Higher hospital volume predicts endoscopy but not the in-hospital mortality rate in patients with acute variceal hemorrhage

BackgroundAcute variceal hemorrhage (AVH) is an important complication of cirrhosis that carries a high mortality rate. Management of AVH requires early initiation of specialized care that may be more readily available at centers that deal with a high volume of AVH.ObjectiveOur purpose was to examine the relationship between the annual hospitalization volume and the in-hospital mortality rate for AVH.DesignCross-sectional study from a national representative sample.SettingA 20% sample of all nonfederal short-term hospitals from 37 states participating in the Nationwide Inpatient Sample 2004.PatientsA total of 28,817 discharges with AVH identified through appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes for bleeding esophageal varices. Hospitals were divided into low-, medium-, and high-volume hospitals if they had 1 to 15, 16 to 35, and 36 or more annual discharges related to AVH.Main Outcome MeasurementIn-hospital mortality rate.ResultsOn multivariate analysis, there was no significant difference in the mortality rate either for medium- (odds ratio [OR] 0.84; 95% CI, 0.67-1.05) or high-volume hospitals (OR 1.06; 95% CI, 0.82-1.37). However, patients both at medium- (OR 1.27; 95% CI, 1.02-1.58) and high-volume hospitals (OR 1.40; 95% CI, 1.07-1.84) were more likely to undergo endoscopy for AVH. Endoscopic intervention for control of variceal hemorrhage was significantly more common in medium- (OR 1.20) and high- (OR 1.33) volume hospitals. Patients at medium- (OR 3.10; 95% CI, 2.09-4.60) and high-volume hospitals (OR 4.12; 95% CI, 2.52-6.75) were also more likely to undergo transjugular intrahepatic portosystemic shunt (TIPS).ConclusionHigher hospital volume is associated with greater rates of endoscopy, endoscopic intervention, and higher utilization of TIPS in the management of AVH.