The Volume-Outcome Relationship in Critical Care: A Systematic Review and Meta-analysis

Abstract

Objective: The purpose of this study was to systematically review the research on volume and outcome relationships in critical care.

Methods: From January 1, 2001, to April 30, 2014, MEDLINE and EMBASE were searched for studies assessing the relationship between admission volume and clinical outcomes in critical illness. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. Of 127 studies reviewed, 46 met inclusion criteria, covering seven clinical conditions. Two investigators independently reviewed each article using a standardized form to abstract information on key study characteristics and results.

Results: Overall, 29 of the studies (63%) reported a statistically significant association between higher admission volume and improved outcomes. The magnitude of the association (mortality OR between the lowest vs highest stratum of volume centers), as well as the thresholds used to characterize high volume, varied across clinical conditions. Critically ill patients with cardiovascular (n = 7, OR = 1.49 [1.11-2.00]), respiratory (n = 12, OR = 1.20 [1.04-1.38]), severe sepsis (n = 4, OR = 1.17 [1.03-1.33]), hepato-GI (n = 3, OR = 1.30 [1.08-1.78]), neurologic (n = 3, OR = 1.38 [1.22-1.57]), and postoperative admission diagnoses (n = 3, OR = 2.95 [1.05-8.30]) were more likely to benefit from admission to higher-volume centers compared with lower-volume centers. Studies that controlled for ICU or hospital organizational factors were less likely to find a significant volume-outcome relationship than studies that did not control for these factors.

Conclusions: Critically ill patients generally benefit from care in high-volume centers, with more substantial benefits in selected high-risk conditions. This relationship may in part be mediated by specific ICU and hospital organizational factors.

Figure 1 –

Flow diagram of study selection. The main reasons for exclusion of full-text articles were absence of details regarding ICU or hospital mortality or majority of population not including critically ill patients.

Figure 2 –

Forrest plots of comparisons between lowest and highest volume institutions for seven clinical conditions. Nb = number.

Figure 3 –

Sensitivity analysis: Forrest plots of comparisons between lowest and highest volume institutions for seven clinical conditions after exclusion of studies with data older than 2001. See Figure 2 legend for expansion of abbreviation.