title: Surgical outcomes for low-volume vs high-volume surgeons in gynecology surgery: a systematic review and meta-analysis.
abstract: OBJECTIVE
  The aim of this study was to determine the impact of gynecological surgeon volumes on patient outcomes.
  
  
  METHODS
  Eligible studies were selected through an electronic literature search from database inception up until September 2015 and references in published studies. Search terms included surgical volume, surgeon volume, low-volume or high-volume, and gynecology or hysterectomy or sling or pelvic floor repair or continence procedure.
  
  
  METHODS
  The literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We defined a low-volume surgeon (LVS) as one performing the procedure once a month or less, and studies were excluded if their definition of LVS was > ±33% of our definition. Primary outcomes were total complications, intraoperative complications, and postoperative complications.
  
  
  METHODS
  All outcome data for individual studies were entered into systematic review software. When 2 or more studies evaluated a designated outcome, a meta-analysis of the entered data was undertaken as per the Cochrane database methodology. Data analysis was entered into a software product, which generated a summary of findings table that included structured and qualified grading (very low to high) of the quality for the evidence of the individual outcomes and provided a measure of effect.
  
  
  RESULTS
  Fourteen peer-reviewed studies with 741,760 patients were included in the systematic review. For gynecology the LVS group had an increased rate of total complications (odds ratio [OR], 1.3, 95% confidence interval [CI], 1.2-1.5), intraoperative complications (OR, 1.6, 95% CI, 1.2-2.1), and postoperative complications (OR, 1.4 95% CI, 1.3-1.4). In gynecological oncology, the LVS group had higher mortality (OR, 1.9, 95% CI, 1.3-2.6). In the urogynecology group, a single study reported that the LVS group had a higher rate of any complication (risk ratio [RR], 1.4, 95% CI, -1.2-1.6). Another single study found that LVS had higher rates of reoperation for mesh complications after midurethral sling procedures (RR, 1.4, 95% CI, 1.2-1.5). The evidence is of moderate to very low quality.
  
  
  CONCLUSIONS
  Gynecologists performing procedures approximately once a month or less were found to have higher rates of adverse outcomes in gynecology, gynecological oncology, and urogynecology, with higher mortality in gynecological oncology.
authors.affiliation: Royal Brisbane and Women's Hospital, University of Queensland, Queensland, Australia. Electronic address: zanhmowat@gmail.com.
authors.forename: Alex
authors.initials: A
authors.lastname: Mowat
authors.affiliation: Royal Brisbane and Women's Hospital, University of Queensland, Queensland, Australia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Maher
authors.affiliation: Queensland Institute of Medical Research, Queensland, Australia.
authors.forename: Emma
authors.initials: E
authors.lastname: Ballard
mesh_terms: D005260:Female; D013509:Gynecologic Surgical Procedures / Q000592:standards / Q000706:statistics & numerical data*; D006176:Gynecology / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans
keywords: gynecology; outcomes; surgeon volume