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J Intensive Care. 2019 Jan 30;7:7. doi: 10.1186/s40560-019-0363-7. eCollection 2019.

Volume-outcome relationship on survival and cost benefits in severe burn injury: a retrospective analysis of a Japanese nationwide administrative database.

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1Trauma and Acute Critical Care Medical Center, Hospital of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510 Japan.
2Emergency and Trauma Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba Japan.
3Department of Health Policy and Informatics, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan.
The Shock Trauma and Emergency Medical Center, Matsudo City General Hospital, 933-1 Sendabori,, Matsudo, Chiba Japan.



Although it has been reported that high hospital patient volume results in survival and cost benefits for several diseases, it is uncertain whether this association is applicable in burn care.


We conducted a retrospective observational study on severe burn patients, defined by a burn index ≥ 10, using 2010-2015 data from a Japanese national administrative claim database. A generalized additive mixed-effect model (GAMM) was used to evaluate the nonlinear associations between patient volume and the outcomes (in-hospital mortality, healthcare costs per admission, and hospital-free days at 90 days). Generalized linear mixed-effect regression models (GLMMs) in which patient volume was incorporated as a continuous or categorical variable (≤ 5 or > 5) were also performed. Patient severity was adjusted using the prognostic burn index (PBI) or the risk adjustment model developed in this study, simultaneously controlling for hospital-level clustering. Sensitivity analyses evaluating patients who were directly transported, those with PBI ≤ 120 and those excluding patients who died within 2 days of admission, were also performed.


We analyzed 5250 eligible severe burn patients from 737 hospitals. The PBI and the developed risk adjustment model had good discriminative ability with areas under the receiver operating characteristic curves of 0.86 and 0.89, respectively. The GAMM plots showed that in-hospital mortality and healthcare costs increased according to the increase in patient volumes; then, they reached a plateau. Fewer hospital-free days were observed in the higher volume hospitals. The GLMM model showed that patient volume (incorporated as a continuous variable) was significantly associated with increased in-hospital mortality (adjusted odds ratio [95% confidence interval (CI)] = 1.14 [1.09-1.19]), high healthcare costs (adjusted difference [95% CI] = $4876 [4436-5316]), and few hospital-free days (adjusted difference [95% CI] = - 3.1 days [- 3.4 to - 2.8]). Similar trends were observed in the analyses in which patient volume was incorporated as a categorical variable. The results of sensitivity analyses showed comparable results.


Analysis of Japanese nationwide administrative database demonstrated that high burn patient volume was significantly associated with increased in-hospital mortality, high healthcare costs, and few hospital-free days. Further studies are needed to validate our results.


Costs and cost analysis; Hospital volume; Mortality; Wounds and injuries

Conflict of interest statement

The institutional review board of the Tokyo Medical and Dental University approved this study (#788). Informed consent from each patient was waived because of the retrospective design of the study and the use of anonymized patient and hospital data.Not applicableThe authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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