Hospital experience and outcomes for esophageal variceal bleeding

Objective. Although higher hospital volume has been associated with better outcomes for many surgical procedures, this relationship does not appear to hold for most common medical diagnoses. We evaluated whether there is a volume-outcome relationship for a rarer and higher-mortality medical diagnosis, esophageal variceal bleeding. Design. Cross-sectional retrospective study of hospital discharge data. Setting. All Maryland hospitals from 1992 through 1996. Study participants. All patients with diagnosis codes for both esophageal variceal bleeding and cirrhosis in relevant diagnosis-related groups. Main outcome measure. Mortality for esophageal variceal bleeding. We classified hospitals by tertiles of admissions as high (>17 cases of variceal bleeding per year), medium (12-17 cases per year) or low (<12 cases per year) volume. Results. There were seven high-volume, 13 medium-volume, and 29 low-volume hospitals. Overall in-hospital mortality was 15%. After multiple regression was used to adjust for differences in age, sex, ethnicity, emergency room admission, use of procedures, complexity, Medicaid status, transfer status, and clinical variables associated with mortality from variceal bleeding, there were no significant differences between the high-, medium-, and low-volume hospital groups in in-hospital mortality (16%, 15%, and 13%, respectively). There were also no significant differences in hospital charges ($17 000, $15 000, and $14 000, respectively) or length of stay (8.5, 8.7, and 7.8 days, respectively) between hospital volume groups. Conclusions. The volume-outcome relationship may not pertain to some medical diseases such as esophageal variceal bleeding. Alternatively, the biases inherent in research using administrative data may make this relationship appear weaker for some medical than for surgical diagnoses in this type of study.