Hospital volume and patient outcomes in pulmonary embolism

Abstract

Background: In numerous high-risk medical and surgical conditions, a greater volume of patients undergoing treatment in a given setting or facility is associated with better survival. For patients with pulmonary embolism, the relation between the number of patients treated in a hospital (volume) and patient outcome is unknown.

Methods: We studied discharge records from 186 acute care hospitals in Pennsylvania for a total of 15 531 patients for whom the primary diagnosis was pulmonary embolism. The study outcomes were all-cause mortality in hospital and within 30 days after presentation for pulmonary embolism and the length of hospital stay. We used logistic models to study the association between hospital volume and 30-day mortality and discrete survival models to study the association between in-hospital mortality and time to hospital discharge.

Results: The median annual hospital volume for pulmonary embolism was 20 patients (interquartile range 10-42). Overall in-hospital mortality was 6.0%, whereas 30-day mortality was 9.3%. In multivariable analysis, very-high-volume hospitals (> or = 42 cases per year) had a significantly lower odds of in-hospital death (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.51-0.99) and of 30-day death (OR 0.71, 95% CI 0.54-0.92) than very-low-volume hospitals (< 10 cases per year). Although patients in the very-high-volume hospitals had a slightly longer length of stay than those in the very-low-volume hospitals (mean difference 0.7 days), there was no association between volume and length of stay.

Interpretation: In hospitals with a high volume of cases, pulmonary embolism was associated with lower short-term mortality. Further research is required to determine the causes of the relation between volume and outcome for patients with pulmonary embolism.

Figure 1: Identification of sample for study of outcomes of pulmonary embolism in relation to hospital case volume. ICD-9-CM = International Classification of Diseases, 9th revision, Clinical Modification.

Figure 2: Unadjusted and adjusted odds ratios for in-hospital mortality among 15 531 patients with pulmonary embolism, by hospital volume (annual number of cases of pulmonary embolism treated). (Adjustments were for hospital region within Pennsylvania, hospital teaching status, race, insurance status, severity of illness and administration of thrombolytic therapy.) OR = odds ratio, CI = confidence interval.

Figure 3: Unadjusted and adjusted odds ratios for 30-day mortality among 15 531 patients with pulmonary embolism, by hospital volume (annual number of cases of pulmonary embolism treated). (Adjustments were for hospital region within Pennsylvania, hospital teaching status, race, insurance status, severity of illness and administration of thrombolytic therapy.) OR = odds ratio, CI = confidence interval.