Disclosures
• Dr
Dr. Joynt has nothing to disclose
disclose.
• Dr. Orav has nothing to disclose.
• Dr. Jha has provided consulting for
UpToDate.
UpToDate
HARVARD
SCHOOL OF PUBLIC HEALTH
Does Volume Matter for Heart Failure?
Evaluating quality, outcomes, and costs of care
Karen E. Joynt, MD
E. John Orav, PhD
Ashish K. Jha, MD, MPH
Background
• Heart failure is common and costly:
– Most frequent cause of hospitalizations
– 1.4 million hospitalizations in 2007
– $17 billion in spending in 2007
• Heart failure outcomes remain poor:
– At
A 30 d
days: 10% mortality,
li 25% readmission
d i i
• Improving
p
g HF outcomes is a national
priority
Rosamond 2008, Hospital Compare 2009
National readmission rates
800
Numb
ber of Hos
spitals
700
600
500
400
600 h
hospitals
it l
1000 h
hospitals
it l
300
200
100
0
≤5 7.5 10 12.5 15 17.5 20 22.5 25 27.5 30 32.5 35 37.5 40 42.5 45 47.5 ≥50
30-day readmission rate (%)
Volume matters
• For surgery and cardiac procedures
procedures,
higher volume leads to:
• Better outcomes
• Shorter length of stay
• Lower costs
• For medical illness,, the storyy is unclear:
• Slight improvement? (HF, MI, PNA)
• Worse care and outcomes? (PNA
(PNA, COPD)
Birkmeyer 2001, Birkmeyer 2002, Hannan 2003, Wu 2004, Jollis 1997, McGrath 2000, Hannan 2005,
Thiemann 1999, Tu 2001, Lindenauer 2006, Ho 2008, Swisher 2000, Kuo 2001, Ross 2010
Specific Aims
• To determine ifif, for heart failure
failure, high
volume hospitals:
– Provide higher quality care
– Have better outcomes
– Have lower costs
Methods
• National Medicare data from 2006 and 2007
• Primary discharge diagnosis of HF
• Exclusions:
– Federal hospitals
– Hospitals outside 50 states and Washington DC
– Fewer than 25 discharges
• Sample:
– 4,009 hospitals
– 699,109 patients
Methods
• Hospital characteristics:
• American Hospital Association survey
• Quality of care:
• Hospital
p
Quality
y Alliance HF score
• Outcomes of care:
• 30
30-day
day risk
risk-adjusted
adjusted all
all-cause
cause mortality
• 30-day risk-adjusted all-cause readmission
• Costs
C t off care:
• Observed to predicted cost ratio
Elixhauser 1998, Southern 2004, Jha 2009
Methods
• Divided hospitals into quartiles by volume
• Even number of hospitals in each quartile
• Regression models for each outcome
• Volume as the sole predictor
p
• Multivariate linear regression models for
each outcome
• Accounting for key hospital characteristics such as
size teaching status
size,
status, and cardiac capability
Results: hospitals by quartile
Quartile 1
Quartile 4
Lowestt
L
volume
Q til 2
Quartile
Q til 3
Quartile
Highest
Hi
h t
volume
Small (6-99)
82%
65%
20%
2%
Med (100-399)
17%
33%
72%
65%
Large (400+)
1%
2%
7%
33%
P<0.001 for trend for each
Results: hospitals by quartile
Quartile 1
Quartile 4
Lowestt
L
volume
Q til 2
Quartile
Q til 3
Quartile
Highest
Hi
h t
volume
For-profit
10%
19%
21%
12%
Non-profit
52%
56%
64%
80%
Public
38%
25%
15%
9%
P<0.001 for trend for each
Results: hospitals by quartile
Quartile 1
Quartile 4
Lowestt
L
volume
Q til 2
Quartile
Q til 3
Quartile
Highest
Hi
h t
volume
Urban
49%
71%
92%
100%
Major teaching
1%
3%
6%
17%
Cardiac
intensive care
11%
22%
38%
67%
P<0.001 for trend for each
Results: patients by quartile
Quartile 1
Quartile 4
Lowestt
L
volume
Q til 2
Quartile
Q til 3
Quartile
Highest
Hi
h t
volume
81
81
80
80
Male sex
40%
41%
43%
45%
Minority
12%
12%
15%
15%
Age
P<0.001 for trend for each
Results: patients by quartile
Quartile 1
Quartile 4
Lowestt
L
volume
Q til 2
Quartile
Q til 3
Quartile
Highest
Hi
h t
volume
Diabetes w/
comp
5%
5%
6%
6%
Hypertension
52%
56%
58%
60%
Renal failure
6%
8%
11%
13%
P<0.001 for trend for each
Volume and quality
100
87.1
HQ
QA HF score, % complia
ant
90
80
88 9
88.9
81.5
75.8
70
60
Quartile 1
Quartile 2
Quartile
Qua
t e3
Quartile 4
50
40
30
20
10
P<0.001
for trend
0
Hospital volume for HF
Volume and mortality
Risk-ad
djusted 3
30-day m
mortality rate, %
13
12 3
12.3
12
11
11.6
10.4
10
9.5
9
Quartile 1
Quartile 2
Quartile
Qua
t e3
Quartile 4
8
7
P<0.001
for trend
6
Hospital volume for HF
Volume and readmission
Risk-ad
djusted 3
30-day re
eadmission rate,,
%
30
26.9
25
24.9
23.4
22.2
20
Quartile
Q
il 1
Quartile 2
Quartile 3
Quartile 4
P<0.001
for trend
15
Hospital volume for HF
Volume and cost ratio
Observed to
o expecte
ed cost rratio
1.1
1.05
1
0.97
0.94
0.94
0.9
Quartile 1
Quartile 2
Quartile
Qua
t e3
Quartile 4
P<0.001
for trend
0.8
Hospital volume for HF
Multivariate analysis
HQA HF
score
30-day
30-day
Cost ratio
mortalityy readmission
Q artile 1 (lowest
Quartile
(lo est volume)
ol me)
78 3
78.3
11 9%
11.9%
25 5%
25.5%
0 96
0.96
Quartile 2
82.9
11.3%
24.4%
0.96
Quartile 3
86.4
10.4%
24.2%
0.98
Quartile 4 (highest volume)
86.4
9.8%
23.7%
1.01
Adjusted for patient characteristics, hospital beds, the presence of a CCU, ownership, teaching status,
system membership, proportion Medicare, proportion Medicaid, urban location, and region.
P<0.001 for trend for each.
Summary
• Hospitals with greater experience caring
for HF patients
– Provided higher quality care
– Had better clinical outcomes
• Do so at somewhat higher costs
• These
Th
results
l persisted
i d even after
f
accounting
g for hospital size, teaching
g
status, and the presence of a CCU
Limitations
• Administrative data for risk adjustment
• Medicare patients only
• We don’t know why volume is associated
with better outcomes
Implications
• The volume
volume-outcome
outcome relationship appears
to extend beyond surgical procedures
• There is no free lunch
• At least in the short run
• This opens up two potential avenues for
improving care for HF patients:
• Regionalization of care
• Partnerships between low and high volume
institutions to share best practices
Acknowledgements
• Mentorship and collaboration: Ashish Jha
• Statistical guidance: John Orav
Quartiles by n of patients
HQA HF 30-day
30-day
score
mortality readmission
Cost ratio
Quartile 1, n=2442 (low vol)
81.5
11.7%
25.6%
0.95
Quartile 2, n=804
88.0
10.2%
22.8%
1.0
Quartile 3
3, n=495
88 9
88.9
9 5%
9.5%
22 1%
22.1%
1 04
1.04
Quartile 4,
4 n
n=268
268 (high vol)
89 2
89.2
9 1%
9.1%
22 1%
22.1%
1 09
1.09
P<0.001 for trend for each
Volume and HQA score
Volume and mortality
Volume and readmission
Volume and cost ratio
Results: patients by quartile
Quartile 1
Quartile 2
Quartile 3
Quartile 4
(25-78
(79-174
(175-361
(362-2839
discharges) discharges) discharges) discharges)
Age
81
81
80
80
Female sex
60%
59%
57%
55%
Non-white race
12%
12%
15%
15%
Diabetes w/ comp
5%
5%
6%
6%
Hypertension
52%
56%
58%
60%
Renal failure
6%
8%
11%
13%
Valvular disease
1%
2%
2%
3%
P<0.001 for trend for each
References
•
•
•
•
•
•
•
•
•
•
•
•
Auerbach AD, Hilton JF, Maselli J, Pekow PS, Rothberg MB, Lindenauer PK. Shop for quality or volume? Volume,
quality, and outcomes off coronary artery bypass surgery. Ann Intern Med. May 19 2009;150(10):696-704.
( )
Birkmeyer JD, Finlayson EV, Birkmeyer CM. Volume standards for high-risk surgical procedures: potential benefits
of the Leapfrog initiative. Surgery. Sep 2001;130(3):415-422.
Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl
J Med.
Med Apr 11 2002;346(15):1128
2002;346(15):1128-1137.
1137
Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care.
Jan 1998;36(1):8-27.
Hannan EL, Wu C, Ryan TJ, et al. Do hospitals and surgeons with higher coronary artery bypass graft surgery
volumes still have lower risk-adjusted
risk adjusted mortality rates? Circulation. Aug 19 2003;108(7):795-801.
2003;108(7):795 801.
Hannan EL, Wu C, Walford G, et al. Volume-outcome relationships for percutaneous coronary interventions in the
stent era. Circulation. Aug 23 2005;112(8):1171-1179.
Ho V, Aloia T. Hospital volume, surgeon volume, and patient costs for cancer surgery. Med Care. Jul
2008;46(7):718-725.
Jha AK, Orav EJ, Dobson A, Book RA, Epstein AM. Measuring efficiency: the association of hospital costs and
quality of care. Health Aff (Millwood). May-Jun 2009;28(3):897-906.
Jollis JG, Peterson ED, Nelson CL, et al. Relationship between physician and hospital coronary angioplasty
volume and outcome in elderly patients. Circulation. Jun 3 1997;95(11):2485-2491.
Kuo EY, Chang Y, Wright CD. Impact of hospital volume on clinical and economic outcomes for esophagectomy.
Ann Thorac Surg. Oct 2001;72(4):1118-1124.
Li B, Evans D, Faris P, Dean S, Quan H. Risk adjustment performance of Charlson and Elixhauser comorbidities
in ICD-9 and ICD-10 administrative databases. BMC Health Serv Res. 2008;8:12.
Lindenauer PK,
PK Behal R,
R Murray CK
CK, Nsa W,
W Houck PM
PM, Bratzler DW.
DW Volume
Volume, quality of care
care, and outcome in
pneumonia. Ann Intern Med. Feb 21 2006;144(4):262-269.
References
•
•
•
•
•
•
•
•
•
•
Lindenauer PK, Pekow P, Gao S, Crawford AS, Gutierrez B, Benjamin EM. Quality of care for patients
hospitalized for
f acute exacerbations off chronic obstructive pulmonary disease. Annals off internal medicine.
2006;144(12):894-903.
McGrath PD, Wennberg DE, Dickens JD, Jr., et al. Relation between operator and hospital volume and outcomes
following percutaneous coronary interventions in the era of the coronary stent. JAMA. Dec 27 2000;284(24):31393144.
3144
Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics--2008 update: a report from the
American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. Jan 29
2008;117(4):e25-146.
g Y, Ko DT, Chen J, Drye
y EE, Keenan PS, Lichtman JH, Bueno H, Schreiner GC,
Ross JS, Normand SL, Wang
Krumholz HM. Hospital volume and 30-day mortality for three common medical conditions. N Engl J Med.
2010;362(12):1110-1118.
Southern DA, Quan H, Ghali WA. Comparison of the Elixhauser and Charlson/Deyo methods of comorbidity
measurement in administrative data. Med Care. Apr 2004;42(4):355-360.
S i h SG
Swisher
SG, Deford
D f d L,
L M
Merriman
i
KW
KW, ett al.
l Eff
Effectt off operative
ti volume
l
on morbidity,
bidit mortality,
t lit and
d hospital
h
it l use
after esophagectomy for cancer. J Thorac Cardiovasc Surg. Jun 2000;119(6):1126-1132.
Thiemann DR, Coresh J, Oetgen WJ, Powe NR. The association between hospital volume and survival after acute
myocardial infarction in elderly patients. N Engl J Med. May 27 1999;340(21):1640-1648.
Tu JV,
JV Austin PC
PC, Chan BT
BT. Relationship between annual volume of patients treated by admitting physician and
mortality after acute myocardial infarction. Jama. Jun 27 2001;285(24):3116-3122.
Ward MM. Hospital experience and mortality in patients with systemic lupus erythematosus: which patients benefit
most from treatment at highly experienced hospitals? J Rheumatol. Jun 2002;29(6):1198-1206.
Wu C,, Hannan EL,, Ryan
y TJ,, et al. Is the impact
p
of hospital
p
and surgeon
g
volumes on the in-hospital
p
mortality
y rate
for coronary artery bypass graft surgery limited to patients at high risk? Circulation. Aug 17 2004;110(7):784-789.