Getting It Right First Time Programme, NHS England and NHS Improvement, London, UK.
Royal National Orthopaedic Hospital, Stanmore, London, UK.
Br J Surg. 2021 Sep 27;108(9):1112-1119. doi: 10.1093/bjs/znab142.
A minimum volume threshold of at least six procedures per annum per surgeon has been set in UK and European guidelines for adrenal surgery. The aim of this study was to investigate outcomes for adrenal surgery in England relative to annual surgeon and hospital trust volume.
Data were extracted from the Hospital Episodes Statistics database for England. A 6-year period (January 2013 to December 2018 inclusive) for all adult admissions for unilateral adrenal surgery was used. The primary outcome measure was an emergency readmission within 30 days of discharge following surgery. Procedures were categorized as open or minimally invasive surgery for analysis. Multilevel modelling was used to adjust for hierarchy and potential confounders.
Data for 4189 adrenalectomies were identified. Only one third of surgeons (who operated on just over a half of all patients) performed at least six procedures in the year prior to the index procedure. For open surgery, emergency readmission rates fell significantly from 15.2 to 6.4 per cent for surgeons and from 13.2 to 6.1 per cent for trusts between the lowest- and highest-volume categories. Significant, but less dramatic falls were also seen for minimally invasive surgery.
A volume-outcome effect was identified for adrenal surgery in England. Minimum volume thresholds should be set, although these may need to be more ambitious than the current threshold if outcomes are to be optimized.
Surgery for disease of the adrenal gland can be complex. In many cases the skill and experience of the surgeon and the wider surgical team is thought to be important in determining the success of the procedure. The relative rarity of adrenal surgery means that there is little evidence to support this view. This study looked at outcomes for all 4189 patients who underwent adrenal surgery in England over a 6-year period. There was evidence that outcomes were better for patents when the surgeon and hospital trust had performed a larger number of adrenal surgery procedures in the year prior to the procedure. This was, however, dependent on which patient outcomes were studied and the type of procedure. These findings will inform the ongoing debate as to whether adrenal surgery in England should only be performed in regional centres by experienced teams.
英国和欧洲的肾上腺手术指南规定，每位外科医生每年至少要进行 6 例手术。本研究旨在调查英国与外科医生和医院信托机构每年手术量相关的肾上腺手术结果。
从英国的医院入院统计数据库中提取数据。使用了为期 6 年（2013 年 1 月至 2018 年 12 月）的所有单侧肾上腺手术成人入院数据。主要观察指标是手术后 30 天内出院后的紧急再入院。对手术进行了开放性手术或微创手术的分类分析。使用多水平模型调整层次结构和潜在混杂因素。
共确定了 4189 例肾上腺切除术的数据。只有三分之一的外科医生（他们只做了超过一半患者的手术）在进行索引手术前的一年中进行了至少 6 例手术。对于开放性手术，从最低到最高手术量类别，外科医生的紧急再入院率从 15.2%降至 6.4%，而信托机构的紧急再入院率从 13.2%降至 6.1%。微创性手术也有显著但不那么显著的下降。
在英国，肾上腺手术的结果与手术量之间存在关联。应设定最低手术量阈值，尽管如果要优化结果，这些阈值可能需要比当前阈值更具野心。
肾上腺疾病的手术可能很复杂。在许多情况下，外科医生和更广泛的外科团队的技能和经验被认为是决定手术成功的重要因素。由于肾上腺手术相对罕见，因此几乎没有证据支持这一观点。本研究调查了在英国接受肾上腺手术的 4189 名患者在 6 年期间的所有结果。有证据表明，当外科医生和医院信托机构在手术前一年进行了更多的肾上腺手术时，患者的预后更好。然而，这取决于研究的患者结果和手术类型。这些发现将为英国是否应仅由经验丰富的团队在区域中心进行肾上腺手术的持续辩论提供信息。
