Mayer Erik K, Purkayastha Sanjay, Athanasiou Thanos, Darzi Ara, Vale Justin A
Department of Urology, St Mary's Hospital Campus, Imperial College Healthcare NHS Trust, London, UK.
BJU Int. 2009 Feb;103(3):341-9. doi: 10.1111/j.1464-410X.2008.08021.x. Epub 2008 Oct 16.
To assess systematically the quality of evidence for the volume-outcome relationship in uro-oncology, and thus facilitate the formulating of health policy within this speciality, as 'Implementation of Improving Outcome Guidance' has led to centralization of uro-oncology based on published studies that have supported a 'higher volume-better outcome' relationship, but improved awareness of methodological drawbacks in health service research has questioned the strength of this proposed volume-outcome relationship.
We systematically searched previous relevant reports and extracted all articles from 1980 onwards assessing the volume-outcome relationship for cystectomy, prostatectomy and nephrectomy at the institution and/or surgeon level. Studies were assessed for their methodological quality using a previously validated rating system. Where possible, meta-analytical methods were used to calculate overall differences in outcome measures between low and high volume healthcare providers.
In all, 22 studies were included in the final analysis; 19 of these were published in the last 5 years. Only four studies appropriately explored the effect of both the institution and surgeon volume on outcome measures. Mortality and length of stay were the most frequently measured outcomes. The median total quality scores within each of the operation types were 8.5, 9 and 8 for cystectomy, prostatectomy and nephrectomy, respectively (possible maximum score 18). Random-effects modelling showed a higher risk of mortality in low-volume institutions than in higher-volume institutions for both cystectomy and nephrectomy (odds ratio 1.88, 95% confidence interval 1.54-2.29, and 1.28, 1.10-1.49, respectively).
The methodological quality of volume-outcome research as applied to cystectomy, prostatectomy and nephrectomy is only modest at best. Accepting several limitations, pooled analysis confirms a higher-volume, lower-mortality relationship for cystectomy and nephrectomy. Future research should focus on the development of a quality framework with a validated scoring system for the bench-marking of data to improve validity and facilitate rational policy-making within the speciality of uro-oncology.
系统评估泌尿肿瘤学中手术量与治疗结果关系的证据质量，从而促进该专业领域的卫生政策制定。因为“改善治疗结果指南的实施”导致泌尿肿瘤学基于已发表的研究进行集中化，这些研究支持“手术量越高 - 治疗结果越好”的关系，但对卫生服务研究中方法学缺陷认识的提高对这种提议的手术量 - 治疗结果关系的强度提出了质疑。
我们系统检索了先前的相关报告，并提取了自1980年起所有评估机构和/或外科医生层面膀胱切除术、前列腺切除术和肾切除术手术量与治疗结果关系的文章。使用先前验证的评分系统评估研究的方法学质量。在可能的情况下，采用荟萃分析方法计算低手术量和高手术量医疗服务提供者之间治疗结果指标的总体差异。
最终分析共纳入22项研究；其中19项是在过去5年发表的。只有四项研究适当探讨了机构手术量和外科医生手术量对治疗结果指标的影响。死亡率和住院时间是最常测量的结果。膀胱切除术、前列腺切除术和肾切除术每种手术类型的总质量得分中位数分别为8.5、9和8（可能的最高分18分）。随机效应模型显示，对于膀胱切除术和肾切除术，低手术量机构的死亡率高于高手术量机构（优势比分别为1.88，95%置信区间1.54 - 2.29和1.28，1.10 - 1.49）。
应用于膀胱切除术、前列腺切除术和肾切除术的手术量 - 治疗结果研究的方法学质量充其量只能说是一般。尽管存在一些局限性，但汇总分析证实了膀胱切除术和肾切除术手术量越高、死亡率越低的关系。未来的研究应侧重于开发一个质量框架，该框架具有经过验证的评分系统用于数据基准化，以提高有效性并促进泌尿肿瘤学专业内的合理政策制定。
