title: Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery.
abstract: BACKGROUND
  : The aim was to investigate whether a relationship existed between case volume and outcome for lower limb vascular surgical procedures.
  
  
  METHODS
  : PubMed, Embase, the Cochrane Library and Google Scholar were searched for all articles on population-based studies on the volume-outcome relationship for lower limb vascular surgery at hospital level. Outcomes were mortality and subsequent amputation after lower limb vascular surgery. The data were subjected to meta-analysis by outcome.
  
  
  RESULTS
  : Some 452 093 patients from ten studies were included in the systematic review and five studies were included in meta-analyses. Seven of these articles found a significant positive hospital-volume outcome relationship. The pooled effect estimate for mortality was odds ratio (OR) 0.81 (95 per cent confidence interval 0.71 to 0.91) and that for amputation was OR 0.88 (0.79 to 0.98), with better results being found after surgery at higher-volume hospitals. Significant heterogeneity was seen in the data.
  
  
  CONCLUSIONS
  : Higher-volume hospitals were associated with reduced amputation and mortality rates after lower limb vascular surgery. These data were not as conclusive as those for other vascular surgical procedures owing to significant heterogeneity.
authors.affiliation: Department of Outcomes Research, St George's Vascular Institute, St George's Healthcare NHS Trust, London SW17 0QT, UK.
authors.forename: A I
authors.initials: AI
authors.lastname: Awopetu
authors.forename: P
authors.initials: P
authors.lastname: Moxey
authors.forename: R J
authors.initials: RJ
authors.lastname: Hinchliffe
authors.forename: K G
authors.initials: KG
authors.lastname: Jones
authors.forename: M M
authors.initials: MM
authors.lastname: Thompson
authors.forename: P J E
authors.initials: PJ
authors.lastname: Holt
mesh_terms: D000671:Amputation, Surgical / Q000401:mortality; D006276:Health Facility Size / Q000706:statistics & numerical data*; D006801:Humans; D007866:Leg / Q000098:blood supply*; D016491:Peripheral Vascular Diseases / Q000401:mortality / Q000601:surgery*; D017594:Publication Bias; D016896:Treatment Outcome