Harold S. Luft

Should operations be regionalized? The empirical relation between surgical volume and mortality.

Abstract This study examines mortality rates for 12 surgical procedures of varying complexity in 1498 hospitals to determine whether there is a relation between a hospitals surgical volume and its...

Effects of Surgeon Volume and Hospital Volume on Quality of Care in Hospitals

A growing body of evidence indicates that certain surgical procedures exhibit a “volume-outcome” relationship in which a higher volume of patients undergoing a particular procedure at a hospital is associated with better outcomes for those patients. The proportion of a hospitals patients operated on by low-volume or less experienced surgeons also may be associated with poor patient outcomes and thus contribute to the hospital “volume-outcome” relationship. This paper analyzes the influence of hospital volume and the proportion of a hospitals patients operated on by low-volume surgeons on patient outcome for 10 procedures, controlling for other selected factors that may influence outcomes. The analysis is based on 503,662 patient abstracts from 757 hospitals. Results indicate that both hospital volume and the proportion of patients operated on by low-volume surgeons are related to quality of care as measured by patient outcomes. Higher hospital volume is positively related to better patient outcomes. These findings are consistent with earlier hospital “volume-outcome” research and add an additional set of procedures using more recent data to the evidence. Unlike previous research on surgeon volume, a positive relationship was found between higher percentage of patients operated on by low-volume surgeons and poorer hospital quality.

The Relation Between Surgical Volume and Mortality: An Exploration of Causal Factors and Alternative Models

A previous study of 12 procedures of varying complexity in 1,498 hospitals identified a strong negative curvilinear relationship between the volume of a particular operation and postoperative mortality. The current study uses multiple regression techniques to explore the role of other potentially important variables and alternative interpretations of the volume-mortality relationship. The dependent variable is the difference between the hospitals actual death rate and its expected death rate based upon the riskiness of its case mix. The inclusion of other variables, such as size of hospital, teaching status, geographic location and cost, improves the fit of the regression, but does not diminish the importance of volume. There is no evidence that volume accumulated over 2 years is a better measure than volume in 1 year. Experience and volume of related operations are important in some cases but not others. Several likely alternative explanations for the observed relationship were not supported: larger hospitals and those with more house staff had outcomes that were worse than expected. Large geographic differences in mortality rates remain unexplained. A simultaneous-equation model is used to test whether higher volume leads to better outcomes or better outcomes lead to higher volumes. Both causal paths are supported, but their relative importance varies with the procedure in ways that are consistent with anticipated referral patterns.

Selecting categories of patients for regionalization. Implications of the relationship between volume and outcome.

A growing number of researchers have demonstrated an inverse relation between the number of patients treated with specific diagnoses or procedures in a hospital and subsequent adverse outcomes. Such findings support the notion that policies should be explored to concentrate patients in selected hospitals to reduce preventable patient mortality or morbidity. The authors used data from 15 diagnoses and procedures demonstrating an inverse relation between volume and mortality to explore the different implications of regionalization policies across categories of patients. In some instances, concentrating patients in hospitals with high volumes of such patients could avert more than 60% of all deaths. For some procedures or diagnoses, however, such mortality savings are. either medically infeasible because of the emergency nature of the problem or logistically impossible because of the extent of regionalization implied.

Hospital volume and patient outcomes. The case of hip fracture patients.

Patients achieve better outcomes at hospitals that treat larger numbers of patients with certain diagnoses or who are undergoing particular procedures. However, the causal direction underlying this relationship is less well understood. Do patients treated at institutions with higher volumes of patients achieve better outcomes because the hospital staff and physicians have gained expertise by practice (the “practice makes perfect” hypothesis)? Do hospitals with a community reputation for excellent results attract higher volumes of patients because primary care physicians refer patients to specialists who practice there (the “selective referral” hypothesis)? Or, are both explanations important? This article addresses this question through a detailed analysis of patients with a particular diagnosis: hip fracture. In addition, two measures of patient outcomes are compared: long hospital stays as a proxy for in-hospital complications and in-hospital death.

The Association of Hospital Volumes of Percutaneous Transluminal Coronary Angioplasty With Adverse Outcomes, Length of Stay, and Charges in California

The objective of this study was to examine whether hospital volumes of percutaneous transluminal coronary angioplasty (PTCA) are associated with adverse outcomes (coronary artery bypass graft surgery after PTCA and/or in-hospital mortality), post-PTCA length of stay (LOS), and hospital charges. Discharge data for 24,856 patients undergoing PTCA in 1989 from 110 California hospitals were analyzed. Regression analysis was used to adjust patient discharge data for risk factors. Actual and predicted adverse outcomes, LOS, and charges were compared for hospital volume categories (using 95% confidence intervals). Rates of adverse outcomes were significantly higher than expected in low-volume hospitals (< 201 PTCAs) and significantly lower than expected in high-volume hospitals (> 400 PTCAs). The results were similar for LOS and charges, although the results for charges were less conclusive. The associations of volumes and outcomes were generally consistent for both unadjusted and adjusted analyses, for patients with and without principal diagnoses of acute myocardial infarction, and using different methods and functional forms. Given this association between hospital volumes of PTCA and outcomes, future research should assess the underlying causes of this association and whether limiting the use of low-volume facilities would improve outcomes.

Competition and Regulation

Perhaps as a reflection of the current medical care environment and governmental budgetary stringencies, cost containment is a major source of policy concern. There are some who would argue that one should have a comprehensive understanding of how the medical care system works in order to design appropriate policies to improve its performance. As other articles in this volume demonstrate, there is still much we do not know about individual aspects of the medical care system, and no article even attempts a comprehensive discussion of the system. Policymakers, however, cannot await research findings, and there have been numerous policy interventions in the last two decades aimed at cost containment.

Medicare’s Policy Not To Pay For Treating Hospital-Acquired Conditions: The Impact

In 2008 Medicare stopped reimbursing hospitals for treating eight avoidable hospital-acquired conditions. Using 2006 California data, we modeled the financial impact of this policy on six such conditions. Hospital-acquired conditions were present in 0.11 percent of acute inpatient Medicare discharges; only 3 percent of these were affected by the policy. Payment reductions were negligible (0.001 percent, or

Assessing the evidence on HMO performance.

0.1 million-equivalent to

Trends in medical care costs. Do HMOs lower the rate of growth

1.1 million nationwide) and are unlikely to encourage providers to improve quality. Options to strengthen the incentives include further payment modifications for hospital-acquired conditions or expanding the hospital-acquired condition policy to exclude payment for consequences, additional procedures, and readmissions.