Influence of Hospital Volume on Nephrectomy Mortality and Complications: A Systematic Review and Meta-analysis Stratified by Surgical Type
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Hsu, R., Salika, T., Maw, J., Lyratzopoulos, G., Gnanapragasam, V., & Armitage, J. (2017). Influence of Hospital Volume on Nephrectomy Mortality and Complications: A Systematic Review and Meta-analysis Stratified by Surgical Type. BMJ Open, 7 (9. e016833)https://doi.org/10.1136/bmjopen-2017-016833
Objectives The provision of complex surgery is increasingly centralised to high volume specialist hospitals. Evidence to support nephrectomy centralisation however has been inconsistent. We conducted a systematic review and meta-analysis to determine the association between hospital case volumes and perioperative outcomes in radical nephrectomy, partial nephrectomy and nephrectomy with venous thrombectomy. Methods Medline, Embase and the Cochrane Library were searched for relevant studies published between 1990 and 2016. Pooled effect estimates for nephrectomy mortality and complications were calculated for each nephrectomy type using the DerSimonian and Laird random-effects model. Sensitivity analyses were performed to examine the effects of heterogeneity on the pooled effect estimates by excluding studies with the heaviest weighting, lowest methodological score, and most likely to introduce bias from misclassification of standardised hospital volume. Results Some 226,372 patients from sixteen publications were included in our review and meta-analysis. Considerable between-study heterogeneity was noted and only a few reported volume-outcome relationships specifically in partial nephrectomy or nephrectomy with venous thrombectomy. High volume hospitals were correlated with a 26% and 52% reduction in mortality for radical nephrectomy (OR 0.74, 95% CI 0.61-0.90, p<0.01) and nephrectomy with venous thrombectomy (OR 0.48, 95% CI 0.29-0.81, p<0.01) respectively. In addition, radical nephrectomy in high volume hospitals was associated with an 18% reduction in complications (OR 0.82, 95% CI 0.73-0.92, p<0.01). No significant volume-outcome relationship in mortality (OR 0.84, 95% CI 0.31-2.26, p=0.73) or complications (OR 0.85, 95% CI 0.55-1.30, p=0.44) was observed for partial nephrectomy. Conclusions Our findings suggest that patients undergoing radical nephrectomy have improved outcomes when treated by high volume hospitals. Evidence of this in partial nephrectomy and nephrectomy with venous thrombectomy is however not yet clear and could be secondary to the low number of studies included and the small patient number in our analyses. Further investigation is warranted to establish the full potential of nephrectomy centralisation particularly as existing evidence is of low quality with significant heterogeneity.
This work was supported by Addenbrooke’s Charitable Trust, the Royal College of Surgeons of England and the Urology Foundation. Cancer Research UK Advanced Clinician Scientist Fellowship award (No. C18081/A18180) has supported GL and TS.
Urology Foundation (Research Scholarship Applicati)
Addenbrooke's Charitable Trust (ACT) (241/15 A/Hsu)
External DOI: https://doi.org/10.1136/bmjopen-2017-016833
This record's URL: https://www.repository.cam.ac.uk/handle/1810/265280
Attribution 4.0 International
Licence URL: http://creativecommons.org/licenses/by/4.0/