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: 17.81). 08/2011; 154(2):94-102. DOI: 10.1059/0003-4819-154-2-201101180-00008
Source: PubMed


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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Available from: Karen E Joynt
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    • "Thus, stakeholders would be satisfied and simultaneously healthcare professionals will have no impact on their remunerations. Joynt et al.[14]used Medicare patients suffering from Congestive Heart Failure (CHF) to find out whether or not experienced healthcare units provide higher quality services. Their results indicate that higher volume units seem to have lower mortality rates, due to experience and better management techniques. "

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    • "Many previous studies have reported that higher hospital case volume was associated with better outcomes in surgical procedures [7-10], non-surgical interventional procedures [11-14], medical treatments [15,16], and in pneumonia in the elderly population [16-18]. Although the evidence is still scarce on the mechanism of the relationship, larger case volume hospital are thought to be associated with better outcome for a number of reasons, such as better standardized care complying with recommended practice guidelines [17,19,20], increased use of peri-procedural testing, monitoring, or preventive processes [21], and care by physicians with greater clinical experience and skill. "
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    ABSTRACT: Background The characteristics and aetiology of pneumonia in the non-elderly population is distinct from that in the elderly population. While a few studies have reported an inverse association between hospital case volume and clinical outcome in elderly pneumonia patients, the evidence is lacking in a younger population. In addition, the relationship between volume and outcome may be different in severe pneumonia cases than in mild cases. In this context, we tested two hypotheses: 1) non-elderly pneumonia patients treated at hospitals with larger case volume have better clinical outcome compared with those treated at lower case volume hospitals; 2) the volume-outcome relationship differs by the severity of the pneumonia. Methods We conducted the study using the Japanese Diagnosis Procedure Combination database. Patients aged 18–64 years discharged from the participating hospitals between July to December 2010 were included. The hospitals were categorized into four groups (very-low, low, medium, high) based on volume quartiles. The association between hospital case volume and in-hospital mortality was evaluated using multivariate logistic regression with generalized estimating equations adjusting for pneumonia severity, patient demographics and comorbidity score, and hospital academic status. We further analyzed the relationship by modified A-DROP pneumonia severity score calculated using the four severity indices: dehydration, low oxygen saturation, orientation disturbance, and decreased systolic blood pressure. Results We identified 8,293 cases of pneumonia at 896 hospitals across Japan, with 273 in-hospital deaths (3.3%). In the overall population, no significant association between hospital volume and in-hospital mortality was observed. However, when stratified by pneumonia severity score, higher hospital volume was associated with lower in-hospital mortality at the intermediate severity level (modified A-DROP score = 2) (odds ratio (OR) of very low vs. high: 2.70; 95% confidence interval (CI): 1.12–6.55, OR of low vs. high: 2.40; 95% CI:0.99–5.83). No significant association was observed for other severity strata. Conclusions Hospital case volume was inversely associated with in-hospital mortality in non-elderly pneumonia patients with intermediate pneumonia severity. Our result suggests room for potential improvement in the quality of care in hospitals with lower volume, to improve treatment outcomes particularly in patients admitted with intermediate pneumonia severity.
    Full-text · Article · Jul 2014 · BMC Health Services Research
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    ABSTRACT: The incidence of chronic heart failure rises with increasing age as does the proportion of diastolic dysfunction in comparison to heart failure with reduced systolic ejection fraction. Symptoms are less specific, such as fatigue, which makes a diagnosis more difficult but classification and diagnostic work-up are the same as in younger patients. Regarding therapy there is less data because the typical study population does not include geriatric patients with multimorbidity. Nevertheless ACE inhibitors, angiotensin receptor blockers, aldosterone antagonists, diuretics and digoxin should also be used in geriatric patients considering indications and contraindications and especially interactions with co-morbidities and other prescribed medication on an individual basis. The numbers of patients above the age of 75 years receiving heart surgery is increasing. Current scores often overestimate the risk of an operation even though after individual stratification surgical and interventional procedures can be performed with low risk.
    No preview · Article · Jun 2011 · Zeitschrift für Gerontologie + Geriatrie
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