目的:本研究提出了一种新的体积-结果(V-O)荟萃分析方法,以确定需要集中的心血管干预措施的最佳年度住院病例量阈值。这种新方法应用于急性A型主动脉夹层(ATAAD)的手术作为说明性示例。
方法:对三个电子数据库进行了系统搜索(2012年1月1日至2023年3月29日)。主要结果是早期死亡率与年住院病例量的关系。数据按体积四分位数(Qs)表示。使用受限三次样条来证明V-O关系,并应用弯管法确定最佳箱容。对于临床解释,计算需要治疗的数量(NNT)。
结果:纳入140项研究,包括38276名患者。观察到显著的非线性V-O效应(p<0.001),早期死亡率的四分位数之间存在显着差异(10.3%[Q4]与16.2%[第一季度],p<0.001)。确定的最佳年病例量为38例/年(95%CI37-40例/年,NNT以最佳音量保存在中心的生命与10例/年=21)。对于长期生存率,观察到更明显的四分位数之间的生存差异(10年生存率[Q4]69%vs.[Q1]51%,p<0.001,调整后的HR0.83,95%CI0.75-0.91每四分位数,NNT以高容量拯救生命[Q4]与低容量中心[Q1)=6)。
结论:使用这种新颖的方法,在统计学上确定了最佳的医院病例量阈值.将ATAAD护理集中到高容量中心可能会改善结果。该方法可以应用于需要集中的各种其他心血管手术。
The current study proposes a novel volume-outcome (V-O) meta-analytical approach to determine the optimal annual hospital
case volume threshold for cardiovascular interventions in need of centralization. This novel method is applied to surgery for acute type A aortic dissection (ATAAD) as an illustrative example.
A systematic search was applied to three electronic databases (1 January 2012 to 29 March 2023). The primary outcome was early mortality in relation to annual hospital
case volume. Data were presented by volume quartiles (Qs). Restricted cubic splines were used to demonstrate the V-O relation, and the elbow method was applied to determine the optimal
case volume. For clinical interpretation, numbers needed to treat (NNTs) were calculated.
One hundred and forty studies were included, comprising 38 276 patients. A significant non-linear V-O effect was observed (P < .001), with a notable between-quartile difference in early mortality rate [10.3% (Q4) vs. 16.2% (Q1)]. The optimal annual
case volume was determined at 38 cases/year [95% confidence interval (CI) 37-40 cases/year, NNT to save a life in a centre with the optimal volume vs. 10 cases/year = 21]. More pronounced between-quartile survival differences were observed for long-term survival [10-year survival (Q4) 69% vs. (Q1) 51%, P < .01, adjusted hazard ratio 0.83, 95% CI 0.75-0.91 per quartile, NNT to save a life in a high-volume (Q4) vs. low-volume centre (Q1) = 6].
Using this novel approach, the optimal hospital
case volume threshold was statistically determined. Centralization of ATAAD care to high-volume centres may lead to improved outcomes. This method can be applied to various other cardiovascular procedures requiring centralization.