1. Beyond volume of patients: Organizational and professional factors related to hospital outcomes R. Blais, PhD, R. Pineault, MD, PhD, P. Boyle, PhD, S. Dubé, MD, D. Larouche, MSc, M. Fournier, MSc GRIS, University of Montreal, Canada APHA 129th Annual meeting, Atlanta, Oct. 24, 2001

2. 2 Background  Hospital managers are looking for ways to reduce cost while maintaining or improving quality of care.  One popular hypothesis is that facilities that treat more patients are more performant and have better clinical outcomes. This has led to many mergers and efforts to increase production capacity.  Yet studies on the relationship between volume and outcomes have produced mixed results, indicating that other factors intervene.  These other factors have not been well documented through quantitative analysis of administrative databases.  New insight may be gained through a qualitative approach to the question of the relationship between volume and outcomes.

3. 3 Objective The purpose of this study was to identify the organizational and professional variables that come into play in the relationship between hospital patient volume and surgical outcomes for specific procedures.

4. 4 Methods Outcome indicators  Target interventions : Cholecystectomy, hysterectomy, prostatectomy  Outcome indicators : Complications during hospitalization plus readmissions for complications <91 days, adjusted for severity (APR-DRG)  Source of data: Quebec provincial discharge-abstract database (1997-1998)

8. 8 Methods Hospital selection for interviews  For each surgical procedure, hospitals were divided into quartiles according to annual volume of study surgery and complication rate (see grid on next page)  Hospitals with lowest volume were excluded  One hospital was randomly selected from each of the four extreme combinations (high volume-high complication rate; low volume- very low complication rate, etc.)

9. 9 Methods (hospital selection) Very lowLow Medium High Low Very low Medium Complication Rate 1hospital1 1 1 Volume

10. 10 Interviews  5 to 7 key informants interviewed per hospital:  medical director  nursing director  president of medical council  president of medical evaluation committee  chief of department of surgery and/or services  chief nurse of operating room  chief nurse of department of surgery  Total : 69 individual interviews conducted (taped)

11. 11 Results Interview themes  1. Hospital characteristics  2. Physician characteristics  3. Nurse characteristics  4. Quality monitoring activities  5. Operating room functioning  6. Pre-op and post-op care  7. Hospital discharge  34 sub-themes

12. 12 Results 1. Hospital characteristics Very low complication rateHigh complication rate High volume Low volume Teaching (except 1) Agreement with community  facilities for post-op care (except 1) Teaching (except 1) No agreement with community facilities for post-op care Non teaching No agreement with community facilities for post-op care Non teaching (except 1) No agreement with community facilities for post-op care (except 1 for day surgery)

13. 13 Results 2. Physician characteristics Very low complication rateHigh complication rate High volume Low volume No medical students/residents  (except 1) Medical students/residents (except 1) No medical students/residents Equivalent workload among  physicians No medical students/residents Unbalanced workload among physicians

14. 14 Results 3. Nurse characteristics Very low complication rateHigh complication rate High volume Low volume More nurses per operating room  Continuing education for  operating room nurses Fewer nurses per operating room No continuing education for operating room nurses (except 1) More nurses per operating room  (except 1) Continuing education for operating room nurses (except 1) Fewer nurses per operating room Continuing education for operating room nurses (except 1)

15. 15 Results 4. Quality monitoring activities Very low complication rateHigh complication rate High volume Low volume More evaluation studies with  objective criteria Fewer evaluation studies with objective criteria Few evaluation studies with objective criteria

16. 16 Results 5. Operating room functioning Very low complication rateHigh complication rate High volume Low volume Low surgery cancellation rate  OR time allocated by needs  Only regular schedule surgery  Adequate equipment (except 1)  High surgery cancellation rate (10%) OR time unequaly allocated Evening, night, weekend surgery (1) Lack of or inadequate equipment Low surgery cancellation rate  Only regular schedule surgery  High surgery cancellation rate (10%) Evening, night, weekend surgery (1)

17. 17 Results 6. Pre-op and post-op care Very lowcomplication rateHigh complication rate High volume Low volume Pre-op patient education Care protocols: variable Pre-op patient education Care protocols: variable Pre-op patient education No care protocols Pre-op patient education No care protocols

18. 18 Results 7. Hospital discharge Very lowcomplication rateHigh complication rate High volume Low volume Telephone follow-up by nurse  after discharge (except 1) Visit to surgeon after discharge No telephone follow-up by nurses after discharge (except 1) Visit to surgeon after discharge Telephone follow-up by nurses after discharge (except 1) Visit to surgeon after discharge Telephone follow-up by nurses after discharge (except 1) Visit to surgeon after discharge (except 1: not always)

19. 19 Discussion  Factors affecting outcomes go beyond physician’s ability and include a wide range of organizational and professional characteristics  Factors may be different whether hospital volume is high or low  Hospital teaching status or size does not guarantee better outcomes  Many factors can actually be changed (e.g., develop agreement with community facilities, provide continuing education to nurses)

20. 20 Limitations  Only 12 hospitals  Only 3 surgical procedures of medium complexity: factors may be different for other types of surgery or non surgical care  Not all variables were documented with the same precision across hospitals  Physician volume not examined

21. 21 Conclusion  Patient outcomes result from the interaction of many factors. Structure variables (e.g. teaching status, number of beds, volume of cases) are insufficient to explain variations in outcomes among hospitals.  Process variables seem to be more important determinant of outcomes.  A more thorough understanding of the process of care is needed to better explain variations in outcomes.

22. 22 For more information Régis Blais, PhD Department of Health Administration University of Montreal - GRIS PO Box 6128, Station Centre-ville Montreal (Quebec), Canada H3C 3J7 Tel: (514) 343-5907 E-mail: regis.blais@umontreal.ca