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\begin{document}

\title{Covariate analysis query: Hospital surgical volume-outcome relationship
in caesarean hysterectomy for placenta accreta spectrum}



\author[1]{Oguljemal Redjepova}%
\author[1]{Jack Lowe-Zinola}%
\author[2]{Christopher Griffin}%
\affil[1]{Sandwell and West Birmingham Hospitals NHS Trust}%
\affil[2]{Notre Dame Medical School}%


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  \date{May 26, 2024}


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Covariate analysis query: Hospital surgical volume-outcome relationship
in caesarean hysterectomy for placenta accreta spectrum

Oguljemal Redjepova\textsuperscript{a}, Jack
Lowe-Zinola\textsuperscript{b}, Christopher Griffin\textsuperscript{c}

\emph{\textsuperscript{a} City Hospital Birmingham, Sandwell and West
Birmingham Hospitals NHS Trust, Dudley Road, Birmingham, United Kingdom}

\emph{\textsuperscript{b} Good Hope Hospital, University Hospitals
Birmingham NHS Trust, Rectory Road, Sutton Coldfield, United Kingdom}

\emph{\textsuperscript{c} Department of Obstetrics and Gynaecology,
Notre Dame Medical School, Fremantle, Western Australia 6160}

Corresponding author:

Jack Lowe-Zinola

\emph{Email:} jack.lowe-zinola@nhs.net

\emph{Professional address:} Good Hope Hospital, Rectory Road, Sutton
Coldfield B75 7RR

\emph{Telephone:} 0121 424 2000

Dear Sirs,

It was with great interest and intrigue that we discussed the thought
provoking article presented by K Matsuo et al, `Hospital surgical
volume-outcome relationship in caesarean hysterectomy for placenta
accreta spectrum'.

We wish to congratulate the authors on this valuable piece of research,
which provides further evidence for practice we see developing in our
own region - a move towards centralised multidisciplinary management of
placenta accreta spectrum disorders (PAS) {[}1{]}.

We noticed in the analysis for volume-outcome relationship, that data
were controlled for patient demographics, pregnancy factors and hospital
characteristics, which included hospital capacity, teaching status and
region.

We would, however, be most interested to examine the complete study
covariates with respect to the following points:

A. Seniority and experience of the Obstetrician and Gynaecologist

B. Availability of interventional radiology pre-, intra- or
post-operatively

C. The use of fellow non-gynaecological surgical specialists either for
immediate recall or present within the operation itself

D. The use of imaging modalities for patient refinement preoperatively

E. The use of formal pre operative multidisciplinary meetings for PAS
cases

Examining the outcome measure differences between high and low volume
centres, the question we would like to ask is, `could the outcome
measure difference be attributed to the 5 aforementioned aspects of
perioperative care?'

High grade evidence is lacking for the treatment of PAS patients.
However, intraoperative PAS surgery blood loss may be reduced with pre
operative temporary aortic or iliac artery balloon occlusion. Post
operative blood loss may be reduced with targeted embolisation. These
two fields are the domains of the interventional radiologist and would
potentially be linked to the outcome measures of haemorrhage, shock and
coagulopathy {[}2{]}.

Furthermore, with bladder involvement posing a potentially
life-threatening problem, often diagnosed intraoperatively, we wonder
how both the preoperative use of different imaging modalities for
characterisation of PAS subtype, and the involvement of urological
surgeons, may relate to the rates of urinary tract injury, as well as
haemorrhage and death {[}3{]}.

We would be very grateful for the opportunity to explore whether the
five aforementioned aspects of perioperative care could have accounted
for the significant differences between high and low volume centre
outcomes as presented by the authors.

Disclosure of interest

The authors declare that they have no conflict of interest

References

{[}1{]} Karkhanis P, Ahmed I, Irani S. Placenta accreta spectrum
disorders -- detection rate and maternal outcomes following
implementation of an institutional protocol. \emph{Journal of Obstetrics
and Gynaecology} 2021; 5:1-7. doi 10.1080/01443615.2021.1887110

{[}2{]} Hawthorn B, Ratnam L. Role of interventional radiology in
placenta accreta spectrum (PAS) disorders. \emph{Best Practice \&
Research Clinical Obstetrics \& Gynaecology} 2021; 72: 25-37. doi
10.1016/j.bpobgyn.2021.01.007

{[}3{]} Konijeti R, Rajfer J, Askari A. Placenta Percreta and the
Urologist. \emph{Reviews in Urology} 2009; 11(3): 173-6. PMCID
PMC2777065

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