOL. Absorbable tacks compared to absorbable sutures No recurrence was observed at one year (very low certainty of evidence). Early postoperative pain was higher in the tacks group (VAS 0 - 10: MD -2.70, 95% CI -6.67 to 1.27; 1 study, 48 participants). It is uncertain whether there is a difference between absorbable tacks compared to absorbable sutures in early postoperative pain because the certainty of evidence was very low. The MD for late follow-up pain was -0.30 (95% CI -0.74 to 0.14; 1 study, 48 participants). We found no study that assessed HRQOL. Combination of different fixation types (tacks and sutures) or materials (absorbable and nonabsorbable) There were mostly negligible or only small differences between combinations (e.g. tacks plus sutures) compared to a single technique (e.g. sutures only), as well as combinations compared to other combinations (e.g. absorbable sutures combined with nonabsorbable sutures compared to absorbable tacks combined with nonabsorbable tacks) in all outcomes. It is uncertain whether there is an advantage for combining different fixation types or materials for recurrence, chronic pain, HRQOL and complications, because the evidence certainty was very low or low, or we found no study on important outcomes. Nonabsorbable tacks compared to fibrin sealant The two studies showed different directions of effects: one showed higher rates for nonabsorbable tacks, and the other showed higher rates for fibrin sealant. Low-certainty evidence suggests that the difference between groups in early postoperative, late follow-up, chronic pain and HRQOL is negligible. Absorbable tacks compared to fibrin sealant One recurrence in the tacks group and none in the fibrin sealant group were noted after one year (low certainty of evidence). Early postoperative pain might be slightly lower using tacks (VAS 0 - 100; MD -12.40, 95% CI -27.60 to, 2.80;1 study, 50 participants; low-certainty evidence). The pattern of pain and HRQOL course over time (up to 1 year) was similar in the groups (low certainty of evidence).

AUTHORS' CONCLUSIONS

Currently none of the techniques can be considered superior to any other, because the certainty of evidence was low or very low for all outcomes.

Systematic review of prospective studies focused on regionalization of care in surgical oncology

To perform a systematic review of studies prospectively analyzing the impact of regionalization of complex surgical oncology care on patient outcomes. High volume care of complex surgical oncology patients has been repeatedly associated with improved outcomes. Most studies, however, are retrospective and have not prospectively accounted for confounders such as financial ability and social support. Four electronic databases (Ovid MEDLINE®, Ovid EMBASE, Cochrane Library (Wiley), and EBSCHOHost) were searched from inception until August 25, 2018. Two authors independently reviewed 5887 references, with a third independent reviewer acting as arbitrator when needed. Data extracted from 11 articles that met inclusion criteria. Risk of bias assessments conducted using MINORS criteria for the non-randomized, observational studies, and the Cochrane tool for the randomized-controlled trial. Of the 11 studies selected, we found 7 historically-controlled trials, two retrospective cohort studies with prospective data collection, one prospective study, and one randomized-controlled trial. 73% of studies were from Northern Europe, 18% from Ontario, Canada, and 9% from England. Pancreatic surgery accounted for 36% of studies, followed by gynecologic oncology (27%), thoracic surgery (18%), and dermatologic surgery (9%). The studies reported varying outcome parameters, but all showed improvement post-regionalization. Included studies featured poor-to-fair risk of bias. 11 studies indicated improved outcomes following regionalization of surgical oncology, but most exhibit poor methodological rigor. Prospective evidence for the regionalization of surgical oncology is lacking. More research addressing patient access to care and specialist availability is needed to understand the shortcomings of centralization.

Comparison of clinical and economic outcomes between minimally invasive liver resection and open liver resection: a propensity-score matched analysis

BACKGROUND

Minimally invasive liver resection (MILR) has gained momentum in recent years. This study of contemporary data compares economic and clinical outcomes between MILR and open liver resection (OLR).

METHODS

We extracted data for patients undergoing liver resection between October 2015-September 2018 from the Premier Healthcare Database. We conducted a propensity score matched analysis to compare complications, in-hospital mortality, inpatient readmissions, discharge to institutional post-acute care, operating room time (ORT), length of stay (LOS), and total hospital cost between MILR and OLR patients.

RESULTS

From the eligible OLR (n = 3349) and MILR (n = 1367) patients, we propensity score matched 1261 from each cohort at a 1:1 ratio. After matching, MILR was associated with lower rates of complications (bleeding: 8.2% vs. 17.4%; respiratory failure: 5.5% vs. 10.9%; intestinal obstruction: 3.6% vs. 6.0%, and pleural effusion: 1.9% vs. 4.9%), in-hospital mortality (0.5% vs. 3.0%), 90-day inpatient readmissions (10.4% vs. 14.3%), discharge to institutional post-acute care (6.9% vs. 12.3%), shorter ORT (257 vs. 308 min) and LOS (4.3 vs. 7.2 days), and lower hospital costs ($19463 vs. $29119) (all P < 0.001).

CONCLUSION

MILR was associated with lower risk of complications and reduced hospital resource utilizations as compared with OLR.

CT Fluoroscopy Guided Thoracic Biopsies (CTTB) Are Highly Accurate and Safe: Outcomes and Predictive Modeling of Complications Utilizing Machine Learning

PURPOSE

CT guided transthoracic biopsy (CTTB) is an established, minimally invasive method for diagnostic evaluation of a variety of thoracic diseases. We assessed a large CTTB cohort diagnostic accuracy, complication rates, and developed machine learning models to predict complications.

MATERIALS AND METHODS

We retrospectively identified 796 CTTB patients in a tertiary hospital (5-year interval). We gathered and coded patient demographics, characteristics of each lesion biopsied, type of biopsy, diagnostic yield, type of diagnosis, and complication rates. Statistical analyses included summary statistics, multivariate logistic regression and machine learning (neural network) methods.

RESULTS

Seven hundred ninety-six CTTBs were performed (43% fine needle aspirations, 5% core biopsies, 52% both). Diagnostic yield was 97.0% (73.9% malignant, 23.1% benign). Complications occurred in 14.7% (12.7% minor, 2.0% major). The most common complication was pneumothorax (13.1%), mostly minor. Multivariate logistic regression models could predict severity of complications with accuracies ranging from 65.5% to 83.5%, with smaller lesion dimension the strongest predictor. Type of biopsy was not a statistically significant predictor. A neural network model improved accuracy to 77.0%-94.2%.

CONCLUSION

CTTB performed by thoracic radiologists in a tertiary hospital demonstrate excellent diagnostic yield (97.0%) with a low clinically important complication rate (2.0%). Machine learning methods including neural networks can accurately predict the likelihood of complications, offering pathways to potentially improve patient selection and procedural technique, in order to further optimize the risk-benefit ratio of CTTB.

Accreditation of specialized surgical units in general and digestive surgery: A step forward by the AEC for quality improvement and subspecialized Fellowship training

At present, in daily practice, the Departments of Surgery in most hospitals in Spain are organized into "Specialized Surgical Units", including specific structure, human resources, organization, teaching and research in the different subspecialties included in General and Digestive Surgery (GDS). Furthermore, there are also several specialized "fellowship-like", training programs in the different subspecialties already working in some of these "Specialized Surgical Units", although not officially financed. However, until now there was no model for accreditation or recognition of these Units or fellowship programs. The AEC has designed a regulation for the accreditation of Specialized Surgical Units in GDS, that will also serve as a model to define subspecialty training in these areas. The accreditation process, and with it, the process of quality improvement, includes different quality indicators, including unit structure, process quality, and result indicators.

Author queries via email text elicited high response and took less reviewer time than data forms - a randomised study within a review

OBJECTIVE

To compare two strategies for requesting additional information for systematic reviews (SR) from study authors.

STUDY DESIGN AND SETTING

Randomised study within a SR of hospital volume-outcome relationships in total knee arthroplasty. We sent personalized email requests for additional information to study authors as either email text ("Email" group) or attachment with self-developed, personalised data request forms ("Attachment" group). The primary outcome was the response rate, the secondary outcomes were the data completeness rate and the reviewer time invested in author contact.

RESULTS

Of 57 study authors, 29 were randomised to the Email group and 28 to the Attachment group. The response rate was 93% for Email and 75% for Attachment (odds ratio 4.5, 95% confidence interval [0.9-24.0]). Complete data were provided by 55% (Email) vs. 36% (Attachment) of authors (odds ratio 2.2 [0.8-6.4]). The mean reviewer time was shorter in the Email (mean ± standard deviation of 20.2±14.4 minutes/author) than the Attachment group (31.8±14.4 minutes/author) with a mean difference of 11.6 [4.1-19.1] minutes/author.

CONCLUSION

Personalised email requests elicited high response but only moderate data completeness rates regardless of the method (email text or attachment). Email requests as text took less reviewer time than creating attachments.

Systematic review and meta-analysis on volume-outcome relationship of abdominal surgical procedures in Germany

BACKGROUND

In the past, for a number of abdominal surgical interventions a correlation between treatment volume of a hospital and the patient's outcome was shown in national and international studies.

METHODS

Based on a systematic literature search we analyzed the absolute and risk-adjusted in-house lethality as well as the rate of complications and the failure to rescue after abdominal surgery in Germany. The hospitals were grouped in quintiles according to the volume of treatment.

RESULTS

11 studies including more than 2 million patients were identified and surgeries for the treatment of 9 disease conditions were studied. The meta-analysis shows a significantly lower absolute and risk-adjusted in-house mortality for surgery in hospitals with high treatment volumes compared to low volume hospitals. In the context of subgroup analysis, this effect is demonstrated especially for complex surgical procedures. The failure to rescue in patients suffering from sepsis is significantly lower in high volume centers compared to low volume centers.

CONCLUSION

This systematic review and meta-analysis shows on more than 2 million patients that there is a volume-outcome relationship for the surgical treatment of abdominal diseases in Germany across various organ systems, which is particularly true for complex interventions.

Machine Learning Algorithms to Predict Recurrence within 10 Years after Breast Cancer Surgery: A Prospective Cohort Study

No studies have discussed machine learning algorithms to predict recurrence within 10 years after breast cancer surgery. This study purposed to compare the accuracy of forecasting models to predict recurrence within 10 years after breast cancer surgery and to identify significant predictors of recurrence. Registry data for breast cancer surgery patients were allocated to a training dataset (n = 798) for model development, a testing dataset (n = 171) for internal validation, and a validating dataset (n = 171) for external validation. Global sensitivity analysis was then performed to evaluate the significance of the selected predictors. Demographic characteristics, clinical characteristics, quality of care, and preoperative quality of life were significantly associated with recurrence within 10 years after breast cancer surgery (p < 0.05). Artificial neural networks had the highest prediction performance indices. Additionally, the surgeon volume was the best predictor of recurrence within 10 years after breast cancer surgery, followed by hospital volume and tumor stage. Accurate recurrence within 10 years prediction by machine learning algorithms may improve precision in managing patients after breast cancer surgery and improve understanding of risk factors for recurrence within 10 years after breast cancer surgery.

[Minimum volumes in surgical treatment of lung cancer : A survey of thoracic surgeons in Germany on the introduction of a minimum volume regulation for surgical treatment of lung cancer]

BACKGROUND

The Federal Joint Committee (G‑BA) is currently discussing the introduction of new minimum volume regulations (MVR) in Germany. The present study examined the current opinions of active thoracic surgeons regarding minimum volumes (MV) for the surgical treatment of lung cancer.

METHODS

The participating centers for the online survey were identified on the basis of the thoracic surgery departments in the 2017 hospital directory (Federal Statistical Office), lung cancer centers (German Cancer Society), certified centers of excellence for thoracic surgery (German Society for Thoracic Surgery), hospitals with a focus on lung surgery and German university hospitals. They were asked about the potential effects of MVR on the quality of results and quality of care, economic aspects and the structure of care. Furthermore, a recommendation for MV was requested and possible provisions for exemption were evaluated.

RESULTS

A total of 145 hospitals (response rate 85%) with 454 thoracic surgeons (response rate 54%) were surveyed. The results showed a high degree of approval for MV to improve the quality of results and 78.4% of the surgeons surveyed expected it to result in centralization of surgical care, although this would not lead to a deterioration in care according to 70.1% of the participants. Approximately 46.1% of the participants expected care to become more economical and 83.3% supported the introduction of an MVR, with the average recommended MV being 67 anatomical lung resections per center per year.

CONCLUSION

An MVR for the surgical treatment of lung cancer met with a high degree of approval among active thoracic surgeons. The MV that was called for (n = 67) was slightly below the prerequisite for primary surgical cases at a certified lung cancer center.

Relationship between volume and outcome for surgery on congenital diaphragmatic hernia: A systematic review

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a rare and life-threatening anomaly that needs surgical therapy after clinical stabilization of the neonate. Given an existing volume-outcome relationship for other high-risk, low volume procedures, we aimed at examining the relationship between hospital or surgeon volume and outcomes for surgery on CDH.

METHODS

We conducted a systematic search in multiple databases in September 2019 and searched for additional literature. We assessed risk of bias of included studies using ROBINS-I and synthesized results in a structured narrative way using GRADE.

RESULTS

We included 5 cohort studies on hospital volume. Results for in-hospital mortality, one-year mortality and length of stay are inconclusive. The certainty of the evidence was very low for all outcomes, due to risk of bias, inconsistency and imprecision. We did not identify any study on surgeon volume.

CONCLUSION

Due to the very low certainty of the evidence it is uncertain whether higher hospital volume is associated with favorable outcomes for neonates undergoing surgery for CDH. There is no evidence on the relationship between surgeon volume and outcomes. Future studies should use more rigorous methodology and analyze additional outcomes to allow for more meaningful inferences.

LEVEL OF EVIDENCE

III SYSTEMATIC REVIEW REGISTRATION: PROSPERO (CRD42018090231).

Provider caseload volume and short-term outcomes following colorectal surgeries in New Brunswick: a provincial-level cohort study

BACKGROUND

American studies have shown that higher provider and hospital volumes are associated with reduced risk of mortality following colorectal surgical interventions. Evidence from Canada is limited, and to our knowledge only a single study has considered outcomes other than death. We describe associations between provider surgical volume and all-cause mortality and postoperative complications following colorectal surgical interventions in New Brunswick.

METHODS

We used hospital discharge abstracts linked to vital statistics, the provincial cancer registry and patient registry data. We considered all admissions for colorectal surgeries from 2007 through 2013. We used logistic regression to identify odds of dying and odds of complications (from any of anastomosis leak, unplanned colostomy, intra-abdominal sepsis or pneumonia) within 30 days of discharge from hospital according to provider volume (i.e., total interventions performed over the preceding 2 years) adjusted for personal, contextual, provider and hospital characteristics.

RESULTS

Overall, 9170 interventions were performed by 125 providers across 18 hospitals. We found decreased odds of experiencing a complication following colorectal surgery per increment of 10 interventions performed per year (odds ratio 0.94, 95% confidence interval 0.91-0.96). We found no associations with mortality. Associations remained consistent across models restricted to cancer patients or to interventions performed by general surgeons and across models that also considered overall hospital volumes.

CONCLUSION

Our results suggest that increased caseloads are associated with reduced odds of complications, but not with all-cause mortality, following colorectal surgery in New Brunswick. We also found no evidence of volume having differential effects on outcomes from colon and rectal procedures.

Patterns and characteristics of patients' selection of cancer surgeons

OBJECTIVE

Despite evidence of volume-outcome relationships for cancer surgery, treatment at low-volume hospitals remains common. Our objective was to evaluate whether individuals actively involved in selecting their cancer surgeon were more likely to go to hospitals recognized for quality cancer care.

METHODS

Individuals diagnosed with breast, prostate and colorectal cancer in 2015 completed online surveys in 2017-2018. Participants were categorized as "directed" to a surgeon (relied on referral) or "active" (sought additional information), and hospitals were categorized by NCI-designation, CoC accreditation, and academic affiliation.

RESULTS

Of 299 participants, 42% were active. Individuals with breast cancer were more active (aOR = 2.46,95%CI:1.32-4.59). Active participants had nonsignificantly higher odds of surgery at NCI-designated facilities (aOR = 2.04,95%CI:0.95-4.38), or academic centers (aOR = 1.51,95%CI:0.86-2.64).

CONCLUSIONS

While most participants were directed to their cancer surgeon, active participants tended to select NCI-designated/academic hospitals. Although centralization of cancer care would require altering referral patterns, decision-support resources may help patients make informed choices.

Subspecialization in pediatric surgery: Results of a survey to the American Pediatric Surgical Association

BACKGROUND

Current practice patterns and opinions regarding subspecialization within pediatric surgery are not well known. We aimed to characterize the prevalence of and attitudes surrounding subspecialization within pediatric surgery.

METHODS

An anonymous survey regarding subspecialization was distributed to all nonresident members of the American Pediatric Surgical Association.

RESULTS

Of 1118 surveys, we received 458 responses (41%). A majority of respondents labeled themselves 'general pediatric surgeons' (63%), while 34% considered themselves general surgeons with a specific clinical focus, and 3% reported practicing solely within a specific niche. Subspecialists commonly serve as consultants for relevant cases (52%). Common niches included oncology (10%) and anorectal malformations (9%). Subspecialists felt to be necessary included transplant (79%) and fetal (78%) surgeons. Opinions about subspecialization were variable: 41% felt subspecialization improves patient care while 39% believe it is detrimental to surgeon well-roundedness. Only 10% felt subspecialists should practice solely within their subspecialty. Practicing at an academic hospital or fellowship program correlated with subspecialization, while length of time in practice did not.

CONCLUSION

While pediatric surgeons report that subspecialization may benefit patient care, concerns exist regarding the unfavorable effect it may have on the individual surgeon. A better understanding of how subspecialization affects quality and outcomes would help clarify its utility.

TYPE OF STUDY

Review article.

LEVEL OF EVIDENCE

Level V.

Relationship between volume and outcome for gastroschisis: a systematic review protocol

BACKGROUND

Gastroschisis is a congenital anomaly that needs surgical management for repositioning intestines into the abdominal cavity and for abdominal closure. Higher hospital or surgeon volume has previously been found to be associated with better clinical outcomes for different especially high-risk, low volume procedures. Therefore, we aim to examine the relationship between hospital or surgeon volume and outcomes for gastroschisis.

METHODS

We will perform a systematic literature search from inception onwards in Medline, Embase, CENTRAL, CINAHL, and Biosis Previews without applying any limitations. In addition, we will search trial registries and relevant conference proceedings. We will include (cluster-) randomized controlled trials (RCTs) and prospective or retrospective cohort studies analyzing the relationship between hospital or surgeon volume and clinical outcomes. The primary outcomes will be survival and mortality. Secondary outcomes will be different measures of morbidity (e.g., severe gastrointestinal complications, gastrointestinal dysfunctions, and sepsis), quality of life, and length of stay. We will systematically assess risk of bias of included studies using RoB 2 for individually or cluster-randomized trials and ROBINS-I for cohort studies, and extract data on the study design, patient characteristics, case-mix adjustments, statistical methods, hospital and surgeon volume, and outcomes into standardized tables. Title and abstract screening, full text screening, critical appraisal, and data extraction of results will be conducted by two reviewers independently. Other data will be extracted by one reviewer and checked for accuracy by a second one. Any disagreements will be resolved by discussion. We will not pool results statistically as we expect included studies to be clinically and methodologically very diverse. We will conduct a systematic synthesis without meta-analysis and use GRADE for assessing the certainty of the evidence.

DISCUSSION

Given the lack of a comprehensive summary of findings on the relationship between hospital or surgeon volume and outcomes for gastroschisis, this systematic review will put things right. Results can be used to inform decision makers or clinicians and to adapt medical care.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework (DOI: https://doi.org/10.17605/OSF.IO/EX34M ; https://doi.org/10.17605/OSF.IO/HGPZ2 ).

Independent Treatment Centres Are Not a Guarantee for High Quality and Low Healthcare Prices in The Netherlands - A Study of 5 Elective Surgeries

Background: Independent treatment centres (ITCs) are a growing phenomenon in many healthcare systems. Focus factory theory predicts that ITCs provide high quality healthcare with low prices, through specialisation, high-volume and routine. This study examines if ITC care outperforms general hospital (GH) care within a regulated competition system in the Netherlands, by focusing on differences in healthcare quality and price.

Methods: The cross-sectional study combined publicly available quality data, list prices and insurer contracts for 2017. Clinical outcomes of 5 elective surgeries (total hip and knee replacement, anterior cruciate ligament (ACL), cataract and carpal tunnel surgeries) were compared using zero-or-one inflated beta-regressions, corrected for underlying structural factors (ie, volume of care, process and structure indicators, and chain affiliation). Furthermore, price differences between ITCs and GHs were examined using ordinary least squares regressions. Lastly, we analysed quality of care in relation to the number of insurance contracts of the 4 largest Dutch insurance companies using ordered logistic regressions.

Results: Quality differences between ITCs and GHs were found to be inconsistent across procedures. No facility type performed better overall. There were no differences exhibited in the list prices between ITCs and GHs. No consistent relationship was found between the underlying factors and quality or price, in different procedures and time. We found no indication for selective contracting based on quality within the ITC sector.

Conclusions: This study found no evidence that ITCs outperform GHs on quality or price. This evidence does not support the focus factory theory. The substantial practice variation in quality of care may justify more evidence-based contracting within the market for elective surgery.

Value and Quality of Care in Head and Neck Oncology

PURPOSE OF REVIEW

The concept of value-based health care (VBHC) was articulated more than a decade ago. However, its clinical implementation remains an on-going process and a particularly demanding one for the domain of head and neck cancer (HNC). These cancers often present with fast growing tumors in functionally and cosmetically sensitive sites and afflict patients with differing circumstances and comorbidity. Moreover, the various treatment modalities and protocols have different effects on functional outcomes. Hence, the interpretation of what constitutes VBHC in head and neck oncology remains challenging.

RECENT FINDINGS

This monograph reviews developments in specific aspects of VBHC for HNC patients, including establishment of registries and quality indices (such as infrastructure, process, and outcome indicators). It emphasizes the importance of the multidisciplinary team, "time to treatment intervals," and adherence to guidelines. The discussion addresses major indicators including survival, quality of life and functional outcomes, and adverse events. Also, strengths and weaknesses of nomograms, prognostic and decision models, and variation of care warrant attention. Health care professionals, together with patients, must properly define quality and relevant outcomes, both for the individual patient as well as the HNC population. It is essential to capture and organize the relevant data so that they can be analyzed and the results used to improve both outcomes and value.

Complications and Effects of Dorsal Root Ganglion Stimulation in the Treatment of Chronic Neuropathic Pain: A Nationwide Cohort Study in Denmark

OBJECTIVES

Dorsal root ganglion (DRG) stimulation is a novel treatment of chronic neuropathic pain and has been shown to be efficacious across several case reports and randomized trials. However, long-term follow-up is limited, as are reports of complication rates. This study presents efficacy and complications for patients treated with DRG stimulation.

MATERIALS AND METHODS

We performed an observational, multicenter cohort study of all patients in Denmark implanted with FDA-approved DRG stimulation systems to treat chronic, neuropathic pain between 2014 and 2018. Follow-up period was one to three years.

RESULTS

Forty-three patients underwent trial DRG stimulation; 33 were subsequently fully implanted. Pain location: 58% lower extremity; 21% upper extremity; 21% thoracic/abdominal. At the end of the observation period, 58% of fully implanted patients were still implanted; 42% had fully functional systems. In these patients, average Numerical Rating Scale (NRS)-score of pain was reduced from 6.8 to 3.5 (p = 0.00049) and worst NRS-score was reduced from 8.6 to 6.0 (p = 0.0039) at 12 months follow-up. Pain Catastrophizing Score was reduced from 32 to 15 (p = 0.0039). Thirteen patients experienced complications related to defect leads (39% of implanted systems). In four patients (12%), lead removal left fragments in the root canal due to lead fracture, and three patients suffered permanent nerve damage during attempts to replace broken leads.

CONCLUSIONS

This study suggests a significant, clinically relevant effect of DRG stimulation on neuropathic pain, but also demonstrates substantial problems with maintenance and revision of currently available systems. Consequently, treatment with equipment marketed specifically for DRG stimulation is currently paused in Denmark.

One-year patient survival correlates with surgeon volume after elective open abdominal aortic surgery

OBJECTIVE

Volume-outcome relationships in surgery have been well established. Studies have shown that high-volume surgeons provide improved outcomes in performing open abdominal aneurysm repairs. The hypothesis of this study was that high-volume surgeons provide superior short-term and midterm outcomes of elective open aortic operations compared with low-volume surgeons.

METHODS

We evaluated patients undergoing elective open abdominal aortic aneurysm repair, aortofemoral bypass, and aortomesenteric bypass by board-certified vascular surgeons using the New York Statewide Planning and Research Cooperative System database from 2002 to 2014. The Contal and O'Quigley technique was used to estimate a cut point objectively and provided an estimate of significance. A division using average yearly volumes (averaged during 3 years) of seven or more cases and fewer than seven cases per year returned the highest Q statistic, and this grouping was used to classify high-volume and low-volume provider groups. Rates of complications during index hospitalization, length of stay, 30-day survival, 90-day survival, 1-year survival, and cause of death were analyzed using mixed effect models.

RESULTS

In 118 hospitals during the 13-year period, 266 board-certified vascular surgeons performed 244 aortomesenteric bypasses, 4202 aortofemoral bypasses, and 6126 abdominal aortic aneurysm repairs. High-volume surgeons' rates of complications during index hospitalization, 30-day survival, 90-day survival, and 1-year survival were superior to those of low-volume surgeons. The Contal and O'Quigley technique returned an estimate of seven operations per year for optimal survival during 1 year. This cutoff is associated with an adjusted 1-year hazard ratio of 0.687 (P = .003), a 2.69% difference in 1-year all-cause survival (P = .003), and a 1.76-day reduction in the mean length of stay at index hospitalization (P < .001). Higher volume surgeons showed a 25.0%, 43.4%, 42.4%, 40.6%, and 45.0% reduction in postoperative rates of acute renal failure (P < .001), hemorrhage (P < .001), pulmonary failure (P < .001), sepsis (P < .001), and venous thromboembolism (P < .001), respectively. Abdominal abscess, acute renal failure, hemorrhage, myocardial infarction, and sepsis were associated with increased cardiovascular cause-specific mortality after open aortic operations (P < .001).

CONCLUSIONS

These data demonstrate that high-volume surgeons performing elective open aortic operations provide reduced complications and improved short-term and midterm survival compared with low-volume surgeons. Clinical and postoperative variables that are associated with increased cardiovascular cause-specific mortality are also identified. These data provide further evidence that elective open abdominal vascular surgery should be centralized to high-volume surgeons.

The results of pancreatic operations after the implementation of multidisciplinary team conference (MDT): A quality improvement study

BACKGROUND

Centralization has improved the outcome of complex operations including cancer surgery. Moreover, the implementation of multidisciplinary team conferences (MDT) has ameliorated the decision making, but the impact on patient outcome is controversial. The aim of the study was to investigate the outcome of pancreatic surgery in the setting of centralization and upfront multidisciplinary decision making.

METHOD

The decisions of MDT from 2010 to 2016 and the outcome of operations were compared with operations from 2003 to 2009 before centralization of pancreatic surgery and implementation of MDT. Data were drawn from the department's database and from hospital's electronic patient files.

RESULTS

From 2010 to 2016, 7.015 patients were evaluated at the MDT. In 72.6% of patients a treatment plan followed the first evaluation, the referral diagnosis was changed in 12.4% of cases. Of 3.362 solid neoplasms, 1.680 (50.0%) were evaluated as resectable and 1.080 (32.1%) patients were operated. The annual resection rate of operated patients was78.3%-88.5% (median 80.0%) compared to 21.4% to 80.% (median 68.6%, p = 0.0001) from 2003 to 2009 with 279 operated patients. The post-operative 30 - and 90-days mortality from 2003 to 2009 and 2010 to 2016 was 3.4% vs. 1.8% (NS) and 5.0% vs 3.6% (NS). In the same periods explorative laparotomies and palliative resections decreased from 18.3% to 3.6% (p = 0.0001) and 18.6%-10.2% (p = 0.0002). The median survival of radically resected pancreatic adenocarcinoma (PAC) from 2003 to 2009 and from 2010 to 2016 was 20.2 and 21.9 months, respectively (p = 0.687).

CONCLUSION

The MDT increased patient flow, improved quality of decision-making and offered more patients surgical treatment without increasing morbidity or mortality. But an impact on the long-term survival of patients with PAC was not found.

Hospital volume-outcome relationship in total knee arthroplasty: protocol for a systematic review and non-linear dose-response meta-analysis

BACKGROUND

Knee osteoarthritis is a common, chronic condition and main contributor to global disability. Total knee arthroplasty (TKA) is the most successful treatment for end-stage knee osteoarthritis. It is assumed that in the field of surgery, there is a relationship between hospital volume and health outcomes and that higher hospital volume results in better health outcomes. As a consequence, minimum volume thresholds have been implemented in Germany for various procedures, including TKA (50 procedures per year). To date, it is unclear whether minimum volume thresholds truly result in better outcomes. The objective of this study will be to quantify the relationship between hospital volume and patient-relevant outcomes in patients undergoing TKA.

METHODS

We will include published or unpublished (cluster-) randomized controlled trials and prospective or retrospective cohort studies that involve patients with primary and/or revision TKA, report at least two different hospital volumes and report at least one patient-relevant outcome. To identify studies, we will systematically search (from inception onwards) PubMed/MEDLINE, Embase, CENTRAL, and CINAHL, as well as trial registers, conference proceedings, and reference lists. We will also contact experts in the field. Study selection and data extraction will be performed by two reviewers independently. The primary outcome will be rate of early revision. Secondary outcomes will include rate of revision > 1 year, mortality, length of stay, readmission rate, surgical complications, adverse events and health-related quality of life. We will assess the risk of bias of the included studies using ROBINS-I or the Cochrane risk of bias tool. Both a linear and a non-linear dose-response meta-analyses will be performed. We will use the GRADE approach to evaluate our confidence in the cumulative evidence. We will incorporate patients' needs, goals and preferences into our recommendations by consulting three focus groups, each consisting of eight participants.

DISCUSSION

The findings of our systematic review will probably be limited by the design of the included studies. We do not expect to identify any (cluster-) randomized controlled trials that meet our inclusion criteria. Therefore, the best available evidence included in our systematic review will most likely consist of cohort studies only. We anticipate that the results of this study will inform future health policy decisions in Germany regarding the minimum volume threshold for TKA. Systematic review registration: PROSPERO CRD42019131209.

Are patients willing to accept longer travel times to decrease their risk associated with surgical procedures? A systematic review

Background

Distance to a hospital is an influencing factor for patients´ decision making when choosing a hospital for surgery. It is unclear whether patients prefer to travel further to regional instead of local hospitals if the risk associated with elective surgery is lower in the farther hospital. The aim of our systematic review was to investigate patient preferences for the location of care, taking into consideration surgical outcomes and hospital distance.

Methods

MEDLINE (PubMed), EconLit, PsycInfo and EMBASE were searched until November 2019. We included experimental choice studies in which participants were asked to make a hypothetical decision where to go for elective surgery when surgical risk and/or distance to the hospitals vary. There was no restriction on the type of intervention or study. Reviewers independently extracted data using a standardized form. The number and proportion of participants willing to accept additional risk to obtain surgery in the local hospital was recorded. We also extracted factors associated with the decision.

Results

Five studies exploring participants´ preferences for local care were included. In all studies, there were participants who, independently of a decreased mortality risk or a higher survival benefit in the regional hospital, adhered to the local hospital. The majority of the patients were willing to travel longer to lower their surgical risk. Older age and fewer years of formal education were associated with a higher risk tolerance in the local hospital.

Conclusions

Whether patients were willing to travel for a lower surgery-associated risk could not be answered in a straightforward manner. The studies we identified showed that decision making also relies on factors other than on rational information on risk or distance to hospital.

Trial registration

International prospective register of ongoing systematic reviews (PROSPERO): CRD42016033655. Registered 1 January 2016.