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Original Investigation |

Association of High-Volume Hospitals With Greater Likelihood of Discharge to Home Following Colorectal Surgery

Courtney J. Balentine, MD1,2,3; Aanand D. Naik, MD1,4,5; Celia N. Robinson, MD2; Nancy J. Petersen, PhD1; G. John Chen, PhD1,4; David H. Berger, MD, MHCM1,2,3; Daniel A. Anaya, MD1,2,3
[+] Author Affiliations
1Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Excellence, Houston, Texas
2Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
3Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
4Division of Geriatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas
5Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, Texas
JAMA Surg. 2014;149(3):244-251. doi:10.1001/jamasurg.2013.3838.
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Importance  Discharge disposition is a patient-centered quality metric that reflects differences in quality of life and recovery following surgery. The effect of hospital volume on quality of recovery measured by rates of successful discharge to home remains unclear.

Objective  To test the hypothesis that patients having colorectal surgery at high-volume hospitals would more likely be discharged to home rather than discharged to skilled rehabilitation facilities to complete recovery.

Design, Setting, and Participants  Longitudinal analysis of 2008 hospital inpatient data to identify patients undergoing colorectal surgery who survived to discharge. The setting was the Nationwide Inpatient Sample, the largest all-payer inpatient care database, containing data from more than 1000 hospitals. Participants were 280 644 patients (≥18 years) who underwent colorectal resections for benign or malignant disease and survived to discharge.

Main Outcomes and Measures  The primary end point was discharge to home (with or without home health care) vs discharge to skilled facilities (skilled nursing, short-term recovery, or rehabilitation hospitals or other institutions). The secondary end point was discharge to home with home health care rather than to a skilled facility for patients with postdischarge care needs. Multiple logistic regression using robust standard errors was used to compute the odds ratios of each outcome based on hospital volume, while adjusting for other important variables.

Results  The odds of discharge to home vs discharge to skilled facilities were significantly greater in high-volume hospitals compared with low-volume hospitals (odds ratio, 2.09; 95% CI, 1.70-2.56), with an absolute increase of 9%. For patients with postdischarge care needs, high-volume hospitals were less likely than low-volume hospitals to use skilled facilities rather than home health care (odds ratio, 0.35; 95% CI, 0.27-0.45), with an absolute difference of 10%.

Conclusions and Relevance  Patients having colorectal surgery at high-volume hospitals are significantly more likely to recover and return home after surgery than individuals having operations at low-volume hospitals. This study is the first step in a process of identifying which features of high-volume hospitals contribute toward desirable outcomes. Efforts to identify the reasons for improved recovery at high-volume hospitals can help lower-volume hospitals adopt beneficial practices.

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Figure 1.
Patients Having Colorectal Surgery at High-Volume Hospitals Compared With Low-Volume Hospitals Are More Likely to Be Discharged to Home Rather Than to a Skilled Facility

A, All patients. B, Patients having any postoperative complication. C, Patients having multiple postoperative complications.

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Figure 2.
Patients Having Colorectal Surgery at High-Volume Hospitals Compared With Low-Volume Hospitals Are Discharged to Home Without Home Health Care at Similar Rates, but the Use of Home Health Care vs Discharge to Skilled Facilities Differs According to Hospital Volume

A, All patients. B, Patients having any postoperative complication. C, Patients having multiple postoperative complications.

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Figure 3.
Odds of Discharge to Home (With or Without Home Health Care) vs Discharge to Skilled Facilities Were Increased at High-Volume Hospitals Relative to Low-Volume Hospitals After Risk Adjustment

Adjusted for age, sex, race/ethnicity, comorbidities, income, cancer vs benign disease, ostomy creation, admission type (elective vs urgent or emergent), teaching vs nonteaching hospital, and urban vs rural location. Limit lines indicate the 95% CI.

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Figure 4.
Among Patients Who Require Continuing Care After Discharge, High-Volume Hospitals Are More Likely Than Low-Volume Hospitals to Use Home Health Care Rather Than Discharge to Skilled Facilities After Risk Adjustment

Adjusted for age, sex, race/ethnicity, comorbidities, income, cancer vs benign disease, ostomy creation, admission type (elective vs urgent or emergent), teaching vs nonteaching hospital, and urban vs rural location. Limit lines indicate the 95% CI.

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