Hospital Volume and Processes, Outcomes, and Costs of Care for Congestive Heart Failure RESPONSE

Harvard School of Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Annals of internal medicine (Impact Factor: 16.1). 08/2011; 154(2):94-102. DOI: 10.1059/0003-4819-154-2-201101180-00008
Source: PubMed

ABSTRACT Congestive heart failure (CHF) is common and costly, and outcomes remain suboptimal despite pharmacologic and technical advances.
To examine whether hospitals with more experience in caring for patients with CHF provide better, more efficient care.
Retrospective cohort study.
4095 hospitals in the United States.
Medicare fee-for-service patients with a primary discharge diagnosis of CHF.
Hospital Quality Alliance CHF process measures; 30-day, risk-adjusted mortality rates; 30-day, risk-adjusted readmission rates; and costs per discharge. National Medicare claims data from 2006 to 2007 were used to examine the relationship between hospital case volume and quality, outcomes, and costs for patients with CHF.
Hospitals in the low-volume group had lower performance on the process measures (80.2%) than did medium-volume (87.0%) or high-volume (89.1%) hospitals (P < 0.001). In the low-volume group, being admitted to a hospital with a higher case volume was associated with lower mortality, lower readmission, and higher costs. Similar, though smaller, relationships were found between case volume and both mortality and costs in the medium- and high-volume hospital groups.
Analysis was limited to Medicare patients 65 years or older. Risk adjustment was performed by using administrative data.
Experience with managing CHF, as measured by an institution's volume, is associated with higher quality of care and better outcomes for patients but a higher cost. Understanding which practices employed by high-volume institutions account for these advantages can help improve quality of care and clinical outcomes for all patients with CHF.
American Heart Association.

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    ABSTRACT: Background: Reducing the rate of rehospitalization among heart failure patients is a major public health challenge; medication non-adherence is a crucial factor shown to trigger rehospitalizations. Objective: To collect pilot data to inform the design of educational interventions targeted to heart failure patients and their caregivers to improve medication adherence. Methods: Heart failure patients with an implantable cardioverter defibrillator and their family caregivers were recruited from an outpatient electrophysiology clinic at an urban university medical center (N=10 caregiver and patient dyads, 70% race/ethnic minority, mean patient age=63 years). Quantitative and qualitative research methods were utilized. Semi-structured individual interviews were conducted to assess patients’ and caregivers’ individual interest in, and access to, new medication adherence technologies. Patient adherence to medications, medication self-efficacy, and depression were assessed by validated questionnaires. Medication adherence and hospitalization rates were assessed among patients at 30-days post-clinic visit by mailed survey. Results: At baseline, 60% of patients reported sometimes forgetting to take their medications. The most common factors associated with non-adherence included forgetfulness (50%), having other medications to take (20%), and being symptom-free (20%). At 30-day follow-up, half of patients reported non-adherence to their medications, and 1 in 10 reported being hospitalized within the past month. Dyads reported widespread access to technology, with the majority of dyads showing interest in mobile applications and text messaging. There was less acceptance of medication-dispensing technologies; caregivers and patients were concerned about added burden. Conclusions: The majority of etiologies of medication non-adherence were subject to intervention. Enthusiasm from patients and caregivers in new technologies to aid in adherence was tempered by potential burden, and should be considered when designing interventions to promote adherence.
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