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Arch Intern Med. 2010 Jul 26;170(14):1202-8. doi: 10.1001/archinternmed.2010.237.

Case volume, quality of care, and care efficiency in coronary artery bypass surgery.

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  • 1Department of Medicine Hospitalist Group, University of California-San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0131, USA.



How case volume and quality of care relate to hospital costs or length of stay (LOS) are important questions as we seek to improve the value of health care.


We conducted an observational study of patients 18 years or older who underwent coronary artery bypass grafting surgery in a network of US hospitals. Case volumes were estimated using our data set. Quality was assessed by whether recommended medications and services were not received in ideal patients, as well as the overall number of measures missed. We used multivariable hierarchical models to estimate the effects of case volume and quality on hospital cost and LOS.


The majority of hospitals (51%) and physicians (78%) were lowest-volume providers, and only 18% of patients received all quality of care measures. Median LOS was 7 days (interquartile range [IQR], 6-11 days), and median costs were $25 140 (IQR, $19 677-$33 121). In analyses adjusted for patient and site characteristics, lowest-volume hospitals had 19.8% higher costs (95% CI, 3.9%-38.0% higher); adjusting for care quality did not eliminate differences in costs. Low surgeon volume was also associated with higher costs, though less strongly (3.1% higher costs [95% CI, 0.6%-5.6% higher]). Individual quality measures had inconsistent associations with costs or LOS, but patients who had no quality measures missed had much shorter LOS and lower costs than those who missed even one.


Avoiding lowest-volume hospitals and maximizing quality are separate approaches to improving health care efficiency through reducing costs of coronary bypass surgery.

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