High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis

Michiel H F Poorthuis; Eelco C Brand; Alison Halliday; Richard Bulbulia; Michiel L Bots; Gert J de Borst

doi:10.1097/SLA.0000000000002880

High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis

Michiel H F Poorthuis, Eelco C Brand, Alison Halliday, Richard Bulbulia, Michiel L Bots, Gert J de Borst

Research output: Contribution to journal › Review article › peer-review

Abstract

OBJECTIVE: To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization.

BACKGROUND: Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated.

METHODS: We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model.

RESULTS: We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts).

CONCLUSIONS: We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications.

REGISTRATION: This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.

Original language	English
Pages (from-to)	631-641
Number of pages	11
Journal	Annals of Surgery
Volume	269
Issue number	4
Early online date	10 Aug 2018
DOIs	https://doi.org/10.1097/SLA.0000000000002880
Publication status	Published - Apr 2019

Keywords

atherosclerosis
carotid artery stenting
carotid endarterectomy
carotid revascularization
carotid stenosis
hospital volume
operator volume
quality of care

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10.1097/SLA.0000000000002880

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@article{fd91f87d0620428a861f8a22c979923f,

title = "High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis",

abstract = "OBJECTIVE: To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization.BACKGROUND: Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated.METHODS: We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model.RESULTS: We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts).CONCLUSIONS: We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications.REGISTRATION: This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.",

keywords = "atherosclerosis, carotid artery stenting, carotid endarterectomy, carotid revascularization, carotid stenosis, hospital volume, operator volume, quality of care",

author = "Poorthuis, {Michiel H F} and Brand, {Eelco C} and Alison Halliday and Richard Bulbulia and Bots, {Michiel L} and {de Borst}, {Gert J}",

year = "2019",

month = apr,

doi = "10.1097/SLA.0000000000002880",

language = "English",

volume = "269",

pages = "631--641",

journal = "Annals of Surgery",

issn = "0003-4932",

publisher = "Lippincott Williams & Wilkins",

number = "4",

}

TY - JOUR

T1 - High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization

T2 - A Systematic Review and Meta-analysis

AU - Poorthuis, Michiel H F

AU - Brand, Eelco C

AU - Halliday, Alison

AU - Bulbulia, Richard

AU - Bots, Michiel L

AU - de Borst, Gert J

PY - 2019/4

Y1 - 2019/4

N2 - OBJECTIVE: To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization.BACKGROUND: Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated.METHODS: We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model.RESULTS: We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts).CONCLUSIONS: We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications.REGISTRATION: This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.

AB - OBJECTIVE: To examine the association between operator or hospital volume and procedural outcomes of carotid revascularization.BACKGROUND: Operator and hospital volume have been proposed as determinants of outcome after carotid endarterectomy (CEA) or carotid artery stenting (CAS). The magnitude and clinical relevance of this relationship are debated.METHODS: We systematically searched PubMed and EMBASE until August 21, 2017. The primary outcome was procedural (30 days, in-hospital, or perioperative) death or stroke. Obtained or estimated risk estimates were pooled with a generic inverse variance random-effects model.RESULTS: We included 87 studies. A decreased risk of death or stroke following CEA was found for high compared to low operator volume with a pooled adjusted odds ratio (OR) of 0.50 (95% confidence interval [CI] 0.28-0.87; 3 cohorts), and a pooled unadjusted relative risk (RR) of 0.59 (95% CI 0.42-0.83; 9 cohorts); for high compared to low hospital volume with a pooled adjusted OR of 0.62 (95% CI 0.42-0.90; 5 cohorts), and a pooled unadjusted RR of 0.68 (95% CI 0.51-0.92; 9 cohorts). A decreased risk of death or stroke after CAS was found for high compared to low operator volume with an adjusted OR of 0.43 (95% CI 0.20-0.95; 1 cohort), and an unadjusted RR of 0.50 (95% CI 0.32-0.79; 1 cohort); for high compared to low hospital volume with an adjusted OR of 0.46 (95% CI 0.26-0.80; 1 cohort), and no significant decreased risk in a pooled unadjusted RR of 0.72 (95% CI 0.49-1.06; 2 cohorts).CONCLUSIONS: We found a decreased risk of procedural death and stroke after CEA and CAS for high operator and high hospital volume, indicating that aiming for a high volume may help to reduce procedural complications.REGISTRATION: This systematic review has been registered in the international prospective registry of systematic reviews (PROSPERO): CRD42017051491.

KW - atherosclerosis

KW - carotid artery stenting

KW - carotid endarterectomy

KW - carotid revascularization

KW - carotid stenosis

KW - hospital volume

KW - operator volume

KW - quality of care

UR - http://www.scopus.com/inward/record.url?scp=85062616091&partnerID=8YFLogxK

U2 - 10.1097/SLA.0000000000002880

DO - 10.1097/SLA.0000000000002880

M3 - Review article

C2 - 30102632

SN - 0003-4932

VL - 269

SP - 631

EP - 641

JO - Annals of Surgery

JF - Annals of Surgery

IS - 4

ER -

High Operator and Hospital Volume Are Associated With a Decreased Risk of Death and Stroke After Carotid Revascularization: A Systematic Review and Meta-analysis

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