A recent study from Taiwanese researchers found that patients admitted to acute care hospitals with heart failure treated by physicians without reaching a volume threshold had higher 30-day mortality, and the volume-outcome relationship was stronger in hospitals without reaching a volume threshold. This research, published in Medical Care, was conducted by PhD candidate Ms. Ying-Yi Chou, and her advisor, Dr. Yu-Chi Tung, associate professor at the Institute of Health Policy and Management, National Taiwan University College of Public Health.
Heart failure is a common reason for hospitalization and mortality rates are high among patients with heart failure. The Centers for Medicare and Medicaid Services (CMS) has considered heart failure 30-day mortality as a hospital quality indicator. Recent research has explored optimal volume thresholds for various surgeries and procedures, but less research for medical conditions. The aim of this study was to identify optimal hospital and physician volume thresholds to improve 30-day mortality and to examine the relative and combined effects of the volume thresholds on heart failure 30-day mortality.
This study identified that hospital and physician volume thresholds related to reducing heart failure 30-day mortality were 40 cases a year and 15 cases a year, respectively. Compared with patients treated by physicians with previous annual volumes ≥15 cases, those treated by physicians with previous annual volumes <15 cases had higher 30-day mortality, and the relationship was stronger in hospitals with previous annual volumes <40 cases.
Finding out the hospital and physician volume thresholds could be applied to quality improvement and physician training. The feasible strategies include development of national protocols and guidelines, and redistributing cases within a hospital. For a physician slightly below the threshold compared with one slightly above the threshold in a hospital or for high-volume hospitals, redistributing cases within a hospital to enhance individual physician volumes not only makes individual physicians keep achieving the volume threshold but also prevents certain physicians from being in burnout due to heavy patient loads. For urban small hospitals, centralizing patients among a smaller group of physicians would enable physicians to reach a volume threshold. For rural hospitals with low volume of patients, consultative services or telemedicine could be used to involve more experienced physicians in patient care while maintaining accessibility. For physician training, it could be applied to fellowship programs allowing fellows to gain more experience of heart failure care.
Source: Chou YY, Yu TH, Tung YC. Do Hospital and Physician Volume Thresholds for the Volume-Outcome Relationship in Heart Failure Exist? Med Care. 2019;57(1):54-62.