gms | German Medical Science

19. Deutscher Kongress für Versorgungsforschung

Deutsches Netzwerk Versorgungsforschung e. V.

30.09. - 01.10.2020, digital

Hospital volume-outcome relationship in total knee arthroplasty: a systematic review and dose-response meta-analysis

Meeting Abstract

  • Tanja Rombey - Institut für Forschung in der Operativen Medizin, Universtität Witten/Herdecke, Köln, Deutschland
  • Charlotte Kugler - Institut für Forschung in der Operativen Medizin, Universtität Witten/Herdecke, Köln, Deutschland
  • Käthe Goossen - Institut für Forschung in der Operativen Medizin, Universtität Witten/Herdecke, Köln, Deutschland
  • Jessica Breuing - Institut für Forschung in der Operativen Medizin, Universtität Witten/Herdecke, Köln, Deutschland
  • Tim Mathes - Institut für Forschung in der Operativen Medizin, Universtität Witten/Herdecke, Köln, Deutschland
  • Simone Hess - Institut für Forschung in der Operativen Medizin, Universtität Witten/Herdecke, Köln, Deutschland
  • René Burchard - Klinik für Orthopädie/Unfallchirurgie, Lahn-Dill-Kliniken Dillenburg, Wetzlar, Deutschland; Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland
  • Dawid Pieper - Institut für Forschung in der Operativen Medizin, Universtität Witten/Herdecke, Köln, Deutschland

19. Deutscher Kongress für Versorgungsforschung (DKVF). sine loco [digital], 30.09.-01.10.2020. Düsseldorf: German Medical Science GMS Publishing House; 2020. Doc20dkvf146

doi: 10.3205/20dkvf146, urn:nbn:de:0183-20dkvf1464

Published: September 25, 2020

© 2020 Rombey et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


Outline

Text

Background and state of (inter)national research: In Germany, there is a minimum volume threshold for total knee arthroplasty (TKA) of n=50 procedures per hospital per year. However, it is unclear whether a hospital volume-outcome relationship exists for TKA, a high-volume low-risk procedure.

Purpose: The objective of this systematic review was to investigate the relationship between hospital volume of TKA and patient-relevant outcomes.

Methods: We included cohort studies, which included TKA patients, reported at least two different hospital volumes, and considered patient-relevant outcomes. To identify studies, we systematically searched (from inception to 14/02/2020) MEDLINE, Embase, CENTRAL, and CINAHL, as well as other sources. The risk of bias of the included studies was assessed with ROBINS-I. We performed a linear dose-response meta-analysis based on best-adjusted effect estimates and calculated odds ratios (ORs) and 95% confidence intervals per 10 additional patients. Heterogeneity was quantified with I2. We will grade the quality of evidence and strength of recommendation using the GRADE approach (work in progress).

To incorporate patients’ preferences into our recommendations, we conducted a focus group (at the outset of the review) and semi-structured telephone interviews (at completion of the review) with patients. We transcribed all conversations and performed qualitative content analysis.

Results: A total of 59 articles including over 11 million patients were eligible. The articles covered data from 1985 to 2018, mostly from the US (n=24) or Germany (n=11). Most studies had a moderate or serious overall risk of bias. Our dose-response meta-analysis showed that higher hospital volume resulted in lower rates of revision within 12 months (OR 0.959 [0.930 to 0.988] per 10 additional TKA patients, n=2 studies, I2=84.5%), slightly lower revision rates at 1-5 years (OR 0.988 [0.967 to 1.010], n=3 studies, I2=95.0%) and lower 30-day mortality (OR 0.981 [0.972 to 0.990], n=9 studies, I2=51.2%). Hospital volume had close to no effect on the 30-day readmission rate (OR 0.996 [0.996 to 0.996], n=2 studies, I2=0%) and there was no evidence of an effect of hospital volume on the rate of revision at 6-10 years (OR 1.000 [0.979 to 1.022], n=3 studies, I2=82.3%).

The participants of the focus group (n=5) and telephone interviews (n=16) generally believed that there is a hospital volume-outcome relationship for TKA, were willing to travel longer distances for better health outcomes, and found that – according to our results – hospital volume has an important influence on the outcome.

Conclusions: Having a minimum volume threshold for TKA in Germany seems acceptable as we found that the hospital volume-outcome relationship is linear, with high-volume hospitals achieving better patient-relevant outcomes. Our findings are limited by the design of the included studies.

Practical implications: No conclusion regarding an optimal cut-off can be drawn from our results, therefore, further research is needed to determine an optimal cut-off. Future studies should assess both hospital and surgeon volume.

Funding: German Federal Ministry of Education and Research – BMBF (01KG1805). Registration: PROSPERO (CRD42019131209).