For certain surgical procedures, can a correlation be shown between the volume of services provided per hospital and the quality of treatment results? This is the question addressed in eight commissions that the Federal Joint Committee (G-BA) awarded to the Institute for Quality and Efficiency in Health Care (IQWiG) in Germany. An IQWiG rapid report is now available for the seventh intervention to be tested, complex pancreatic surgery.
According to the findings, for complex pancreatic surgery a positive correlation can be inferred between the volume of services and the quality of treatment results: In hospitals with larger case volumes, the survival probabilities for patients are higher overall, fewer fatal complications occur and hospital stays are mostly shorter.
High-risk procedures usually performed as elective surgery
The pancreas produces both digestive secretions and hormones such as insulin, glucagon or somatostatin, which have a regulating effect on carbohydrate metabolism and digestion.
Surgical procedures of the pancreas are considered complex and thus high risk, and are usually performed as elective, i.e. planned, surgery. These procedures are largely performed due to complications caused by chronic inflammation or due to malignant neoplasms.
Between 2009 and 2014, about 35,000 complex surgical procedures of the pancreas were performed overall in Germany due to malignant neoplasms.
The hospital mortality rates for patients who underwent complex pancreatic surgery in Germany between 2009 and 2013 were around 10 percent. The G-BA has set a minimum volume for complex pancreatic surgery in Germany, which currently stands at ten procedures per year and hospital location.
Positive correlation between volume of services and survival probability
The IQWiG project team identified 42 retrospective observational studies investigating the correlation between the volume of services and the quality of treatment results in complex pancreatic surgery. Of these studies, 36 contained usable data.
The data analysis showed that the overall survival probabilities for patients who undergo pancreatic surgery are higher when they are treated in hospitals with larger case volumes and by surgeons with more routine in this type of surgery.
For the outcomes "treatment-related complications" and "length of hospital stay", a correlation between the volume of services and the quality of treatment results can also be shown at both the hospital and surgeon level, to the benefit of hospitals and surgeons with a high volume of services.
For the outcomes "fatal complications" and "tumour-free resection margin", a positive correlation between the volume of services and the quality of treatment results can be inferred at the hospital level. For other outcomes, either no such correlation can be shown or no usable data are available.
IQWiG found no meaningful studies examining the effects of specific minimum case volumes introduced into the health care system for complex pancreatic surgery on the quality of treatment results.
Process of report production
In February 2019, the G-BA commissioned IQWiG to prepare a report on the correlation between the volume of services and the quality of treatment results for complex pancreatic surgery in an accelerated procedure as a so-called rapid report. The work on the project started in January 2020. This rapid report was sent to the contracting agency, the G-BA, in August 2020.
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