ABSTRACT
BACKGROUND: The legally prescribed minimum volume standards for complex esophageal and pancreatic surgery have been increased or will increase in 2023 and 2025, respectively. Hospitals not reaching the minimum volume standards are no longer allowed to perform these surgeries and are not entitled tor reimbursement. OBJECTIVE: The study aims to explore which effects are expected by healthcare professionals and patient representatives and what possible solutions exist for Brandenburg, a rural federal state in northeast Germany. MATERIAL AND METHODS: In this study 19 expert interviews were conducted with hospital employees (head/senior physicians, nursing director), resident physicians and patient representatives between July 2022 and January 2023. The data analysis was based on content analysis. RESULTS: Healthcare professionals and patient representatives expect a redistribution into a few clinics for surgical care (specialized centres); conversely more clinics that do not (no longer) perform the defined surgeries but could function as gatekeeping hospitals for basic care, diagnostics and follow-up (regional centres). The redistribution could also impact forms of treatment that are not directly defined within the regulation for minimum volume standards. The increased thresholds could also affect medical training and staff recruitment. A solution could be collaborations between different hospitals, which would have to be structurally promoted. CONCLUSION: The study showed that minimum volume standards not only influence the quality of outcomes and accessibility but also have a multitude of other effects. Particularly for rural regions, minimum volume standards are challenging for access to esophageal and pancreatic surgery as well as for communication between specialized and regional centres or resident providers.
Subject(s)
Digestive System Surgical Procedures , Hospitals , Humans , Delivery of Health Care , Esophagus , Health PersonnelABSTRACT
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 ).
