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Higher Spending CA Hospitals Demonstrate Lower Mortality Rates

 |  By cclark@healthleadersmedia.com  
   February 01, 2011

In contrast with one well-known report from Dartmouth Atlas of Healthcare, an analysis of more than 2.5 million Medicare California hospital admissions has found that greater spending results in lower inpatient mortality, at least for six common medical conditions.

That's the conclusion of a report in the Annals of Internal Medicine, which calls into question some prevailing assumptions about value and quality care, and suggests that Medicare spending is not associated with better healthcare outcomes, or better process measures. 

The distinction, the report implies, is that within the hospital, higher spending is equated with lower mortality, but that spending in outpatient settings may not be so cost-effective or useful.

The study looked at six diagnoses at admission: acute myocardial infarction, congestive heart failure, acute stoke gastrointestinal hemorrhage, hip fracture and pneumonia, at 208 California hospitals for 1999 to 2003 and from 2004 to 2008.

"Across theses conditions, controlling as best we can for patient health status, hospital characteristics like teaching affiliation, and regional factors, ...we found that hospitals that spend the most tend to have lower inpatient mortality," says John Romley, of the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California.

Romley says that it's possible this could be just a California phenomenon. "But my own feeling is that this is probably hospital care versus other kinds of care. It could be that certain kinds of care in the hospital are more efficacious than certain kinds of care outside the hospital.

Another part of the study found that hospitals with lower mortality and intensive spending may not have high adherence standard process measures, such as giving an aspirin at admission for patients who arrive with a heart attack. "Reported process measures may simply do a poor job of explaining variation in hospital mortality," the authors wrote.

The report goes against findings in the Dartmouth Atlas that spearheaded much of what is being looked at in healthcare reform regulations, that expensive care is not necessarily better care, and may in fact be worse care.

"A convincing set of studies (Dartmouth Atlas) demonstrates that U.S. regions that spend more on medical care have similar or poorer patient outcomes than areas that spend less on medical care," Romley and colleagues write. That study found that "regions vary widely in both spending and quality of care, with high-spending regions using more specialists, diagnostic tests and imaging, and inpatient hospital care, yet generally producing no better care."

The report has several limitations. For starters, it excluded patients with cancer, which is known for its high cost of care.

It also does not identify the specific types of high-cost interventions that high-spending hospitals undertake to achieve lower mortality.

However, the authors wrote, there is some suggestion from prior studies patients whose conditions give them have a high or moderate risk of death are less likely to die in hospitals that put more of their patients in intensive care units, provide mechanical ventilation or administer dialysis.

Also perhaps influential are "early and more frequently coronary revascularization for acute myocardial infarctions and upper and lower endoscopies for gastrointestinal hemorrhages.

Another possibility, they wrote, is that patients admitted to higher spending hospitals might just be healthier from the start, "either because of where those hospitals are located or because higher-spending hospitals have lower thresholds for hospital admission.

Romley authored the report with colleagues Anupam Jena, MD and Dana Goldman, and received funding from the National Institute on Aging and the RAND Health Bing Center for Health Economics.

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