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Hospital specialization failed to improve outcome in CABG procedure
Girotra S. Circ Cardiovasc Outcomes. 2010;3:607-614.
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Results from a study featuring more than 700,000 Medicare patients have indicated that higher hospital specialization was not associated with a clinically significant reduction in mortality or length of stay after adjustment for CABG volume.
“Hospital specialization is theoretically appealing and has been advocated by champions drawn from industry and corporate strategy,” Saket Girotra, MD, and colleagues wrote. “Although some studies suggest that hospital specialization may be associated with improved patient outcomes, there are others, including ours, that have found little or no association.”
In the retrospective cohort study, 705,084 Medicare patients from 1,130 hospitals who were undergoing CABG between 2001 and 2005 were analyzed. The Iowa-based researchers defined hospital cardiac specialization as the degree to which a hospital’s resources were concentrated on treating patients with CVD relative to other diseases, specifically measuring cardiac specialization as the proportion of all Medicare discharges classified as Major Diagnostic Category 5.
According to study data, the median cardiac specialization for all hospitals was 29.7%. After comparing patient and hospital characteristics and outcomes across quintiles of cardiac specialization, researchers reported that patients’ characteristics were similar across quintiles based on the degree of cardiac specialization. However, mean annual CABG volume increased progressively from the least specialized quintile (1) to the most specialized (5).
Additionally, hospitals in quintiles 1 to 4 had similar unadjusted 30-day mortality rates (4.7% to 4.9%), whereas those in quintile 5 were noticeably lower (4.3%; trend P<.001). Despite a strong inverse association between hospital cardiac specialization and 30-day mortality after adjustment for patient characteristics (P<.001), additional adjustment for CABG volume resulted in the relationship being no longer significant (P=.65). These results were found to be similar with length of stay.
Among the limitations mentioned by the researchers include the risk-adjustment model being based on administrative claims data, the lack of certain measures such as patient satisfaction and quality of life, which limit the ability to examine the influence of specialization on these outcomes, and the population of Medicare patients aged 66 years or older, which limits the application of these data to other age groups.
“Hospital specialization may lead to increasing health care costs by driving use of costly but discretionary procedures,” the researchers said. “Also, by cherry-picking low-risk wealthy patients, highly specialized hospitals may adversely impact the financial health of the competitor general hospitals and prevent them from cross-subsidizing necessary but unprofitable care (eg, emergency care).”
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