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Meta-Analysis
. 2022 Aug;30(8):2862-2877.
doi: 10.1007/s00167-021-06692-8. Epub 2021 Sep 8.

Hospital volume-outcome relationship in total knee arthroplasty: a systematic review and dose-response meta-analysis

C M Kugler  1 , K Goossen  2 , T Rombey  2   3 , K K De Santis  2   4 , T Mathes  2 , J Breuing  2 , S Hess  2 , R Burchard  5   6   7 , D Pieper  2
Affiliations
Meta-Analysis

Hospital volume-outcome relationship in total knee arthroplasty: a systematic review and dose-response meta-analysis

C M Kugler et al. Knee Surg Sports Traumatol Arthrosc. 2022 Aug.

Abstract

Purpose: This systematic review and dose-response meta-analysis aimed to investigate the relationship between hospital volume and outcomes for total knee arthroplasty (TKA).

Methods: MEDLINE, Embase, CENTRAL and CINAHL were searched up to February 2020 for randomised controlled trials and cohort studies that reported TKA performed in hospitals with at least two different volumes and any associated patient-relevant outcomes. The adjusted effect estimates (odds ratios, OR) were pooled using a random-effects, linear dose-response meta-analysis. Heterogeneity was quantified using the I2-statistic. ROBINS-I and the GRADE approach were used to assess the risk of bias and the confidence in the cumulative evidence, respectively.

Results: A total of 68 cohort studies with data from 1985 to 2018 were included. The risk of bias for all outcomes ranged from moderate to critical. Higher hospital volume may be associated with a lower rate of early revision ≤ 12 months (narrative synthesis of k = 7 studies, n = 301,378 patients) and is likely associated with lower mortality ≤ 3 months (OR = 0.91 per additional 50 TKAs/year, 95% confidence interval [0.87-0.95], k = 9, n = 2,638,996, I2 = 51%) and readmissions ≤ 3 months (OR = 0.98 [0.97-0.99], k = 3, n = 830,381, I2 = 44%). Hospital volume may not be associated with the rates of deep infections within 1-4 years, late revision (1-10 years) or adverse events ≤ 3 months. The confidence in the cumulative evidence was moderate for mortality and readmission rates; low for early revision rates; and very low for deep infection, late revision and adverse event rates.

Conclusion: An inverse volume-outcome relationship probably exists for some TKA outcomes, including mortality and readmissions, and may exist for early revisions. Small reductions in unfavourable outcomes may be clinically relevant at the population level, supporting centralisation of TKA to high-volume hospitals.

Level of evidence: III.

Registration number: The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42019131209 available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131209 ).

Keywords: Dose–response meta-analysis; Hospital volume; Hospital volume–outcome relationship; Knee osteoarthritis; Systematic review; Total knee arthroplasty (TKA).

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Conflict of interest statement

The authors declare no conflict of interest. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram showing selection of articles for review
Fig. 2
Fig. 2
Linear dose–response meta-analysis for mortality (a) and readmission (b)
See this image and copyright information in PMC

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