Influence of trends in hospital volume over time on patient outcomes for high-risk surgery

Cécile Payet, Stéphanie Polazzi, Jean-Christophe Lifante, Eddy Cotte, Daniel Grinberg, Matthew J Carty, Stéphane Sanchez, Muriel Rabilloud, Antoine Duclos, Cécile Payet, Stéphanie Polazzi, Jean-Christophe Lifante, Eddy Cotte, Daniel Grinberg, Matthew J Carty, Stéphane Sanchez, Muriel Rabilloud, Antoine Duclos

Abstract

Background: The "practice makes perfect" concept considers the more frequent a hospital performs a procedure, the better the outcome of the procedure. We aimed to study this concept by investigating whether patient outcomes improve in hospitals with a significantly increased volume of high-risk surgery over time and whether a learning effect existed at the individual hospital level.

Methods: We included all patients who underwent one of 10 digestive, cardiovascular and orthopaedic procedures between 2010 and 2014 from the French nationwide hospitals database. For each procedure, we identified three groups of hospitals according to volume trend (increased, decreased, or no change). In-hospital mortality, reoperation, and unplanned hospital readmission within 30 days were compared between groups using Cox regressions, taking into account clustering of patients within hospitals and potential confounders. Individual hospital learning effect was investigated by considering the interaction between hospital groups and procedure year.

Results: Over 5 years, 759,928 patients from 694 hospitals were analysed. Patients' mortality in hospitals with procedure volume increase or decrease over time did not clearly differ from those in hospitals with unchanged volume across the studied procedures (e.g., Hazard Ratios [95%] of 1.04 [0.93-1.17] and 1.08 [0.97-1.21] respectively for colectomy). Furthermore, patient outcomes did not improve or deteriorate in hospitals with increased or decreased volume of procedures over time (e.g., 1.01 [0.95-1.08] and 0.99 [0.92-1.05] respectively for colectomy).

Conclusions: Trend in hospital volume over time did not appear to influence patient outcomes based on real-world data.

Trial registration: NCT02788331, June 2, 2016.

Keywords: Surgery; Trend; Volume-outcome.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Number of hospitals by trend in volume of procedures between 2010 and 2014. PCI percutaneous coronary intervention, CABG coronary artery bypass grafting, AAA abdominal aortic aneurysm
Fig. 2
Fig. 2
Mortality difference and individual hospital learning effect between hospital groups according to trends in procedures volume from 2010 to 2014. CABG coronary artery bypass grafting, AAA abdominal aortic aneurysm, PCI percutaneous coronary intervention. a Comparison of patient mortality across hospitals by comparing hospitals with increasing or decreasing volume with hospitals with unchanged volume. Hazard-ratios estimated from Cox model with adjustment regarding patient (age, gender, Elixhauser list of comorbidities, type and year of procedure, transfer, emergency admission, and median income) and hospital characteristics (hospital status, volume of procedures, specialization degree, and attraction rate). b Analyse to determine if mortality improved or deteriorated over time within hospital that increased or decreased its volume. The ratio of hazard ratio (RHR) compared the change in the mortality rate between two groups. A RHR greater than 1 suggests that the increase of mortality over time was greater in hospitals experiencing volume increase/decrease than in hospitals with unchanged volume

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