title: Association of hospital volume with readmission rates: a retrospective cross-sectional study.
abstract: OBJECTIVE
  To examine the association of hospital volume (a marker of quality of care) with hospital readmission rates.
  
  
  METHODS
  Retrospective cross-sectional study.
  
  
  METHODS
  4651 US acute care hospitals.
  6,916,644 adult discharges, excluding patients receiving psychiatric or medical cancer treatment.
  
  
  METHODS
  We used Medicare fee-for-service data from 1 July 2011 to 30 June 2012 to calculate observed-to-expected, unplanned, 30 day, standardized readmission rates for hospitals and for specialty cohorts medicine, surgery/gynecology, cardiorespiratory, cardiovascular, and neurology. We assessed the association of hospital volume by quintiles with 30 day, standardized readmission rates, with and without adjustment for hospital characteristics (safety net status, teaching status, geographic region, urban/rural status, nurse to bed ratio, ownership, and cardiac procedure capability. We also examined associations with the composite outcome of 30 day, standardized readmission or mortality rates.
  
  
  RESULTS
  Mean 30 day, standardized readmission rate among the fifth of hospitals with the lowest volume was 14.7 (standard deviation 5.3) compared with 15.9 (1.7) among the fifth of hospitals with the highest volume (P<0.001). We observed the same pattern of lower readmission rates in the lowest versus highest volume hospitals in the specialty cohorts for medicine (16.6 v 17.4, P<0.001), cardiorespiratory (18.5 v 20.5, P<0.001), and neurology (13.2 v 14.0, p=0.01) cohorts; the cardiovascular cohort, however, had an inverse association (14.6 v 13.7, P<0.001). These associations remained after adjustment for hospital characteristics except in the cardiovascular cohort, which became non-significant, and the surgery/gynecology cohort, in which the lowest volume fifth of hospitals had significantly higher standardized readmission rates than the highest volume fifth (difference 0.63 percentage points (95% confidence interval 0.10 to 1.17), P=0.02). Mean 30 day, standardized mortality or readmission rate was not significantly different between highest and lowest volume fifths (20.4 v 20.2, P=0.19) and was highest in the middle fifth of hospitals (range 20.6-20.8).
  
  
  CONCLUSIONS
  Standardized readmission rates are lowest in the lowest volume hospitals-opposite from the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics and was only partially attenuated by examining mortality and readmission together. Our findings suggest that readmissions are associated with different aspects of care than mortality or complications.
authors: Division of Healthcare Delivery Science, Department of Population Health, New York University Langone Medical Center, New York, NY, USA Center for Healthcare Innovation and Delivery Science, New York University School of Medicine, New York leora.horwitz@nyumc.org.
authors: Leora I
authors: LI
authors: Horwitz
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA.
authors: Zhenqiu
authors: Z
authors: Lin
authors: Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven Health Research and Educational Trust, Chicago IL, USA.
authors: Jeph
authors: J
authors: Herrin
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven.
authors: Susannah
authors: S
authors: Bernheim
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA Department of Pediatrics, Yale School of Medicine, New Haven.
authors: Elizabeth E
authors: EE
authors: Drye
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven Section of Health Policy and Administration, Yale School of Epidemiology and Public Health, New Haven.
authors: Harlan M
authors: HM
authors: Krumholz
authors: Harold J
authors: HJ
authors: Hines
authors: Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA Section of General Internal Medicine, Department of Medicine, Yale School of Medicine, New Haven Section of Health Policy and Administration, Yale School of Epidemiology and Public Health, New Haven.
authors: Joseph S
authors: JS
authors: Ross
mesh_terms: D000368:Aged; D003430:Cross-Sectional Studies; D061847:Hospitals, High-Volume / Q000706:statistics & numerical data*; D061846:Hospitals, Low-Volume / Q000706:statistics & numerical data*; D006801:Humans; D010359:Patient Readmission / Q000706:statistics & numerical data*; D012189:Retrospective Studies