The Association Between Hospital Volume and Processes, Outcomes, and Costs of Care for Congestive Heart Failure

Study Questions:

Do hospitals with more experience in caring for patients with congestive heart failure (CHF) provide better, more efficient care?


This was a retrospective cohort study of 4,095 US hospitals with primary discharge diagnosis of CHF in Medicare fee-for-service patients (1,029,497 discharges; ≥99.5% of eligible CHF discharges). The study investigators examined Hospital Quality Alliance CHF process measures; 30-day, risk-adjusted mortality rates; 30-day, risk-adjusted readmission rates; and costs per discharge. The investigators also used National Medicare claims data from 2006 to 2007 to determine the relationship between hospital case volume (low volume = 25-200 discharges, medium volume = 201-400 discharges, and high volume = >400 discharges) and quality, outcomes, and costs for patients with CHF. They limited the analysis to Medicare patients ages ≥65 years and performed risk adjustment by using administrative data.


The investigators found that hospitals in the low-volume group had lower performance on the process measures (80.2%) than did medium-volume (87.0%) or high-volume (89.1%) hospitals (p < 0.001). In the low-volume group, being admitted to a hospital with a higher case volume was associated with lower mortality, lower readmission, and higher costs. Similar, though smaller, relationships were found between case volume and both mortality and costs in the medium- and high-volume hospital groups.


The study authors concluded that experience with managing CHF, as measured by an institution’s volume, is associated with higher quality of care and better outcomes for patients, but a higher cost. Understanding which practices employed by high-volume institutions account for these advantages can help improve quality of care and clinical outcomes for all patients with CHF.


Although this is a retrospective study, this paper has an important message that suggests high-volume hospitals with probably better resources for management of HF (such as disease management programs, dedicated protocols, and rapid response teams) and more efficient utilization of resources are associated with cost savings and improved mortality. Prospective data are now needed to support these important findings so that hospitals can make thoughtful provisions to improve the management of HF. However, before designing a new study, it is important to keep in mind that current HF performance measures, aside from prescription of an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker at discharge, may have little relationship to patient mortality and combined mortality/rehospitalization in the first 60-90 days after discharge (JAMA 2007;297:61-70).

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Heart Failure, Cost Savings, Medicare, Hospitals, High-Volume, United States, Risk Adjustment

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