Volume, Quality of Care, and Outcome in Pneumonia

21 February 2006 | Volume 144 Issue 4 | Pages 262-269

Background: The establishment of minimum volume thresholds has been proposed as a means of improving outcomes for patients with various medical and surgical conditions.

Objective: To determine whether volume is associated with either quality of care or outcome in the treatment of pneumonia.

Design: Retrospective cohort study.

Setting: 3243 hospitals participating in the National Pneumonia Quality Improvement Project in 1998 and 1999.

Patients: 13 480 patients with pneumonia cared for by 9741 physicians.

Measurements: The association between the annual pneumonia caseload of physicians and hospitals and adherence to quality-of-care measures and severity-adjusted in-hospital and 30-day mortality rates.

Results: Physician volume was unrelated to the timeliness of administration of antibiotics and the obtainment of blood cultures; however, physicians in the highest-volume quartile had lower rates of screening for and administration of influenza (21%, 19%, 20%, and 12% for quartiles 1 through 4, respectively; P < 0.01) and pneumococcal (16%, 13%, 13%, and 9% for quartiles 1 through 4, respectively; P < 0.01) vaccines. Among hospitals, the percentage of patients who received antibiotics within 4 hours of hospital arrival was inversely related to pneumonia volume (72%, 64%, 60%, and 56% for quartiles 1 through 4, respectively; P < 0.01), while selection of antibiotic, obtainment of blood cultures, and rates of immunization were similar. Physician volume was not associated with in-hospital or 30-day mortality rates. Odds ratios for in-hospital mortality rates rose with increasing hospital volume (1.14 [95% CI, 0.87 to 1.49], 1.34 [CI, 1.03 to 1.75], and 1.32 [CI, 0.97 to 1.80] for quartiles 2 to 4, respectively); however, odds ratios for 30-day mortality rates were similar.

Limitations: This study was limited to Medicare beneficiaries 65 years of age and older. Ascertainment of some measures of the quality of care and severity of illness depended on the documentation practices of the physician.

Conclusion: Among both physicians and hospitals, higher pneumonia volume is associated with reduced adherence to selected guideline recommendations and no measurable improvement in patient outcomes.

Editors' Notes Context Better outcomes have been associated with care by high-volume providers for many surgical procedures and medical conditions. It is not clear whether the same is true for other common conditions, such as pneumonia. Contribution Using data from the Medicare National Pneumonia Quality Improvement Project, these investigators found that after adjusting for severity of illness and other factors, there was no association between high physician or hospital volume and 30-day mortality rates. Adherence to guidelines was better and length of stay was shorter in low-volume hospitals. Implications High volume does not necessarily lead to better process of care or better outcomes in all clinical conditions. —The Editors

 

Author and Article Information

From Baystate Medical Center, Springfield, Massachusetts; Tufts University School of Medicine, Medford, Massachusetts; University HealthSystem Consortium, Oak Brook, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois; University of Central Oklahoma, Edmond, Oklahoma; Oklahoma Foundation for Medical Quality, Oklahoma City, Oklahoma; and School of Public Health and Community Medicine, University of Washington, Seattle, Washington.

Disclaimer: The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. The authors assume full responsibility for the accuracy and completeness of the ideas presented.

Grant Support: The analyses on which this publication is based were performed under contract number 500-99-P619, titled "Utilization and Quality Control Peer Review Organization for the State of Oklahoma," sponsored by the Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services. This article is a direct result of the Health Care Quality Improvement Program initiated by CMS, which has encouraged identification of quality improvement projects derived from analyses of patterns of care, and therefore required no special funding on the part of this contractor.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Peter K. Lindenauer, MD, MSc, Division of Healthcare Quality, Baystate Medical Center, 759 Chestnut Street P-5931, Springfield, MA 01199; e-mail, Peter.Lindenauer{at}bhs.org.

Current Author Addresses: Dr. Lindenauer: Division of Healthcare Quality, Baystate Medical Center, 759 Chestnut Street P-5931, Springfield, MA 01199.

Dr. Behal: University HealthSystem Consortium, Suite 700, 2001 Spring Road, Oak Brook, IL 60523.

Dr. Murray: University of Central Oklahoma, 100 North University Drive, Edmond, OK 73303.

Drs. Nsa and Bratzler: Oklahoma Foundation for Medical Quality, 14000 Quail Springs Parkway, Oklahoma City, OK 73134.

Dr. Houck: U.S. Public Health Service, 2201 Sixth Avenue, MS-20, Seattle, WA 98121.