Regionalizing Health Care: Volume Standards vs' RiskAdjusted Mortality Rate

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Regionalizing Health CareVolume Standards vs.
Risk-Adjusted Mortality Rate

• Laurent G. Glance, M.D.
• Associate Professor
• Department of Anesthesiology
• This project was supported by a grant from the
  Agency for Healthcare and Quality Research (R01
  HS 13617)

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Team members

• Laurent G Glance, MD (University of Rochester)
• Turner M. Osler, MD (University of Vermont)
• Dana B. Mukamel, PhD. (University of California,
  Irvine)
• Andrew W. Dick, PhD (RAND)

Project officer Yen-Pin Chiang, PhD
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Scope of the Problem
Between 44,000 and 98,000 deaths each year due to
medical errors.
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National Agenda to Improve Patient Safety
AHRQ-sponsored report designated localizing
specific surgeries and procedures to high-volume
centers as a High Priority area for patient
safety research.
Making Health Care Safer A Critical Analysis of
Patient Safety Practices. Evidence
Report/Technology Assessment Number 43. AHRQ
Publication No. 01-E058, July 2001. Agency for
Healthcare Research and Quality, Rockville, MD.
http//www.ahrq.gov/clinic/ptsafety/
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Hypotheses

• Selective Referral Selectively referring
  high-risk surgery patients to high-quality
  centers will lead to better population outcomes
  than selectively referring patients to
  high-volume centers.
• Selective Avoidance Diverting high-risk patients
  from low quality centers will lead to better
  population outcomes than diverting patients from
  low-volume centers.

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Data

• HCUP California SID (1998-2000)
• Administrative data (ICD-9-CM codes)
• 30 diagnoses
• 21 procedures
• POA indicator
• Study Populations
• CABG
• PCI
• AAA surgery

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Model Development

• Random-Intercept model
• Demographics
• Age, gender, transfer status, admission type
  (elective vs. non-elective)
• Comorbidities
• Disease Staging
• Elixhauser Comorbidity Algorithm

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Hospital Quality

• Hospital intercept term

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Identification of High-Volume and Low-Volume
Centers

• High-Volume based on Leapfrog Criteria
• AAA gt 50 cases/yr
• CABG gt 450 cases/yr
• PCI gt 400 cases/yr
• Low-Volume
• Lower volume quartile

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Estimating Impact of Regionalization

• Added binary variable to base model to indicate
  whether a patient was treated at a high-volume
  center
• Simulated mortality rate
• Estimated mortality rate for patients diverted to
  high-volume centers
• Observed mortality rate for patients already
  treated at high-volume centers

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Volume-Outcome Association

• Hospital volume is NOT a good proxy for Hospital
  Quality

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Impact of Regionalization
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Findings

• Selective Referral
• High-Volume Centers 0-20 mortality reduction
  70-99 hospital closure
• High-Quality Centers 50 mortality reduction
  90-99 hospital closure
• Selective Avoidance
• Low-Volume Centers 0-2.5 reduction in
  mortality 25 hospital closure
• Low-Quality Centers 2-5 mortality reduction
  1-8 hospital closure

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Policy Implications

• Hospital Volume is a POOR Quality Indicator
  should not be used as the basis for selective
  referral or selective avoidance
• Selective Referral to High-Quality Centers is NOT
  PRACTICAL
• Selective Avoidance of Low-Quality Centers may
  achieve modest reductions in mortality
• Consider Improving Overall Hospital Quality

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Quality Improvement based on Feedback of
Risk-Adjusted Outcomes

• NSQIP
• NNE

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NSQIP

• 27 decrease in mortality
• 45 decrease in morbidity
• No change in casemix

Khuri. Arch Surgery 2002.
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NNE Cardiovascular Study
OConnor GT. JAMA 1996.
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Current Project
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Project Officer Michael Handrigan, PhD
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Hypothesis

• Providing trauma and non-trauma centers with
  information on their risk-adjusted outcomes will
  lead to improved outcomes.

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