Hospital volume and outcome after coronary angioplasty: is there a role for certificate of need regulation?

Do patients choose hospitals with high quality ratings? Empirical evidence from the market for angioplasty in the Netherlands

A necessary condition for competition to promote quality in hospital markets is that patients are sensitive to differences in hospital quality. In this paper we examine the relationship between hospital quality, as measured by publicly available quality ratings, and patient hospital choice for angioplasty using individual claims data from a large health insurer. We find that Dutch patients have a high propensity to choose hospitals with a good reputation, both overall and for cardiology, and a low readmission rate after treatment for heart failure. Relative to a mean readmission rate of 8.5% we find that a 1%-point lower readmission rate is associated with a 12% increase in hospital demand. Since readmission rates are not adjusted for case-mix they may not provide a correct signal of hospital quality. Insofar patients base their hospital choice on such imperfect quality information, this may result in suboptimal choices and risk selection by hospitals.

The impact of new hospital orthopaedic surgery programs on total joint arthroplasty utilization

BACKGROUND

Utilization of arthroplasty is increasing, but there are little data exploring the causes of this increase. The objective of this study was to examine the relationship between new programs for arthroplasty of the lower extremity joints and the utilization of arthroplasty.

METHODS

We identified twenty-four markets (hospital referral regions) that experienced the entry of new physician-owned specialty hospitals, using 1991 to 2005 Medicare data. We matched each market with a new specialty hospital to two different control markets (one market with a new arthroplasty program in a general hospital and one market without a new arthroplasty program), using a propensity score that accounted for market supply and demand for orthopaedic surgery and the regulatory environment. We compared the utilization of arthroplasty of the lower extremity joints (total hip arthroplasty and total knee arthroplasty) in each group of markets over a five-year window, extending from two years before to three years after the entry of new orthopaedic surgery programs.

RESULTS

The twenty-four markets with new specialty orthopaedic hospitals had higher utilization of arthroplasty at baseline (10.9 arthroplasties per 1000 Medicare beneficiaries per year) and follow-up (12.7 per 1000 beneficiaries) compared with the twenty-four markets with new arthroplasty programs in general hospitals (9.7 and 11.4, respectively) and the twenty-four markets with no new programs (9.9 and 11.3), although the differences were not significant (p > 0.05). Growth in the utilization of arthroplasty was similar in markets with new specialty hospitals before (an increase of 0.63 procedure per 1000 beneficiaries per year) and after the entry of new specialty hospitals (an increase of 0.39) compared with markets with new surgery programs in general hospitals (an increase of 0.24 before and 0.43 after) and markets with no new programs (an increase of 0.38 before and 0.33 after the entry of new specialty hospitals) (p > 0.05 for all comparisons).

CONCLUSIONS

The utilization of arthroplasty is increasing at similar rates in markets with and without new arthroplasty programs.

The effect of burn center and burn center volume on the mortality of burned adults--an analysis of the data in the National Burn Repository

Regional variations of care, and improved outcomes with larger volumes, have been well described in the medical and surgical literature for a variety of conditions including heart surgery, vascular surgery, and orthopedic surgery. Burn care has not been recently subjected to such an analysis. The National Burn Repository (NBR) contains de-identified patient and burn center data to allow this analysis. The NBR was queried for adult burn patients admitted for an acute thermal burn injury. A multivariable regression analysis to identify risk of death was performed incorporating patient characteristics, de-identified burn center, and burn center volume. Patient characteristics such as age, size of burn, mechanism of burn, inhalation injury, race, and sex determine mortality. There is also a statistically significant difference in death rates when individual, de-identified centers are compared. This difference in care persists even when accounting for burn center volume. Analysis of registries like the NBR, insurance claims databases, and statewide hospital discharge databases may help identify opportunities to improve burn care. According to this analysis of data available in the NBR, burn mortality depends not only on patient characteristics but also where the patient is treated. Mortality does not linearly improve with burn center volume and plateaus with increasing burn center size. The optimal burn center size is a complicated and contentious question. Future discussions about burn center size and density should incorporate not only mortality but also the region's ability to absorb surges in volume, and the optimal "staffing" ratios for the multidisciplinary aspects of burn care.

Assessing changes in high-volume hospital use: hospitals, payers, and aggregate volume trends

The relationship between higher procedure volumes and medical outcomes has generated recommendations for greater use of high-volume hospitals, with research and advocacy on this issue intensifying during the 1990s. Despite this interest, the trends presented here showed only limited changes between 1995 and 2002. For a number of services, less than half of patients received care at high-volume hospitals, and for several services, there was a surprising decline in the proportion at high-volume hospitals. Trends in the rate of high-volume hospital use appeared to be associated with trends in aggregate volume, at the same time that there were only modest changes in either patient use of high-volume hospitals or the number of hospitals offering these services. These trends suggested the importance of research on factors that affect patient choices, hospital decisions, and payer incentives concerning hospital use, especially in the context of declining aggregate procedure volumes.

U.S. Trends In CABG Hospital Volume: The Effect Of Adding Cardiac Surgery Programs

Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality.