Beyond Volume: Hospital-Based Healthcare Technology for Better Outcomes in Cerebrovascular Surgical Patients Diagnosed With Ischemic Stroke A Population-Based Nationwide Cohort Study From 2002 to 2013 Jae-Hyun Kim, PhD, Eun-Cheol Park, MD, PhD, Sang Gyu Lee, MD, MBA, PhD, Tae-Hyun Lee, PhD, and Sung-In Jang, MD, PhD Abstract: We examined whether the level of hospital-based healthcare technology was related to the 30-day postoperative mortality rates, after adjusting for hospital volume, of ischemic stroke patients who under- went a cerebrovascular surgical procedure. Using the National Health Insurance Service-Cohort Sample Data- base, we reviewed records from 2002 to 2013 for data on patients with ischemic stroke who underwent cerebrovascular surgical procedures. Statistical analysis was performed using Cox proportional hazard models to test our hypothesis. A total of 798 subjects were included in our study. After adjusting for hospital volume of cerebrovascular surgical procedures as well as all for other potential confounders, the hazard ratio (HR) of 30-day mortality in low healthcare technology hospitals as compared to high healthcare technology hospitals was 2.583 (P < 0.001). We also found that, although the HR of 30-day mortality in low healthcare technology hospitals with high volume as compared to high healthcare technology hospitals with high volume was the highest (10.014, P < 0.0001), cerebrovascular surgical procedure patients treated in low healthcare technology hospitals had the highest 30-day mortality rate, irrespective of hospital volume. Although results of our study provide scientific evidence for a hospital volume/30-day mortality rate relationship in ischemic stroke patients who underwent cerebrovascular surgical procedures, our results also suggest that the level of hospital-based healthcare technology is associated with mortality rates independent of hospital volume. Given these results, further research into what components of hospital-based healthcare technology significantly impact mortality is warranted. (Medicine 95(11):e3035) Abbreviations: HR = Hazard Ratio, ICD-10 = International Classification of Diseases, 10th Revision, IRB = Institutional Review Board, MRIm = agnetic resonance imaging, NHIS-CSD = National Health Insurance Service-Cohort Sample Data, PCCLp = atient clinical complexity level. INTRODUCTION C erebrovascular disease is a major cause of disability and death and is high-risk, requiring safe practices and advanced medical techniques for diagnosis and treatment. Accurate assessment of hospital performance for surgical pro- cedures has become increasingly important since the imple- mentation of pay-for-performance programs designed to link payments to clinical outcomes and public reporting of assessment results. 1,2 Thus, the success of quality improvement programs, such as pay-for-performance programs, in improving surgical outcomes is based on accurate performance assessments and the ability to identify truly high-performing hospitals. One of the most simple and easily available performance measures in surgery is the surgical procedure volume of a hospital based on the intuitively attractive ‘‘more is better’’ concept. Considerable evidence exists that higher hospital surgical volume is associated with improved clinical outcomes such as operative mortality, 3 length of stay, cost, 4 and survival. 3 Despite these observations, since the majority of peer- reviewed literature is primarily aimed at determining the pre- sence of the volume–outcome relationships for various pro- cedures, the true mechanism of the volume–outcome association remains in dispute. For example, the magnitude of the volume–outcome relationship varies according to the technical difficulty of the surgery and the availability of specific healthcare technology. 5 Evidence from qualitative studies 6 suggests that hospital volume reflects hospital characteristics, such as technical capabilities, personalities of the physicians or staff, culture, leadership, structure, strategy, information, com- munication pathways, skills training, and physician engage- ment. These contributors to hospital volume may partially explain the relationship between volume and outcomes. How- ever, they do not fully reveal what volume is a proxy for. It is also possible that, as prior evidence 7 has demonstrated, high healthcare technology is associated with lower mortality rates and the improved outcomes are derived from the range of critical care and treatment services offered in high healthcare technology hospitals. Characteristics of high healthcare technology hospitals may also include availability of new tech- nologies, highly equipped operating rooms, better management Editor: Kevin Harris. Received: November 23, 2015; revised: February 10, 2016; accepted: February 11, 2016. From the Department of Preventive Medicine and Public Health (J-HK), Ajou University School of Medicine, Suwon; Institute of Health Services Research (J-HK, E-CP, SGL, T-HL, S-IJ), Department of Public Health (S-IJ), Graduate School, and Department of Hospital Management (SGL, T-HL), Graduate School of Public Health, Yonsei University; Department of Preventive Medicine (E-CP), Yonsei University College of Medicine, Seoul, Republic of Korea. Correspondence: Sung-In Jang, Department of Preventive Medicine and Institute of Health Services Research, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea (e-mail: jangsi@yuhs.ac). All authors contributed to designing the study and editing the manuscript. J-HK, SGL, T-HL, E-CP, and S-IJ collected, analyzed, and interpreted the data and write the manuscript. The authors have no funding and conflicts of interest to disclose. Copyright # 2016 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000003035 Medicine ® OBSERVATIONAL STUDY Medicine  Volume 95, Number 11, March 2016 www.md-journal.com | 1