Association of hospital volume with readmission rates: a retrospective cross-sectional studyBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h447 (Published 09 February 2015) Cite this as: BMJ 2015;350:h447
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This study provides useful insight and overall perspective on the correlation between hospital volume and delivery outcomes. We appreciate the size and breadth of the study population, which few published studies have been able to match.[1–5] Despite the dataset originating from America, the results of this study are likely still appropriate to the UK.
Such large-scale studies are relevant to hospital administrators and healthcare policymakers focused on improving the patient care. 30-day emergency readmission rates are currently part of Domain 3 - Helping people to recover from episodes of ill health or following injury of the NHS Outcomes Framework, and mortality in NHS trusts is tracked using the Summary Hospital-level Mortality Indicator (SHMI). They are but a fraction of the many indicators collected by the Health and Social Care Information Centre for accountability and improvement.
The positive association between overall hospital-wide mean standardized readmission rates and hospital volume is not surprising and the same association was identified for all specialty cohorts that are less procedure-dependent. While these findings suggest that the pressures of high patient-turnover lead to poorer supportive peri-discharge care and hence increased readmissions, it is more pertinent to consider what can be done to mitigate this adverse effect against a backdrop of rising healthcare demand in the UK.
Even as we medical professionals consistently bemoan the undercapacity and shrinking bed space within the NHS, each of us should more readily assume the responsibility of improving our health services from the ground up. The utility of grassroots quality improvement projects can unfortunately be limited by the capabilities of staff on the ground in proposing, designing and implementing entire change processes and existing frameworks should be continually reviewed, simplified and made more robust to encourage such commendable initiatives. There should also be a focus on fostering innovation within the NHS for staff as early as possible in their respective training pathways. The devolvement of power to the individual change agent is likely to result in superior healthcare outcomes.
Currently, the NHS is certainly taking the right steps by seeking fully interoperable electronic health records to facilitate care transitions. Such critical nation-wide infrastructure, and the resultant productivity improvements, are not bonuses but key necessities in improving long-term mortality, readmission rates, health outcomes and care delivery. If implemented correctly, such unprecedented nation-wide data perspectives will provide both the breadth and granularity that our £100 billion-a-year national business needs.
It is only through emergent leadership from healthcare professionals at every level, in lockstep with consistent, long-term political will that the NHS will be able to deal with the challenges of greater case loads and thrive in the evermore challenging future.
1 Burns EM, Bottle a., Aylin P, et al. Volume analysis of outcome following restorative proctocolectomy. Br J Surg 2011;98:408–17. doi:10.1002/bjs.7312
2 Burns EM, Bottle A, Almoudaris AM, et al. Hierarchical multilevel analysis of increased caseload volume and postoperative outcome after elective colorectal surgery. Br J Surg 2013;100:1531–8. doi:10.1002/bjs.9264
3 Joynt KE, Orav EJ, Jha AK. Physician volume, specialty, and outcomes of care for patients with heart failure. Circ Heart Fail 2013;6:890–7. doi:10.1161/CIRCHEARTFAILURE.112.000064
4 Pamilo KJ, Peltola M, Mäkelä K, et al. Is hospital volume associated with length of stay, re admissions and reoperations for total hip replacement? A population based register analysis of 78 hospitals and 54,505 replacements. Arch Orthop Trauma Surg 2013;133:1747–55. doi:10.1007/s00402-013-1860-0
5 Tsai TC, Joynt KE, Orav EJ, et al. Variation in surgical-readmission rates and quality of hospital care. N Engl J Med 2013;369:1134–42. doi:10.1056/NEJMsa1303118
6 Department of Health. The NHS Outcomes Framework 2014/15. 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
7 Clinical Indicators Team. Summary Hospital-level Mortality Indicator (SHMI) – Hospital Episode Statistics (HES) SHMI Data Guidance. Leeds: 2014. http://www.hscic.gov.uk/media/16111/HESSHMI-Data-Guidance/pdf/HES_SHMI_D... (accessed 10 Feb2015).
8 Horwitz LI, Lin Z, Herrin J, et al. Association of hospital volume with readmission rates: a retrospective cross-sectional study. Bmj 2015;350. doi:10.1136/bmj.h447
9 Committee on Public Service and Demographic Change. Ready for Ageing? 2013. http://www.publications.parliament.uk/pa/ld201213/ldselect/ldpublic/140/... (accessed 15 Feb2015).
10 The King’s Fund. The future of leadership and management in the nhs: No more heroes. London Kings Fund 2011;:38.http://www.kingsfund.org.uk/publications/nhs_leadership.html\nhttp://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:The+future...
11 NHS England. Five year forward view. 2014. http://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
12 PricewaterhouseCoopers LLP. A review of the potential benefits from the better use of information and technology in Health and Social Care Final report. 2013. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
Competing interests: No competing interests