Blogger's Note: universal healthcare system, this study included colorectal cancer patients, comparisons between Canadian/U.S. systems, note authors' affiliations
Association of Hospital Spending Intensity With Mortality and Readmission Rates in Ontario Hospitals, March 14, 2012
"Our objective was to assess whether acute care patients admitted to Canadian hospitals that treat patients more intensively
(and at higher cost) have lower mortality and readmissions and higher quality of care.......We studied 4 common conditions that have moderate to high incidence and mortality, that can be validly ascertained using health
administrative data, and for which treatment follows relatively standard protocols.
"
Design Overview
We undertook a longitudinal cohort
study of patients hospitalized with selected acute clinical conditions
in Ontario, Canada,
and assessed the content, quality, and outcomes
with respect to “exposure” to the index hospital's medical spending
intensity.
Medical intensity is defined as the quantity of
medical care provided overall to similarly ill patients and is a marker
of
a hospital's propensity to treat similarly ill
patients more (or less) intensively. It reflects the component of
spending
variation attributable to practice style rather
than to differences in illness or price.
Because sicker patients use more
services, higher-spending hospitals may appear to have worse outcomes,
in part because patients
are more severely ill. We used several
techniques to remove this potential “reverse causality,” as in previous
work.
1,
2,
3,
4
COMMENT
We found that higher hospital spending
intensity was associated with better survival, lower readmission rates,
and better
quality of care for seriously ill, hospitalized
patients in Ontario in a universal health care system with more
selective
access to medical technology. Higher-spending
hospitals were higher-volume teaching or community hospitals with
high-volume
or specialist attending physicians and having
specialized programs, such as regional cancer centers, and specialized
services,
such as on-site cardiac catheterization, cardiac
surgery, and diagnostic imaging facilities. The study also points to
plausible
mechanisms through which higher spending may be
associated with better outcomes.
Benefits appeared early, suggesting an
acute-phase hospital effect. For acute conditions, timely access to
preoperative and
in-hospital specialist care, skilled nursing staff,
rapid response teams, cardiac high-technology services, and regional
cancer
centers, all found in the higher-spending systems,
are related to better outcomes.
21,27,34,35,36,37,38,39 These systems also provided consistently, but not strikingly, higher levels of evidence-based care and collaborative ambulatory
care, both shown to improve care.
22,23,40 Higher spending on evidence-based services delivered in the acute phase of care for severely ill hospitalized patients—by
far the largest component of spending for our cohorts—is indeed likely to be beneficial.
It would be facile to interpret this
study as demonstrating that higher spending is causally related to
better outcomes and
that providing more money to lower-spending
hospitals would necessarily improve their outcomes. Higher-spending
hospitals
differed in many ways, such as greater use of
evidence-based care, skilled nursing and critical care staff, more
intensive
inpatient specialist services, and high technology,
all of which are more expensive.
To place the study in context, the United
States has a 3- to 4-times higher per capita supply of specialized
technology, such
as computed tomography and magnetic resonance
imaging scanners, but a similar supply of acute care beds and nurses.
41 Ontario 2001 population rates of cardiac testing and revascularization lagged behind corresponding 1992 US rates and paralleled
the supply of cardiologists and catheterization facilities.
42,43,44
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.
45,46 Canada's health care expenditures per capita are about
57% of those in the United States.
47
At this spending level, there might still be a positive association
between spending and outcomes. For example, the same-day
PCI rate for patients with AMI in low-intensity
hospitals in 2008 was 3.5%, leaving room for improvement. This pattern
is
consistent with studies in the United States
showing a positive association between spending and outcomes among
low-intensity
hospitals or regions but no association at average
or higher intensity levels.
5,6
Strengths of the study include the
population-based, longitudinal cohort design; the consistency of
findings across cardiac,
cancer, medical, and surgical patients; the
examination of plausible clinical mechanisms whereby higher intensity
may be associated
with better outcomes; and the examination of
readmissions.
The “look-back” (EOL-EI) and “look-forward” (AC-EI)
measures of
spending intensity were highly correlated and
produced similar findings, as in US studies.
2
Several limitations should be considered.
Because the design precludes strong inferences about causation, we
cannot know which
components of care may have led to better outcomes.
In observational studies, comparisons of exposure groups may be biased
because of unobserved selection bias.
13
It is unlikely that the findings are the result of unmeasured case mix,
because patients in higher-spending hospitals had
similar or higher illness severity at admission,
which would, if anything, bias toward finding worse outcomes. We cannot
rule
out the possibility that higher-intensity hospitals
coded more aggressively, but there is less incentive to do so in a
system
with global hospital budgets. Although admission
severity would be determined more accurately using clinical detail from
medical
charts, previous work has shown high concordance
between risk-adjusted hospital outcomes using chart and administrative
data.
48,49 Canadian data distinguish between comorbidities present at admission and complications, leading to improved admission severity
coding. The EOL-EI has been critiqued for the purpose of estimating hospital efficiency
50,51 but is used here simply to distinguish high- and low-intensity hospitals, as in other US studies.
1,2,3,4
The findings may not generalize to chronic conditions, for which
avoiding exacerbations of disease that lead to hospitalization
through coordinated ambulatory care is key. The
findings also may not generalize to jurisdictions in which hospital
resources
are more abundant and are used in cost-effective as
well as cost-ineffective ways, leading to inefficiency.
45,46
This study shows that in Ontario, a
province with global hospital budgets and fewer specialized health care
resources than
the United States, outcomes following an acute
hospitalization are positively associated with higher hospital spending
intensity.
Higher spending intensity, in turn, is associated
with greater use of specialists, better patient care, and more use of
advanced
procedures. 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.
pdf file:
http://jama.ama-assn.org/content/307/10/1037.full.pdf
