Lowest Volume Quartile Research Articles

Association between hospital volume and outcomes in invasive ovarian cancer in Belgium: A population-based study

ObjectivesTo study the association between hospital volume and outcomes in patients with invasive epithelial ovarian cancer (EOC). MethodsThis study included 3988 patients diagnosed with invasive EOC between 2014 and 2018, selected from the population-based database of the Belgian Cancer Registry (BCR), and coupled with health insurance and vital status data. The associations between hospital volume and observed survival since diagnosis were assessed with Cox proportional hazard models, while volume associations with 30-day post-operative mortality and complicated recovery were evaluated using logistic regression models. ResultsTreatment for EOC was very dispersed with half of the 100 centres treating fewer than six patients per year. The median survival of patients treated in centres with the highest-volume quartile was 2.5 years longer than in those with the lowest-volume quartile (4.2 years versus 1.7 years). When taking the case-mix of hospitals into account, patients treated in the lowest volume centres had a 47% higher hazard to die than patients treated in the highest volume centres (HR: 1.47, 95% CI: 1.11–1.93, p = 0.006) over the first five years after incidence. A similar association was found when focussing on the surgical volume of the hospitals and considering only operated patients with invasive EOC. Lastly, the 30-day post-operative mortality decreased significantly with increasing surgical volume. ConclusionsThe large dispersion of care and expertise within Belgium and the volume-outcome associations observed in this study support the implementation of the concentration of care for patients with invasive EOC in reference centres.

Partial Nephrectomy Drives the Association Between High-volume Centers and Decreased Mortality: A Surveillance, Epidemiology, and End Results-Medicare Analysis

To better understand the association between high-volume surgical kidney cancer centers and decreased mortality. To identify quality metrics that mediate this association. We designed a cohort of 14,044 patients who were diagnosed with kidney cancer between 2004 and 2013 and underwent a partial or radical nephrectomy using SEER-Medicare data. Hospitals were divided into quartiles based on their total nephrectomy volume for the study period. We investigated 6 quality metrics as potential mediators of the association between hospital volume and mortality using a mediation model. At the highest volume centers, survival was higher at 1-, 3-, 5-, and 10-year time intervals, respectively (91% vs 89%, 80% vs 76%, 70% vs 66%, 45% vs 38%, P<.001) compared to the lowest quartile nephrectomy centers. Receipt of partial nephrectomy for stage ≤T1a tumors explains 52.3% of the total association between hospital nephrectomy volume and mortality. Additionally, patients at the highest-volume centers were more likely to be younger (20% vs 26% 80≤ years old, P<.001), white (82% vs 78%, P<.001), reside in more densely populated counties (≥1 million residents, 62% vs 42%, P>.001), have a shorter mean length of stay (5.03 vs 5.88days, P<.001) when compared to those in the lowest-volume quartile. This analysis of SEER-Medicare data is the first to suggest that partial nephrectomy in the setting of T1a tumors mediates the association between hospital volume and mortality. Quality metrics that reduce mortality should be harnessed to develop more efficient and higher-quality health systems.

The Implication of Center Volumes in Donation After Circulatory Death for Liver Transplantation: Donor–Recipient Selection and Outcomes

The use of donation after circulatory death liver transplant (DCD LT) has increased and the outcomes have improved. There are little data concerning the details of centers' practice. Using the United Network for Organ Sharing Standard Transplant Analysis and Research data, the centers were stratified into 4 quartiles: lowest-, low-, high-, and highest-volume quartiles. High-risk donors, defined as older donors (≥50 years) or obese donors (body mass index ≥ 30 kg/m2), linearly increased in line with the centers' volumes (P < .001), while cold ischemia time (CIT) showed an inverse correlation (P < .001). High-risk recipients, defined as those with high Model for End-stage Liver Disease score, re-LT, inpatient, or ventilator/dialysis before LT, did not show any significant difference (P=.74) except in the highest-volume quartile (P < .001). One-year graft survival showed a bimodal pattern across the 4 quartiles (P=.027): superior graft survival in the highest-volume quartile and in the low-volume quartile and inferior graft survival in the high-volume quartile and in the lowest-volume quartile. High-risk donors can achieve satisfactory outcomes by being matched with low-risk recipients and shortening CIT. However, high-risk recipients may not result in favorable outcomes with DCD LT even with centers' experience and shorter CIT.

Volume-outcome relationships in laryngeal trauma processes of care: a retrospective cohort study.

The extent to which patients with laryngeal trauma undergo investigation and intervention is largely unknown. The objective of this study was to therefore determine the association between hospital volume and processes of care in patients sustaining laryngeal trauma. This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database. Adult patients (≥ 18) who sustained traumatic laryngeal injuries between 2012 and 2016 were eligible. The exposure of interest was average annual laryngeal trauma volume categorized into quartiles. The primary and secondary outcomes of interest were the performances of diagnostic and therapeutic laryngeal procedures respectively. Multivariable logistic regression under a generalized estimating equations approach was utilized. In total, 1164 patients were included. The average number of laryngeal trauma cases per hospital ranged from 0.2 to 7.2 per year. Diagnostic procedures were performed in 31% of patients and therapeutic in 19%. In patients with severe laryngeal injuries, diagnostic procedures were performed on a higher proportion of patients at high volume centers than low volume centers (46% vs 25%). In adjusted analysis, volume was not associated with the performance of diagnostic procedures. Patients treated at centers in the second (OR 1.94 [95% CI 1.29-2.90]) and third (OR 1.67 [95% CI 1.08-2.57]) volume quartiles had higher odds of undergoing a therapeutic procedure compared to the lowest volume quartile. Hospital volume may be associated with processes of care in laryngeal trauma. Additional research is required to investigate how these findings relate to patient and health system outcomes.

Relation Between Operator and Hospital Volumes and Long-Term Outcomes for Percutaneous Coronary Intervention in New York

Little is known about whether there is an inverse relation between provider volume and long-term adverse outcomes for percutaneous coronary interventions (PCIs). For patients who underwent PCI procedures from December 2013 through November 2014 in New York, we examined a continuous relation and different annual PCI volume cut points at hospital and operator levels to investigate the relation between volume and 1-year adverse outcomes (mortality and mortality/acute myocardial infarction). There were 34,498 patients who underwent PCI procedures from 60 hospitals and 408 operators. We detected a significant continuous inverse association between 1-year mortality and annual hospital PCI volume. However, we did not find that there was a hospital volume and 1-year mortality relation for the 2013 ACCF/AHA/SCAI's hospital annual PCI volume cutoff value of 200 or a significant inverse operator volume-outcome relation using the operator annual PCI volume cutoff value of 50, or for any other practical volume cutoffs. Similar findings were obtained when we used the 1-year mortality/acute myocardial infarction outcome. We did find that providers in the highest volume quartile were associated with lower adverse outcome rates than providers in the lowest volume quartile. In conclusion, no significant volume-outcome relations were found between annual hospital or operator PCI volume and risk-adjusted 1-year outcomes for any practical volume cutoff values including 2013 Guidelines' recommended hospital/operator minimal annual PCI volumes. Providers in the highest annual volume quartile, however, were associated with lower adverse outcome rates than providers in the lowest volume quartile.

Procedural Volume and Outcomes for Transcatheter Aortic-Valve Replacement

BackgroundDuring the introduction of transcatheter aortic-valve replacement (TAVR) in the United States, requirements regarding procedural volume were mandated by the Centers for Medicare and Medicaid Services as a condition of reimbursement. A better understanding of the relationship between hospital volume of TAVR procedures and patient outcomes could inform policy decisions.MethodsWe analyzed data from the Transcatheter Valve Therapy Registry regarding procedural volumes and outcomes from 2015 through 2017. The primary analyses examined the association between hospital procedural volume as a continuous variable and risk-adjusted mortality at 30 days after transfemoral TAVR. Secondary analysis included risk-adjusted mortality according to quartile of hospital procedural volume. A sensitivity analysis was performed after exclusion of the first 12 months of transfemoral TAVR procedures at each hospital.ResultsOf 113,662 TAVR procedures performed at 555 hospitals by 2960 operators, 96,256 (84.7%) involved a transfemoral approach. There was a significant inverse association between annualized volume of transfemoral TAVR procedures and mortality. Adjusted 30-day mortality was higher and more variable at hospitals in the lowest-volume quartile (3.19%; 95% confidence interval [CI], 2.78 to 3.67) than at hospitals in the highest-volume quartile (2.66%; 95% CI, 2.48 to 2.85) (odds ratio, 1.21; P=0.02). The difference in adjusted mortality between a mean annualized volume of 27 procedures in the lowest-volume quartile and 143 procedures in the highest-volume quartile was a relative reduction of 19.45% (95% CI, 8.63 to 30.26). After the exclusion of the first 12 months of TAVR procedures at each hospital, 30-day mortality remained higher in the lowest-volume quartile than in the highest-volume quartile (3.10% vs. 2.61%; odds ratio, 1.19; 95% CI, 1.01 to 1.40).ConclusionsAn inverse volume–mortality association was observed for transfemoral TAVR procedures from 2015 through 2017. Mortality at 30 days was higher and more variable at hospitals with a low procedural volume than at hospitals with a high procedural volume. (Funded by the American College of Cardiology Foundation National Cardiovascular Data Registry and the Society of Thoracic Surgeons.)

Minimally Invasive vs Open Pyeloplasty in Children: The Differential Effect of Procedure Volume on Operative Outcomes

To assess the differential effect of volume-outcome dynamics on the outcomes of open pyeloplasty (OP) and minimally invasive pyeloplasty (MIP) in the management of pediatric ureteropelvic junction obstruction in the setting of increasing utilization of MIP. Within the Nationwide Inpatient Sample, a weighted estimate of 6006 pediatric patients (≤18years; 2008-2010) with ureteropelvic junction obstruction underwent either OP or MIP. National trends in utilization and comparative effectiveness outcomes were examined in terms of intraoperative and postoperative complications, prolonged length of stay, and excessive hospital charges. Hospitals were stratified into volume quartiles. Specifically, the volume-outcome dynamics of the highest and lowest volume quartiles of both the approaches were examined with binary logistic regression models. MIP accounted for 17.2% of cases during the study years. In individual multivariate models, high-volume OP patients had a significantly lower risk of developing postoperative complications, genitourinary complications, and excessive hospital charges compared with high-volume MIP, low-volume OP, and low-volume MIP patients. Regardless of hospital volume, MIP patients experienced shorter hospital stays. Although there has been a substantial increase in the utilization of MIP, high-volume hospitals performing OP have the best perioperative outcomes in terms of postoperative complications, genitourinary complications, and overall hospital charges. However, high-volume hospitals performing MIP have better outcomes compared with low-volume hospitals performing OP. Shorter hospital stay is the one mitigating factor of MIP.

Prevalence and adverse impact of extended antibiotic prophylaxis in urologic oncology surgery.

294 Background: Providers exhibit variation in the selection of the class, dose, and duration of prescribed antibiotic prophylaxis (ABP) to prevent postsurgical infections. We sought to evaluate ABP practice patterns for common inpatient urologic oncology surgeries and ascertain the association between extended ABP and hospital-acquired Clostridium difficile (C. diff) infections. Methods: From the PREMIER database for 2007–2012, we identified patients who underwent radical prostatectomy (RP), radical or partial nephrectomy (Nephx), or radical cystectomy (RC). We defined extended ABP from charges for antibiotics ≥ 2 days after surgery; exclusive of patients with a switch in antibiotic class within 2 postoperative days for presumption of infection. We identified postoperative C. diff infections using ICD-9 diagnosis codes. Hierarchical linear regression models were constructed by procedure to identify patient and provider factors associated with extended ABP. Logistic regression models evaluated the association between extended ABP and postoperative C. diff infection, adjusting for patient and provider characteristics. Results: We identified 59,184 RP patients, 27,921 Nephx patients, and 5,425 RC patients. RC patients were more likely to receive extended ABP (56%) than RP (18%) or Nephx (29%) patients (p&lt;0.001). Other factors associated with extended ABP included prolonged postoperative length of stay (OR ≥ 1.69, p&lt;0.001 for all procedures), and surgical volume (p&lt;0.001 for highest vs. lowest volume quartiles). Hospital identity explained 35% of the variability in ABP after RP, 23% after Nephx, and 20% after RC. Among Nephx and RC patients, extended ABP was associated with significantly higher odds of postoperative C. diff infection (OR 3.79, 95% CI 2.46–5.84, and OR 1.64, 95% CI 1.12–2.39, respectively). Conclusions: We identified marked hospital-level variability in extended ABP following RP, Nephx, and RC, which was associated with significantly increased odds of hospital-acquired C. diff infections. Efforts to increase provider compliance with national ABP guidelines may decrease preventable hospital-acquired infections after urologic cancer surgery.

Influence of Patient, Physician, and Hospital Factors on 30-Day Readmission Following Pancreatoduodenectomy in the United States

IMPORTANCE It is not known whether hospital and surgeon volumes have an association with readmission among patients undergoing pancreatoduodenectomy. To evaluate patient-, surgeon-, and hospital-level factors associated with readmission. Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare data with cases diagnosed from January 1, 1998, to December 31, 2005, and followed up until December 2007. Population-based cancer registry data were linked to Medicare data for the corresponding patients. A total of 1488 unique individuals who underwent a pancreatoduodenectomy were identified. Undergoing pancreatoduodenectomy at hospitals classified by volume of pancreatoduodenectomy procedures performed at the facility were either very-low, low, medium, or high volume. Undergoing pancreatoduodenectomy by surgeons classified by volume of pancreatoduodenectomy procedures performed by the surgeon were either very-low, low, medium, or high volume. In-hospital morbidity, mortality, and 30-day readmission were examined. The median age was 74 years, and 1436 patients (96.5%) had a least 1 medical comorbidity. Patients were treated by 575 distinct surgeons at 298 distinct hospitals. Length of stay was longest (median, 17 days) and 90-day mortality highest (17.2%) at very-low-volume hospitals (P < .001). Among all pancreatoduodenectomy patients, 292 (21.3%) were readmitted within 30 days of discharge. There was no effect of surgeon volume and a modest effect of hospital volume (odds ratio for highest- vs lowest-volume quartiles, 1.85; 95% CI, 1.22-2.80; P = .02). The presence of significant preoperative medical comorbidities was associated with an increased risk for hospital readmission after pancreatoduodenectomy. A comorbidity score greater than 13 had a pronounced effect on the chance of readmission following pancreatoduodenectomy (odds ratio, 2.06; 95% CI, 1.56-2.71; P < .001). The source of variation in readmission was primarily attributable to patient-related factors (95.4%), while hospital factors accounted for 4.3% of the variability and physician factors for only 0.3%. Nearly 1 in 5 patients are readmitted following pancreatoduodenectomy. While variation in readmission is, in part, attributable to differences among hospitals, the largest share of variation was found at the patient level.

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Introduction: Therapeutic hypothermia (TH) is a commonly applied therapy for comatose patients who are hospitalized following out-of-hospital cardiac arrest (OHCA). Hypothesis: We hypothesized that rates of TH at individual hospitals are proportional to the annual volume of patients hospitalized following OHCA. Methods: This was a retrospective chart review of patients with OHCA admitted to 21 medical centers between 2007 and 2011. A standardized clinical protocol and educational program promoting the use of TH was in place at all study hospitals during this time period. Only patients who were admitted without planned limitations of care were considered for study inclusion. Abstractors determined standard pre-hospital predictors of outcome, as well as TH application and eligibility for TH as defined by the standardized clinical protocol. Hospitals were divided into grouped quartiles based on annual volume of patients admitted following OHCA. A test of multiple proportions was applied to assess for differences between hospital quartiles. Results: A total of 913 patients met study inclusion criteria: 55.2% (504 of 913) patients were eligible for TH at the time of hospital admission, and 46.8% (236 of 504) of these patients received TH. There were no significant differences in the rates of TH provided at hospitals in the top three quartiles (from highest to lowest volume quartiles, rates of TH were 47.1%, 46.3% and 57.0%, overall chi square = 2.71 with alpha = 0.26). However, rates of TH were much lower at hospitals in the lowest volume quartile (less than 3 study cases per year) as compared to all other quartiles (15.4%, overall chi square = 13.6 with alpha = 0.004). Conclusions: We conclude that, except among hospitals with the very least experience, rates of TH application are similar regardless of annual volume of patients admitted following OHCA.

Recurrence of inguinal hernia in general and hernia specialty hospitals in Ontario, Canada

BACKGROUND: We compared hernia recurrence rates in patients undergoing primary elective inguinal hernia repair at general hospitals with the Shouldice Hospital in Ontario, Canada. METHODS: We conducted an administrative data analysis of persons who underwent inguinal hernia repair in Ontario, Canada from 1993-2007. Risk of recurrent hernia repair was estimated according to hospital type and volume, using Cox proportional-hazards regression models. RESULTS: Recurrence risk in the lowest volume quartile was 5.7%, compared to 3.9% at high volume general hospitals and 1.1% at the Shouldice hospital. Compared to persons who had surgery at the lowest volume hospitals, hernia recurrence among Shouldice Hospital patients was substantially lower after adjustment for confounding variables (hazard ratio 0.18, CI (0.16 to 0.19), P <0.001). CONCLUSIONS: Persons who had elective primary inguinal hernia repair at the Shouldice Hospital had a substantially lower risk of recurrence than those treated at general hospitals, including high volume general hospitals.%%%%MAST

Predictors of Colorectal Cancer Following a Negative Colonoscopy in the Medicare Population

The incidence of colorectal cancer following a normal colonoscopy in the Medicare population is not known. A 5% national sample of Medicare enrollees from 1996 to 2005 was used to identify patients undergoing complete colonoscopy. A colonoscopy not associated with any procedure (e.g., biopsy, polypectomy or fulguration) was defined as a negative colonoscopy. Patients with history of inflammatory bowel disease, colorectal cancer or death within 12months of colonoscopy were excluded. A multivariable model was constructed to evaluate the factors associated with a new diagnosis of colorectal cancer in the period from 12 to 120months following the negative colonoscopy. Among 200,857 patients (mean age 74years, 61% female, 92% White) with a negative colonoscopy, the incidence of colorectal cancer was 1.8 per 1,000 person-years. The incidence rate for matched follow-up periods decreased from 2.0/1,000 person-years for patients undergoing colonoscopy during 1996-2000 to 1.2/1,000 person years during 2001-2005. Multivariate analysis revealed a significant regional variation in the incidence of colorectal cancer following a negative colonoscopy. The incidence was higher in patients >85years, males and patients who underwent a negative colonoscopy by a non-gastroenterologist or endoscopist in the lowest volume quartile. On stratified analyses, endoscopist volume was a significant predictor for non-gastroenterologists only. The specialty and experience of the endoscopist are significant predictors of the incidence rate of colorectal cancer in Medicare patients with a negative colonoscopy.

Relationship Between Hospital Volume and Outcomes Following Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction

Primary percutaneous coronary intervention (PCI) is an important treatment option for patients with acute myocardial infarction (MI). Although an inverse association between a hospital's PCI volume and in-hospital mortality has been observed in Western studies, previous Japanese investigations have not found any such relationship. A retrospective analysis of 8,391 cases of acute MI, obtained from administrative data from 2006. The primary outcome was in-hospital mortality. Hospitals were divided into quartiles based on the number of PCI procedures per half-year (6-13, 14-22, 23-38, 39-134) and mortality rates were compared across the groups. Crude-mortality in the lowest-volume quartile was 7.0%, compared with 4.9% in the highest-volume quartile. An inverse association was found between primary PCI procedure volume and crude in-hospital mortality (P = 0.016). After case-mix adjustment, a significant decrease in mortality risk for patients treated at high-volume (3rd and 4th quartile) hospitals compared to the lowest-volume (1(st) quartile) hospitals was found. Based on this administrative data, there is an inverse association between a hospital's primary PCI volume and in-hospital mortality for patients with acute MI. Periodic outcomes research is necessary in conjunction with progress in PCI practice and technology to establish the recommended PCI volume and regionalization for improvements in care.

Specialty Differences in Polyp Detection, Removal, and Biopsy during Colonoscopy

Background Colonoscopy is a technically complex procedure commonly performed to detect and remove colorectal pathology. This study examined the influence of provider characteristics on polyp detection, polyp removal, and diagnostic biopsy rates. Methods We conducted a retrospective cross-sectional study using a 20% sample of 2003 Medicare claims. Primary outcome measures were use of diagnostic biopsy, polyp detection, and polyp removal. We used generalized estimating equations to identify independent predictors of the outcomes, adjusting for patient and provider characteristics. Results Among 328,167 outpatient colonoscopies, polyp detection and removal rates were significantly lower for nongastroenterologists than gastroenterologists, with adjusted relative risk for polyp detection between 0.80 (95% confidence interval [CI], 0.77-0.83) for general surgeons and 0.93 (95% CI, 0.89-0.98) for internists. Compared with gastroenterologists, diagnostic biopsy was significantly less likely for general (relative risk [RR] 0.69; 95% CI, 0.65-0.74) or colorectal surgeons (RR 0.58; 95% CI, 0.52-0.65). The likelihood of polyp detection and removal was higher for physicians in the middle 2 quartiles of annual colonoscopy volume, but similar for physicians in the highest and lowest volume quartiles. Polyp detection and removal were significantly less likely for examinations in ambulatory surgery centers or offices than hospital outpatient settings, while diagnostic biopsy was significantly less likely in office settings. Conclusions Physician specialty, annual colonoscopy volume, and site of service are significant predictors of polyp detection, polyp removal, and diagnostic biopsy. These findings may have important implications for the effectiveness of colonoscopy.

Primum Non Nocere: The Case for Watchful Waiting in Asymptomatic “Severe” Degenerative Mitral Regurgitation

“ The physician must … have two special objects in view with regard to disease, namely, to do good or to do no harm ” — Hippocrates 1 The optimal surgical treatment for severe mitral regurgitation resulting from degenerative disease (flail or prolapse caused by myxomatous change or fibroelastic deficiency) is mitral repair.2–5 Although the decision to intervene on a symptomatic patient is relatively straightforward, current guidelines also define other triggers for surgery in patients who are asymptomatic.6,7 In the absence of symptoms, left ventricular (LV) dysfunction, defined as an LV ejection fraction (LVEF) of 30% to 60% or an LV end-systolic diameter (LVESD) of ≥40 mm6 (>45 mm7), is a class I indication. Class IIa indications in the asymptomatic patient with preserved LV function include atrial fibrillation and pulmonary hypertension (pulmonary artery systolic pressure >50 mm Hg at rest or >60 mm Hg after exercise). It is also deemed reasonable (class IIa6 or IIb7) to regard the presence of severe mitral regurgitation as a sole and sufficient indication for surgery provided that the likelihood of repair is high (≥90%)6 and operative risk is low.7 This last recommendation has generated considerable debate because no randomized controlled trial has defined the best treatment for asymptomatic patients with severe degenerative mitral regurgitation. Proponents of prophylactic repair favor an aggressive surgical approach, whereas opponents lobby for a strategy of close medical follow-up until conventional triggers are met (watchful waiting). Here, we present our argument for watchful waiting. Response by Enriquez-Sarano and Sundt see p 813 Because by definition a strategy of prophylactic surgery in asymptomatic patients cannot improve their sense of well-being, it must be associated with better surgical and/or clinical outcomes relative to a triggered strategy. It is our position that this benefit has …

Association Between Physician Specialty and Volumes of Treated Patients and Mortality Among Patients Hospitalized for Newly Diagnosed Heart Failure

Purpose To assess the effects of hospital care by a specialist or nonspecialist physician, and by volume of treated patients, on mortality among hospitalized patients with newly diagnosed heart failure. Methods Data describing heart failure patients in Alberta, Canada, from April 1, 1994, to March 31, 2000, were extracted from hospital abstracts and analyzed using hierarchical regression, with adjustment for patient demographic characteristics, comorbid conditions, physician volume, physician specialty, and hospital volume. Results There were 16,162 hospital discharges for heart failure. Nonspecialist physicians were predominantly in the two lowest-volume quartiles (93%) and specialists were predominantly in the two highest-volume quartiles (68%). Considering the effects of volume alone and after adjustment for comorbidity, for each 10 additional hospital patients treated by a physician, the odds ratio for in-hospital mortality was 0.97 (95% confidence interval [CI]: 0.95 to 0.98), and the odds ratio for 1-year mortality was 0.99 (95% CI: 0.98 to 0.999). In analyses that considered both volume and specialty, the odds of in-hospital mortality decreased by 4% for each 10 additional in-hospital patients treated by a physician (odds ratio [OR] = 0.96; 95% CI: 0.95 to 0.98). In these same analyses, the odds ratio for in-hospital mortality was 1.32 (95% CI: 1.13 to1.53) for general practitioners with specialist consultation and 1.32 (95% CI: 1.08 to 1.61) for specialists compared with general practitioners without specialist consultations. At 1 year, mortality was not associated significantly with the volume of in-hospital patients treated, or with the specialty of the treating physician. Conclusion Treatment by high-volume physicians during hospitalization for newly diagnosed heart failure was associated with a decrease in mortality, but these benefits did not persist at 1 year. The increased mortality noted in patients treated by specialists may be due to residual confounding or unmeasured comorbidity.

Association between physician specialty and volumes of treated patients and mortality among patients hospitalized for newly diagnosed heart failure

To assess the effects of hospital care by a specialist or nonspecialist physician, and by volume of treated patients, on mortality among hospitalized patients with newly diagnosed heart failure. Data describing heart failure patients in Alberta, Canada, from April 1, 1994, to March 31, 2000, were extracted from hospital abstracts and analyzed using hierarchical regression, with adjustment for patient demographic characteristics, comorbid conditions, physician volume, physician specialty, and hospital volume. There were 16,162 hospital discharges for heart failure. Nonspecialist physicians were predominantly in the two lowest-volume quartiles (93%) and specialists were predominantly in the two highest-volume quartiles (68%). Considering the effects of volume alone and after adjustment for comorbidity, for each 10 additional hospital patients treated by a physician, the odds ratio for in-hospital mortality was 0.97 (95% confidence interval [CI]: 0.95 to 0.98), and the odds ratio for 1-year mortality was 0.99 (95% CI: 0.98 to 0.999). In analyses that considered both volume and specialty, the odds of in-hospital mortality decreased by 4% for each 10 additional in-hospital patients treated by a physician (odds ratio [OR] = 0.96; 95% CI: 0.95 to 0.98). In these same analyses, the odds ratio for in-hospital mortality was 1.32 (95% CI: 1.13 to 1.53) for general practitioners with specialist consultation and 1.32 (95% CI: 1.08 to 1.61) for specialists compared with general practitioners without specialist consultations. At 1 year, mortality was not associated significantly with the volume of in-hospital patients treated, or with the specialty of the treating physician. Treatment by high-volume physicians during hospitalization for newly diagnosed heart failure was associated with a decrease in mortality, but these benefits did not persist at 1 year. The increased mortality noted in patients treated by specialists may be due to residual confounding or unmeasured comorbidity.

Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals.

Studies of several complex medical conditions have shown that outcomes are better at hospitals that treat more cases. We tested the hypothesis that patients with subarachnoid hemorrhage treated at high-volume hospitals have better outcomes. Using a database of all admissions to nonfederal hospitals in California from 1990 to 1999, we obtained discharge abstracts for patients with a primary diagnosis of subarachnoid hemorrhage who were admitted through the emergency department. Hospital volume, defined as the average number of subarachnoid hemorrhage cases admitted each year, was divided into quartiles. Rates of mortality, adverse outcomes (death or discharge to long-term care), length of stay, and hospital charges were computed by univariate analysis and by multivariable general estimating equations, with adjustment for demographic and admission characteristics. A total of 12 804 patients were admitted for subarachnoid hemorrhage through the emergency departments of 390 hospitals. Hospital volumes varied from 0 to 8 cases per year in the first quartile to 19 to 70 cases per year in the fourth quartile. The mortality rate in the lowest volume quartile (49%) was larger than that in the highest volume quartile (32%, P<0.001). In multivariable analysis, the difference persisted (odds ratio comparing highest with lowest volume quartiles 0.57, 95% CI 0.48 to 0.67; P<0.001). At higher volume hospitals, lengths of stay were longer, and hospital charges were greater in univariate and multivariable models (all P<0.001). Only 4.8% of those admitted to hospitals in the lowest volume quartile were transferred to hospitals in the highest quartile. In this study of discharge abstracts in California, hospitals that treated more cases of subarachnoid hemorrhage had substantially lower rates of in-hospital mortality. Few patients with subarachnoid hemorrhage are being transferred to high-volume centers.

The influence of hospital and surgeon volume on in-hospital mortality for colectomy, gastrectomy, and lung lobectomy in patients with cancer

Background. This study explores the volume-mortality relationship for 3 groups of cancer procedures to determine whether higher-volume hospitals, higher-volume surgeons, or both are associated with lower in-hospital mortality. Methods. New York's Statewide Planning and Research Cooperative System was used to identify more than 32,000 hospital inpatients with a cancer diagnosis who underwent colectomy, lobectomy of the lung, or gastrectomy between January 1, 1994, and December 31, 1997. The association of in-hospital mortality rates with provider (hospital and surgeon) volume was examined after adjusting for differences in age, demographics, organ metastasis, socioeconomic status, and comorbidities. Results. For hospital volume for gastrectomy, the highest-volume quartile had an absolute risk-adjusted mortality rate that was 7.1% lower (P <.0001) than the lowest-volume quartile, although the overall mortality rate for the procedure was only 6.2%. For surgeon volume for colectomy, the highest- and lowest- volume quartiles differed by 1.9% (P <.0001), although the procedure mortality rate was only 3.5%. For hospital volume for lung lobectomy, the absolute difference in mortality was 1.7%. Patients undergoing operations performed by high-volume surgeons in high-volume hospitals usually had significantly lower risk-adjusted mortality rates than did patients who had low-volume surgeons or who were in low-volume hospitals, or both. Conclusions. For all 3 procedure groups, the risk-adjusted in-hospital mortality is significantly lower when the procedures are performed by high-volume providers. (Surgery 2002;131:6-15.)