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Kaier K, Oettinger V, Reinecke H, Schmoor C, Frankenstein L, Vach W, Hehn P, von zur Mühlen C, Bode C, Zehender M, Reinöhl J. Volume-outcome relationship in transcatheter aortic valve implantations in Germany 2008-2014: a secondary data analysis of electronic health records. BMJ Open 2018; 8:e020204. [PMID: 30056377 PMCID: PMC6067393 DOI: 10.1136/bmjopen-2017-020204] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES We examine the volume-outcome relationship in isolated transcatheter aortic valve implantations (TAVI). Our interest was whether the volume-outcome relationship for TAVI exists on the centre level, whether it occurs equally for different outcomes and how it develops over time. DESIGN Secondary data analysis of electronic health records. The comprehensive German Federal Bureau of Statistics Diagnosis Related Groups database was queried for data on all isolated TAVI procedures performed in Germany between 2008 and 2014. Logistic and linear regression analyses were carried out. Risk adjustment was applied using a predefined set of patient characteristics to account for differences in the risk factor composition of the patient populations between centres and over time. Centres performing TAVI were stratified into groups performing <50, 50-99 and ≥100 procedures per year. SETTING Germany 2008-2014. PARTICIPANTS All patients undergoing isolated TAVI in the observation period. INTERVENTIONS None. PRIMARY AND SECONDARY OUTCOME MEASURES In-hospital mortality, bleeding, stroke, probability of ventilation >48 hours, length of hospital stay and reimbursement. RESULTS Between 2008 and 2014, a total of 43 996 TAVI procedures were performed in 113 different centres in Germany with a total of 2532 cases of in-hospital mortality. Risk-adjusted in-hospital mortality decreases over the years and is lower the higher the annual procedure volume at the centre is. The magnitude of the latter effect declines over the observation period. Our results indicate a ceiling effect in the volume-outcome relationship: the volume-outcome relationship is eminent in circumstances of relatively unfavourable outcomes. Alongside improving outcomes, however, the volume-outcome relationship decreases. Also, a volume-outcome relationship seems to be absent in circumstances of constantly low event rates. CONCLUSIONS The hypothesised volume-outcome relationship for TAVI exists but diminishes and may disappear over time. This should be taken into account when considering mandatory minimum thresholds.
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Affiliation(s)
- Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center–University of Freiburg, Freiburg, Germany
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany
| | - Vera Oettinger
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany
| | - Holger Reinecke
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Claudia Schmoor
- Clinical Trials Unit, Medical Center–University of Freiburg, Freiburg, Germany
| | - Lutz Frankenstein
- Department of Cardiology, Angiology, Pulmonology, University of Heidelberg, Heidelberg, Germany
| | - Werner Vach
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center–University of Freiburg, Freiburg, Germany
- Department of Orthopaedics and Traumatology, University Hospital Basel, Basel, Switzerland
| | - Philip Hehn
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center–University of Freiburg, Freiburg, Germany
| | | | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany
| | - Jochen Reinöhl
- Department of Cardiology and Angiology I, Heart Center Freiburg University, Freiburg, Germany
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Kong AL, Pezzin LE, Nattinger AB. Identifying patterns of breast cancer care provided at high-volume hospitals: a classification and regression tree analysis. Breast Cancer Res Treat 2015; 153:689-98. [DOI: 10.1007/s10549-015-3561-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/20/2015] [Indexed: 11/30/2022]
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Sen S, Soulos PR, Herrin J, Roberts KB, Yu JB, Lesnikoski BA, Ross JS, Krumholz HM, Gross CP. For-profit hospital ownership status and use of brachytherapy after breast-conserving surgery. Surgery 2014; 155:776-88. [PMID: 24787104 PMCID: PMC4008843 DOI: 10.1016/j.surg.2013.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 12/06/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Little is known about the relationship between operative care for breast cancer at for-profit hospitals and subsequent use of adjuvant radiation therapy (RT). Among Medicare beneficiaries, we examined whether hospital ownership status is associated with the use of breast brachytherapy--a newer and more expensive modality--as well as overall RT. METHODS We conducted a retrospective study of female Medicare beneficiaries who received breast-conserving surgery for invasive breast cancer in 2008 and 2009. We assessed the relationship between hospital ownership and receipt of brachytherapy or overall RT by using hierarchical generalized linear models. RESULTS The sample consisted of 35,118 women, 8.0% of whom had breast-conserving operations at for-profit hospitals. Among patients who received RT, those who underwent operation at for-profit hospitals were more likely to receive brachytherapy (20.2%) than patients treated at not-for-profit hospitals (15.2%; odds ratio [OR] for for-profit versus not-for-profit: 1.50; 95% confidence interval [95% CI] 1.23-1.84; P < .001). Among women aged 66-79 years, there was no relationship between hospital ownership status and overall use of RT. Among women ages 80-94 years of age--the group least likely to benefit from RT due to shorter life expectancy--undergoing breast-conserving operations at a for-profit hospital was associated with greater overall use of RT (OR 1.22; 95% CI 1.03-1.45, P = .03) and brachytherapy use (OR 1.66; 95% CI 1.18-2.34, P = .003). CONCLUSION Operative care at for-profit hospitals was associated with increased use of the newer and more expensive RT modality, brachytherapy. Among the oldest women who are least likely to benefit from RT, operative care at a for-profit hospital was associated with greater overall use of RT, with this difference largely driven by the use of brachytherapy.
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Affiliation(s)
- Sounok Sen
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT
| | - Pamela R Soulos
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Jeph Herrin
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Health Research & Educational Trust, Chicago, IL; Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Kenneth B Roberts
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - James B Yu
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | | | - Joseph S Ross
- JFK Medical Center, Atlantis, FL; Robert Wood Johnson Clinical Scholars Program, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Harlan M Krumholz
- Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Robert Wood Johnson Clinical Scholars Program, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT; Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center and Yale University School of Medicine, New Haven, CT; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT.
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Peltoniemi P, Huhtala H, Holli K, Pylkkänen L. Effect of surgeon's caseload on the quality of surgery and breast cancer recurrence. Breast 2012; 21:539-43. [DOI: 10.1016/j.breast.2012.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Accepted: 04/18/2012] [Indexed: 11/30/2022] Open
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Measuring the influence of colleagues on a consultant team's use of breast conserving surgery. Int J Technol Assess Health Care 2010; 26:156-62. [PMID: 20392318 DOI: 10.1017/s0266462310000061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this study was to examine potential reasons why the use of breast conserving surgery (BCS) for breast cancer varies substantially between hospital teams in England, and in particular to examine whether colleague influence has a role in influencing BCS rates locally. METHODS Routinely collected Hospital Episode Statistics (HES) data relating to 420 surgical teams in England who performed more than ten breast cancer operations during the financial year 2006/07 were used to identify predictors of team BCS use. Team BCS rates (as a proportion of all types of breast excision surgery) were subject to a regression analysis that incorporated, as independent variables, a range of patient, organizational, and local demographic factors, as well as the BCS rate of colleagues working alongside them in the same hospitals(s). RESULTS After adjusting for the effects of other variables, BCS use by colleagues working in the same hospital(s) was a significant predictor of a team's own BCS rate (standardized b = 0.224; p < .001), denoting a typical 3 percent increase in a team's BCS rate for every 10 percent increase in the BCS rate of colleagues. CONCLUSIONS The practice of colleagues seems to have a measurable influence upon a surgical team's BCS usage. Guidance from HTA organizations can set national standards about the use of new techniques and innovations, but dissemination can be either slowed down or accelerated by the influence of local colleagues. A strategy of disseminating guidance through professional networks or "local champions" could be a powerful avenue for change.
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Fedeli U, Novara G, Alba N, Ficarra V, Artibani W, Spolaore P. Trends from 1999 to 2007 in the surgical treatments of kidney cancer in Europe: data from the Veneto Region, Italy. BJU Int 2010; 105:1255-9. [DOI: 10.1111/j.1464-410x.2009.08929.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Scharl A, Göhring UJ. Does Center Volume Correlate with Survival from Breast Cancer? Breast Care (Basel) 2009; 4:237-244. [PMID: 20877661 PMCID: PMC2941652 DOI: 10.1159/000229531] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
With its high incidence and long history of patient advocacy, breast cancer has generated the most concern about the quality of its care and the volume-outcome relationship. In breast cancer surgery, the risk of perioperative morbidity or mortality is low, but surgery is only one single piece in the mosaic of multidisciplinary care that eventually determines survival. Only a limited number of articles is available investigating the relationship between case volume of physicians and hospitals and specialization of surgeons and survival. In summary, there is evidence to support the hypothesis that specialization, research interest, and caseload of physicians and hospitals is positively correlated with providing state-of-the-art care and with survival. However, it is less clear what impact might be attributed to the surgical routine gained with increasing number of procedures compared to the deeper insight into the biology of breast cancer that comes with specialization in oncology and the weight of the multidisciplinary setting that is more easily established and maintained with a higher caseload.
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Affiliation(s)
- Anton Scharl
- Brustzentrum, Klinikum St. Marien Amberg, Germany
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