Volume-outcome relationship in neurotrauma care

Clinical article

R. Carter Clement M.D., M.B.A.1,2, Brendan G. Carr M.D., M.A., M.S.H.P.4,5,3, Michael J. Kallan M.S.5, Catherine Wolff M.S.5, Patrick M. Reilly M.D.6, and Neil R. Malhotra M.D.7
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  • 1 Perelman School of Medicine at the University of Pennsylvania;
  • | 2 Wharton School of Business at the University of Pennsylvania;
  • | 4 Leonard Davis Institute of Healthcare Economics;
  • | 5 Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; and
  • | 3 Departments of Emergency Medicine
  • | 6 Surgery, and
  • | 7 Neurological Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Object

A positive correlation between outcomes and the volume of patients seen by a provider has been supported by numerous studies. Volume-outcome relationships (VORs) have been well documented in the setting of both neurosurgery and trauma care and have shaped regionalization policies to optimize patient outcomes. Several authors have also investigated the correlation between patient volume and cost of care, known as the volume-cost relationship (VCR), with mixed results. The purpose of the present study was to investigate VORs and VCRs in the treatment of common intracranial injuries by testing the hypotheses that outcomes suffer at small-volume centers and costs rise at large-volume centers.

Methods

The authors performed a cross-sectional cohort study of patients with neurological trauma using the 2006 Nationwide Inpatient Sample, the largest nationally representative all-payer data set. Patients were identified using ICD-9 codes for subdural, subarachnoid, and extradural hemorrhage following injury. Transfers were excluded from the study. In the primary analysis the association between a facility's neurotrauma patient volume and patient survival was tested. Secondary analyses focused on the relationships between patient volume and discharge status as well as between patient volume and cost. Analyses were performed using logistic regression.

Results

In-hospital mortality in the overall cohort was 9.9%. In-hospital mortality was 14.9% in the group with the smallest volume of patients, that is, fewer than 6 cases annually. At facilities treating 6–11, 12–23, 24–59, and 60+ patients annually, mortality was 8.0%, 8.3%, 9.5%, and 10.0%, respectively. For these groups there was a significantly reduced risk of in-hospital mortality as compared with the group with fewer than 6 annual patients; the adjusted ORs (and corresponding 95% CIs) were 0.45 (0.29–0.68), 0.56 (0.38–0.81), 0.63 (0.44–0.90), and 0.59 (0.41–0.87), respectively. For these same groups (once again using < 6 cases/year as the reference), there were no statistically significant differences in either estimated actual cost or duration of hospital stay.

Conclusions

A VOR exists in the treatment of neurotrauma, and a meaningful threshold for significantly improved mortality is 6 cases per year. Emergency and interfacility transport policies based on this threshold might improve national outcomes. Cost of care does not differ significantly with patient volume.

Abbreviations used in this paper:

AIS = Abbreviated Injury Scale; CABG = coronary artery bypass graft; ICH = intracranial hemorrhage; LOS = length of stay; NIS = Nationwide Inpatient Sample; VCR = volume-cost relationship; VOR = volume-outcome relationship.

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