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The relationship between hospital volume and mortality in mechanical ventilation: an instrumental variable analysis.

ABSTRACT: To examine the relationship between hospital volume and mortality for nonsurgical patients receiving mechanical ventilation.Pennsylvania state discharge records from July 1, 2004, to June 30, 2006, linked to the Pennsylvania Department of Health death records and the 2000 United States Census.We categorized all general acute care hospitals in Pennsylvania (n=169) by the annual number of nonsurgical, mechanically ventilated discharges according to previous criteria. To estimate the relationship between annual volume and 30-day mortality, we fit linear probability models using administrative risk adjustment, clinical risk adjustment, and an instrumental variable approach.Using a clinical measure of risk adjustment, we observed a significant reduction in the probability of 30-day mortality at higher volume hospitals (>or=300 admissions per year) compared with lower volume hospitals (<300 patients per year; absolute risk reduction: 3.4%, p=.04). No significant volume-outcome relationship was observed using only administrative risk adjustment. Using the distance from the patient's home to the nearest higher volume hospital as an instrument, the volume-outcome relationship was greater than observed using clinical risk adjustment (absolute risk reduction: 7.0%, p=.01).Care in higher volume hospitals is independently associated with a reduction in mortality for patients receiving mechanical ventilation. Adequate risk adjustment is essential in order to obtained unbiased estimates of the volume-outcome relationship.

SUBMITTER: Kahn JM

PROVIDER: S-EPMC2699912 | biostudies-literature | 2009 Jun

REPOSITORIES: biostudies-literature

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The relationship between hospital volume and mortality in mechanical ventilation: an instrumental variable analysis.

Kahn Jeremy M JM Ten Have Thomas R TR Iwashyna Theodore J TJ

Health services research 20090317 3

<h4>Objective</h4>To examine the relationship between hospital volume and mortality for nonsurgical patients receiving mechanical ventilation.<h4>Data sources</h4>Pennsylvania state discharge records from July 1, 2004, to June 30, 2006, linked to the Pennsylvania Department of Health death records and the 2000 United States Census.<h4>Study design</h4>We categorized all general acute care hospitals in Pennsylvania (n=169) by the annual number of nonsurgical, mechanically ventilated discharges ac ...[more]

PMID: 19674428

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Project description:OBJECTIVES:Prior studies investigating hospital mechanical ventilation volume-outcome associations have had conflicting findings. Volume-outcome relationships within contemporary mechanical ventilation practices are unclear. We sought to determine associations between hospital mechanical ventilation volume and patient outcomes. DESIGN:Retrospective cohort study. SETTING:The California Patient Discharge Database 2016. PATIENTS:Adult nonsurgical patients receiving mechanical ventilation. INTERVENTIONS:The primary outcome was hospital death with secondary outcomes of tracheostomy and 30-day readmission. We used multivariable generalized estimating equations to determine the association between patient outcomes and hospital mechanical ventilation volume quartile. MEASUREMENTS AND MAIN RESULTS:We identified 51,689 patients across 274 hospitals who required mechanical ventilation in California in 2016. 38.2% of patients died in the hospital with 4.4% receiving a tracheostomy. Among survivors, 29.5% required readmission within 30 days of discharge. Patients admitted to high versus low volume hospitals had higher odds of death (quartile 4 vs quartile 1 adjusted odds ratio, 1.40; 95% CI, 1.17-1.68) and tracheostomy (quartile 4 vs quartile 1 adjusted odds ratio, 1.58; 95% CI, 1.21-2.06). However, odds of 30-day readmission among survivors was lower at high versus low volume hospitals (quartile 4 vs quartile 1 adjusted odds ratio, 0.77; 95% CI, 0.67-0.89). Higher hospital mechanical ventilation volume was weakly correlated with higher hospital risk-adjusted mortality rates (? = 0.16; p = 0.008). These moderately strong observations were supported by multiple sensitivity analyses. CONCLUSIONS:Contrary to previous studies, we observed worse patient outcomes at higher mechanical ventilation volume hospitals. In the setting of increasing use of mechanical ventilation and changes in mechanical ventilation practices, multiple mechanisms of worse outcomes including resource strain are possible. Future studies investigating differences in processes of care between high and low volume hospitals are necessary.

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The relationship between hospital volume and mortality in mechanical ventilation: an instrumental variable analysis.

Publications

The relationship between hospital volume and mortality in mechanical ventilation: an instrumental variable analysis.

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