Physician volume, specialty, and outcomes of care for patients with heart failure.
BACKGROUND
There is an urgent need to improve outcomes and reduce costs for patients with heart failure (HF). Physician volume is associated with better outcomes for patients undergoing procedures, but its association with outcomes for medically managed diseases, such as HF, is not well understood.


RESULTS
We used Medicare inpatient data in 2009 to examine all HF admissions to acute care hospitals in the United States. We divided physicians into quintiles according to their volume of patients with HF. We used patient-level regression to compare 30-day risk-adjusted mortality, readmissions, and costs across volume groups, controlling for patient, physician, and hospital characteristics. We examined physician volume within strata of hospital volume and physician specialty. Patients cared for by the high-volume physicians had lower mortality than those by the low-volume physicians (8.9% versus 9.7%; P<0.001); this relationship was strongest in low-volume hospitals. In contrast, patients cared for by high-volume physicians had higher readmission rates (25.8% versus 21.5%; P<0001); this relationship was similar across hospital volume groups. Finally, costs were higher for the high-volume physicians ($8982 versus $8731; P=0.002, a difference that was consistent across hospital volume groups). The relationship between physician volume and mortality was strongest for internists (9.2% versus 10.6%; P<0.001) and weakest for cardiologists (6.4% versus 6.7%; P=0.485).


CONCLUSIONS
Physician volume is associated with lower mortality for HF, particularly in low-volume institutions and among noncardiologist physicians. Our findings suggest that clinician expertise may play an important role in HF care.
Department of Health Policy and Management and Department of Biostatistics, Harvard School of Public Health, Boston, MA; Cardiovascular Division and Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; and VA Boston Healthcare System, Boston, MA.
Karen E
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Ashish K
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D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D006302:Health Services Research; D006333:Heart Failure / Q000175:diagnosis / Q000191:economics / Q000401:mortality / Q000628:therapy*; D017721:Hospital Costs; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data; D061846:Hospitals, Low-Volume / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare; D008511:Medicine / Q000706:statistics & numerical data; D010043:Outcome and Process Assessment, Health Care / Q000191:economics / Q000706:statistics & numerical data; D010359:Patient Readmission; D010820:Physicians / Q000191:economics / Q000706:statistics & numerical data; D019984:Quality Indicators, Health Care / Q000191:economics / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014481:United States
health care costs; heart failure; patient readmission; quality of health care