Does physicians' case volume impact inpatient care costs for pneumonia cases?

The relationship between physician case volume and in-hospital mortality of critically ill children with a diagnosis of pneumonia: a cross-sectional observational analytical study

PURPOSE

The aim of this study is to examine the relationship between physician case volume and the outcomes of critically ill children with pneumonia.

MATERIALS AND METHODS

This is a population-based cohort study analyzed data provided from by the National Health Insurance Research Database of Taiwan, 2006-2009. Children (aged 3 months to 17 years) having records of intensive care unit (ICU) admission and a diagnosis of pneumonia were included. A total of 9754 critically ill children and 1042 attending physicians were enrolled. The children were assigned to 1 of 4 groups based on the physician's pneumonia case volume.

RESULTS

The patients in the very high case volume group had a significantly lower length of hospital stay, in-hospital mortality rate, and hospitalization expenses, and a significantly higher ratio of ICU to hospital stays than the other 3 groups (P<.001). The probability of death tended to be lower when the physician's case volume was higher. The risk-adjusted odds ratio for in-hospital mortality of very-high case volume group was 0.48 (95% confidence interval, 0.35-0.65; P<.001) compared to low case volume group.

CONCLUSIONS

A higher physician's pneumonia case volume is associated with a lower length of hospital stay, lower in-hospital mortality rate, and lower hospitalization expenses among critically ill children with pneumonia.

Clinical characteristics and economic consequence of Klebsiella pneumoniae liver abscess in Taiwan

BACKGROUND

Klebsiella pneumoniae liver abscess (KPLA) has emerged as an endemic disease in Taiwan, and its prevalence has been increasing in east Asian countries in the past three decades. The utilization of healthcare resources associated with KPLA is assumed to be substantial, and may be of future concern. This study investigated the clinical characteristics and economic burden of KPLA in Taiwan in 2011 and 2012.

METHODS

Adult patients with KPLA were identified retrospectively in a tertiary medical center in Taiwan from January 2011 to December 2012. The clinical characteristics, total and daily hospitalization expenditure, and the risk factors for the costs of KPLA were analyzed.

RESULTS

Among patients with KPLA, the median cost was $5290.80 in US dollars, and the mean cost was $6337.50 ± $4363.40. Length of hospital stay was the only independent risk factor for the high total hospitalization expenditure. The duration of antibiotic use was nearly the same as the length of hospital stay. The prolonged stay in the general ward (≥21 days) also contributed to the high total cost of hospitalization. The independent risk factors for the high average daily cost of hospitalization were a higher Charlson Comorbidity Index and the requirement of intensive care on admission.

CONCLUSION

The current study is the first to demonstrate the high economic burden resulting from KPLA in a medical center in Taiwan. Standardizing the treatment protocol for KPLA inpatients and introducing an outpatient parenteral antimicrobial therapy center to reduce the length of stay may reduce costs, whereas development of a vaccine may be necessary to tackle endemic KPLA in the future.

Physician volume, specialty, and outcomes of care for patients with heart failure

BACKGROUND

There is an urgent need to improve outcomes and reduce costs for patients with heart failure (HF). Physician volume is associated with better outcomes for patients undergoing procedures, but its association with outcomes for medically managed diseases, such as HF, is not well understood.

METHODS AND RESULTS

We used Medicare inpatient data in 2009 to examine all HF admissions to acute care hospitals in the United States. We divided physicians into quintiles according to their volume of patients with HF. We used patient-level regression to compare 30-day risk-adjusted mortality, readmissions, and costs across volume groups, controlling for patient, physician, and hospital characteristics. We examined physician volume within strata of hospital volume and physician specialty. Patients cared for by the high-volume physicians had lower mortality than those by the low-volume physicians (8.9% versus 9.7%; P<0.001); this relationship was strongest in low-volume hospitals. In contrast, patients cared for by high-volume physicians had higher readmission rates (25.8% versus 21.5%; P<0001); this relationship was similar across hospital volume groups. Finally, costs were higher for the high-volume physicians ($8982 versus $8731; P=0.002, a difference that was consistent across hospital volume groups). The relationship between physician volume and mortality was strongest for internists (9.2% versus 10.6%; P<0.001) and weakest for cardiologists (6.4% versus 6.7%; P=0.485).

CONCLUSIONS

Physician volume is associated with lower mortality for HF, particularly in low-volume institutions and among noncardiologist physicians. Our findings suggest that clinician expertise may play an important role in HF care.

Factors associated with pneumonia outcomes: a nationwide population-based study over the 1997-2008 period

BACKGROUND

Pneumonia is the most common infectious cause of death worldwide. Over the last decade, patient characteristics and health care factors have changed. However, little information is available regarding systematically and simultaneously exploring effects of these changes on pneumonia outcomes.

OBJECTIVES

We used nationwide longitudinal population-based data to examine which patient characteristics and health care factors were associated with changes in 30-day mortality rates for pneumonia patients.

DESIGN

Trend analysis using multilevel techniques.

SETTING

General acute care hospitals throughout Taiwan.

PARTICIPANTS

A total of 788,011 pneumonia admissions.

MEASUREMENTS

Thirty-day mortality rates. Taiwan's National Health Insurance claims data from 1997 to 2008 were used to identify the effects of patient characteristics and health care factors on 30-day mortality rates.

RESULTS

Male, older, or severely ill patients, patients with more comorbidities, weekend admissions, larger reimbursement cuts and lower physician volume were associated with increased 30-day mortality rates. Moreover, there were interactions between patient age and trend on mortality.

CONCLUSIONS

Male, older or severely ill patients with pneumonia have higher 30-day mortality rates. However, mortality gaps between elderly and young patients narrowed over time; namely, the decline rate of mortality among elderly patients was faster than that among young patients. Pneumonia patients admitted on weekends also have higher mortality rates than those admitted on weekdays. The mortality of pneumonia patients rises under increased financial strain from cuts in reimbursement such as the Balanced Budget Act in the United States or global budgeting. Higher physician volume is associated with lower mortality rates.

Surgeon age and operative outcomes for primary rhegmatogenous retinal detachment: a 3-year nationwide population-based study

PURPOSE

The aim was to study the association of surgeon age with operative outcomes for primary rhegmatogenous retinal detachment (RRD) in Taiwan.

METHODS

A total of 7427 adult patients of primary RRD who were treated by 284 ophthalmologists with scleral buckling (SB), pars plana vitrectomy (PPV), or their combination from 2002 to 2004 were identified in the Taiwan National Health Insurance Research Database. The adjusted odds ratios (OR) of 180-day readmission between ophthalmologist age groups were calculated.

RESULTS

For SB, patients treated by ophthalmologists aged >or=51 years had a greater 180-day readmission rate (OR=1.44, 95% confidence interval (CI)=1.01-2.07, P<0.05) than those treated by ophthalmologists aged 41-50 years. For PPV, patients treated by ophthalmologists aged <or=40 years had a lower 180-day readmission rate than those treated by ophthalmologists aged 41-50 and >or=51 years (OR=0.58 and 0.22, 95% CI=0.47-0.71 and 0.13-0.63, P<0.001 and <0.001, respectively). For PPV+SB, patients treated by ophthalmologists aged >or=51 years had a higher 180-day readmission rate than those treated by ophthalmologists aged <or=40 and 41-50 years (OR=3.32 and 2.45, 95% CI=2.29-4.21 and 1.36-4.40, P<0.01 and <0.01, respectively). The absolute differences in the 180-day readmission rate by surgeon age ranged from -0.1 to 3.2%. The proportions of selecting primary SB (without PPV) as the treatment modality were 33.1, 35.6, and 70.6% for the <or=40-, 41-to 50-, and >or=51-year groups, respectively.

CONCLUSIONS

Surgeon age is a relatively weak predictor for the outcomes of primary RRD surgery in aggregate in Taiwan and certainly not appropriate for discriminating performance among individual surgeons.