{"id":39045,"date":"2013-09-27T09:00:34","date_gmt":"2013-09-27T13:00:34","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=39045"},"modified":"2013-09-24T16:29:00","modified_gmt":"2013-09-24T20:29:00","slug":"higher-physician-volume-leads-to-lower-mortality-in-heart-failure","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/09\/27\/higher-physician-volume-leads-to-lower-mortality-in-heart-failure\/","title":{"rendered":"Higher Physician Volume Leads to Lower Mortality in HF"},"content":{"rendered":"

CardioExchange\u2019s Editor-in-Chief, Harlan Krumholz<\/strong>, interviewed lead author Karen Joynt<\/strong> about her <\/em>Circulation: Heart Failure<\/a> study<\/a>, which examined the relationship between physician volume, clinical outcomes, and costs among patients with heart failure (HF). The researchers found that high physician volume was associated with lower mortality, and that the association was particularly strong in lower-volume hospitals and among noncardiologist physicians.<\/em><\/p>\n

Krumholz:<\/em> You showed that physician volume is associated with lower mortality for HF, especially in low-volume institutions. Given that most patients see many doctors, how did you determine the volume of patients for each doctor?<\/strong><\/p>\n

Joynt:<\/strong><\/em> For this study, we only looked at the attending of record for each patient. If the attending of record was a physician that saw only two Medicare HF patients in 2009, then the patient was classified into the \u201clow-volume\u201d group. We didn\u2019t evaluate whether or not there were additional physicians consulting on that patient\u2019s care.<\/p>\n

Krumholz: Are you confident that you were able to control for differences in the types of patients that seen by high- and low-volume doctors?<\/em><\/strong><\/p>\n

Joynt:<\/strong><\/em> Controlling for differences in patient factors is always tricky when using administrative data, because we just don\u2019t have clinical variables like ejection fraction or creatinine that would let us precisely estimate each patient\u2019s risk. We think the models, particularly for mortality, are reasonably good, but they are certainly not perfect. Intuitively, it seems likely that high-volume physicians see the sickest patients \u2013 people refer the most challenging patients to the \u201cexperts\u201d rather than the other way around, so if anything this would have biased us against finding a relationship, but it\u2019s hard to know for sure.<\/p>\n

Krumholz: Why do you think that the relationship was stronger in low-volume institutions?<\/strong><\/em><\/p>\n

Joynt:<\/strong> <\/em>I suspect that the volume-outcome relationship was strongest in low-volume institutions because the care of an HF patient depends not only on the physician, but on the whole team. The nurses, physical therapists, nutritionists, and social workers play an absolutely critical role in HF patients\u2019 hospitalizations. A low-volume institution may have fewer systems in place, or less-uniform care, and the effect of a physician\u2019s experience may carry more weight. At a high-volume institution, there are a lot more people who have a great deal of expertise in caring for HF patients, so even if you have a relatively low-volume physician, you still have a lot of collective experience surrounding that patient. Additionally, centers that have a lot of HF patients are more likely to have care protocols, discharge protocols, etc., that may improve outcomes even independent of the clinicians involved in the patients\u2019 care \u2013 the \u201csystems\u201d effect.<\/p>\n

Krumholz: Is there a message here for patients?<\/strong><\/em><\/p>\n

Joynt:<\/em> <\/strong>The main take-away for patients is that both physician and hospital volume matter. If you have HF, it may be worth it to seek out a clinician who treats a lot of HF patients, or perhaps a center that treats a lot of HF patients. It\u2019s also worth stating that it\u2019s not realistic for all patients to see high-volume HF doctors in person if they happen to live someplace that is geographically isolated \u2013 but it doesn\u2019t mean they shouldn\u2019t have access to experienced specialists. We need to do a better job of developing partnerships and technologies that allow for things like telemedicine, or remote consultation, to bring the experts to the patients rather than the other way around.<\/p>\n

<\/p>\n","protected":false},"excerpt":{"rendered":"

Karen Joynt discusses her research group’s study of the relationship between physician volume, clinical outcomes, and costs among patients with HF.<\/p>\n","protected":false},"author":829,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,14],"tags":[287,1995,801,1994],"class_list":["post-39045","post","type-post","status-publish","format-standard","hentry","category-general","category-heart-failure","tag-heart-failure-2","tag-hospital-volume","tag-mortality","tag-physician-volume"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/39045","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/829"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=39045"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/39045\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=39045"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=39045"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=39045"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}