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Published on: December 11, 2017
Case load and valve surgery outcome in Australia
E Anne Russell1, Robert A Baker2, Jayme S Bennetts3
1Baker IDI, Melbourne, Victoria, Australia.
Insights
Higher volume heart valve surgery centers did not consistently show better outcomes. This study found no simple link between surgeon or site case load and improved patient survival, challenging consolidation recommendations.
Area of Science:
- Cardiovascular Surgery
- Health Services Research
Background:
- Recommendations exist in Australia to consolidate heart valve surgery, especially for rheumatic heart disease (RHD), in high-volume centers.
- International cardiac surgery data suggest higher volume centers yield better outcomes.
- The impact of site and surgeon caseload on long-term heart valve surgery outcomes remains under-investigated.
Purpose of the Study:
- To investigate the association between average annual site and surgeon caseload and short-term complications.
- To determine the relationship between caseload and both short-term and long-term survival after heart valve surgery.
Main Methods:
- Analysis of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database.
- Adjusted analysis of 20,116 heart valve procedures across 25 sites and 93 surgeons.
- Examination of associations between caseload and outcomes including ventilation time, reoperation, anticoagulant complications, acute kidney injury, 30-day mortality, and long-term survival.
Main Results:
- Increasing site and surgeon caseload correlated with longer ventilation, reduced reoperation, and more anticoagulant complications.
- Higher surgeon caseload was linked to less acute kidney injury.
- No significant association was found between caseload and adjusted 30-day mortality.
- No consistent relationship between site caseload and long-term survival was observed.
- The highest volume surgeons showed poorer adjusted long-term survival.
Conclusions:
- The association between surgeon/site caseload and heart valve surgery outcomes in Australia is complex and inconsistent.
- Larger volume centers or surgeons did not demonstrate superior overall outcomes.
- Findings do not support mandating specific site caseloads or minimum procedure numbers for surgeons in the Australian context.
Background:
In Australia it has been suggested that heart valve surgery, particularly for rheumatic heart disease (RHD), should be consolidated in higher volume centres. International studies of cardiac surgery suggest large volume centres have superior outcomes. However the effect of site and surgeon case load on longer term outcomes for valve surgery has not been investigated.
Methods:
The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database was analysed. The adjusted association between both average annual site and surgeon case load on short term complications and short and long-term survival was determined.
Results:
Outcomes associated with 20,116 valve procedures at 25 surgical sites and by 93 surgeons were analysed. Overall adjusted analysis showed increasing site and surgeon case load was associated with longer ventilation, less reoperation and more anticoagulant complications. Increasing surgeon case load was also associated with less acute kidney injury. Adjusted 30-day mortality was not associated with site or surgeon case load. There was no consistent relationship between increasing site case load and long term survival. The association between surgeon case load and outcome demonstrated poorer adjusted survival in the highest volume surgeon group.
Conclusions:
In this Australian study, the adjusted association between surgeon and site case load was not simple or consistent. Overall larger volume sites or surgeons did not have superior outcomes. Mandating a particular site case load level for valve surgery or a minimum number of procedures for individual surgeons, in an Australian context, cannot be supported by these findings.
