The more hospitals spend, the lower are death rates and readmissions

A study published in the March 14 issue of JAMA , reveals that patients of hospitals in Ontario, Canada, have better quality of care, lower rates of death and readmissions if they receive treatment in hospitals that spend more on procedures, higher intensity nursing and greater use of specialists. Although studies have examined if greater health care spending results in higher quality of care and improved patient outcomes, evidence in the U.S., as well as other nations, has been conflicting. According to the researchers: "The extent to which better spending produces higher-quality care and better patient outcomes in a universal health care system with selective access to medical technology in unknown." Therese A. Stukel, Ph.D., of the Institute for Clinical Evaluative Sciences, Toronto, and her team conducted a study in order to analyze if acute care patients admitted to higher-spending hospitals in Canada, had higher quality of care, and lower readmissions and mortality. All of the patients examined in the study were aged 18 years or older and hospitalized in Ontario, Canada, between 1998 and 2008. Patients received follow-up to one year. The researchers examined: 179,139 patients with a first admission for acute myocardial infarction (AMI; heart attack) 26,195 patients with colon cancer 92,377 patients with congestive heart failure (CHF) 90,046 patients with hip fracture The spending intensity index of a hospital was also the end-of-life expenditure index. It was calculated as the adjusted hospital's average spending, including the hospital's emergency department (ED) and the service physicians provided to the deceased during their last year of life. The findings revealed that amongst all hospitals, the adjusted spending intensity varied by almost double, with acute care expenditure index ranging from U.S. $19,281 - $32,548 per patient per year and end-of-life expenditure index varying from $21,978 - $44,955 per patient per year. The team found that higher-spending hospitals were usually: community or higher-volume teaching hospitals have specialized services be located in urban areas be linked to regional cancer centers Furthermore, results showed that attending physicians in higher-spending hospitals tended to be specialists or cared for a higher number of patients with that condition. Patients admitted to these hospitals had more medical specialist visits during the index episode, were not as likely to be admitted to an intensive care unit, and were hospitalized longer, while cardiac patients were more likely to receive evidence-based discharge medications and cardiac interventions. For higher-spending hospitals, the age- and sex-adjusted 30-day mortality rate was 12.7% for AMI compared with 12.8% for lowest-spending hospitals, 3.3% for colon cancer compared with 3.9%, 10.2% for CHF vs. 12.4%, and 7.7% for hip fracture vs. 9.7%. The researchers said: "The age- and sex-adjusted 30-day major cardiac event rate was 17.4 percent vs. 18.7 percent for patients with AMI and 15.0 percent vs. 17.6 percent for those with CHF. The age- and sex-adjusted 30-day readmission rate was 23.1 percent vs. 25.8 percent for patients with hip fracture and 10.3 percent vs. 13.1 percent for those with colon cancer. In higher-spending hospitals, age- and sex-adjusted mortality and readmission rates were lower for all cohorts." The team found that results for 1-year readmission, mortality, and major cardiac events were comparable. They write: "Higher-spending hospitals had higher nursing staff ratios, and their patients received more inpatient medical specialist visits, interventional (AMI cohort) and medical (AMI and CHF cohorts) cardiac therapies, preoperative specialty care (colon cancer cohort), and post-discharge collaborative care with a cardiologist and primary care physician (AMI and CHF cohorts)." The researchers highlight that the U.S. has a 3-4 times greater per patient supply of specialized technology, such as magnetic resonance imaging scanners and computed tomography, although they have a similar supply of acute care beds and nurses. They explain: "Ontario 2001 population rates of cardiac testing and revascularization lagged behind corresponding 1992 U.S. rates and paralleled the supply of cardiologists and catheterization facilities. It is therefore possible that Canadian hospitals, with fewer specialized resources, selective access to medical technology, and global budgets, are using these resources more efficiently, especially during the inpatient episode for care-sensitive conditions. Canada's health care expenditures per capita are about 57 percent of those in the United States. At this spending level, there might still be a positive association between spending and outcomes." They conclude: "These results suggest that it is critical to understand not simply how much money is spent but whether it is spent on effective procedures and services." In an associated report, Karen E. Joynt, M.D., M.P.H., and Ashish K. Jha, M.D., M.P.H., of the Harvard School of Public Health, Boston, said: "The relationship between cost and quality is entirely dependent on whom and what are examined and how the money Is spent. In regions of the United States where the delivery system is fragmented, the resulting care is, in aggregate, of poor quality and very high cost. At the systems level, high costs may represent spending on wasteful, inefficient, and duplicative services. Yet, this appears less true for individual clinicians and health care centers. For instance, many physicians and hospitals that are 'expensive' may in fact be spending money directly on patient care, with resultant better outcomes. This is not to suggest that there are not inefficiencies in hospital care. It simply suggests that when hospitals spend more, the expenditures often involve resources for nurses, specialists, and technology - all of which in aggregate improve the outcomes of acutely ill patients."