It is widely known that, for many medical conditions and surgical procedures, outcomes are better when delivered by high-volume providers. It is not known if this holds true for patients with community-acquired pneumonia. To determine the association between physician/hospital volume and patient quality/outcomes, researchers utilized data from the Medicare National Pneumonia Quality Improvement Project. They included patients with an ICD9 diagnosis of pneumonia (850 patients were randomly selected from each state) at acute care hospitals with general or family medicine attendings. They excluded patients with no documentation of pneumonia, a normal chest X-ray, age <65, death on day one, comfort measures only, and departure against medical advice or transfer. Each physician and hospital volume were calculated from Medicare Part A claims for the same calendar year and analyzed by quartiles of volume.
Of the 9,741 physicians analyzed (13,480 patients), the median annual number of pneumonia patients was four, nine, 15, and 29 (in quartiles 1-4). Physician volume of care had little or no effect on performance rates of the timing of antibiotics, appropriate initial antibiotic, use of blood cultures, or in-hospital/30-day mortality rates. Low volume providers were significantly more likely to provide pneumococcal and influenza screening.
Of the 3,243 hospitals analyzed, the median annual pneumonia caseload was 57, 142, 262, and 465 (in quartiles 1-4). Hospital volume of care had little or no effect on performance rates of the appropriate initial antibiotic, use of blood cultures, pneumococcal/influenza screening, or in-hospital/30-day mortality rates (after severity of illness adjustment). Low volume centers were significantly more likely to give the first antibiotic within four hours.
In conclusion, volume of care by individual providers and hospital systems does not necessarily translate into better quality outcomes in pneumonia care. This may be partially explained by the challenges that larger medical centers face regarding delivering timely care (in overcrowded emergency rooms) and influencing behavior change (such as with standardized order sets).
By Debra Anoff, MD, assistant professor of medicine, Lucy Guerra, MD, assistant professor of medicine, Bjorn Holmstrom, MD, assistant professor of medicine, Asha Ramsakal, DO, assistant professor of medicine and chief, Richard Gross, MD, FACP, professor of medicine and chief, Division of Internal and Hospital Medicine H. Lee Moffitt Cancer Center and Research Institute, University of South Florida College of Medicine
Risk Factors for Mortality in Neutropenic Cancer Patients
Kuderer, NM, Dale DC, Crawford J, et al. Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. Cancer. 2006 May 15;106(10):2258-2266.
Background: Neutropenic fever in a cancer patient is considered a medical emergency. Most episodes of febrile neutropenia result in hospital admission with prompt institution of broad spectrum antibiotics. The definition of neutropenia is usually regarded as an absolute neutrophil count (neutrophils plus bands) less than 500 cells/µL. The mortality rate of a cancer patient hospitalized with neutropenic fever ranges from 5 to 11%. There have been numerous small studies looking at risk factors associated with inpatient mortality. However, their small sample size and very select group of patients limit their generalizability to a standard hospitalist practice.
Methods: The authors used a longitudinal discharge database derived from 115 U.S. medical centers—both academic and community-based—in 39 states, looking retrospectively at all adult cancer patients hospitalized for febrile neutropenia between 1995 and 2000. The database included 55,276 hospitalizations and 41,779 patients and was analyzed for length of stay, cost per episode, mortality, and the clinical factors associated with mortality and prolonged hospitalization.
Results: The mortality rate for cancer patients with neutropenic fever averaged 9.5% per hospital. The average mortality rate was 14.3% for leukemia, 8.9% for lymphoma, and 8.0% for solid tumors. Lung cancer had the highest average mortality rate, 13.4%, followed by colorectal cancer at 8.8%, and breast cancer, which had the lowest mortality rate with 3.6%. Moreover, the highest mortality rate, 39.2%, was seen in those patients with a documented infection with invasive aspergillosis, while the rate of mortality for invasive candidiasis was 36.7%, followed by gram-negative bacteremia at 33.9%, pneumonia at 26.5%, and gram-positive bacteremia at 21.2%.