School of Health and Related Research, University of Sheffield, Sheffield, UK.
Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
Br J Surg. 2017 Sep;104(10):1273-1283. doi: 10.1002/bjs.10593. Epub 2017 Jun 20.
Hospitals that conduct more procedures on the carotid arteries may achieve better outcomes. In the context of ongoing reconfiguration of UK vascular services, this systematic review was conducted to evaluate the relationship between the volume of carotid procedures and outcomes, including mortality and stroke.
Searches of electronic databases identified studies that reported the effect of hospital or clinician volume on outcomes. Reference and citation searches were also performed. Inclusion was restricted to European populations on the basis that the model of healthcare delivery is similar across Europe, but differs from that in the USA and elsewhere. Analyses of hospital and clinician volume, and carotid endarterectomy (CEA) and carotid artery stenting (CAS) were conducted separately.
Eleven eligible studies were identified (233 411 participants), five from the UK, two from Sweden, one each from Germany, Finland and Italy, and a combined German, Austrian and Swiss population. All studies were observational. Two large studies (179 736 patients) suggested an inverse relationship between hospital volume and mortality (number needed to treat (NNT) as low as 165), and combined mortality and stroke (NNT as low as 93), following CEA. The evidence was less clear for CAS; multiple analyses in three studies did not identify convincing evidence of an association. Limited data are available on the relationship between clinician volume and outcome in CAS; in CEA, an inverse relationship was identified by two of three small studies.
The evidence from the largest and highest-quality studies included in this review support the centralization of CEA.
进行更多颈动脉手术的医院可能会取得更好的效果。在英国血管服务不断重组的背景下，本系统评价旨在评估颈动脉手术量与包括死亡率和中风在内的结果之间的关系。
电子数据库的检索确定了报告医院或临床医生手术量对结果影响的研究。还进行了参考文献和引文的检索。纳入仅限于欧洲人群，因为欧洲的医疗保健提供模式在整个欧洲相似，但与美国和其他地区不同。分别对医院和临床医生的手术量以及颈动脉内膜切除术（CEA）和颈动脉血管成形术（CAS）进行了分析。
确定了 11 项符合条件的研究（233411 名参与者），其中 5 项来自英国，2 项来自瑞典，1 项分别来自德国、芬兰和意大利，以及德国、奥地利和瑞士的综合人群。所有研究均为观察性研究。两项大型研究（179736 名患者）表明，CEA 后，医院手术量与死亡率（低至 165 的需要治疗人数（NNT））呈负相关，与死亡率和中风合并发生率（低至 93 的 NNT）呈负相关。CAS 的证据不太明确；三项研究中的多项分析并未发现与死亡率之间有明显关联。关于 CAS 中临床医生手术量与结果的关系，数据有限；CEA 中，三项小型研究中的两项发现了呈负相关的证据。
本评价纳入的最大和最高质量的研究证据支持 CEA 的集中化。
