Published in the April 2006 version of Today’s Hospitalist
A new study examining pneumonia care at U.S. hospitals offers encouraging news for consumers, but it raises questions for physicians like hospitalists who treat large numbers of patients with common medical conditions.
When researchers examined how well hospitals met basic performance measures in treating pneumonia “the timing of antibiotics and the use of vaccinations, for example “they found that facilities that see relatively few numbers of pneumonia patients offer a similar quality of care and achieve comparable outcomes as higher-volume facilities. On a few measures, in fact, the lower-volume hospitals actually fared better.
This is good news for patients who don’t have easy access to large hospitals. For common medical conditions like pneumonia, the study says, you’re probably as well off going to the hospital down the street as traveling to a large hospital an hour away.
For hospitalists, however, the research brings mixed news. When it comes to treating pneumonia, at least, the study challenges the old adage that practice makes perfect. It also raises questions about the value that hospitalists bring to treating common medical conditions.
Lower volume, better quality?
The study, which was published in the Feb. 21, 2006, Annals of Internal Medicine, examined the care of patients 65 and older hospitalized with uncomplicated cases of pneumonia. In an effort to explore the relationship between patient volume and quality, researchers divided hospitals and physicians into four groups based on how many pneumonia patients they treated a year.
Researchers then looked at performance measures examining whether physicians and hospitals gave antibiotics within four hours of admission to the hospital, whether they ordered blood cultures before administering antibiotics, and whether they vaccinated patients for the flu and pneumonia.
The study found that for most of the performance measures, hospitals that treated relatively few pneumonia patients “low-volume hospitals “did just as well as their high-volume counterparts. Even more surprisingly, researchers found that low-volume hospitals and physicians outperformed their higher-volume counterparts on a handful of measures.
Physicians who care for high volumes of pneumonia patients, for example, were about 40 percent less likely than their lower-volume colleagues to give vaccines for the flu and pneumonia to pneumonia patients. And hospitals that treat large numbers of pneumonia patients were less likely to administer antibiotics within four hours.
Bucking the conventional wisdom
The results came as a surprise in part because a number of previous studies have found a positive relationship between volume and performance in areas like surgery. It seemed reasonable, therefore, to expect to find similar outcomes in an area like pneumonia.
“Our findings are a bit provocative because they challenge the notion that doing more of something necessarily leads to better outcomes,” says Peter K. Lindenauer, MD, MSc, the study’s lead author and a longtime hospitalist who works in the division of health care quality at Baystate Medical Center in Springfield, Mass. “It surprised me that the higher-volume physicians neither performed better on the process-of-care measures nor achieved superior outcomes than the doctors who took care of just a few pneumonia patients each year.”
In the Annals article, Dr. Lindenauer and his co-investigators offer several hypotheses to help explain why high-volume physicians and hospitals didn’t provide better care for pneumonia patients. One is the notion that pneumonia is so common ” and its management is so relatively straightforward “that treating more cases of the disease doesn’t necessarily give physicians or hospitals any expertise or advantage.
“Perhaps pneumonia care is so straightforward that even physicians who care for only one or two cases per year can be as proficient as those who care for 30 cases each year,” Dr. Lindenauer says.
He is quick to point out, however, that some of the data his study collected don’t support that view, particularly when you consider that overall scores on the performance measures were mediocre at best.
“None of the groups performed superbly on all of the measures,” Dr. Lindenauer notes. “There continue to be many opportunities for improvement.”
The QI effect
There is another factor that may explain the lackluster performance of high-volume hospitals and physicians: the prevalence of quality improvement initiatives focusing on pneumonia care. Dr. Lindenauer says that the multitude of interventions focusing on pneumonia care “everything from practice guidelines to order sets, from alerts and reminders to case managers “may be leveling the playing field between high-volume and low-volume hospitals.
“I suspect that these interventions may mitigate any natural volume-quality relationships,” he explains. “When you think about a condition like pneumonia, it seems reasonable to believe that low-volume physicians will benefit greatly from the use of standardized order sets and the implementation of hospital-wide systems intended to improve care.”
And while many people may think that bigger is better when it comes to hospitals, Dr. Lindenauer says that large hospitals may actually have a disadvantage when it comes to tasks that involve speed. The long waits that are typical at large emergency rooms, he explains, can make it difficult to identify pneumonia patients quickly enough to deliver a vaccination within four hours.
The message for hospitalists
The study’s results raise interesting questions not only about the relationship between patient volume and performance, but about the role of hospitalists in improving quality of care for common conditions like pneumonia.
Because the data showed that for pneumonia, at least, experienced attending physicians brought no advantage to the table, what does that say about hospitalists’ ability to improve care? Dr. Lindenauer says that it would be overreaching to conclude that the added experience hospitalists bring to common medical conditions does not help improve quality.
It’s possible, he adds, that hospitalists could have an edge with more complicated cases of pneumonia. They might also improve care in treating conditions like stroke, COPD and pancreatitis that have not been the subject of national quality improvement initiatives.
“You might really need to look at the more complicated cases that hospitalists take care of before you see any relationship between volume and quality emerge,” he explains. Dr. Lindenauer also says his study’s data point to opportunities for hospitalists, particularly those working in large institutions, to improve patient care.
“Familiarize yourself with your hospital’s performance and work with the leaders of the emergency department to identify strategies,” he says. “Try to reach a goal of the early identification of patients who may have pneumonia to accelerate their work-up and initiation of therapy.”
“We know how much more challenging it is to influence and change behavior in large hospitals as compared to small hospitals,” Dr. Lindenauer explains. “It’s often said that implementing change in large, complex environments is hard. I think that our data lend some added credence to that idea.”
Edward Doyle is Editor of Today’s Hospitalist.