Relationship between surgeon volume and outcomes: a systematic review of systematic reviews

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Abstract

Background

The surgeon volume-outcome relationship has been discussed for many years and its existence or nonexistence is of importance for various reasons. A lot of empirical work has been published on it. We aimed to summarize systematic reviews in order to present current evidence.

Methods

Medline, Embase, Cochrane database of systematic reviews (CDSR), and health technology assessment websites were searched up to October 2015 for systematic reviews on the surgeon volume-outcome relationship. Reviews were critically appraised, and results were extracted and synthesized by type of surgical procedure/condition.

Results

Thirty-two reviews reporting on 15 surgical procedures/conditions were included. Methodological quality of included systematic reviews assessed with the assessment of multiple systematic reviews (AMSTAR) was generally moderate to high albeit included literature partly neglected considering methodological issues specific to volume-outcome relationship. Most reviews tend to support the presence of a surgeon volume-outcome relationship. This is most clear-cut in colorectal cancer, bariatric surgery, and breast cancer where reviews of high quality show large effects.

Conclusions

When taking into account its limitations, this overview can serve as an informational basis for decision makers. Our results seem to support a positive volume-outcome relationship for most procedures/conditions. However, forthcoming reviews should pay more attention to methodology specific to volume-outcome relationship. Due to the lack of information, any numerical recommendations for minimum volume thresholds are not possible. Further research is needed for this issue.

Electronic supplementary material

The online version of this article (doi:10.1186/s13643-016-0376-4) contains supplementary material, which is available to authorized users.

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Most cited references 50

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Is volume related to outcome in health care? A systematic review and methodologic critique of the literature.

Ethan A. Halm, Clara Lee, Mark Chassin (2002)

To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them. The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions. Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results. The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume-outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume-outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data. High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.

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How quickly do systematic reviews go out of date? A survival analysis.

Kaveh Shojania, Margaret Sampson, Mohammed T Ansari … (2007)

Systematic reviews are often advocated as the best source of evidence to guide clinical decisions and health care policy, yet we know little about the extent to which they require updating. To estimate the average time to changes in evidence that are sufficiently important to warrant updating systematic reviews. Survival analysis of 100 quantitative systematic reviews. Systematic reviews published from 1995 to 2005 and indexed in ACP Journal Club. Eligible reviews evaluated a specific drug or class of drug, device, or procedure and included only randomized or quasi-randomized, controlled trials. Quantitative signals for updating were changes in statistical significance or relative changes in effect magnitude of at least 50% involving 1 of the primary outcomes of the original systematic review or any mortality outcome. Qualitative signals included substantial differences in characterizations of effectiveness, new information about harm, and caveats about the previously reported findings that would affect clinical decision making. The cohort of 100 systematic reviews included a median of 13 studies and 2663 participants per review. A qualitative or quantitative signal for updating occurred for 57% of reviews (95% CI, 47% to 67%). Median duration of survival free of a signal for updating was 5.5 years (CI, 4.6 to 7.6 years). However, a signal occurred within 2 years for 23% of reviews and within 1 year for 15%. In 7%, a signal had already occurred at the time of publication. Only 4% of reviews had a signal within 1 year of the end of the reported search period; 11% had a signal within 2 years of the search. Shorter survival was associated with cardiovascular topics (hazard ratio, 2.70 [CI, 1.36 to 5.34]) and heterogeneity in the original review (hazard ratio, 2.15 [CI, 1.12 to 4.11]). Judgments of the need for updating were made without involving content experts. In a cohort of high-quality systematic reviews directly relevant to clinical practice, signals for updating occurred frequently and within a relatively short time.

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Should operations be regionalized? The empirical relation between surgical volume and mortality.

Harold Luft, John P. Bunker, Alain C Enthoven (1979)

This study examines mortality rates for 12 surgical procedures of varying complexity in 1498 hospitals to determine whether there is a relation between a hospital's surgical volume and its surgical mortality. The mortality of open-heart surgery, vascular surgery, transurethral resection of the prostate, and coronary bypass decreased with increasing number of operations. Hospitals in which 200 or more of these operations were done annually had death rates, adjusted for case mix, 25 to 41 per cent lower than hospitals with lower volumes. For other procedures, the mortality curve flattened at lower volumes. For example, hospitals doing 50 to 100 total hip replacements attained a mortality rate for this procedure almost as low as that of hospitals doing 200 or more. Some procedures, such as cholecystectomy, showed no relation between volume and mortality. The results may reflect the effect of volume or experience on mortality, or referrals to institutions with better outcomes, as well as a number of other factors, such as patient selection. Regardless of the explanation, these data support the value of regionalization for certain operations.

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Author and article information

Contributors

Johannes Morche: johannes.morche@googlemail.com

Tim Mathes: tim.mathes@uni-wh.de

Dawid Pieper: dawid.pieper@uni-wh.de

Journal

Journal ID (nlm-ta): Syst Rev

Journal ID (iso-abbrev): Syst Rev

Title: Systematic Reviews

Publisher: BioMed Central (London )

ISSN (Electronic): 2046-4053

Publication date (Electronic): 29 November 2016

Publication date PMC-release: 29 November 2016

Publication date Collection: 2016

Volume: 5

Electronic Location Identifier: 204

Affiliations

[1 ]Institute of Health Economics and Clinical Epidemiology, The University Hospital of Cologne (AöR), Gleueler Str. 176-178, 50935 Cologne, Germany

[2 ]Faculty of Health, School of Medicine, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109 Cologne, Germany

Article

Publisher ID: 376

DOI: 10.1186/s13643-016-0376-4

PMC ID: 5129247

PubMed ID: 27899141

SO-VID: 1078147e-6f20-4a2a-bfa1-6b60ca0de628

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 13 June 2016

Date accepted : 8 November 2016

Funding

Funded by: No funding

Custom metadata

ScienceOpen disciplines: Public health

Keywords: systematic review of systematic reviews,volume-outcome,surgeon volume,clinical outcome,quality assurance,patient safety

Data availability:

ScienceOpen disciplines: Public health

Keywords: systematic review of systematic reviews, volume-outcome, surgeon volume, clinical outcome, quality assurance, patient safety

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Relationship between surgeon volume and outcomes: a systematic review of systematic reviews

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Most cited references 50

Is volume related to outcome in health care? A systematic review and methodologic critique of the literature.

How quickly do systematic reviews go out of date? A survival analysis.

Should operations be regionalized? The empirical relation between surgical volume and mortality.

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Cited by 102

Most referenced authors 1,842