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. 2015 Feb 9:350:h447.
doi: 10.1136/bmj.h447.

Association of hospital volume with readmission rates: a retrospective cross-sectional study

Leora I Horwitz  1 , Zhenqiu Lin  2 , Jeph Herrin  3 , Susannah Bernheim  4 , Elizabeth E Drye  5 , Harlan M Krumholz  6 , Harold J Hines Jr, Joseph S Ross  7
Affiliations

Association of hospital volume with readmission rates: a retrospective cross-sectional study

Leora I Horwitz et al. BMJ. .

Erratum in

Abstract

Objective: To examine the association of hospital volume (a marker of quality of care) with hospital readmission rates.

Design: Retrospective cross-sectional study.

Setting: 4651 US acute care hospitals.

Study data: 6,916,644 adult discharges, excluding patients receiving psychiatric or medical cancer treatment.

Main outcome measures: We used Medicare fee-for-service data from 1 July 2011 to 30 June 2012 to calculate observed-to-expected, unplanned, 30 day, standardized readmission rates for hospitals and for specialty cohorts medicine, surgery/gynecology, cardiorespiratory, cardiovascular, and neurology. We assessed the association of hospital volume by quintiles with 30 day, standardized readmission rates, with and without adjustment for hospital characteristics (safety net status, teaching status, geographic region, urban/rural status, nurse to bed ratio, ownership, and cardiac procedure capability. We also examined associations with the composite outcome of 30 day, standardized readmission or mortality rates.

Results: Mean 30 day, standardized readmission rate among the fifth of hospitals with the lowest volume was 14.7 (standard deviation 5.3) compared with 15.9 (1.7) among the fifth of hospitals with the highest volume (P<0.001). We observed the same pattern of lower readmission rates in the lowest versus highest volume hospitals in the specialty cohorts for medicine (16.6 v 17.4, P<0.001), cardiorespiratory (18.5 v 20.5, P<0.001), and neurology (13.2 v 14.0, p=0.01) cohorts; the cardiovascular cohort, however, had an inverse association (14.6 v 13.7, P<0.001). These associations remained after adjustment for hospital characteristics except in the cardiovascular cohort, which became non-significant, and the surgery/gynecology cohort, in which the lowest volume fifth of hospitals had significantly higher standardized readmission rates than the highest volume fifth (difference 0.63 percentage points (95% confidence interval 0.10 to 1.17), P=0.02). Mean 30 day, standardized mortality or readmission rate was not significantly different between highest and lowest volume fifths (20.4 v 20.2, P=0.19) and was highest in the middle fifth of hospitals (range 20.6-20.8).

Conclusions: Standardized readmission rates are lowest in the lowest volume hospitals-opposite from the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics and was only partially attenuated by examining mortality and readmission together. Our findings suggest that readmissions are associated with different aspects of care than mortality or complications.

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Conflict of interest statement

Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that all authors have support from the Centers for Medicare & Medicaid Services for the submitted work. In addition, JSR is a member of a scientific advisory board for FAIR Health, and HMK chairs a cardiac scientific advisory board for UnitedHealth and is the recipient of research grants from Medtronic and Johnson & Johnson through Yale University.

Figures

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Fig 1 Scatter plots of hospital-wide unplanned, 30 day readmission rate by hospital volume: (a) observed rate, (b) standardized rate
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Fig 2 Distribution of standardized readmission rate, by hospital volume group and specialty cohort
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