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Original Research: Critical Care Medicine |

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

Yên-Lan Nguyen, MD, MPH; David J. Wallace, MD, MPH; Youri Yordanov, MD; Ludovic Trinquart, PhD; Josefin Blomkvist, MSc; Derek C. Angus, MD, MPH, FCCP; Jeremy M. Kahn, MD; Philippe Ravaud, MD, PhD; Bertrand Guidet, MD
Author and Funding Information

From the Anesthesiology and Surgical Critical Care Department (Dr Nguyen), Cochin Hospital, Assistance Publique - Hôpitaux de Paris (APHP), Paris Descartes University, Paris, France; Clinical Epidemiology Center, Institut National de la Santé et de la Recherche Médicale (INSERM) U1153, (Drs Nguyen, Yordanov, Trinquart, and Ravaud and Ms Blomkvist), Hôtel-Dieu Hospital, APHP, Paris, France; Institut Pierre Louis d’Epidémiologie et de Santé Publique INSERM U1136 (Drs Nguyen and Guidet), UPMC Université Paris 06, Sorbonne Universités, Paris, France; CRISMA Center (Drs Wallace, Angus, and Kahn), Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; Emergency Department (Dr Yordanov), Saint Antoine Hospital, APHP, Paris, France; French Cochrane Centre, The Cochrane Collaboration (Drs Trinquart and Ravaud and Ms Blomkvist), Paris, France; and Medical Intensive Care Unit (Dr Guidet), Saint Antoine Hospital, APHP, Paris, France.

CORRESPONDENCE TO: Yên-Lan Nguyen, MD, MPH, Anesthesiology and Surgical Critical Care Department, CHU Cochin, Université Paris Descartes, 27 rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France; e-mail: yenlanc.nguyen@gmail.com


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(1):79-92. doi:10.1378/chest.14-2195
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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 Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies.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.

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