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Hospital volume may not predict quality of HF care
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Hospital volume was associated with process measures, but not with 30-day outcomes and marginally with 6-month outcomes in older patients with HF, according to an analysis published in Circulation.
“What this tells us is that the number of patients that a hospital sees with heart failure is by itself a very poor discriminant of how well the patients will do long term, but it does tell us that there are several processes that higher-volume centers have in place as far as being able to adhere to national guidelines,” Dharam J. Kumbhani, MD, SM, associate professor of internal medicine at the University of Texas Southwestern Medical Center in Dallas, told Cardiology Today. “Those are the things that we highlight that if we can understand ways of making these more broadly applicable, then that will go a much longer way in improving patient outcomes.”
Researchers analyzed Medicare inpatient data from 125,595 patients from the Get With the Guidelines-Heart Failure registry who were admitted to 342 hospitals for HF between 2005 and 2014. Those who were transferred out, left against medical advice or had missing discharge information were excluded from the analysis.
Patient-level data were collected through a patient management tool and included socioeconomic status, patient demographics, medications, medical history, in-hospital treatment, laboratory data, in-hospital outcomes, discharge status and discharge medications.
Annual HF admission volume was used to categorize hospitals: very low (5-38; n = 6,969; mean age, 80 years; 58% women), low (39-77; n = 19,948; mean age, 80 years; 54% women), medium (78-122; n = 33,035; mean age, 81 years; 54% women) and high (123-457; n = 65,643; mean age, 81 years; 54% women).
The primary process measures of interest were HF achievement measures, HF quality measures, HF reporting measures and composite metrics. Primary outcome measures of interest were 30-day all-cause mortality and readmissions, in-hospital mortality and length of stay, and 6-month all-cause mortality and readmissions.
Patients admitted to higher-volume hospitals were more likely to be white, older and have more comorbidities except for smoking and insulin-dependent diabetes.
Lower-volume hospitals were the least likely to adhere to HF process-of-care measures, whereas higher-volume hospitals were the most likely to follow them.
Higher-volume hospitals did not have a difference in 30-day mortality (HR = 0.99; 95% CI, 0.97-1.01), in-hospital mortality (OR = 0.99; 95% CI, 0.94-1.05) or 30-day readmissions (HR = 0.99; 95% CI, 0.97-1)
Hospitals with higher volumes were associated with a slight decrease in 6-month readmissions (HR = 0.98; 95% CI, 0.97-1) and 6-month mortality (HR = 0.98; 95% CI, 0.97-0.99).
“Traditionally, the working presumption for a lot of people in policy has been that higher volume is automatically a measure of higher quality, and that if you’re a higher volume for anything, that, that automatically means that you’re going to be good at whatever that procedure or that condition is,” Kumbhani told Cardiology Today. “What our paper shows is that, that’s not true, and we need to find ways in which we can make lower-volume hospitals better. A lot of it has to do with understanding what process measures can be replicated from higher-volume hospitals.” – by Darlene Dobkowski
Disclosures: Get With the Guidelines-Heart Failure is sponsored by Amgen Cardiovascular and funded by GlaxoSmithKline, Medtronic and Ortho-McNeil. Kumbhani reports he is a consultant for Somahlution. Please see the study for all other authors’ relevant financial disclosures.
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