Können Mindestmengen für Knieprothesen anhand von Routinedaten errechnet werden?

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 ).

Impact of suspending minimum volume requirements for knee arthroplasty on hospitals in Germany: an uncontrolled before-after study

Background

In 2004, the Federal Joint Committee, supreme decision-making body in German healthcare, introduced minimum volume requirements (MVRQs) as a quality instrument. Since then, MVRQs were implemented for seven hospital procedures. This study evaluates the effect of a system-wide intermission of MVRQ for total knee arthroplasty (TKA), demanding 50 annual cases per hospital.

Methods

An uncontrolled before–after study based on federal-level data including the number of hospitals performing TKA, and TKA cases from the external hospital quality assurance programme in Germany (2004–2017). Bi- and multivariate analyses based on hospital-level secondary data of TKA cases and TKA quality indicators extracted from hospital quality reports in Germany (2006–2014).

Results

The number of TKAs performed in Germany decreased by 11% after suspending the TKA-MVRQ in 2011, and rose by 13% after its reintroduction in 2015. The number of hospitals with less than 50 cases rose from 10 to 25% and their case share from 2 to 5.5% during suspension. Change in hospital volume after the suspension of TKA-MVRQ was not associated with hospital size, ownership, or region. All four evaluable quality indicators increased significantly in the year after their first public reporting. Compared to hospitals meeting the TKA-MVRQ, three indicators show slight but statistically significant better quality in hospitals below the TKA-MVRQ.

Conclusions

In Germany, TKA-MVRQs seem to induce in-hospital caseload adjustments rather than foster regional inter-hospital case transfers as intended.

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.

[Minimal provider volume in total knee replacement : an analysis of the external quality assurance program of North Rhine-Westphalia (QS-NRW)]

BACKGROUND

A minimal provider volume for total knee replacement (TKR) was introduced in 2006. Does this lead to an improvenment in quality or not? The records of treatment in the compulsory external quality assurance program of the Land of North Rhine-Westphalia (QS-NRW) were evaluated.

METHOD

A total of 125,324 comparable records from the QS-NRW program were available to determine the appearance of general and surgical complications. In a logistical regression model the risk factors age, gender, ASA classification, comorbidity and duration were taken into account.

RESULTS

A significant reduction could only be shown for pneumonia, thrombotic events and lung embolisms as well as vascular injury. In 2006 and 2007 malpositioning of implants was significantly higher and from 2005 to 2008 the number of fractures rose compared to 2004. Deep infections and reoperations did not change significantly during the whole study period.

CONCLUSION

This evaluation could not show an improvement in quality due to the minimal provider volume. Thus the minimal provider volume should not be taken into account as a main criterion to improve quality. Further outcome studies and creating an arthroplasty register in Germany are more useful.

[Determining the indication for primary total hip and knee replacement. Results of external quality assurance of over 270,000 primary total hip and knee replacements]

BACKGROUND

The German mandatory quality assurance programme collects data from all primary total hip and knee replacements. The quality of the indication is measured by clinical and radiological criteria. The results were analysed in terms of differences in establishing the indication subject to patient and hospital characteristics.

MATERIALS AND METHODS

Data on more than 270,000 primary total hip and knee replacements that were operated in 2006 in Germany were analysed concerning differences in the quality of the indication subject to age, gender, hospital volume and density of population and hospitals (metropolitan vs rural areas). The statistical analysis was done by exact Fisher's test.

RESULTS

The quality of the indication was statistically significantly better in men, patients 60 and older, in rural areas and in high volume hospitals (50 and more joint replacements per year).

DISCUSSION

Data of this mandatory German quality assurance programme are useful to describe differences in medical care. The results are valid and complete. An exact analysis of the reasons for these differences is difficult though. Data focus is on quality assurance and represent only in-hospital results.

CONCLUSION

Further analyses are necessary to ascertain whether the differences in quality of care are deficits or only variances in medical care.

[Minimum provider volumes in heart surgery]

The introduction of minimum provider volumes for certain medical procedures has been the subject of scientific investigation and political controversy for quite a while. The core of the discussion focuses on the hypothesis that minimum provider volumes could significantly improve operative results and cost efficiency. In Germany the Fifth Volume of Social Law (Sozialgesetzbuch V) set the legal stage for the implementation of minimum provider volumes. This article is a brief review on the experience with minimum provider volumes in cardiac surgery. The main focus is on coronary artery bypass surgery, as this happens to be the most frequently investigated procedure.

Erfahrungen mit Mindestmengen in der Orthopädie

The implementation of minimum provider volumes in orthopaedic surgery appears to be logically evident. A general volume outcome relationship could be found for total knee and hip replacement on a high level of evidence, but no definite threshold value could be identified. For other orthopaedic procedures the evaluated data hint at a volume outcome relationship but do not prove one. Preliminary model calculations on the effects of a regulation based on volume outcome considerations concerning medical care in Germany show that, though for total hip and knee replacement quite a large number of hospitals would be excluded from medical care, the number of patients to be reallocated would be small. Since 1 January 2007 a minimum provider volume of 50 total knee replacements per year per hospital has been mandatory in Germany. The further application of a minimum requirement regulation based on volume outcome considerations in the German health care system must be performed very carefully, because significant effects are to be expected.