Background:
Congestive heart failure (CHF) is common and costly, and outcomes remain suboptimal despite pharmacologic and technical advances.
Objective:
To examine whether hospitals with more experience in caring for patients with CHF provide better, more efficient care.
Design:
Retrospective cohort study.
Setting:
4095 hospitals in the United States.
Patients:
Medicare fee-for-service patients with a primary discharge diagnosis of CHF.
Measurements:
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.
Results:
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.
Limitations:
Analysis was limited to Medicare patients 65 years or older. Risk adjustment was performed by using administrative data.
Conclusion:
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.
Primary Funding Source:
American Heart Association.
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Author, Article and Disclosure Information
From Harvard School of Public Health, Brigham and Women's Hospital, and Veterans Affairs Boston Health Care System, Boston, Massachusetts.
Acknowledgment: The authors thank Jie Zheng, PhD, from the Department of Health Policy and Management, Harvard School of Public Health, for assistance with statistical programming. Dr. Zheng received compensation as part of regular employment. The authors also thank Peter Lindenauer, MD, MSc, for reviewing an earlier draft of the manuscript.
Grant Support: By an American Heart Association Clinical Research Program grant (10CRP3780037). Dr. Joynt was supported by a National Institutes of Health Training Grant (T32HL007604-24) held by Brigham and Women's Hospital Division of Cardiovascular Medicine.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-1177.
Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Joynt (e-mail, [email protected]
Corresponding Author: Karen E. Joynt, MD, MPH, Brigham and Women's Hospital, 75 Francis Street, Boston MA 02115; e-mail, [email protected]
Current Author Addresses: Dr. Joynt: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
Dr. Orav: Brigham and Women's Hospital, Division of General Internal Medicine, 1620 Tremont Street, 3rd Floor, Boston, MA 02115.
Dr. Jha: Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
Author Contributions: Conception and design: K.E. Joynt, A.K. Jha.
Analysis and interpretation of the data: K.E. Joynt, E.J. Orav, A.K. Jha.
Drafting of the article: K.E. Joynt, A.K. Jha.
Critical revision of the article for important intellectual content: K.E. Joynt, E.J. Orav, A.K. Jha.
Final approval of the article: K.E. Joynt, A.K. Jha.
Provision of study materials or patients: A.K. Jha.
Statistical expertise: E.J. Orav.
Obtaining of funding: K.E. Joynt, A.K. Jha.
Collection and assembly of data: K.E. Joynt, A.K. Jha.
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