BACKGROUND: The volume-outcome relationship in severely injured patients remains under debate and this has consequences for the designation of trauma centers.
OBJECTIVES: The aim of this study was to evaluate the relationship between hospital or surgeon volume and health outcomes in severely injured patients.
METHODS: Six electronic databases were searched from 1980 up to January 30 2018 to identify studies that describe the relationship between hospital or surgeon volume and health outcomes in severely injured patients (preferably Injury Severity Score (ISS) above 15). Selection of relevant studies, data extraction and critical appraisal of the methodological quality were performed by two independent reviewers. Pooled adjusted and unadjusted estimates of the effect of volume on in-hospital mortality, only in study populations with ISS > 15, were calculated with a random-effects meta-analysis. A mixed effects linear regression model was used to assess hospital volume as continuous parameter.
RESULTS: Eighteen observational cohort studies were included. The majority (13/18, 72%) reported an association between higher hospital or surgeon volume and lower mortality rate. Overall, the quality of the included studies was reasonable, with insufficient adjustment as one of the most common limitations. Eight studies were included in the meta-analysis with a total of 222,418 patients. High hospital volume (>240 admitted severely injured patients per year) was associated with a lower risk of mortality (adjusted odds ratio 0.85, 95% confidence interval (CI) 0.76-0.94). Four studies were included in the regression model, providing a beta of -0.17 per 10 patients (95% CI -0.27 to -0.07). There was no clear association between surgeon volume and mortality rates based on three available studies.
CONCLUSION: Our systematic overview of the literature reveals a modest association between high volume centers and lower mortality in severely injured patients, suggesting that designation of high volume centers might improve outcomes among severely injured patients.level III, Systematic review and meta-analysisPROSPERO registration ID CRD42017056729.
Aims and objectives To systematically review the relationship of trauma centre characteristics and trauma patient outcomes. Background Numerous studies have documented the impact of trauma centre level, trauma centre verification, volume per centre and per surgeon or resource availability on outcomes among trauma patients. However, there continues to be debated about whether trauma care is comparable by these trauma centre characteristics. Design Systematic review. Methods Eligible studies were identified via electronic database searches, footnote chasing and contact with clinical experts. Quality of selected studies was assessed in terms of internal and external validity using 14 questions. Two reviewers independently examined titles, abstracts and whether each met the predefined criteria. Results A total of 50 studies which met criteria were selected. Ten of 17 articles showed that level I trauma centres had better patient outcomes than level II centres. The achievement of trauma centre verification by American College of Surgeons or State was beneficial to decreasing mortality and length of stay in 9 of 11 studies. High trauma admission volume was beneficial in 8 of 16 studies. The volume per trauma surgeon did not contribute to better patient outcomes in 4 of 5 studies. The availability of in-house trauma surgeon was beneficial to lower mortality and shorter length of stay in only 2 of 9 studies. Conclusion This review supports that achieving the trauma centre verification by American College of Surgeons or State is definitely beneficial to patient outcomes. However, the benefit of level I centres compared with level II centres, and volume of annual trauma patients to outcomes is still debating. Further prospective study examining this relationship is required. Relevance to clinical practice Understanding which characteristics of trauma centre provides the best prospect for improved outcomes depending on patient need and resource availability would allow further appreciation of the processes that foster such enhancement.
Specialized centers of care for spinal cord injury (SCI) were first established in 1944 in England. The objective of these centers is to improve care and neurological recovery of patients suffering from a spinal cord injury. An interdisciplinary group of experts composed of medical and surgical specialists treating patients with SCI formulated the following questions: (1) Is there any evidence to suggest that specialized centers of care in SCI decrease the length of patient stay? and (2) Is there evidence that specialized centers of care for SCI reduce mortality and secondary complications? A systematic review of the current evidence was performed using multiple databases to answer these two specific questions. Two independent reviewers graded each paper using the Black and Downs method. Recommendations were then formulated based on the evidence available and were reviewed by a panel of experts using a modified Delphi approach. Two recommendations were formulated and both received complete agreement from a panel of experts. The first recommendation is "Early transfer of a patient with traumatic SCI to a specialized center of care should be done promptly to decrease overall length of stay." The second recommendation is "Early transfer of patients with traumatic SCI to an integrated multidisciplinary specialized center of care decreases overall mortality, and the number and severity of complications."
Background and Objective: Accreditation is usually a voluntary program in which trained external peer reviewers evaluate a healthcare organization's compliance and compare it with pre-established performance standards. The aim of this study was to evaluate the impact of accreditation programs on the quality of healthcare services Methods : We did a systematic review of the literature to evaluate the impact of accreditation programs on the quality of healthcare services. Several databases were systematically searched, including Medline, Embase, Healthstar, and Cinhal. Results: Twenty-six studies evaluating the impact of accreditation were identified. The majority of the studies showed general accreditation for acute myocardial infarction (AMI), trauma, ambulatory surgical care, infection control and pain management; and subspecialty accreditation programs to significantly improve the process of care provided by healthcare services by improving the structure and organization of healthcare facilities. Several studies showed that general accreditation programs significantly improve clinical outcomes and the quality of care of these clinical conditions and showed a significant positive impact of subspecialty accreditation programs in improving clinical outcomes in different subspecialties, including sleep medicine, chest pain management and trauma management. Conclusions: There is consistent evidence that shows that accreditation programs improve the process of care provided by healthcare services. There is considerable evidence to show that accreditation programs improve clinical outcomes of a wide spectrum of clinical conditions. Accreditation programs should be supported as a tool to improve the quality of healthcare services.
BACKGROUND: The aim of this study was to document the present knowledge from the medical literature on (1) efficacy of aeromedical evacuation (helicopter emergency medical service, HEMS) and (2) influence of the level of the first receiving hospital on mortality of patients. METHODS: Systematic review of the literature between 1970 and 2003; identification of studies with an evidence level of at least III and included control group; own results. RESULTS: (1) 17 studies concerning the efficacy of HEMS were included into the review. No single study yielded shorter rescue times with the use of HEMS. 11 of 17 studies showed a significantly higher survival rate (8.2 to 52%) with the employment of HEMS especially with mid-degree polytrauma. (2) All 6 relevant studies dealing with hospital level found a considerable lower mortality rate (19 to 42%) for patients treated primarily at a level 1 trauma center or comparable institution. CONCLUSIONS: The analyzed studies showed a trend toward decreased mortality rates with the employment of HEMS. Considering the comparable hospital level and even longer rescue times with HEMS, these differences can be explained with higher quality of initial diagnosis and treatment of the HEMS rescue team. Furthermore, mortality rates can be lowered significantly through primary treatment at a level 1 trauma center. Thus, the more flexible choice of the first receiving hospital represents a specific, clinically relevant advantage of HEMS in emergency medicine.
BACKGROUND: To date, systematic reviews on the relationship between the volume of specific diagnoses and procedures and patient outcomes have several limitations, including the omission of the most recent publications.
OBJECTIVE: To investigate the relationship between hospital and physician volume and patient mortality rate for all diagnoses and interventions in health care.
RESEARCH DESIGN: Medline and the Cochrane Library were searched from January 1990 to December 2000 for all studies published in Dutch, English, French, German, and Italian. The following Boolean search statement was used: hospitals AND volume AND (outcome OR mortality OR quality). Studies were included in which patient enrollment ended within 10 years of the current study and that were adjusted for case-mix. For each diagnosis and intervention, the study most likely to provide an unbiased estimate of the effect of volume on mortality rate was identified using a specific algorithm (best study).
RESULTS: A total of 34 diagnoses and interventions with at least one qualifying study on the volume-outcome relationship were identified. The summary odds ratio/relative risk for the best studies on hospital and physician volume were 0.87 (95% confidence interval [CI], 0.85-0.89) and 0.87 (95% CI, 0.81-0.94), respectively. From the best studies on hospital volume, 48.5% (16 of 33) were published either in 1999 or 2000.
CONCLUSIONS: There is evidence for a volume-mortality relationship for hospitals and physicians. The use of appropriate methods for analyzing additional diagnoses and interventions as well as a continuous systematic evaluation of the evidence is recommended.
The relationship between volume and surgical outcome seems logical, but needs to be demonstrated in the real world. A qualitative systematic review has been conducted to verify this hypothesis. Five systematic reviews and hundred original papers have been retreived and analysed. Most of the studies were retrospective and used administrative data instead of medical charts. Moreover few studies involved a good case mix adjustment when comparing surgical units or individual surgeons. These methodological flaws do not allow any evidence based conclusions. Even though a positive relationship is suggested for surgical units, the relationship between volume and outcome was however less obvious for an individual surgeon. There is some evidence that the relationship varied greatly according to the specialty or the procedure evaluated.Anew approach based on predictive scores comparing expected versus observed outcomes is mandatory and seems to be the best way to assess objectively the relationship between surgical volume and outcomes.
PURPOSE: In this report, the importance of the patient count for the treatment quality at hospital and at the level of the doctor is evaluated. The report also assesses the relevance of the results of international scientific literature to the Norwegian healthcare system. METHODS: The report of York ("Concentration and choice in the provision of hospital services" (1997)) has been the basis for the work. There are further searches for primary studies of scientific literature from medical databases for the period 1997-2000. Studies that satisfy the given criteria (see the main report) are then examined. Special attention has been paid to a satisfactory assessment of the patient mix ("case mix"). Moreover, information from the Norwegian Patient Register has been obtained for a selection of procedures conducted at Norwegian hospitals in the period 1995-98. The method assessment was carried out by an expert group at the Center for Medical Methodology Assessment under management by Professor Per Teisberg and with Dr. Philos Inger N.Norderhaug as Project Coordinator. RESULTS: 112 scientific articles published after the York report release are considered. Of 87, it was found that hospital or leg volume has a bearing on treatment quality. Quality is most often expressed with mortality or complication rates. The research activity around volume quality has mainly included surgical interventions. The documentation of a volume-quality context is best for patients with cancer or cardiovascular disease treated with surgery. Likewise, it is documented the quality of organ transplantation and AIDS treatment is better at the hospital's high volume. However, in the case of trauma and at orthopedic surgery, no consistent relationship between volume and mortality or complications has been demonstrated. (The studies concerning injuries are from the United States The treatment is organized in ITRA centers with different levels of competence.) In other diseases or operations studied, there is insufficient basis for drawing safe conclusions. The report also presents an overview of the activity level at Norwegian hospitals for surgical procedures and medical diagnoses. The survey shows that many Norwegian hospital practitioners planned surgical procedures and medical treatment with a volume that was very low. COMMENTS: Scientific work on volume-quality relationships is exposed to multiple possible sources of error. An important aspect of this report is that such sources of error have been discussed and the studies are evaluated critically to reduce the effects of the error sources on the results. Knowledge of volume quality is mainly based on information from studies conducted in IUSA. Only five of the studies in this and the York report are from Norway or include Norwegian hospitals. Knowledge of conditions at Norwegian hospitals should ideally be used as a starting point for assessments of volume-quality dimensions in Norwegian health services. Such knowledge is to some extent available, or may be, through clinical quality registers. However, the findings in the literature that are considered are relevant to Norwegian conditions. Although the evaluated scientific evidence indicates that higher volumes provide better quality-like quality is defined here, this is not a conclusion that can be automatically transferred to other areas of medical treatment. The volume-quality relationship has been studied extensively in the treatment of patients with chronic disorders and non-surgical diseases. The size of the volume effect is also not evaluated against other factors that are crucial to the quality. There are also studies that show no connection between volume and quality, and for some medical areas, the study is contradictory. The quality of treatment in this and York report is most often expressed as mortality and complications associated with or after treatment. There are very few scientific workers dealing with long-term effects, for example. function level, long-term survival rate of implant and reoperation rates (eg by joint prosthesis). In some areas where there is scientific evidence, the relevance for Norwegian relations is clear. Some hospitals have such a small volume that one must fear that the quality is not optimal. In addition, the volumes are so small that it is doubtful whether hospitals can say something about their own quality in a conciliatory way. Creating quality records for areas where the volume dimension is important will therefore be an important quality enhancement measure in Norway. This report will provide a basis for discussion in both the academic and social policy circles. The report is a challenge for the professional communities in relation to the requirement to document results in the work performed. It challenges health politicians in relation to planning, task allocation and quality assurance. The volume quality dimension is one of many factors that must be emphasized and must be balanced against other factors, such as accessibility, geographical equality and patient satisfaction. SMM would like to thank the members of the Expert Group for an impressive work.
The volume-outcome relationship in severely injured patients remains under debate and this has consequences for the designation of trauma centers.
OBJECTIVES:
The aim of this study was to evaluate the relationship between hospital or surgeon volume and health outcomes in severely injured patients.
METHODS:
Six electronic databases were searched from 1980 up to January 30 2018 to identify studies that describe the relationship between hospital or surgeon volume and health outcomes in severely injured patients (preferably Injury Severity Score (ISS) above 15). Selection of relevant studies, data extraction and critical appraisal of the methodological quality were performed by two independent reviewers. Pooled adjusted and unadjusted estimates of the effect of volume on in-hospital mortality, only in study populations with ISS > 15, were calculated with a random-effects meta-analysis. A mixed effects linear regression model was used to assess hospital volume as continuous parameter.
RESULTS:
Eighteen observational cohort studies were included. The majority (13/18, 72%) reported an association between higher hospital or surgeon volume and lower mortality rate. Overall, the quality of the included studies was reasonable, with insufficient adjustment as one of the most common limitations. Eight studies were included in the meta-analysis with a total of 222,418 patients. High hospital volume (>240 admitted severely injured patients per year) was associated with a lower risk of mortality (adjusted odds ratio 0.85, 95% confidence interval (CI) 0.76-0.94). Four studies were included in the regression model, providing a beta of -0.17 per 10 patients (95% CI -0.27 to -0.07). There was no clear association between surgeon volume and mortality rates based on three available studies.
CONCLUSION:
Our systematic overview of the literature reveals a modest association between high volume centers and lower mortality in severely injured patients, suggesting that designation of high volume centers might improve outcomes among severely injured patients.level III, Systematic review and meta-analysisPROSPERO registration ID CRD42017056729.
