Influence of hospital volume and outcomes of adult structural heart procedures

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.

Effect of Operator Experience on Transcatheter Mitral Valve Repair Outcomes

Transcatheter mitral valve repair with MitraClip is a novel, intricate therapy for mitral regurgitation that improves survival and quality of life. Similar to other medical procedures, there is a relationship between procedural experience and clinical outcomes. MitraClip results and the efficiency and safety of the procedure all improved with increasing experience at both the institutional and operator level in two large studies from the Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapy Registry. Patient selection was also found to have a significant role in procedure success. The old adage of “See one, do one, teach one” does not necessarily apply to complex interventions, such as MitraClip, given that the learning curve does not appear to plateau even as operators approach a 150-case experience.

Hospital volume-outcome relationship in severe traumatic brain injury: stratified analysis by level of trauma center

OBJECTIVE

The nature of the volume-outcome relationship in cases with severe traumatic brain injury (TBI) remains unclear, with considerable interhospital variation in patient outcomes. The objective of this study was to understand the state of the volume-outcome relationship at different levels of trauma centers in the United States.

METHODS

The authors queried the National Trauma Data Bank for the years 2007-2014 for patients with severe TBI. Case volumes for each level of trauma center organized into quintiles (Q1-Q5) served as the primary predictor. Analyzed outcomes included in-hospital mortality, total hospital length of stay (LOS), and intensive care unit (ICU) stay. Multivariable regression models were performed for in-hospital mortality, overall complications, and total hospital and ICU LOSs to adjust for possible confounders. The analysis was stratified by level designation of the trauma center. Statistical significance was established at p < 0.001 to avoid a type I error due to a large sample size.

RESULTS

A total of 122,445 patients were included. Adjusted analysis did not demonstrate a significant relationship between increasing hospital volume of severe TBI cases and in-hospital mortality, complications, and nonhome hospital discharge disposition among level I-IV trauma centers. However, among level II trauma centers, hospital LOS was longer for the highest volume quintile (adjusted mean difference [MD] for Q5: 2.83 days, 95% CI 1.40-4.26 days, p < 0.001, reference = Q1). For level III and IV trauma centers, both hospital LOS and ICU LOS were longer for the highest volume quintile (adjusted MD for Q5: LOS 4.6 days, 95% CI 2.3-7.0 days, p < 0.001; ICU LOS 3.2 days, 95% CI 1.6-4.8 days, p < 0.001).

CONCLUSIONS

Higher volumes of severe TBI cases at a lower level of trauma center may be associated with a longer LOS. These results may assist policymakers with target interventions for resource allocation and point to the need for careful prehospital decision-making in patients with severe TBI.

Does Hospital Volume Affect Outcomes in Spine Surgeries? A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To assess the impact of hospital volume on postoperative outcomes in spine surgery.

SUMMARY OF BACKGROUND DATA

Several strategies have recently been proposed to optimize provider outcomes, such as regionalization to higher volume centers and setting volume benchmarks.

MATERIALS AND METHODS

We performed a systematic review examining the association between hospital volume and spine surgery outcomes. To be included in the review, the study population had to include patients undergoing a primary or revision spinal procedure. These included anterior/posterior cervical fusions, anterior/posterior lumbar fusions, laminectomies, discectomies, spinal deformity surgeries, and surgery for spinal malignancies. We searched the Pubmed, OVID MEDLINE (1966-2018), Google Scholar, and Web of Science (1900-2018) databases in January 2018 using the search criteria ("Hospital volume" OR "volume" OR "volume-outcome" OR "volume outcome") AND ("spine" OR "spine surgery" OR "lumbar" OR "cervical" OR "decompression" OR "deformity" OR "fusions"). There were no restrictions placed on study design, publication date, or language. The studies were evaluated with respect to the quality of methodology as outlined by the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Twelve studies were included in the review. Studies were variable in defining hospital volume thresholds. Higher hospital volume was associated with statistically significant lower risks of postoperative complications, a shorter length of stay, lower cost of hospital stay, and a lower risk of readmissions and reoperations/revisions.

CONCLUSIONS

Our findings suggest a trend toward better outcomes for higher volume hospitals; however, further study needs to be carried out to define objective volume thresholds for specific spine surgeries for hospitals to use as a marker of proficiency.

Surgical myectomy: Rationale and personalized technique

Septal myectomy is currently the gold standard treatment for symptomatic patients with hypertrophic cardiomyopathy. The procedure needs to be tailored and performed in a personalized fashion, taking into consideration the anatomical spectrum of this disease. The procedure needs to address the various components that contribute to the clinical and pathological picture of this disease including, the fibrous trigones, accessory tissues, papillary muscles, mitral valve and myocardial bridges. The operation can be performed with very low mortality and morbidity in high-volume experienced centers with predictable excellent short and long-term outcomes. There is a need for broadening the experience of this procedure to the rest of the world and for future development of new enhanced precision imaging and surgical tools.