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CHF Patients May Fare Better, Pay More at High-Volume Hospitals

 |  By cclark@healthleadersmedia.com  
   January 21, 2011

It's well-established that the more surgical and cardiovascular procedures performed at a given hospital, the better the chances for improved outcomes. That's also true for hospitals that treat congestive heart failure, a new study concludes.

Hospitals with greater experience treating CHF patients demonstrate lower patient mortality, fewer readmissions, and higher quality scores than hospitals with fewer such patients.

"Patients discharged from hospitals with 200 CHF discharges had, on average, 18% lower odds of death than those discharged from hospitals with 20 CHF discharges," says the study published this week in the Annals of Internal Medicine.

"However, the typical stay at a hospital with 200 CHF discharges would cost approximately $400 more per hospitalization," wrote the authors, Karen E. Joynt, MD, John Orav and Ashish K. Jha, MD, of the Harvard School of Public Health. 

With an estimated 1.4 million hospitalizations for patients with CHF in 2007 alone, and because one in 10 CHF patients die within 30 days of hospitalization and one in four survivors is readmitted, their finding has important implications for public health, they wrote.

They added that benefits of volume apparently reach a threshold "beyond which additional volume was associated with little additional benefit," decreasing "once volume reached approximately 200 Medicare CHF discharges," over the study period of 23 months.

"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," they wrote.

The researchers used Medicare claims data from 2006 and 2007 to evaluate Hospital Quality Alliance process measures for CHF, 30-day risk-adjusted mortality rates, 30-day risk-adjusted readmission rates and costs per discharge.

Why might hospitals with more experience have better outcomes in CHF patients? 

The authors speculated that hospitals with more patients "might have more incentive to retain familiarity with professional society care guidelines or invest in systems to monitor for adherence to quality metrics."

Or, they might also be more likely to do a better job with patient education, or involve discharge planners.

"In addition, nurses at high-volume centers might be more familiar with CHF-specific patient are and education needs, although we have no data regarding this."

The authors also speculated that higher quality care may provoke higher volume, but they discounted that theory.

"Previous studies have found that patients rarely use publicly available quality data to select a hospital or clinician, and that publishing provider performance has little effect on that provider's market share," they wrote.

"Therefore, if selective referral is a key part of the mechanism by which high performing hospitals have higher volume, it is probably a result of having a reputation as a high-quality hospital."

Their report has three key messages, they wrote.

1. The largest benefits may be seen in targeting quality improvements at hospitals with lower volume.

2. Policymakers have advocated that patients who need high-risk surgeries should be sent to the few hospitals that achieve very high volumes, "but that strategy may not be necessary with CHF because so many hospitals meet the volume threshold."

3. No threshold effect was seen for cost of care, "which suggests that beyond a certain level of spending, additional resource utilization may not be associated with better outcomes."

The authors said they could not explain how those hospitals with higher levels of spending allocated those $400 extra dollars, or whether that money "led directly to the improved outcomes."

Their research was funded by a grant from the American Heart Association Clinical Research Program.

The study may be viewed here.

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